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The Great Cheesecake Robbery

In a well-publicized and well-written article in the New Yorker, Atul Gawande (one of my doctor writing heroes) talks about his visit to the popular restaurant, The Cheesecake Factory, and how that visit got him thinking about the sad state of health care.

The chain serves more than eighty million people per year. I pictured semi-frozen bags of beet salad shipped from Mexico, buckets of precooked pasta and production-line hummus, fish from a box. And yet nothing smacked of mass production. My beets were crisp and fresh, the hummus creamy, the salmon like butter in my mouth. No doubt everything we ordered was sweeter, fattier, and bigger than it had to be. But the Cheesecake Factory knows its customers. The whole table was happy (with the possible exception of Ethan, aged sixteen, who picked the onions out of his Hawaiian pizza).

I wondered how they pulled it off. I asked one of the Cheesecake Factory line cooks how much of the food was premade. He told me that everything’s pretty much made from scratch—except the cheesecake, which actually is from a cheesecake factory, in Calabasas, California.

I’d come from the hospital that day. In medicine, too, we are trying to deliver a range of services to millions of people at a reasonable cost and with a consistent level of quality. Unlike the Cheesecake Factory, we haven’t figured out how. Our costs are soaring, the service is typically mediocre, and the quality is unreliable. Every clinician has his or her own way of doing things, and the rates of failure and complication (not to mention the costs) for a given service routinely vary by a factor of two or three, even within the same hospital.

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Op-Ed: Robot-assisted Surgery – The Leading Treatment for Prostate Cancer

da Vinci

Prostate cancer surgeons around the world are using surgical robots to assist in the most delicate operative procedures. Across the country, nearly 1,000 of these robots have entered hospital operating rooms, including our institution: Swedish Medical Center in Seattle, Wash.

These minimally invasive devices, called daVinci surgical robots, offer patients substantially less pain, short recovery time and quicker return to normal activities than traditional open surgery. And because of this, the da Vinci and I have done more than 900 procedures together.

The da Vinci robot assists me during surgery by taking my movements and making them better: more precision, greater freedom of movement and no surgical tremor. These robots offer unmatched surgical precision – meaning my hand cannot compare to the dexterity of the robotic arms. We simply cannot turn our hands 540 degrees.  Da Vinci has 4 robotic arms, which I control at all times at the surgeon’s console. I look through a 3-D viewfinder at the console, which gives me visual depth, and a magnified view 10 to 15 times closer than human vision allows.  This magnified view gives me more precision as well.  Better visibility, better instrument movement means better surgery.

Through my years using da Vinci surgical technology, I know that it offers several advantages over conventional open surgery.  These include less pain, faster recovery, and less blood loss which means reduced need for blood transfusions. Because the surgery is performed through small incisions there is less internal scarring and less risk of bowel adhesions.

Most importantly, with regard to prostate surgery, using the robot has demonstrated improved outcomes over open prostatectomy.  In my experience this has resulted in less urinary incontinence, less erectile dysfunction, and excellent cancer control.

Coincidentally, I was diagnosed with prostate cancer in April 2006, and like all of my patients, the news was devastating. I looked at all the available treatment options and decided to pursue the robotic surgery over radiation therapy or open surgery.  For me, radiation was a shotgun approach and the nerves that control sexual function are potentially at risk from the radiation.  Having the prostate removed gave me information about the amount of cancer and whether it was contained inside the prostate.  This is important in predicting the future behavior of the cancer and I would not get this critical information if I radiated the prostate.

Another important factor in my decision is that once radiation is performed, and if the cancer were to come back, surgery is not an option after radiation due to the high complication rate and difficulty created by the effects of radiation on the tissues. Tissue just does not heal well after it has been radiated.  Conversely, if I had surgery first, and the cancer came back, then radiation was still an option. Essentially, I would be eliminating one treatment option if I had chosen radiation first.

Robot-assisted surgery allowed me to return to my normal activities quickly and this was important for my patients and practice. Through five small incisions about a half-inch in length, the robotic instruments and cameras are inserted into the patient (in this case, me). Compared to the open surgical incision, these incisions are significantly smaller and for many patients this alone is reason enough to consider the procedure over traditional open surgery. I was at home in just one day and at work within two weeks.

The typical prostate surgery patient after a more traditional operation is in the hospital two to three days and is recovering for four to six weeks.  Almost all my patients have gone home the day following surgery, and most are back to normal activities by two weeks.  90 percent of my patients don’t take narcotic pain medication once they leave the hospital.

Today, prostate cancer affects 1 in 6 men in America. A non-smoking man, for example, is more likely to develop prostate cancer than he is to develop colon, bladder, melanoma, lymphoma and kidney cancers combined.

Every man is at risk for prostate cancer. While the causes for prostate cancer are largely unknown, one thing is certain – the chance of developing prostate cancer increases in men over 50. While age is clearly associated, I am seeing more and more men with prostate cancer under the age of 50 and even under 40.  Close relatives of men with prostate cancer are also more likely to be affected.

This means that annually more than 192,000 men will be diagnosed with prostate cancer, and more than 27,000 men will die from the disease.  This ranks prostate cancer as the second leading cause of cancer death in men just behind lung cancer.

However, the future is no longer as bleak as it once was. If caught early, prostate cancer is a treatable disease, which many men have survived. Today about 85 percent of prostate cancer surgery is performed using the da Vinci robot – it has become the norm for the surgical removal of the prostate.

As a surgeon, I’m acutely aware that the location of the prostate gland deep inside the pelvis makes these surgeries a complex and delicate procedure. Removing the prostate is just part of the procedure.  Preserving the integrity of the tissues surrounding the prostate is essential to maintain urinary control and sexual function. That is why the benefits of robot-assisted surgery can be so critical.

Many men elect a robot-assisted prostatectomy because it often provides the fastest return to normal daily activities. My experience as both a surgeon and as a patient is proof. If you are diagnosed with prostate cancer, be sure to make an informed decision about your course of treatment by doing your homework and researching the best approaches available, including robot-assisted surgery.

Dr. James Porter is director of surgical robotics at Swedish Medical Center in Seattle, Wash. and a prostate cancer survivor. Under his leadership, Swedish is one of the first medical centers in the Pacific Northwest to perform robot-assisted surgery. Swedish’s robot-assisted surgical program was first established at Swedish in 2005. Since then, Swedish-affiliated surgeons have performed more than 2,000 procedures using the da Vinci Surgical System, more than any other robot-assisted surgical program in the Pacific Northwest. Dr. Porter is the first medical professional in the country to perform a retroperineral robot-assisted partial nephrectomy using the da Vinci robot (removal of a kidney tumor). Dr. Porter trains surgeons from around the globe how to use the da Vinci robot.

The demands for robotic surgery

Many months ago,
I wrote about the da Vinci Robot Surgical System and expressed doubts
about whether there was evidence to support the clinical efficacy of
this equipment, as opposed to the marketing efficacy of the company
selling it. Well, the time has come to graciously say, “Uncle!”

Without
making any representations about the relative clinical value of this
robotic system versus manual laparoscopic surgery, I am writing to let
you know we have decided to buy one for our hospital.

Why? Well, in
simple terms, because virtually all the academic medical centers and
many community hospitals in the Boston area have bought one. Patients
who are otherwise loyal to our hospital and our doctors are
transferring their surgical treatments to other places.

Prospective
residents who are trying to decide where to have their surgical
training look upon our lack of the robot as a deficit in our education
program. Prospective physician recruits feel likewise. And, these
factors are now spreading beyond urology into the field of
gynecological surgery. So as a matter of good business planning,
concern for the quality of our training program, and to continue to
attract and retain the best possible doctors, the decision was made for
us.

So there you have it. This is an illustrative story of the health care system in which we operate

Paul Levy is the President and CEO of Beth Israel Deconess Medical
Center in Boston. He blogs about his
experiences at, Running a Hospital, one of the few blogs we know of maintained by a senior hospital executive.

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