July 18, 2024 • 29 mins
Embark on an enlightening journey with Dr. Ian Soriano, UCSF's head of robotic surgery, as he unveils his continuous quest for excellence in both the medical field and personal growth. Our recent conversation illuminates the transformative power of stepping outside one’s comfort zone, exemplified by both Dr. Soriano and even Tammie. Their stories serve as a beacon, guiding us through the importance of quality improvement and patient safety that has sculpted Dr. Soriano's illustrious career and his pivotal role in guiding UCSF's Clinical Performance and Improvement Committee.
Venture into the future of medicine as we dissect the advantages of robotic surgery beyond its clinical implications. Discover how cutting-edge technology not only enhances patient care but also safeguards the physical well-being of surgeons, offering a persuasive argument for the ergonomic benefits of robots in the operating room. Dr. Soriano demystifies the concept of robotic surgery, clarifying its intricacies and the necessity for surgeons to be at the helm, guiding with precision and finesse. His personal anecdotes underscore the seamless integration and adaptability of robotics in contemporary surgical practices, challenging the myths surrounding these technological marvels.
Our dialogue with Dr. Soriano extends to the delicate dance between efficiency and patient safety in the realm of surgery. He shares invaluable insights into how data-driven evaluations of surgical techniques contribute to refining a surgeon's craft, ensuring the highest quality of care. We wrap up with an appetite for more discussion, as we touch upon the symbiosis of robotics and surgery's future. Although constrained by time, our exchange was rich with the promise of continued exploration into how technological strides are reshaping healthcare and the global surgical landscape. Join us and be inspired by the innovation and unwavering dedication that propels the world of surgery forward.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
Welcome to Core Bariatrics Podcast hosted by
Bariatric Surgeon Dr MariaIliakova and TMA LaCose,
bariatric Coordinator and apatient herself.
Our goal is building andelevating our community.
The Core Bariatric Podcast doesnot offer medical advice,
diagnosis or treatment.
On this podcast, we aim toshare stories, support and
(00:22):
insight into the world beyondthe clinic.
Let's get into it.
Speaker 2 (00:26):
So today we have with us the head of robotic surgery
from UCSF, the University ofCalifornia, san Francisco.
He's a Bariatric and MinimallyInvasive Surgeon, also a
recreational cyclist and qualityfanatic.
He's actually the co-directorof UCSF's Clinical Performance
and Improvement Committee.
He actually hails from thePhilippines, where he did
medical school and residency atEinstein Medical Center
(00:48):
fellowship at Cleveland Clinic.
He's my personal mentor andguru.
Ladies and gentlemen, we'd liketo welcome Dr Ian Soriano.
Speaker 3 (00:55):
Hey Maria, Thank you very much for that Very warm.
And is that really me?
This is my UCSF's page bio.
Thank you for having me.
It's time to be here.
Oh, it's so nice.
Thank you for being here.
Speaker 2 (01:04):
yes, which is just such a delight and such a treat,
because you have instilled inme a very intense focus on
quality.
That's something that, evenfrom some of the very first
discussions we got to havetogether, you were always
focusing on how do you makeyourself better and how do you
make the whole process better.
(01:25):
So can you tell me a little bitabout where that comes from for
you?
Speaker 3 (01:29):
Yeah, I guess it's something I've always been
interested in is it's just howto be better, both from a
personal perspective, from aprofessional perspective as well
as from a health system ordepartment perspective.
So essentially, everything thatcomes from within involves
everything outside of you and ifyou look at, if you want to
(01:50):
make yourself better and you canget there, why not expand that
to everyone else you work with,to everything else you do and
everyone you interact with?
Essentially, it's philosophy inlife, because we never really
end products right Until the daywe die we are possibly changing
.
So why not do something about itand be like so?
(02:11):
I guess that's how that gotstarted.
Professionally, when I was atPenn I became involved in a
couple of projects that startedwith just trying to see how we
can make things better withinthe department from a clinical
perspective and that got meinterested into formal processes
as well as getting reallyinvolved in quality improvement
(02:35):
from a curriculum and dataperspective.
And so I enrolled at the Centerfor Health Improvement, quality
Improvement and Patient Safetyat Penn and for initial
certificate course there twoyears ago and in the process of
finishing up that course as afull master's program, mostly in
a couple of years, and socontinuing that into a formal
(02:57):
role when I was at Penn and thenhere now at UCSF for as Virgin
Champion for the ACS or AmericanConscious Surgeon's Natural
Circle.
Speaker 2 (03:06):
I think, because you're already such an
accomplished person and such awell educated, you're at the top
of your field in many ways andyet you're still continuing to
educate yourself, both ininformal and informal ways.
Can you tell me a little bitabout how is that common?
Do all surgeons do that?
Is that just something that youreally find important, and what
impact does that have on thosearound you?
Speaker 3 (03:28):
I think, by nature, surgeons are very curious people
as well, as I think, physiciansin general are always searching
for.
How can we know more?
Because it never ends right.
The minute you think we knowsomething or we reach a state of
more time or what has beenformally termed as unconscious
(03:49):
competence, where you canactually do things without even
thinking about it, something newcomes about.
For example, I finishedfellowship in 2007 and I'm
dating myself now.
Maria, we're probably still inMemphis.
We're going to finishfellowship.
Speaker 2 (04:02):
Not, even Not again.
Speaker 3 (04:03):
That was fellowship right, and that was mainly
invasive laparoscopic surgeryRight.
And then, a few years later,robotics started to come in.
So now, what am I going to dowith it?
Am I just going to sit back andjust watch everyone take on
robotics and not learn it?
Or do I accept the vicioustechnology that we can begin
back on my patients?
(04:23):
So how do we go about learningit?
And so I have to, as an adult,learning new concepts and
approaches, new skills.
You need to have an openmindset that if you approach it
in a systematic way, that youcan actually do it.
So I followed the protocol oflearning, going back to now
(04:44):
being consciously incompetent,meaning I knew I did not know
what I was going to be doing andI progressively learned more
and more things, to the pointthat I get to where I am right
now, being proficient, and thenalso taking the next step, which
is then learning how to teachthat to others, and that in
itself is also different.
Speaker 2 (05:03):
So you mentioned an unconscious competence basically
when you're on autopilot andlike you're able to do things so
well that you don't even haveto think about it to taking
yourself to consciouslyincompetent, which is actively
going into a field you reallydon't know anything about and
trying and striving.
That actually really strikes meas something Tammy also did.
So Tammy is a respiratorytherapist and took herself
(05:24):
completely out of her comfortzone to become our bariatric
coordinator.
I just think that's such abrave thing to do to admit you
don't know something and to tryjust to figure it out, jump in
with both feet and do that.
So I think that's actuallysomething that links the two of
you, even though you do verydifferent things and have very
different roles.
Speaker 3 (05:42):
And I think it does link everyone who has an
interest in growing as, both asa person and as a professional.
I someone says introduceyourself, get your title.
Just this past week theyactually had dinner with a
couple of folks from Stanford,which was across all the nation,
collaboration of oureducational divisions, and
(06:04):
everyone introduced themselvesas staff surgeon.
It was like we all wanted tojust be there to learn.
And I added to that I'm PGY 23.
I love it.
I'm just saying I'm anassociate professor.
I said I'm a PGY 23 becauseyou've never stopped learning
for always.
How many years out from when westarted learning?
Speaker 2 (06:21):
And so how does that manifest with your interactions
with patients, the people thatyou take care of?
When you talk with people aboutbariatric surgery, or you're
thinking about innovations youmentioned robotics and others
that you've learned along theway what kind of impact does
that have on the people you takecare of?
Speaker 3 (06:36):
I think what it does is it makes it fun to explain
exactly what they're goingthrough and what it means to
actually have surgery, what thatprocess entails, addressing
their fears, addressing theirconcerns, and explain it to a
way that actually they canrelate to.
(06:57):
One of the things I always askpatients is what do they do or
what are their passions, andthen what I try to do is then
relate how I explain theprocedure directly to what they
do or what affects thempersonally.
For example, if someone is agolfer, I thought that their gut
probably won't get in the wayof their swing and they probably
hit them all fast.
(07:17):
If someone is recently was apsychic, that's a pererobotic
procedure and I mentioned why Ithink it should be done mainly
invasive versus open.
I said you can recover itquicker.
You can get back to doing thethings you do in one or two
weeks versus three or five weeks.
So by being able to connectwhat the procedure and how it
(07:43):
directly affects them on apersonal basis, then on a
generalized risk benefits 1%bleeding, the usual shield we
have we say 1% risk of bleeding.
In fact, if it's from theorgans, I actually say you will
be able to ride your bike fast,you'll be able to swing harder.
Speaker 2 (08:02):
I may be able to fix your swing Exactly, but you can
probably swing it harder becauseyou'll have more flexibility
and you'll be able to actuallywalk the path on a path,
absolutely, and during thecourse of the time that you came
out of fellowship, you saidbefore robotics was really big
in the field and now it's muchbigger and you're actually the
(08:22):
director of robotics surgery atUCSF.
So in the time course that youwent from really not having
anything to do with robotics tonow have you encountered, have
those conversations withpatients or other providers
changed as you've changed thetechnology that you use?
Speaker 3 (08:38):
Yeah, I think early on, everyone was very reluctant
or had significant concernsabout technology, and rightfully
so.
Right the first time Iperformed robotic procedure,
back in 2012, I was very upfrontwith the patient you are my
first patient that I'm doingthis procedure on and I won't be
at the bedside doing thisprocedure.
(08:59):
But at the same time, Ianswered their fears.
If I say one of my trustedassistants will be at the
bedside, I will be in the sameroom and not at home doing the
procedure.
I'm right beside you.
The robot's not doing theprocedure and so I am in charge
of the controls and all theinsurance that are.
And then that got better.
(09:20):
And then, as publications cameabout, there were questions were
being put about the robot.
That question goes up and downin terms of how patients like
hearing about robotics surgeryor not.
Recently there are a couple ofpublications and questions about
whether that robot surgery isof any benefit, as past
physicians need to be able totrack and update it.
(09:42):
And all of these changes inperception, as well as reality,
of the technology that we usefor patients and evaluate
whether it's fit into ourpractice, whether or not is
robotics beneficial for alltypes of patients, all types of
bariatric.
I think you have to reallyevaluate who it's best for and
(10:02):
think we are learning, but wehave to put new questions and
then learning from it.
Speaker 2 (10:09):
What drives this passion for robotics?
What do you think is thebenefit or what do you think?
Why do you think it's soimportant to study it and to
implement kind of newtechnologies as you go?
Speaker 3 (10:19):
I think that we need to provide the best care that we
can give to our patients, but,at the same time, one of the
things is that A lot ofhealthcare around us has
forgotten is the health ofphysicians.
Laparoscopic surgery is such apredominantly challenging
(10:40):
position to perform forlaparoscopic surgery,
particularly bariatric, wherewe're finding the sticking novel
wall.
And I can tell you, havingswitched, I did laparoscopic
surgery from 2007 to 2012, and Idid my first robotic procedure
and I only did have my bariatricprocedure laparoscopic and
after robotic for the firstthree years, and I can
(11:03):
definitely see a difference inhow my body felt after each day
of laparoscopy versus a day ofrobotics.
And so, unfortunately, you weresuch.
I think we sometimes forgetthat we also need to be healthy
for our patients in order to beable to provide them or compare,
and a lot of physicians neglecttheir own health and a lot of
(11:26):
surgeons who were the earlyabout laparoscopic surgery and
neck surgeries, back surgery,shoulder surgeries and all those
things, and I don't want to bepart of that.
And so I think robotics doesgive us that advantage in
prolonging surgeons for years,but we also have to do it
correctly.
We've got a couple of papersout there that show that if you
(11:48):
do not position yourselfproperly at the console and if
you don't position the robotproperly, your assistant might
be suffering from beingnon-organotic physicians, and so
I think it's having just thatgeneral awareness that holding
positions long term by aprocedure can create a lot of
strain on our joints and whichcan lead to injury, and I think
(12:12):
there's just so many things thatwe are learning that we didn't
know before.
That's made robotics both anadvantage in terms of our
patients but also foruncertainties for you.
Speaker 2 (12:22):
There's a lot of folks who listen to this podcast
that aren't surgeons and don'treally have any touch to the
medical field, necessarily.
Would you mind describing alittle bit what it looks like to
do robotic surgery?
Speaker 3 (12:33):
Sure.
So I think the better pain ofnature is that we're describing
how we did surgery for robotics,which is, with open surgery,
you're standing at the patient'sbedside, you make an incision
and then the whole thing seewhat graspers and retractors,
which are instruments that havejaws, that can keep things open
(12:54):
while you're sewing, dividingand dissecting and putting
things together.
And usually that incision isabout 10 to 12, 14 inches.
For example, for bariatricsurgery it's about the eight to
10 inch incision and you have towork through the stick of domo
to be able to do that procedure.
So that's how, and actuallywhen I was in residency, we did
(13:16):
open bariatrics and thecomplications rate were higher,
the bleeding rates were higher,the infection rates were higher,
patients stayed in the hospitalmuch longer.
Actually, for a while I did notimagine we could do bariatrics.
As soon as finishing residency,laparoscopic surgery for
bariatrics was becoming moredeveloped, and so I did the
(13:37):
fellowship and saw that two,four or five small incisions do
the exact same operation.
And that's what's important forpatients to know is that,
regardless of the approach, whatis done is the same exact
operation to find the stoma andthe connecting things.
But now I was doing it withdensil-sized instruments put in
through with incisions in thebelly, but that meant that I had
(14:00):
to fight the thickness of theabdominal wall to lift up the
stoma, the liver and otherorgans, and then that also meant
fighting the abdominal wall andthe thickness and the weight of
the patient.
With robotics it's the sameinstruments, same incisions, but
now the surgeon is sitting at aconsole, just like you would at
(14:22):
the video game.
At your game, just sitting at aconsole, your hands are on
controllers that now control theinstruments that are inserted
into the patient, that areconnected to the robot that
essentially holds theinstruments, and what that does
is allows you to one-on-one whatyou do with your fingers, what
(14:43):
the tips of the instruments do.
So it's not robotic surgeon,the sense that the robot's doing
the surgery.
Now, there's now something inbetween the patient and the
surgeon, which is the robot thatdoes what the surgeon is doing
inside the patient withouthaving to be directly in contact
(15:04):
with the patient.
It's actually remote surgery,in a way, and allowing you to
control instruments withoutdirectly handing them.
And now you're gonna have tosit down all over.
Speaker 1 (15:16):
Sorry, I did not know that Maria was doing my surgery
robotically and I found outwhen we were doing our
accreditation and we had to gothrough the OR and take pictures
of everything and I'm like,wait a second, she was over
there, I was over here and yougot this spider lot.
Literally it's a spider, itlooks like robot that is doing
(15:38):
all the work, as she's sittingthere with her crocs to the side
of her at the console doing thesurgery.
It was crazy to see thattechnology has come in so far
and that is something nobodyeven needed to tell me that
doing it robotically reallyhelps the surgeon because you're
able to position yourselfinstead of moving around your
(16:00):
body, around laparoscopic oropen.
Speaker 3 (16:04):
Yeah, and that's one of the things that I think we
forget, and so I think whathappens is because of robotics.
It also brings us back to openand laparoscopic surgery and
learning how to do thingsdifferently, and I think that is
one of the advantages ofknowing all three different ways
of surgeries, as you then canadapt to know and open what you
know in laparoscopic, what youknow in robotics, and put them
(16:25):
together and be in a moreergonomic position.
Know all set things differently.
So now, when, actually, when Ido robot, laparoscopic or open
procedures, I just set it up theway I would do it robotically.
Or when I say to do some thingsrobotically, I set up the
insights how I would dolaparoscopic.
So essentially, you're puttingtogether all these different
things that are separate andmaking it one approach to
(16:48):
surgery, and so sometimes I willdo part of a procedure open or
part of procedure roboticallyand finish it open, or do part
of procedure laparoscopic andfinish it open.
So then I can whatever I thinkwould be best for the patient's
own.
Speaker 2 (17:01):
It sounds like one of the biggest benefits of knowing
these technologies, especiallyas newer technologies are coming
out, is versatility.
You basically become a moreagile.
You're able to take care ofthings in a way where one
informs the other and you're notjust limited to one approach or
one specific way, but you havethis way and it's, and you have
a backup, many backup plans andmany versions of informing the
(17:22):
same thing.
It's like knowing multiplelanguages, almost yeah.
Speaker 3 (17:25):
And what that does is that you get a more holistic
picture not to some of thepatient, but a more holistic
approach to taking care of thatpatient.
You're building on thefoundation of your open, your
laparoscopic robotic knowledgeand not laring them on top of
each other, but now mixing themup and seeing what best results
(17:48):
in a better outcome for thepatients.
Speaker 2 (17:50):
Yeah, cause just like you wouldn't cook like broccoli
the same way every time, youwouldn't necessarily.
Just there's not just one wayto do things, there's many ways
to do things and we evolve overtime.
Speaker 1 (18:01):
And you don't always have to follow the recipe.
Speaker 3 (18:04):
Sometimes you add, want to add a little bit more
salt, a little bit more sugar,based on how you want it to
taste.
Instead of you have a bad, youenjoy the experience.
Speaker 2 (18:12):
Yeah, I think this is the first time we've made an
analogy to cooking on this showwith surgery, but I really I
enjoy that a lot because therethere is a lot of creativity to
it and I imagine I know, atleast in art program when we
started doing robotics we alsobrought in the ERAS protocol,
the enhanced recovery aftersurgery protocol so it really
made us reevaluate everythingbecause we had brought in a new
(18:33):
technology.
It gave us a chance to actuallylook at the big picture and see
what else we could improve andpotentially change, and that's
something that actually was veryinspired by you, because that's
a huge element of quality andimproving things over time,
taking the chance to actuallyreassess when you can.
So you made a huge impact, evenon the people that I got to
take care of and that Tammy gotto take care of, and I think I'm
(18:55):
very grateful for that.
Speaker 3 (18:56):
Paying forward is always the best reward.
You can't pay me back, but youcan pay it forward and pay it to
your benefit of people you workwith your patients and, of
course, your professionaldevelopment.
Speaker 2 (19:08):
Can you talk a little bit about why you care so much
about mentorship andprofessional development,
because you didn't just touch mylife, you've touched many other
surgeons in the US, but even inthe Philippines as well.
If you do regular trips foreducation purposes, can you tell
me a little bit about what thatlooks like for you and why that
matters?
Speaker 3 (19:26):
Sure, as you alluded to, I went to medical school in
the Philippines.
I then moved to the UnitedStates in the residency here and
since I finished residency in2006 and in 2007, I've been to
the Philippines at least once,not twice, a year to collaborate
with the surgeons.
And it's not just anydirectional, it's bi-directional
(19:47):
.
We both learn from each otherby working together.
They have approaches, not justin your body or in this topic,
that I'm also able to learn fromand bring back here.
But I think it's just I look atthings that are more global
perspective, having not gone tomedical school in the United
(20:09):
States since that we might.
There are other countries thatare doing things that seem
better or worse, justdifferently, and I think, as we
started opening our minds to thefact that we there are so many
ways we can be better bylearning from others than if it
helps with that.
(20:30):
And the trip started with,initially just on the invitation
of some of my mentors actuallyin medical school who share what
I learned with withaparthotopic and robotic
bariatric treatments.
Soon it turned into more thanthat in trying to come up with
various clinical and developmentand programmatic improvements,
(20:53):
and then now also with roboticsand ergonomics, where we,
anything that we are indevelopment here, we also try to
incorporate into the same thingthat they are doing the
Philippines, whether it's inlaparoscopic or robotic surgery,
especially now that theyactually are installing the XIs
for the first time in thePhilippines this year.
(21:14):
So I'm very excited about that,that they are finally getting
the latest technology that wehave here in the Philippines,
because they have excellenttechnical surgeons, excellent
laparoscopic surgeons, excellentopen surgeons and they just
need to get access totechnologies.
We're able to sort the learningcurve by working together and
helping them overcome thatlearning curve in a shorter
(21:36):
amount.
Speaker 2 (21:36):
That is pretty cool because I think a lot of folks
don't necessarily realize thisis a global community, that when
we do bariatric surgery, whenwe figure out what's the best
technique, what's the best way,new innovation in it, we study
it.
It's a global field.
So I'm curious what is yourtake on?
You said it was a two-waystreet.
So what kinds of things are youlearning from surgeons in the
(21:58):
Philippines or elsewhere, or forprograms that has informed your
practice?
Speaker 3 (22:03):
Yeah, first of all, we're talking about Gluopdici.
Gluopdici is just about thelast week, I believe.
There are now a billion people,with about 70 percent adults
and 30 percent of that beingteenagers, who are suffering
from this.
Wow, one of the most efficientsurgeons in the world is in
India and if you look at theirexperience, I believe he did 20
(22:30):
procedures in 48 hours in termsof efficiency and in a very
efficient manner.
Surgeons they're work with lessresources and so they're able
to adapt a lot of things that hetakes for granted.
The carbon footprint of the ORin the United States is two to
(22:51):
three times bigger than thecarbon footprint of procedures
in other countries.
Because of how there is a lotto learn.
It doesn't necessarily have todo with technique.
It might have to do withphilosophy and approach.
That's the limited resources,and that is certainly something
that we can learn from resourcechallenge countries.
Speaker 2 (23:11):
What you're saying actually really resonates.
You're in San Francisco, wepracticed in Iowa City and the
resources can be very differenteven within the United States
and different communities indifferent hospital settings, and
I do definitely believe that,like necessity is the mother of
invention, lack of resources isthe mother of efficiency,
because you have to be efficientin order to get things done
(23:33):
where your resources are notunlimited.
Can you speak a little bitabout what impact that actually
has on safety and quality,though?
I think that's a?
Really we sometimes don't seethe link between the two, but I
think you've been reallyinstrumental in helping people
understand that better.
Speaker 3 (23:48):
Yeah.
So in terms of what's, there'sa I forget now which one of my
buddies said this but first youhave to be good, and in order to
be good, you have to be safe.
Once you're safe, then you canbe good.
Once you can be good, then youcan be fast.
Let's get fast.
And so what it speaks to isthat, first of all, you need to
(24:10):
know the basics.
You need to know how to performa procedure from start to
finish and do it safely, andthen you learn how to do the
exact same procedure in lesssteps, because you're finishing,
for example, an SML systeminstead of taking 10 minutes and
doing it in 5 minutes, and timein the OR is one, and then,
(24:31):
rather than using two or threesutures, you're able to then
finish it with one suture andthen, with each instrument, one
less instrument you're openingone less thing you're opening.
Then you're reducing the carbonfootprint, but then you know
that you need to know that youroutcomes are also good.
So you need to track your, andthat involves creating a
(24:53):
database following your outcomes, following your patients.
But also one of the things Ithink we've learned with
robotics is that even inlaparoscopies, there are ways to
evaluate a surgeon's safety andefficiency by watching their
moves in the OR there's variousratings, you know looking at
(25:13):
laparoscopic and robotic skillsand being able to assess with
how that light's being taken,how that air is being exposed,
and all that that teaches usabout how to assess someone's
safety.
And then we've learned over timealso that economy of motion,
economy of time, is a goodsurrogate of evaluating that.
(25:35):
I think we're learning too thattime is a good surrogate of
it's somewhat of might be asomewhat surrogate of evaluating
efficiency.
Economy of motion and notnecessarily safety, but at least
can give us a gauge of thatsurgeon's skills that we but we
won't know about.
But looking at how we canevaluate those things in a
(25:59):
objective manner, not just asubjective manner, then we can
get an idea of really howsurgeons are skilled in terms of
how surgeons, how skilledsurgeons are.
We do take that to the nextstep of evaluating patient
outcomes.
I think is still a work inprogress.
So I do think that we, byunderstanding that we have to be
(26:25):
efficient, can have betteroutcomes on how being safe can
also be to better outcomes.
That's all important to putthat all together as we evaluate
our own outcomes and patientoutcomes.
That last a little bit.
Let's go back.
Speaker 2 (26:39):
I think it's.
I think you're right, it'scomplicated.
I think it's a big picture hereof it's not.
I'm actually really glad thatyou're talking about it and not
trying to just make it supersimple, because I do think a lot
of people don't necessarilyunderstand how much thought and
process goes into creating safesurgeries that have good
outcomes.
It's, there's actually a lot ofthought put into this.
Speaker 3 (27:01):
Yeah, there's not.
If you look at a couple ofpapers that have come out the
past year or two, they're nowlooking at how to evaluate
textbook outcomes in variousprocedures.
Right, because a lot ofoutcomes are described in the
textbook.
We don't necessarily achievethem, so how do we get there?
I think that is the bigquestion.
It's just like any complicatedprocess.
(27:23):
The way to simplify it is tobreak it down into component
pieces, evaluate each componentpiece separately and then
hopefully that gives you abigger, a better picture of the
big picture.
And so, for example, if it takesa surgeon, the average surgeon
and that's a science aboutrobotics the whole thing is
(27:44):
timed on the console.
You can see your times.
And so if it takes the averagesurgeon, for example, 16 minutes
across the United States to doan ingol hernia, why is it that
some surgeon are taking twohours and some surgeon that's
10% are doing it in 30 minutes?
So what are the surgeons whoare doing it in 30 minutes doing
and are their outcomes just asgood as the surgeon in 60
(28:07):
minutes?
So the surgeons who are doingit in two hours have the same
outcomes as the ones in 60minutes, and how can they
shorten that time.
But then if the outcomes of theones who in 30 minutes are not
the same or worse than the oneswho are doing 60 minutes, then
they're doing it too fast incompromising safety, but they've
been doing it in 30 minutes andthe outcomes are just as good
(28:27):
as the ones who are doing 60minutes.
Then we all need to learn whatare those surgeons doing?
Are they doing certain thingsless?
Are they doing it with less orno?
And that is how you developbeing good, to being fast, to
being safe and hopefully beingvalue driven.
Get a barrier of saying it,then cheat.
Speaker 2 (28:49):
Right and I do think you're creating a good setting
where we understand the balancebetween.
Faster doesn't mean better,necessarily.
If they're not equal to eachother, faster can, can, but
there's got to be an element ofsafety in making sure that
things are done properly.
It's not just a matter of thetime is the most important thing
.
Speaker 3 (29:06):
Exactly, exactly.
Speaker 2 (29:09):
Yeah, there's a lot to discuss here, so I think
we're just going to have to comehave you back at some point to
talk a lot more, because wedidn't even get to some of the
topics we wanted to talk about.
But for this recording, it ishow it goes when you've got
interesting people who know alot and have been in this space
for a long time.
I'm just really grateful you'rehere with us today and all of
your insight about robotics andquality and global surgery.
It's been a really greatconversation, so thank you so
(29:31):
much for having it with us.
Speaker 1 (29:32):
Yes, thank you.
Speaker 3 (29:34):
Thanks for having me Really enjoyed my time here and
looking forward to being backand more discussions about so
many other things, including howbeing a sous vide and then
pan-frying it afterwards iscombining two different
techniques and having a betteroutcome.
Speaker 2 (29:49):
I love that.
That's a great analogy.
We all are food people, sowe'll work on that path with you
.
Speaker 3 (29:54):
All righty Sounds good Thanks.
Speaker 1 (29:56):
Alex, thank you so much Thank you.
Welcome to Core Bariatrics Podcast hosted by
Bariatric Surgeon Dr MariaIliakova and TMA LaCose,
bariatric Coordinator and apatient herself.
Our goal is building andelevating our community.
The Core Bariatric Podcast doesnot offer medical advice,
diagnosis or treatment.
On this podcast, we aim toshare stories, support and
(00:22):
insight into the world beyondthe clinic.
Let's get into it.
Speaker 2 (00:26):
So today we have with us the head of robotic surgery
from UCSF, the University ofCalifornia, san Francisco.
He's a Bariatric and MinimallyInvasive Surgeon, also a
recreational cyclist and qualityfanatic.
He's actually the co-directorof UCSF's Clinical Performance
and Improvement Committee.
He actually hails from thePhilippines, where he did
medical school and residency atEinstein Medical Center
(00:48):
fellowship at Cleveland Clinic.
He's my personal mentor andguru.
Ladies and gentlemen, we'd liketo welcome Dr Ian Soriano.
Speaker 3 (00:55):
Hey Maria, Thank you very much for that Very warm.
And is that really me?
This is my UCSF's page bio.
Thank you for having me.
It's time to be here.
Oh, it's so nice.
Thank you for being here.
Speaker 2 (01:04):
yes, which is just such a delight and such a treat,
because you have instilled inme a very intense focus on
quality.
That's something that, evenfrom some of the very first
discussions we got to havetogether, you were always
focusing on how do you makeyourself better and how do you
make the whole process better.
(01:25):
So can you tell me a little bitabout where that comes from for
you?
Speaker 3 (01:29):
Yeah, I guess it's something I've always been
interested in is it's just howto be better, both from a
personal perspective, from aprofessional perspective as well
as from a health system ordepartment perspective.
So essentially, everything thatcomes from within involves
everything outside of you and ifyou look at, if you want to
(01:50):
make yourself better and you canget there, why not expand that
to everyone else you work with,to everything else you do and
everyone you interact with?
Essentially, it's philosophy inlife, because we never really
end products right Until the daywe die we are possibly changing
.
So why not do something about itand be like so?
(02:11):
I guess that's how that gotstarted.
Professionally, when I was atPenn I became involved in a
couple of projects that startedwith just trying to see how we
can make things better withinthe department from a clinical
perspective and that got meinterested into formal processes
as well as getting reallyinvolved in quality improvement
(02:35):
from a curriculum and dataperspective.
And so I enrolled at the Centerfor Health Improvement, quality
Improvement and Patient Safetyat Penn and for initial
certificate course there twoyears ago and in the process of
finishing up that course as afull master's program, mostly in
a couple of years, and socontinuing that into a formal
(02:57):
role when I was at Penn and thenhere now at UCSF for as Virgin
Champion for the ACS or AmericanConscious Surgeon's Natural
Circle.
Speaker 2 (03:06):
I think, because you're already such an
accomplished person and such awell educated, you're at the top
of your field in many ways andyet you're still continuing to
educate yourself, both ininformal and informal ways.
Can you tell me a little bitabout how is that common?
Do all surgeons do that?
Is that just something that youreally find important, and what
impact does that have on thosearound you?
Speaker 3 (03:28):
I think, by nature, surgeons are very curious people
as well, as I think, physiciansin general are always searching
for.
How can we know more?
Because it never ends right.
The minute you think we knowsomething or we reach a state of
more time or what has beenformally termed as unconscious
(03:49):
competence, where you canactually do things without even
thinking about it, something newcomes about.
For example, I finishedfellowship in 2007 and I'm
dating myself now.
Maria, we're probably still inMemphis.
We're going to finishfellowship.
Speaker 2 (04:02):
Not, even Not again.
Speaker 3 (04:03):
That was fellowship right, and that was mainly
invasive laparoscopic surgeryRight.
And then, a few years later,robotics started to come in.
So now, what am I going to dowith it?
Am I just going to sit back andjust watch everyone take on
robotics and not learn it?
Or do I accept the vicioustechnology that we can begin
back on my patients?
(04:23):
So how do we go about learningit?
And so I have to, as an adult,learning new concepts and
approaches, new skills.
You need to have an openmindset that if you approach it
in a systematic way, that youcan actually do it.
So I followed the protocol oflearning, going back to now
(04:44):
being consciously incompetent,meaning I knew I did not know
what I was going to be doing andI progressively learned more
and more things, to the pointthat I get to where I am right
now, being proficient, and thenalso taking the next step, which
is then learning how to teachthat to others, and that in
itself is also different.
Speaker 2 (05:03):
So you mentioned an unconscious competence basically
when you're on autopilot andlike you're able to do things so
well that you don't even haveto think about it to taking
yourself to consciouslyincompetent, which is actively
going into a field you reallydon't know anything about and
trying and striving.
That actually really strikes meas something Tammy also did.
So Tammy is a respiratorytherapist and took herself
(05:24):
completely out of her comfortzone to become our bariatric
coordinator.
I just think that's such abrave thing to do to admit you
don't know something and to tryjust to figure it out, jump in
with both feet and do that.
So I think that's actuallysomething that links the two of
you, even though you do verydifferent things and have very
different roles.
Speaker 3 (05:42):
And I think it does link everyone who has an
interest in growing as, both asa person and as a professional.
I someone says introduceyourself, get your title.
Just this past week theyactually had dinner with a
couple of folks from Stanford,which was across all the nation,
collaboration of oureducational divisions, and
(06:04):
everyone introduced themselvesas staff surgeon.
It was like we all wanted tojust be there to learn.
And I added to that I'm PGY 23.
I love it.
I'm just saying I'm anassociate professor.
I said I'm a PGY 23 becauseyou've never stopped learning
for always.
How many years out from when westarted learning?
Speaker 2 (06:21):
And so how does that manifest with your interactions
with patients, the people thatyou take care of?
When you talk with people aboutbariatric surgery, or you're
thinking about innovations youmentioned robotics and others
that you've learned along theway what kind of impact does
that have on the people you takecare of?
Speaker 3 (06:36):
I think what it does is it makes it fun to explain
exactly what they're goingthrough and what it means to
actually have surgery, what thatprocess entails, addressing
their fears, addressing theirconcerns, and explain it to a
way that actually they canrelate to.
(06:57):
One of the things I always askpatients is what do they do or
what are their passions, andthen what I try to do is then
relate how I explain theprocedure directly to what they
do or what affects thempersonally.
For example, if someone is agolfer, I thought that their gut
probably won't get in the wayof their swing and they probably
hit them all fast.
(07:17):
If someone is recently was apsychic, that's a pererobotic
procedure and I mentioned why Ithink it should be done mainly
invasive versus open.
I said you can recover itquicker.
You can get back to doing thethings you do in one or two
weeks versus three or five weeks.
So by being able to connectwhat the procedure and how it
(07:43):
directly affects them on apersonal basis, then on a
generalized risk benefits 1%bleeding, the usual shield we
have we say 1% risk of bleeding.
In fact, if it's from theorgans, I actually say you will
be able to ride your bike fast,you'll be able to swing harder.
Speaker 2 (08:02):
I may be able to fix your swing Exactly, but you can
probably swing it harder becauseyou'll have more flexibility
and you'll be able to actuallywalk the path on a path,
absolutely, and during thecourse of the time that you came
out of fellowship, you saidbefore robotics was really big
in the field and now it's muchbigger and you're actually the
(08:22):
director of robotics surgery atUCSF.
So in the time course that youwent from really not having
anything to do with robotics tonow have you encountered, have
those conversations withpatients or other providers
changed as you've changed thetechnology that you use?
Speaker 3 (08:38):
Yeah, I think early on, everyone was very reluctant
or had significant concernsabout technology, and rightfully
so.
Right the first time Iperformed robotic procedure,
back in 2012, I was very upfrontwith the patient you are my
first patient that I'm doingthis procedure on and I won't be
at the bedside doing thisprocedure.
(08:59):
But at the same time, Ianswered their fears.
If I say one of my trustedassistants will be at the
bedside, I will be in the sameroom and not at home doing the
procedure.
I'm right beside you.
The robot's not doing theprocedure and so I am in charge
of the controls and all theinsurance that are.
And then that got better.
(09:20):
And then, as publications cameabout, there were questions were
being put about the robot.
That question goes up and downin terms of how patients like
hearing about robotics surgeryor not.
Recently there are a couple ofpublications and questions about
whether that robot surgery isof any benefit, as past
physicians need to be able totrack and update it.
(09:42):
And all of these changes inperception, as well as reality,
of the technology that we usefor patients and evaluate
whether it's fit into ourpractice, whether or not is
robotics beneficial for alltypes of patients, all types of
bariatric.
I think you have to reallyevaluate who it's best for and
(10:02):
think we are learning, but wehave to put new questions and
then learning from it.
Speaker 2 (10:09):
What drives this passion for robotics?
What do you think is thebenefit or what do you think?
Why do you think it's soimportant to study it and to
implement kind of newtechnologies as you go?
Speaker 3 (10:19):
I think that we need to provide the best care that we
can give to our patients, but,at the same time, one of the
things is that A lot ofhealthcare around us has
forgotten is the health ofphysicians.
Laparoscopic surgery is such apredominantly challenging
(10:40):
position to perform forlaparoscopic surgery,
particularly bariatric, wherewe're finding the sticking novel
wall.
And I can tell you, havingswitched, I did laparoscopic
surgery from 2007 to 2012, and Idid my first robotic procedure
and I only did have my bariatricprocedure laparoscopic and
after robotic for the firstthree years, and I can
(11:03):
definitely see a difference inhow my body felt after each day
of laparoscopy versus a day ofrobotics.
And so, unfortunately, you weresuch.
I think we sometimes forgetthat we also need to be healthy
for our patients in order to beable to provide them or compare,
and a lot of physicians neglecttheir own health and a lot of
(11:26):
surgeons who were the earlyabout laparoscopic surgery and
neck surgeries, back surgery,shoulder surgeries and all those
things, and I don't want to bepart of that.
And so I think robotics doesgive us that advantage in
prolonging surgeons for years,but we also have to do it
correctly.
We've got a couple of papersout there that show that if you
(11:48):
do not position yourselfproperly at the console and if
you don't position the robotproperly, your assistant might
be suffering from beingnon-organotic physicians, and so
I think it's having just thatgeneral awareness that holding
positions long term by aprocedure can create a lot of
strain on our joints and whichcan lead to injury, and I think
(12:12):
there's just so many things thatwe are learning that we didn't
know before.
That's made robotics both anadvantage in terms of our
patients but also foruncertainties for you.
Speaker 2 (12:22):
There's a lot of folks who listen to this podcast
that aren't surgeons and don'treally have any touch to the
medical field, necessarily.
Would you mind describing alittle bit what it looks like to
do robotic surgery?
Speaker 3 (12:33):
Sure.
So I think the better pain ofnature is that we're describing
how we did surgery for robotics,which is, with open surgery,
you're standing at the patient'sbedside, you make an incision
and then the whole thing seewhat graspers and retractors,
which are instruments that havejaws, that can keep things open
(12:54):
while you're sewing, dividingand dissecting and putting
things together.
And usually that incision isabout 10 to 12, 14 inches.
For example, for bariatricsurgery it's about the eight to
10 inch incision and you have towork through the stick of domo
to be able to do that procedure.
So that's how, and actuallywhen I was in residency, we did
(13:16):
open bariatrics and thecomplications rate were higher,
the bleeding rates were higher,the infection rates were higher,
patients stayed in the hospitalmuch longer.
Actually, for a while I did notimagine we could do bariatrics.
As soon as finishing residency,laparoscopic surgery for
bariatrics was becoming moredeveloped, and so I did the
(13:37):
fellowship and saw that two,four or five small incisions do
the exact same operation.
And that's what's important forpatients to know is that,
regardless of the approach, whatis done is the same exact
operation to find the stoma andthe connecting things.
But now I was doing it withdensil-sized instruments put in
through with incisions in thebelly, but that meant that I had
(14:00):
to fight the thickness of theabdominal wall to lift up the
stoma, the liver and otherorgans, and then that also meant
fighting the abdominal wall andthe thickness and the weight of
the patient.
With robotics it's the sameinstruments, same incisions, but
now the surgeon is sitting at aconsole, just like you would at
(14:22):
the video game.
At your game, just sitting at aconsole, your hands are on
controllers that now control theinstruments that are inserted
into the patient, that areconnected to the robot that
essentially holds theinstruments, and what that does
is allows you to one-on-one whatyou do with your fingers, what
(14:43):
the tips of the instruments do.
So it's not robotic surgeon,the sense that the robot's doing
the surgery.
Now, there's now something inbetween the patient and the
surgeon, which is the robot thatdoes what the surgeon is doing
inside the patient withouthaving to be directly in contact
(15:04):
with the patient.
It's actually remote surgery,in a way, and allowing you to
control instruments withoutdirectly handing them.
And now you're gonna have tosit down all over.
Speaker 1 (15:16):
Sorry, I did not know that Maria was doing my surgery
robotically and I found outwhen we were doing our
accreditation and we had to gothrough the OR and take pictures
of everything and I'm like,wait a second, she was over
there, I was over here and yougot this spider lot.
Literally it's a spider, itlooks like robot that is doing
(15:38):
all the work, as she's sittingthere with her crocs to the side
of her at the console doing thesurgery.
It was crazy to see thattechnology has come in so far
and that is something nobodyeven needed to tell me that
doing it robotically reallyhelps the surgeon because you're
able to position yourselfinstead of moving around your
(16:00):
body, around laparoscopic oropen.
Speaker 3 (16:04):
Yeah, and that's one of the things that I think we
forget, and so I think whathappens is because of robotics.
It also brings us back to openand laparoscopic surgery and
learning how to do thingsdifferently, and I think that is
one of the advantages ofknowing all three different ways
of surgeries, as you then canadapt to know and open what you
know in laparoscopic, what youknow in robotics, and put them
(16:25):
together and be in a moreergonomic position.
Know all set things differently.
So now, when, actually, when Ido robot, laparoscopic or open
procedures, I just set it up theway I would do it robotically.
Or when I say to do some thingsrobotically, I set up the
insights how I would dolaparoscopic.
So essentially, you're puttingtogether all these different
things that are separate andmaking it one approach to
(16:48):
surgery, and so sometimes I willdo part of a procedure open or
part of procedure roboticallyand finish it open, or do part
of procedure laparoscopic andfinish it open.
So then I can whatever I thinkwould be best for the patient's
own.
Speaker 2 (17:01):
It sounds like one of the biggest benefits of knowing
these technologies, especiallyas newer technologies are coming
out, is versatility.
You basically become a moreagile.
You're able to take care ofthings in a way where one
informs the other and you're notjust limited to one approach or
one specific way, but you havethis way and it's, and you have
a backup, many backup plans andmany versions of informing the
(17:22):
same thing.
It's like knowing multiplelanguages, almost yeah.
Speaker 3 (17:25):
And what that does is that you get a more holistic
picture not to some of thepatient, but a more holistic
approach to taking care of thatpatient.
You're building on thefoundation of your open, your
laparoscopic robotic knowledgeand not laring them on top of
each other, but now mixing themup and seeing what best results
(17:48):
in a better outcome for thepatients.
Speaker 2 (17:50):
Yeah, cause just like you wouldn't cook like broccoli
the same way every time, youwouldn't necessarily.
Just there's not just one wayto do things, there's many ways
to do things and we evolve overtime.
Speaker 1 (18:01):
And you don't always have to follow the recipe.
Speaker 3 (18:04):
Sometimes you add, want to add a little bit more
salt, a little bit more sugar,based on how you want it to
taste.
Instead of you have a bad, youenjoy the experience.
Speaker 2 (18:12):
Yeah, I think this is the first time we've made an
analogy to cooking on this showwith surgery, but I really I
enjoy that a lot because therethere is a lot of creativity to
it and I imagine I know, atleast in art program when we
started doing robotics we alsobrought in the ERAS protocol,
the enhanced recovery aftersurgery protocol so it really
made us reevaluate everythingbecause we had brought in a new
(18:33):
technology.
It gave us a chance to actuallylook at the big picture and see
what else we could improve andpotentially change, and that's
something that actually was veryinspired by you, because that's
a huge element of quality andimproving things over time,
taking the chance to actuallyreassess when you can.
So you made a huge impact, evenon the people that I got to
take care of and that Tammy gotto take care of, and I think I'm
(18:55):
very grateful for that.
Speaker 3 (18:56):
Paying forward is always the best reward.
You can't pay me back, but youcan pay it forward and pay it to
your benefit of people you workwith your patients and, of
course, your professionaldevelopment.
Speaker 2 (19:08):
Can you talk a little bit about why you care so much
about mentorship andprofessional development,
because you didn't just touch mylife, you've touched many other
surgeons in the US, but even inthe Philippines as well.
If you do regular trips foreducation purposes, can you tell
me a little bit about what thatlooks like for you and why that
matters?
Speaker 3 (19:26):
Sure, as you alluded to, I went to medical school in
the Philippines.
I then moved to the UnitedStates in the residency here and
since I finished residency in2006 and in 2007, I've been to
the Philippines at least once,not twice, a year to collaborate
with the surgeons.
And it's not just anydirectional, it's bi-directional
(19:47):
.
We both learn from each otherby working together.
They have approaches, not justin your body or in this topic,
that I'm also able to learn fromand bring back here.
But I think it's just I look atthings that are more global
perspective, having not gone tomedical school in the United
(20:09):
States since that we might.
There are other countries thatare doing things that seem
better or worse, justdifferently, and I think, as we
started opening our minds to thefact that we there are so many
ways we can be better bylearning from others than if it
helps with that.
(20:30):
And the trip started with,initially just on the invitation
of some of my mentors actuallyin medical school who share what
I learned with withaparthotopic and robotic
bariatric treatments.
Soon it turned into more thanthat in trying to come up with
various clinical and developmentand programmatic improvements,
(20:53):
and then now also with roboticsand ergonomics, where we,
anything that we are indevelopment here, we also try to
incorporate into the same thingthat they are doing the
Philippines, whether it's inlaparoscopic or robotic surgery,
especially now that theyactually are installing the XIs
for the first time in thePhilippines this year.
(21:14):
So I'm very excited about that,that they are finally getting
the latest technology that wehave here in the Philippines,
because they have excellenttechnical surgeons, excellent
laparoscopic surgeons, excellentopen surgeons and they just
need to get access totechnologies.
We're able to sort the learningcurve by working together and
helping them overcome thatlearning curve in a shorter
(21:36):
amount.
Speaker 2 (21:36):
That is pretty cool because I think a lot of folks
don't necessarily realize thisis a global community, that when
we do bariatric surgery, whenwe figure out what's the best
technique, what's the best way,new innovation in it, we study
it.
It's a global field.
So I'm curious what is yourtake on?
You said it was a two-waystreet.
So what kinds of things are youlearning from surgeons in the
(21:58):
Philippines or elsewhere, or forprograms that has informed your
practice?
Speaker 3 (22:03):
Yeah, first of all, we're talking about Gluopdici.
Gluopdici is just about thelast week, I believe.
There are now a billion people,with about 70 percent adults
and 30 percent of that beingteenagers, who are suffering
from this.
Wow, one of the most efficientsurgeons in the world is in
India and if you look at theirexperience, I believe he did 20
(22:30):
procedures in 48 hours in termsof efficiency and in a very
efficient manner.
Surgeons they're work with lessresources and so they're able
to adapt a lot of things that hetakes for granted.
The carbon footprint of the ORin the United States is two to
(22:51):
three times bigger than thecarbon footprint of procedures
in other countries.
Because of how there is a lotto learn.
It doesn't necessarily have todo with technique.
It might have to do withphilosophy and approach.
That's the limited resources,and that is certainly something
that we can learn from resourcechallenge countries.
Speaker 2 (23:11):
What you're saying actually really resonates.
You're in San Francisco, wepracticed in Iowa City and the
resources can be very differenteven within the United States
and different communities indifferent hospital settings, and
I do definitely believe that,like necessity is the mother of
invention, lack of resources isthe mother of efficiency,
because you have to be efficientin order to get things done
(23:33):
where your resources are notunlimited.
Can you speak a little bitabout what impact that actually
has on safety and quality,though?
I think that's a?
Really we sometimes don't seethe link between the two, but I
think you've been reallyinstrumental in helping people
understand that better.
Speaker 3 (23:48):
Yeah.
So in terms of what's, there'sa I forget now which one of my
buddies said this but first youhave to be good, and in order to
be good, you have to be safe.
Once you're safe, then you canbe good.
Once you can be good, then youcan be fast.
Let's get fast.
And so what it speaks to isthat, first of all, you need to
(24:10):
know the basics.
You need to know how to performa procedure from start to
finish and do it safely, andthen you learn how to do the
exact same procedure in lesssteps, because you're finishing,
for example, an SML systeminstead of taking 10 minutes and
doing it in 5 minutes, and timein the OR is one, and then,
(24:31):
rather than using two or threesutures, you're able to then
finish it with one suture andthen, with each instrument, one
less instrument you're openingone less thing you're opening.
Then you're reducing the carbonfootprint, but then you know
that you need to know that youroutcomes are also good.
So you need to track your, andthat involves creating a
(24:53):
database following your outcomes, following your patients.
But also one of the things Ithink we've learned with
robotics is that even inlaparoscopies, there are ways to
evaluate a surgeon's safety andefficiency by watching their
moves in the OR there's variousratings, you know looking at
(25:13):
laparoscopic and robotic skillsand being able to assess with
how that light's being taken,how that air is being exposed,
and all that that teaches usabout how to assess someone's
safety.
And then we've learned over timealso that economy of motion,
economy of time, is a goodsurrogate of evaluating that.
(25:35):
I think we're learning too thattime is a good surrogate of
it's somewhat of might be asomewhat surrogate of evaluating
efficiency.
Economy of motion and notnecessarily safety, but at least
can give us a gauge of thatsurgeon's skills that we but we
won't know about.
But looking at how we canevaluate those things in a
(25:59):
objective manner, not just asubjective manner, then we can
get an idea of really howsurgeons are skilled in terms of
how surgeons, how skilledsurgeons are.
We do take that to the nextstep of evaluating patient
outcomes.
I think is still a work inprogress.
So I do think that we, byunderstanding that we have to be
(26:25):
efficient, can have betteroutcomes on how being safe can
also be to better outcomes.
That's all important to putthat all together as we evaluate
our own outcomes and patientoutcomes.
That last a little bit.
Let's go back.
Speaker 2 (26:39):
I think it's.
I think you're right, it'scomplicated.
I think it's a big picture hereof it's not.
I'm actually really glad thatyou're talking about it and not
trying to just make it supersimple, because I do think a lot
of people don't necessarilyunderstand how much thought and
process goes into creating safesurgeries that have good
outcomes.
It's, there's actually a lot ofthought put into this.
Speaker 3 (27:01):
Yeah, there's not.
If you look at a couple ofpapers that have come out the
past year or two, they're nowlooking at how to evaluate
textbook outcomes in variousprocedures.
Right, because a lot ofoutcomes are described in the
textbook.
We don't necessarily achievethem, so how do we get there?
I think that is the bigquestion.
It's just like any complicatedprocess.
(27:23):
The way to simplify it is tobreak it down into component
pieces, evaluate each componentpiece separately and then
hopefully that gives you abigger, a better picture of the
big picture.
And so, for example, if it takesa surgeon, the average surgeon
and that's a science aboutrobotics the whole thing is
(27:44):
timed on the console.
You can see your times.
And so if it takes the averagesurgeon, for example, 16 minutes
across the United States to doan ingol hernia, why is it that
some surgeon are taking twohours and some surgeon that's
10% are doing it in 30 minutes?
So what are the surgeons whoare doing it in 30 minutes doing
and are their outcomes just asgood as the surgeon in 60
(28:07):
minutes?
So the surgeons who are doingit in two hours have the same
outcomes as the ones in 60minutes, and how can they
shorten that time.
But then if the outcomes of theones who in 30 minutes are not
the same or worse than the oneswho are doing 60 minutes, then
they're doing it too fast incompromising safety, but they've
been doing it in 30 minutes andthe outcomes are just as good
(28:27):
as the ones who are doing 60minutes.
Then we all need to learn whatare those surgeons doing?
Are they doing certain thingsless?
Are they doing it with less orno?
And that is how you developbeing good, to being fast, to
being safe and hopefully beingvalue driven.
Get a barrier of saying it,then cheat.
Speaker 2 (28:49):
Right and I do think you're creating a good setting
where we understand the balancebetween.
Faster doesn't mean better,necessarily.
If they're not equal to eachother, faster can, can, but
there's got to be an element ofsafety in making sure that
things are done properly.
It's not just a matter of thetime is the most important thing
.
Speaker 3 (29:06):
Exactly, exactly.
Speaker 2 (29:09):
Yeah, there's a lot to discuss here, so I think
we're just going to have to comehave you back at some point to
talk a lot more, because wedidn't even get to some of the
topics we wanted to talk about.
But for this recording, it ishow it goes when you've got
interesting people who know alot and have been in this space
for a long time.
I'm just really grateful you'rehere with us today and all of
your insight about robotics andquality and global surgery.
It's been a really greatconversation, so thank you so
(29:31):
much for having it with us.
Speaker 1 (29:32):
Yes, thank you.
Speaker 3 (29:34):
Thanks for having me Really enjoyed my time here and
looking forward to being backand more discussions about so
many other things, including howbeing a sous vide and then
pan-frying it afterwards iscombining two different
techniques and having a betteroutcome.
Speaker 2 (29:49):
I love that.
That's a great analogy.
We all are food people, sowe'll work on that path with you
.
Speaker 3 (29:54):
All righty Sounds good Thanks.
Speaker 1 (29:56):
Alex, thank you so much Thank you.
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