Category: Technology

Categories
Clinical General Healthcare Costs Innovation Quality Improvement Technology

Let Me Be Brief: Principles of Value-Based Health Care

A series of briefs by Texas Medical Students

By: Sanjana Reddy, Tsola Efejuku, and Courtney Holbrook

In the seminal 2006 text, Redefining Health Care, Harvard Business School professors Michael Porter and Elizabeth Teisberg describe a healthcare market with a “positive sum” game; a market where all professional and economic incentives are aligned towards the maximization of “value,” defined as the “the quality of patient outcomes relative to the dollars expended.”1 Value in health care is the measured improvement in a patient’s health outcomes for the cost of achieving that improvement.1 Value-based care transformation is often conflated with cost reduction methods, quality improvement, or even evidence-based care guidelines. Rather, the goal of value-based care is to enable healthcare systems to improve health outcomes for patients over the full cycle of care. Tiesberg further elucidates three key dimensions (the Triple C’s) for measuring patient outcomes: capability (the ability for patients to do what is important to them), comfort (relief from emotional and physical suffering), and calm (reducing the chaos of navigating the healthcare ecosystem).2

In the U.S., improving patient-centered outcomes has become a highly discussed topic with ABIM’s Choosing Wisely program3, American College of Physicians’ High Value Care initiative4, and even major publications like the American Journal of Medicine’s recurring column on high-value care practice.5 In response to escalating healthcare costs, the Centers for Medicare & Medicaid Services (CMS) and other payers have shifted from traditional fee-for-service payments to value-based reimbursements such as the CMS Merit-Based Incentive Payment System (MIPS).6 Value-based health care empowers the clinician-patient relationship, places care delivery decisions at the expertise of a coordinated clinical team, and focuses on outcomes that matter most to patients.

The leadership of professional organizations, such as the Texas Medical Association (TMA), is invaluable to the process of defining and upholding the principles of value-based health care for systems and individual practitioners. Current TMA policy recognizes the need to advocate for high-value care principles in undergraduate and graduate medical education (Res. 201-A-18)7 and the adoption of the Choosing Wisely campaign (265.023).8 Although the evidence-based model (265.018.)9 previously adopted by the TMA does not encompass the full principles of the value-based decision making model, TMA resolutions on Cost Effectiveness (110.002)10 and Cost Containment (110.007)11 reinforce the need for cost-effective utilization of care.

On the federal level, exceptions to key legislation have been enforced recently to further advocate for value-based healthcare options. In November 2020, the CMS and Department of Health and Human Services Office of the Inspector General (OIG) released new exceptions to the Anti-Kickback Statute and the Stark law, effective January 19, 2021. These exceptions now allow more providers to participate in coordinated and value-based care arrangements that can improve quality and outcomes, lower costs, and increase health system efficiency, without the fear of severe criminal or civil legal backlash.12

The practice of value-based health care, although strong in theory, is not without flaws. The primary weakness of this system is that physicians are often responsible for things out of their control, such as referred providers’ costs and pre-existing conditions.13 This system requires widespread buy-in from all providers in order to collectively reduce costs and increase quality of care—effectively changing the culture of health care. Notably, this system inherently disincentivizes caring for patients of low socioeconomic status, particularly minorities, who inevitably generate higher costs due to health disparities.14 Weinick et al. emphasize adding a metric to the value-based healthcare system that addresses equity in health care. Their guide illustrates how to utilize value-based health care to reduce racial disparities, primarily by appending equity in pay-for-performance models.15

Goals of the Medical Student Section include staying informed about current policies regarding value-based health care since these policies are constantly changing and significantly affect reimbursement rates. Medical students are afforded the opportunity to learn about the principles of value-based health care from the very beginning of their training. Knowing the alphabet soup of value-based care (MIPS, APM, MACRA, etc.) will benefit patients and providers alike by improving outcomes, reducing costs, and maximizing reimbursements. In an effort to emphasize value-based health care early in the practice of medicine, the American Board of Internal Medicine sanctioned the Dell Medical School Value Institute for Health & Care’s STARS (Students and Trainees Advocating for Resource Stewardship) program. Over the past few years, student representatives across the country have met to learn about the principles of high-value care, review the Choosing Wisely campaign, and start their own initiatives at their respective medical schools. In Texas, students at UTHSC San Antonio’s Long School of Medicine created an ongoing Value-Based Health Care elective and degree distinction pathway. Dell Medical School offers online instructional modules and is a leader in patient-centered outcomes research. Medical students have a tremendous opportunity to impact high-value care through education, research, and student-led initiatives.

References:

  1. Porter ME, Teisberg EO. Redefining Health Care: Creating Value-Based Competition on Results. 2006. Boston, MA: Harvard Business School Press.
  2. Liu TC, Bozic KJ, Teisberg EO. “Value-based healthcare: person-centered measurement: focusing on the three C’s.” Clin Orthop Relat Res. 2017;475:315–317.
  3. https://www.choosingwisely.org/
  4. https://www.acponline.org/clinical-information/high-value-care
  5. https://amjmed.org/advancing-high-value-health-care-a-new-ajm-column-dedicated-to-cost-conscious-care-quality-improvement/
  6. https://www.cms.gov/newsroom/fact-sheets/quality-payment-program
  7. Texas Medical Association. Policy Compendium. Evidence-Based Medicine 265.018.
  8. Ibid. High-Value Care in Undergraduate and Graduate Medical Education 200.054.
  9. Ibid. Choosing Wisely Campaign 265.023.
  10. Ibid. Cost Effectiveness 110.002.
  11. Ibid. Cost Containment 110.007. 
  12. Modernizing and Clarifying the Physician Self-Referral Regulations Final Rule (CMS-1720-F). CMS. Accessed May 27, 2021. https://www.cms.gov/newsroom/fact-sheets/modernizing-and-clarifying-physician-self-referral-regulations-final-rule-cms-1720-f.
  13. Burns, J. “What’s the downside to value-based purchasing and pay for performance?” Association of Health Care Journalists. September 6, 2014. https://healthjournalism.org/blog/2014/09/whats-the-downside-to-value-based-purchasing-and-pay-for-performance/.
  14. “Value-Based Health Care Must Value Black Lives,” Health Affairs Blog, September 3, 2020. DOI: 10.1377/hblog20200831.419320
  15. Weinick, Robin & Rafton, Sarah & Msw, & Walton, Jim & Do, & Hasnain-Wynia, Moderator & Flaherty, Katherine & Scd,. (2021). Creating Equity Reports: A Guide for Hospitals.
Categories
General Technology

Trending Factors That Will Revolutionize The Future Of Education

a student using AR/VR to study

The future of education will play a key role in the future of the world as we know it. What learners are taught and how they are taught will help them assimilate into society after school. Over the years, education has changed in different ways but it is going to keep changing with time. Right now, one of the key factors that will shape the future of education is technology. Contrary to popular opinion, technology isn’t the only factor that will revolutionize education. Many other factors are already trending in today’s education industry. Some of them are listed below:

1. Project-based Learning 

This learning method allows students to gain knowledge by participating in real-world projects. The projects could either be assigned to groups or individuals and teachers check their progress over time. Depending on the complexity of the project, the timeline could be days, weeks, or the entire semester. The goal is to keep the students engaged and teach them meaningful life skills. It allows students to tap into their creativity, collaboration, and communication skills, among others

2. Video-based Learning 

Video-based learning is a popular teaching approach in learning and cognition that relies on videos in the designation of knowledge. However, it is now becoming a more mainstream method of teaching that uses visual and auditory cues. While the videos are the primary source of information, audio is used for elaboration. Video-based learning is more effective when classes are divided into short videos rather than incredibly long sections. 

3. Tech-based Learning 

Tech-based learning is a combination of different electronic technologies like audio, satellite broadcasts, intranets, webcasts, video conferencing, CD-ROM, and the Internet in general. In this Covid-19 era, tech-based learning became even more popular. Students could not attend in-person classes during the lockdown. So, they had to rely on technology to get the education they need. Older students have also been taking online tech courses on Bootcamprankings.com and Computersciencehero.com. 

4. Teaching Data Interpretation 

As technology advances, the manual aspects of literacy become less relevant. Students will still be taught the three major literacy courses but they will focus more on data interpretation. Computers will be handling every form of mathematical and statistical data analysis but humans will still be needed to interpret this data. Students are now being taught how to predict trends from the data they interpret. They are taught how to apply numbers to theoretical knowledge but they also need human reasoning. 

5. Diversification of Interests 

When you ask children below age 10 what they want to do with their lives, they typically pick any one of the most popular occupations. One would say he wants to be a doctor, another wants to be a lawyer, and one wants to be a nurse. Even if some of these children change their minds when they become more mature learners, some hold on to their early dreams for too long and it shapes their career path. In the future, teachers will promote the diversification of interests among students. They will consciously and unconsciously shape the future career of their students allowing them to develop interests in other fields. 

6. Real-world Skill Training 

In the future, schools will focus less on theories and more on real-world skill training. Proponents of this form of education believe that it is a more efficient method of teaching and it prepares learners for life after school. Since the beginning of the Covid-19 pandemic, many schools have had difficulty providing in-person practicals for their students to experience real-world training. Some of these schools have turned to virtual reality for a solution to their problems. Using virtual reality allows students to immerse themselves in the virtual world in a more realistic way than any other technology. It might not be the same as face to face skills training but it’s the next best thing. 

Bottomline 

The future of education will be shaped by several factors but the ones listed above will have the most significant impact. All these variables have a few things in common. First of all, they are all directed toward making the learning process more engaging. The more engaged students are, the more attentive they will be in the classroom. This will aid in the retention of knowledge as well.

Categories
Global Health Innovation Technology

How Remote Work Is Changing Medical Practice in the Era of Coronavirus

a group of medical workers

Societies across the world have been disrupted by the Covid-19 pandemic, with millions of people being forced to stay indoors and many losing their jobs. But this very disruption has ushered us into what could be the new future of work. Remote work itself has been around for years but, traditionally, companies prefer their employees to work at their physical headquarters. That’s all beginning to change as a result of the pandemic.

With no choice for companies, entire industries and employees alike were forced to embrace remote work—yet this may just be the beginning. In fact, Business Insider recently discussed 12 different companies that were extending remote work, with some end dates as far away as the summer of 2021.

For other industries, however, there may not even be a return to the office on the horizon. 

Technology has made remote work possible but, ironically, has also been a disruptive force that has uprooted traditional jobs. This trend has only been accelerated by remote work—employers have realized just how many jobs can be done from the comfort of their homes. 

Over the past few years, the medical field has been slowly merging with technology. Every aspect of the healthcare system, from entire hospitals to physicians, is being influenced by new technological trends, including remote work. The future of the field has never been more unclear.

Flexibility with Administrative Tasks and Employees

In the coronavirus era, medical professionals are in high demand for obvious reasons. Many medical facilities have transitioned to working remotely. In fact, the automation of administrative tasks has been a major byproduct of the Covid-19 pandemic.

Offices around the country report feeling positive overall about these changes. Medical Economics recently examined Lugo Surgical Group, based out of Texas, who have been operating remotely for two years, showing that this is viable.

Each week, the owner of this clinic, Rafael Lugo, reserves a day and a half to meet with patients. Every other aspect of the surgical process—including billing, scheduling, and follow-ups—are done remotely. 

While doctors and nurses still need to meet with patients in person, it is clear that this is not the case for administration. This new hybrid business model has altered the jobs available in the medical field. In fact, the Bureau of Labor Statistics projects a 9% decline in secretarial or administrative assistant jobs over the next decade. Nonetheless, Covid-19 has highlighted the need for in-person physicians but has demonstrated that administrative workers are not essential for the office.

The Emergence of Artificial Intelligence Systems

While admin roles may be on an accelerated decline due to Covid-19, their replacement is coming far quicker. Artificial intelligence systems are impacting every field of business and its impact on medical practices is profound. Handling administrative tasks is just the tip of the iceberg for these advanced systems; however, there is a downfall. The trust medical offices have placed on these systems during the pandemic may result in them relying on AI to handle more intricate jobs.

As such, AI is changing medical practices, particularly when it comes to patient care. Surgeries powered by robotic instruments that are controlled by a surgeon are becoming extremely popular, and some systems are now able to diagnose patients quickly based on information inputted in the system. As these systems continue to develop, new jobs will open in the field of medicine based on regulating this technology and developing it.

Entire companies may form, focused on developing and then producing these AI and robotic systems. DaVinci Systems is a modern example, as the company produces surgical robots that are controlled via a human surgeon at a desk. These devices have already been approved for urological procedures, radical tonsillectomy, and even tongue base resections. Remote work has shown a new way in which these systems can be helpful. In truth, this pandemic could very well result in a future where there isn’t even a human surgeon behind the robot.   

Altering Career Paths and Customer Expectations

Before the pandemic, a common headache for patients was the annoying wait times and variability in the quality of service provided by the doctor. During the pandemic, though, wait times have become non-existent, with medical professionals able to conduct their job over a Zoom call. Additionally, the advancements of artificial intelligence systems could result in more accurate diagnosing in the future. Having access to medical professionals wherever and whenever, however, may have its drawbacks—patients may become disgruntled if medical practices return to normal after the pandemic settles.

As for doctors and other medical practitioners themselves, Covid-19 isn’t just changing the way they work, but also how they progress in their career. Online nursing programs, offered by accredited schools such as Johns Hopkins University and Rutgers University, have become more popular during this pandemic. With the number of people earning their degrees online increasing, remote learning practices may ease the transition to remote work. This could also contribute to the industry-wide switch over to automation powered by artificial intelligence.

Covid-19 has changed the way entire industries operate and the medical field is no exception. From artificial intelligence replacing administrative jobs to the way budding practitioners are learning the ropes, reliance on technology has increased as a byproduct of the pandemic. This is likely to lead to a future where medical practices are largely automated and in-person visits to the doctor are disrupted by robotics. 

Based on current trends, these changes were inevitable, but the pandemic may have accelerated them. While the future of the coronavirus is unclear, its effects on the workforce and jobs may be permanent—the way work is handled could be disrupted forever.

Categories
Technology The Medical Commencement Archive

“Talk to the Radiologist”: Dr. Robert Wachter, 2017 Commencement Address of the University of Pennsylvania School of Medicine.

This week we have the pleasure of hearing Dr. Robert Wachter’s speech at the 2017 University of Pennsylvania School of Medicine Commencement, titled “Talk to the Radiologist.”

Robert M. Wachter, M.D. is Professor and current Chair of the Department of Medicine at the University of California, San Francisco. He is also former President of the Society of Hospital Medicine and former Chair of the American Board of Internal Medicine. Having coined the term “hospitalist” in 1996, he is often considered the “father” of the hospitalist field, the fastest growing specialty in the history of modern medicine. Dr. Wachter is the author of 250 articles and 6 books.

In the safety and quality arenas, he edits the U.S. government’s leading website on patient safety and has written two books on the subject, including Internal Bleeding and Understanding Patient Safety, the world’s best selling safety primer. In 2004, he received the nation’s top honor in patient safety the John M. Eisenberg Award. In 2016, Modern Healthcare magazine ranked him as the fourth most influential physician-executive in the U.S., his ninth consecutive year in the top 50 (he was #1 on the list in 2015). He has additionally served on the healthcare advisory boards of several companies, including Google. His 2015 book, The Digital Doctor: Hope, Hype and Harm at the Dawn of Medicine’s Computer Age, is a New York Times science bestseller. He recently chaired a blue ribbon commission advising England’s National Health Service on its digital strategy.

We all have people in our lives that we credit with influencing our decision to become physicians. For Dr. Wachter, it was his father who played a significant role in this decision-making.  His father held a fascination with the medical profession. He went so far as to wear a garage door opener on his belt in imitation of a physician’s pager. Altogether, his father’s intrigue with medicine, as well as his unexpected and emergent cancer diagnosis, guided Dr. Wachter toward a career in medicine. He states:

“The experience taught me many things. How terrifying illness is for patients and family members. How doctors aren’t necessarily too great at prognosticating. And how important human-to-human contact is in medicine – not just between doctors and patients, but also among members of the care team.”

“Medicine is changing.”  Dr. Wachter conveys this message throughout the speech.  In particular, he focuses on the technological surge that is making its way through medicine.  He calls it “widespread digitization.” Is this change for better or for worse?  He does not explicitly answer this question.  Instead, he encourages us to take these technologies and apply them creatively, namely in a manner that will improve our ability to care for patients.  He implores caution, however, as he reminds us that we signed up for this career to treat patients, not diseases.

“As the work becomes digitized and the software gets better, we will spend more of our time interacting with our digital tools, and less interacting with each other, and with our patients. This is natural, and –assuming the tools are any good – it might even be OK. After all, computers will hold much of the information, and they will be where we develop and implement many of our diagnostic and treatment plans.

But, there is a huge danger from hunkering down in our digital caves. You can never fully understand a consultant’s thinking by reading her note. You can never place a complex radiology finding in context without speaking to the radiologist. You can never allay the anxiety of a sick patient’s spouse by sending a text message. And you can never comfort a dying patient without             sitting at the bedside and holding his hand.”

Indeed, technology will allow us to push the bounds of diagnostic and treatment capabilities.  In this regard I remain optimistic, though Dr. Wachter’s words have reminded me that at the end of the day, technology is a tool.  Tools supplement –not replace— our creativity, compassion, and ability to connect with others.

Dr. Wachter concludes with a call to action:

“We have the opportunity today to do more for our patients than ever before. And you have the knowledge, skills, values, and habits of mind to thrive in this changing world. You are the ones who will reinvent the work to deliver for our patients. And you will figure out how to balance our new digital capabilities with the enduring truth that medicine is, and must remain, the most human of professions.

Thank you for the honor of speaking to you today. Congratulations to each and every one of you.”

 

Read the full speech in the Commencement Archive: https://www.themspress.org/journal/index.php/commencement/article/view/289/307

Categories
Empathy Technology

Robots: Not just for kids any more

Years ago, my brother and I shared a metal robot with moveable arms and legs. This plaything belonged to the same fantasy realm as Barbie dolls and Power Rangers, and the idea that it might one day be a colleague was not only unfathomable, it was laughable. Fast-forward two decades to the present day, and robots have a very real role in medical care. At present, hundreds of thousands of surgeries are performed each year using robotic technology[1]. This past June, two Belgian hospitals began employing robotic receptionists that can understand up to twenty languages[2]. In Japan, robots have been used to lift and transfer patients from their hospital beds[3].  And right here in America, Watson, the same robot that won Jeopardy in 2011, is being put through his medical residency in the University of North Carolina Lineberger Comprehensive Cancer Center[4]. Just a few months ago, Watson, who has never experienced the years of grueling drudgery to which we have subjected ourselves as medical students, correctly identified the cancer of a patient whose diagnosis had stumped physicians across the globe[5]. As humankind continues to create technologies with the potential to outsmart their creators, it’s hard not to wonder whether we, as doctors, may soon become obsolete.

While mulling over this very question, I saw a young patient who needed blood work. Upon finding out that she was being sent to the lab, the young girl was filled with sheer terror. After much crying, kicking, and screaming, her mother eventually managed to drag her down to the lab. After we had seen our next patient, the doctor with whom I was working decided to go down to the lab to check on our very petrified young patient. At that moment, I was reminded that our ability to care for people in the most trying times of their lives makes us as doctors unique from most other professionals. As doctors, we will have the privilege of making human connections with each of our patients. Robots can digest huge amounts of information, stay up to date on the most current medical practices, and make correct diagnoses in puzzling patient histories, but they will never eclipse physicians because they do not have a reliable set of ethics, nor do they have the shared human experience that underlies the doctor-patient relationship.

The prospect of artificial intelligence in medical practice may be heralded by some as a major scientific breakthrough, but it is important not to hyperbolize the role of robots on a medical team. Though the prospect of finding forms of artificial intelligence in your local hospital is becoming increasingly likely as time passes, many of us can only speculate what it would be like to work alongside a robotic colleague. No matter what, artificial intelligence should only be viewed as a physician aid, not a physician replacement. While it is true that forms of artificial intelligence may certainly help us with diagnoses and complex surgical procedures, these tasks are only one small part of the care that we as physicians have agreed to provide to our patients. The other part of this care is the genuine concern that we show to our patients. Robots may be more knowledgeable and more hardworking than some human doctors, but until a robot can sense human suffering, walk down to a lab, and hold the hand of a little girl who is scared senseless by the idea of having her blood drawn, they are still incapable of providing the most important medical service of all: empathy.

Featured image:
robot! by Crystal

Categories
General Lifestyle Technology

Keyboards and Stethoscopes: A reflection on digital etiquette in medical school

February 26th marks the 47th anniversary of the landmark freedom of speech case, Tinker v. Des Moines. This case concerned a group of students who wished to wear black armbands to protest the Vietnam War. When their school banned the armbands to quash the protest, the students decided to sue, and the case made it to the United States Supreme Court. In the final ruling, Justice Abe Fortas wrote, “It can hardly be argued that either students or teachers shed their constitutional rights to freedom of speech or expression at the schoolhouse gate.” When writing his response, Justice Fortas probably didn’t imagine the digital age that we would be living in just half a century later.

Thanks to the power of the Internet, people can connect from thousands of miles away and ideas can go viral in mere seconds. The freedom of expression that the Internet affords us is practically limitless. The Internet can bring greater awareness to important humanitarian issues like ALS through the Ice Bucket Challenge, but its power as a terrorist recruitment tool can also be harnessed to spread chaos and destruction.

I wonder, as medical students, what our responsibilities are towards using social media responsibly, and how we balance these responsibilities without sacrificing our freedom of speech. In observing our class Facebook page and reflecting on my own bevy of social media faux pas, I have come up with the following five suggestions that I believe strike a balance between our professional responsibilities as medical students and our First Amendment rights.

  1. If something on Facebook offends you, have a face-to-face conversation with the person who posted the content. Avoid writing an angry response or a long rant, which can perpetuate further miscommunication. If a face-to-face conversation is not possible, give yourself a cooling off period before you respond.
  2. Never take down someone’s post without first talking to him or her about it. In our class, we’ve had a few situations where administrators of our group pages have taken down posts that they deem to be offensive or inappropriate. Conceivably, this was done to protect the integrity of the group and keep our Facebook page a “safe space”, but in reality, taking down someone’s post violates their freedom of speech and can make them feel unsafe. Before choosing the safety of the many over the safety of the few, talk to the person who posted questionable content and see if they will alter or possibly remove their post on their own.
  3. No babysitters! School administrators and faculty should not “babysit” class Facebook groups. A class Facebook page should be about fostering a sense of camaraderie amongst students, not about representing a school’s public identity. Therefore, the page should be private, and it should be the collective property of the students who chose to use it. Should disputes arise, they should be settled amongst students. Administrators should avoid getting involved in social media disputes unless they are directly asked to step in. Handling miscommunications and managing uncomfortable situations with our colleagues is important training for our professional careers.
  4. It’s okay to be a backstage comedian. Though this is likely my most controversial suggestion, I strongly believe that in our high-stress lives as students, and later as physicians, we benefit from being able to let off steam in a protected environment. A few months ago, we received a rather outrageous and somewhat distasteful lecture from some guest speakers. Not surprisingly, certain members of our class took to Facebook to share their “fond memories” of this unforgettable class. Somehow, the school administration was alerted to this content, and the students were asked to remove their posts. It’s only natural that from time to time, we’re going to find humor in something that happens in school or in the workplace. I think that it’s healthy to derive enjoyment and levity from these occurrences. In his writing, Immanuel Kant argues that laughter at an event is not a show of superiority, but rather an acknowledgement that the event differed from any reasonable expectations. Acknowledging the comedy of a situation is not at odds with our professional identities when it helps us to process and move on with overwhelming or uncomfortable events.
  5. Express yourself! I love when my classmates post articles that they find that I would have never otherwise discovered, or when a discussion from class spills over onto Facebook page. It makes me feel like I’m part of a community of people who value learning and exploration, and I have learned a lot from these posts.

Reach out to me on the MSPress Facebook page! I would love to hear your thoughts on Facebook and social media etiquette in medical school.

Featured image:
Der Blogger… by Dennis Skley

Categories
Clinical Innovation Opinion Technology

The 21st century Frankenstein Revival

Background

Human head transplantation (the head anastomosis venture project – HEAVEN) has been for a long time merely a neurosurgical and medical theoretical concept that did not enjoy much attention among the medical community. However, in recent times, there have been voices trying to revitalize this question. Italian neurosurgeon, Dr. Sergio Canavero, is one of the most prominent protagonists in this regard. The idea behind this concept is to help people who have severe physical disabilities (such as neuromuscular dystrophies or tetraplegia), but have an intact head and brain. There is a vast array of medical, ethical and physiological questions and obstacles that are ahead of this endeavor. Despite a lot of skepticism, Dr. Canavero has laid out a couple of transplantation protocols he believes can get the job done. In these protocols, he tried to answer and address every possible challenge that is expected to occur during this delicate and immensely complex procedure. The main purpose of this short article is to analyze the crucial components of his protocols and try to determine if they have any rational scientific relevance and ethical/medical justification.

Why do it?

Before you chop someone’s head off, you’d better have some good reasons, right? This is fundamental. In medicine, conditions are treated if the potential benefits of the treatment outweigh the potential risks. For each particular disease state, there has to be a justified medical indication and logical/rational foundation behind treatment. This is the sine qua non of every medical intervention. You have to bear in mind that anything you do has to lead, ultimatively, to a better quality of life. In that regard, I doubt that this procedure would accomplish that goal  at the present moment and it principally acts as an academic exercise, albeit lethal one. I generally do not support doing things just for the sake of doing them, especially in medicine where such behavior can be costly and unethical. Sure, you can become hero of the day and act in a „told you so“ manner if things go your way, but what if they don’t?

Even if you theoretically manage to overcome the technical and technological barriers that are inherent to this procedure, the question still remains: will this person experience improved quality of life? Dr. Canavero’s logic is that people who suffer from severe and/or progressive neurological conditions, e.g. muscular dystrophy or quadriplegia, could potentially benefit from this procedure. How? Well, if your peripheral nervous system does not work but you do have preserved cognitive functions (brain and brain stem), then you would be able to theoretically join healthy brain with healthy body of a deceased donor. The idea is that this body would be donated by those people who were clinically confirmed as brain-dead due to, for example, severe head trauma, but still had a fully functional body to offer. On the other hand, the „recipient“ of the body would give an informed consent that he/she is willing to undergo a body transplantation procedure, regardless of a high risk that this procedure could end in death. In  popular jargon – „people who have nothing to lose“ are the group of people that are targeted as candidates for this procedure in Dr. Canavero’s opinion.

Feasability

Dr. Canavero laid out 2 operative protocols that provide a theoretical framework for this type of experiment. One of them is called HEAVEN1 and addresses head-to-body anastomosis, while the other is named GEMINI2 and features a spine fusion protocol. The physiological obstacles that Dr. Canavero needs to overcome in order to succeed in this endeavour are tremendous, but I will try to briefly tackle the 4 major ones.

  1. Brain perfusion problems – in only a few minutes post-decapitation, it is expected that neurons will be exposed to a hypoperfusive state, ultimately resulting in brain tissue death.
  2. Fusion of two ends of the spinal tract – this has never been done before in humans.
  3. Reparation and regeneration of neuronal connections and spinal tracts/projections within the CNS and the restoration of the motor and sensory functionality.
  4. Post-transplantation complications – this includes potential tissue transplant rejection reactions that are immunologically mediated.

Should we do it?

At this point, we just do not know enough about the proposed procedures. Some of them have been performed on animal models and some were done only in a Petri dish. Results obtained through animal experiments and in-vitro molecular models might not correlate (and most commonly they don’t) with human physiology. In the early 1970s, American neurosurgeon Robert Joseph White performed the first monkey head transplantation onto a body of another monkey3. The recipient monkey lived for 8 days, and there were no surgical complications encountered. However, the monkey was quadriplegic since the surgical protocol did not address the problem of spinal fusion4. This resulted in a monkey who was completely paralyzed from the neck down, but who could still eat and follow objects with its eyes since the cranial nerves, brain stem and other brain structures were intact and perfused by the circulatory system of the donor’s body. Moreover, it was reported that the transplanted head could hear sounds and smell/taste food. However, immunologic reactions in the form of graft rejection ensued and the monkey died from them.

In this regard, Canavero’s protocol is essentially just a „compilation“ of biotech solutions for a wide spectrum of problems in medicine. Successful translation of any of these theoretical concepts into the clinical arena would be a giant leap in medicine. However, strictly lege artis, there is no strong evidence that these techniques will be successfull at all. Patients undergoing this procedure could be left in much more catastrophic and miserable conditions than those endured prior the procedure. Transplantation of a human head onto a new human body should not be perceived merely as transplanting a flower from one pot to another. We do not know how the brain would interact with the new neurochemical and biochemical milleu of the body that it just received. How would the brain integrate and process new signals arriving from the newly discovered periphery? How would the brain process perception and information coming from these new muscles and other body structures? These problems were emphasized in a recent letter written by Dr. Cartolovni and Dr. Spagnolo, published in the Surgical Neurology International journal. In this letter, the authors argue that Canavero’s perception of the human body functional framework is strictly mechanistic, and largely disregards the importance of body self-cognition, which plays a real part in the formation of human self.

Additionally, they state that head transplant procedures raise significant social and ethical problems in terms of organ donation. A leading medical ethicist, Dr. Arthur Caplan from NYU’s Langone Medical Center, states that the implications of this procedure are far-reaching and extremely dangerous from the ethical and medical standpoint. Similarly, Dr. Jerry Silver from Case Western University states that he perceives human transplants as a barbaric method at this point in time. Moreover, he said that he does not expect such procedures to be successfully performed for at least the next hundred years.

In my opinon, we are not ready for this type of procedure, at least in light of the most recent evidence-based medicine. Even if the tremendous technical difficulties could be surpassed, it still remains a question how the brain (center) would integrate with the periphery. At this point, I assume that the brain would be overwhelmed with the amount of input that it would receive from the periphery, ultimately leading the transplant recipient to derangement, pain and insanity. The prospects of this experiment are simply grim and unfavorable, with our present knowledge and, therefore, I would advocate for its halt.

References

  1. Canavero S. HEAVEN: The head anastomosis venture Project outline for the first human head transplantation with spinal linkage (GEMINI). Surg Neurol Int. 2013;4(2):S335-42.
  2. Canavero S. The „Gemini“ spinal cord fusion protocol: Reloaded. Surg Neurol Int. 2015;6:18.
  3. White RJ, Wolin LR, Massopust LC Jr, Taslitz N, Verdura J. Primate cephalic transplantation: Neurogenic separation, vascular association. Transplant Proc. 1971;3:602-4.
  4. White RJ. Hypothermia preservation and transplantation of brain. Resuscitation. 1975;4:197-210.
  5. Čartolovni A, Spagnolo AG. Ethical considerations regarding head transplantation. Surg Neurol Int. 2015;6:103.

Featured image:
Floating head, neck redone by TaylorHerring

Categories
Innovation Opinion Technology

Medical Technology: Implementation Without Cause?

A trip through my apartment is a serious lesson in buyer’s remorse. My iPad? What I thought would be a useful note taking and studying tool is more of a $500 YouTube and Netflix consumption machine. My spiffy dual monitor setup that I thought would amp up my productivity? Most of the time I forget to plug in my other monitor and spend my computing sessions staring at my 13” MacBook screen. In fact, that exact situation is occurring right now as I write this. My fancy Bluetooth speaker that I thought would be useful for jamming out when I had friends over? I’ve used it a handful of times, lost the charging cable so the thing won’t even turn on, and have absolutely no desire or intention to either find or buy a new cable.

Photo courtesy of reirhart_luna
Photo courtesy of reirhart_luna

You may be asking yourself what the point of that rant was, and I don’t blame you. What unifies all those examples is that they are situations when I either purchased or was given a new tech toy that I thought would be life changing, but instead turned out to be unnecessary or obsolete. What I’ve learned from years of accumulating new technology is that while everything comes with copious advertising and monstrous hype, few devices actually deliver as promised.

The medical field is no stranger to this. Hospital administrators and clinical program directors are people too, and they enjoy new toys just as much as the rest of us. Hospitals and universities try to justify their actions by citing journal articles and claiming that having “X” item allows them to remain “on the leading edge of Y specialty.” Let’s be honest, no one is being fooled here. Those new collections of surgical mallets aren’t any better at impacting components than the ones made 20 years ago.

One of the most sought-after technologies is robot-assisted surgical systems, such as the da Vinci©. Are these systems, while definitely innovative and interesting, akin to my iPad? Are they just shiny new toys that don’t justify their cost? Well, let’s find out.

What exactly is this technology?

Robot-assisted surgical systems are surgical workstations, containing robotic arms with cameras and tools, which can be controlled and manipulated by physicians. The most prominent and successful robotic system is the da Vinci©, manufactured by Intuitive Surgical of Sunnyvale, California. The features of this system include four robotic arms that can control surgical tools, a magnified 3D high-definition visual system, and wristed instruments that can produce a range of motion beyond that of the human wrist.1 The claimed benefit of this system is that surgery can be performed with smaller incisions, thus decreasing the pain and recovery time that is usually associated with open surgery.1 These and other systems are currently in use in many different fields such as cardiac, colorectal, gynecological, thoracic, and urological surgery.1 These systems are not cheap however, running upwards of $1 million plus large maintenance and service contracts that can reach into hundreds of thousands of dollars per year.2

Photo courtesy of PresidenciaRD
Photo courtesy of PresidenciaRD

What does the literature say about these systems?

There has been much study about these surgical systems, with the number of peer-reviewed articles reaching into the thousands.  However, there have been a few recently published studies that have shed some concern about the use of robotic surgical systems. In a letter to the New England Journal of Medicine, physicians from Sloan-Kettering Memorial Cancer Center found little to no advantage when using the da Vinci© system for radical cystectomy.3 They found robotic and open surgery to have similar rates of perioperative complications. They also found that while the patients who underwent robotic surgery had lower blood loss, they also had longer mean length of stay after surgery.3 The longer mean length of stay invariably led to greater costs when using the robotic system.

The American Congress of Obstetricians and Gynecologists, in a March 2013 statement issued by President James T. Breeden, denounced the use of robotic surgical systems.4 Dr. Breeden claims, “There is not good data proving that robotic hysterectomy is even as good as – let alone better – than existing, and far less costly, minimally invasive procedures.”4 This speech came after studies published by researchers at Columbia University cast doubts about the perceived advantages of robotic surgical systems.2

These two examples only represent a few of the many opinions divulged about the topic of robotic surgical systems.  The literature is rife with both positive and negative opinions, and it is up to hospital administrators and faculty to gauge the worth of these systems.

Why do so many hospital centers have this technology?

Implementation of these robotic surgical systems has occurred in major surgical centers in the US, France, Italy, Germany, Spain and many other places. If the literature is conflicting on the efficacy of these systems, why is implementation so widespread? I believe the answer is marketing. Top medical centers have a need to “keep up with the Jones’.” If one renowned medical center acquires certain technology, all of the other medical centers instinctively implement that technology as well to avoid a perception of inferiority. There is also a marketing aspect in terms of patient recruitment, as new technology and the promises of a “superior” surgical experience may lure prospective patients away from competing hospital systems. Whether or not the added income from patient recruitment offsets the initial and recurring costs of these systems is, to my knowledge, yet unknown.

My conclusion on this topic is that these surgical systems are akin to my iPad.  They are good in theory, but their cost and relative utility make them a bad investment at the moment. However, this is not to say that these systems will never find justifiable use. With new innovation these systems may find a niche that makes them both efficacious and profitable. Just as a new app may breathe more life into my iPad, new research and better training with the robotic surgical systems may lead to advancements that will justify their implementation.

References
1.http://www.intuitivesurgical.com/
2.http://online.wsj.com/news/articles/SB10001424127887323764804578314182573530720
3.Bochner, B. H., Sjoberg, D. D., & Laudone, V. P. (2014). A randomized trial of robot-assisted laparoscopic radical cystectomy. N Engl J Med, 371(4),389-390.
4.http://www.acog.org/About-ACOG/News-Room/News-Releases/2013/Statement-on-Robotic-Surgery

Featured image:
Da Vinci Surgical Robot by Ars Electronica