The Doctor of the Future

By: Chuck SalterFri May 1, 2009 at 2:00 PM

Photograph by Jamie Chung | Prop Styling by Bryan Byrn

Cost, access, quality -- the prognosis for American health care may look grim, but innovation is the cure. The medicine of tomorrow is being born today.

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Photograph by Tanit Sakakini

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One of the paradoxes of modern medicine is that it demands continual innovation yet often resists change. This is particularly true for highly complex surgeries, such as open-heart operations. After all, the traditional procedure works. Why change it? But Dr. Douglas Murphy, 59, a cardiac surgeon at St. Joseph's Hospital in Atlanta, has led the way in repairing the heart's mitral valve robotically, using Intuitive Surgical's da Vinci Surgical System. The procedure has proven more effective, quicker to do, and dramatically less invasive. Now he's on a mission to make it more widely adopted, providing a model for both high-tech surgery and remote medical education.

Murphy's achievements in the operating room are nothing short of miraculous to the rest of us. Instead of cutting the sternum and splitting open the chest, one of the more violent operations performed on the body, he inserts long, slender instruments, including a robotic camera, through a few fingertip-size incisions. Slipping the tremor-free instruments between the ribs, he's able to slice and enter the heart. "It's like building a ship in a bottle," he says. The camera gives him a three-dimensional, high-definition view (and magnification up to 10 times stronger than the human eye). The small size of the incisions nearly eliminates the risk of infection; there hasn't been one in 750 surgeries.

"Traditional heart surgery has always been a mixed blessing," Murphy says. "Sure, it's life-saving, but it takes you two or three months to recover. The heart recovers in a couple of hours. But the body takes much longer. With robotic surgery, the patient is out of the hospital in less than half the time and recovered in three weeks. I'm talking back to playing golf or tennis."

Why isn't robotic cardiac surgery already the treatment of choice? Murphy estimates that it takes 100 cases to learn to perform it efficiently, and there's no immediate financial incentive to do that since the reimbursement is the same. That means few surgeons -- let alone other members of the surgical team -- can afford to travel and observe an expert in action. What's necessary, Murphy realized, is robot college.

So earlier this year, his hospital launched the International College of Robotic Surgery, the first such remote facility with a cardiac focus. Murphy and his colleagues teach via a secure Internet site. Tuition runs as high as $100,000 for a comprehensive package that includes more than 30 presentations, live video feeds of operations, proctoring, and sessions tailored to each role on the surgical team -- surgeon, surgical assistant, nurse, anesthesiologist, and so on. "There are review sections, checklists, a section I call 'Things I wish I hadn't done,'" Murphy says. "We've documented 750 cases on video, so I can show it all -- the great examples, what's routine, what's not routine. They get the know-how of the first 100 cases before they do their first."

Murphy, who performed heart transplants before moving into less-invasive surgeries, teaches repair of the mitral valve -- a flap in the heart's upper chamber that can become leaky, leading to congestive heart failure. The optimal treatment is repairing the existing valve, but in nearly half of all nonrobotic procedures, surgeons install an artificial replacement, a considerably more expensive process. With robotics' 3-D magnification, Murphy is able to repair more than 90%. Dr. Sudhir Srivastava, who joined St. Joseph's from the University of Chicago Medical Center this year, teaches an even rarer robotic procedure: coronary bypass surgery on a beating heart.

Currently, hospitals around the world have more than 1,100 da Vinci systems, at a cost of $1 million to $1.7 million apiece. Using them more for cardiac procedures makes sense both medically and economically. The demand is there: Murphy has a two-month waiting list, with patients from all over. St. Joseph's, which has five da Vincis, has grown its total annual robotics-surgery revenue to $25.5 million from scratch in six years. And the need for less-invasive measures is expected to increase as the population ages, because traditional surgery is too traumatic for the elderly.

"We're toward the end of our careers, and we decided that rather than grind out more cases, we wanted to teach this worldwide," says Murphy. "Every major metropolitan area should have one or two teams that are proficient in this."

Last year, robotic surgery using the da Vinci system, the only one with FDA approval for soft-tissue surgery, reached a milestone: More than half of the 80,000 prostate removals in the United States were performed by surgeons manipulating robotic metallic arms instead of wielding scalpels in their own hands. A total of 136,000 operations involved da Vinci robots, a 60% increase from 2007. This revolution in the OR is likely to pick up speed as surgeons like Murphy and Srivastava perfect new robotic procedures -- and exploit telemedicine technology to share that knowledge efficiently.