Embedded - 12: You Have a Jedi Sword

Episode Date: July 31, 2013

Dr. Edward White spoke with Elecia about how technology has changed medicine. He described gadgets used in surgery (harmonic scalpel!), how hospitals acquire tools, and why engineers should be focused on patient benefit.  iPhone based EKG

This is Elysia White, and we're on location today. Welcome to Making Embedded Systems, the show for people who love gadgets. Today, I'll be talking about the best and most complicated gadget of all, the human body, and also medical gadgets. Today, my co-host is surgeon Dr. Edward White. Hello, Dr. White. Thank you for joining me. Glad to be here. Thank you. Tell us a bit about yourself, please. Well, I'm a general surgeon, which to most people sounds a lot like a general practitioner,

but in fact, it's a specialty. And in general, we deal with things that are pertaining to overall cancer surgeries, abdominal surgeries. We use a lot of technical instruments in performing those procedures, but it has been narrowed down more recently by the loss of some specialty areas to other groups that do only those types of surgery. Nonetheless, there's a lot of abdominal surgery that involves highly technical instrumentation, and there are a lot of instruments that we use to perform things in a minimalist fashion.

So our background tends to be overall exposure to anatomical areas of the abdomen as well as endocrine surgeries that involve the head and neck. And very often, and much of our surgery is associated with cancer surgery. So one of the things I'm really excited about is how similar the debugging techniques are between a human body and embedded systems. So I want to get to that. But first, I understand we have some legalese to get through.

Well, I just want to point out that I have no financial arrangements with any organizations that involve instrumentation or any companies. So anything I say is based on my personal experience and my personal opinion. That is always true for me. Anybody who's listening, always just my opinion. Although, if you'd like to pay me to do the show, I'm up for it. So, give me a baseline. How do you feel about technology in surgery? Well, it's really become very critical. When I originally started training, the operative procedures were performed in a standard fashion with direct approaches. The instrumentation was all instrumentation

that dated back to the 1800s, practically, with minor changes. By direct approach, you mean slice somebody open and check it all out. Right, it's a bit of a euphemistic term, right? So, yeah, you'd make an incision, you go in, you do what you need to do to correct the errors that are presently noted, and then you'd close the patient up. The recovery time, therefore, was partly due to the illness the patient experienced,

but then on a secondary, it was partly due to the harm that you had caused by doing the procedure. The giant gaping hole that was created to fix whatever was actually wrong. Correct. And now the classic example being the removal of a gallbladder, which was the initial minimally invasive procedure that was really developed. You end up with very small incisions, and what was originally an operation that would take a recovery period of, say, four to five days in the hospital is now an outpatient procedure.

That's all based on instrumentation. But the instrumentation also requires special knowledge of the physician and special training in order to be able to perform it safely in that fashion. So the instrumentation, you mean like the laparoscopic, the 80-bitty little camera that goes in there and lets you look around? What else do you mean by the instrumentation? Well, it's not only the camera, it's the tools that you use through additional ports, through additional small incisions that may be half a centimeter in size that allow you to grasp tissues, to move them around, to cut what needs to be cut, to control it, to use suctioning devices to control any fluids or bleeding at the time

so that you can safely perform the operation with good visualization. Now there are pushes to do this in an even less invasive fashion, some of which I suspect is driven by marketing and by the possibility. So now people are trying to do the same operation that is done laparoscopically through typically four very small incisions through one incision, a so-called single incision procedure, which requires even a higher level of instrumentation and technical development in order to do that. Are these like intuitive surgical with the robots? Well, robots still are. There are people who are doing robotic single incision procedures, but that's not generally out there.

A robotic procedure is a separate entity similar to laparoscopic procedures, but in theory it gives better visualization and better control, but it is at a price. It is a price of increased expense for sure, and perhaps not so much a return on the recovery side in most procedures. There are exceptions to that. Okay, so let's go back a second there in case people don't know that there exists robot-assisted surgery. It's a big machine and the surgeon sits kind of over off to a side and doesn't manipulate things inside the body. Instead, they manipulate a robot that then works onto little tiny, tiny little instruments that go in the body. That's basically correct. There are the same port access that we call a port,

a tube that goes through the abdominal wall. A hole in me. Exactly. That allows instruments to move in and out through that port. There are valves on there. The abdominal cavity is inflated with carbon dioxide, so you're working inside a chamber with a light and multiple tubes that allow passage of instruments in and out.

With a robot, some of those instruments actually have little graspers that can be controlled by finger action from the console, which is remote, there's always a person or usually persons around the patient engaged in making certain that the robot is appropriately attached and that there's not going to be some conflict between the various arms of the robot, which is a problem. So the robot has to work in a very defined direction. You can't work in the lower part of the abdomen and immediately do things also in the upper part of the abdomen from the same setup. But the surgeon who's actually performing the procedure is off to the side, usually sitting comfortably rather than standing uncomfortably at a console with the hands on the device controllers and then visualizing inside the abdomen.

And the device controllers actually give some tactile feedback. There is some, yeah. Your fingers are engaged in part of the device that allows you to move your fingers, and the responding instrument then is moving things inside the abdomen. Any sort of feedback helps you figure out what's going on. It's a very similar concept to when I'm debugging a system. I have to be able to see it. I need a port into what I'm looking at. And once I get there, I have to get some sort of information back from it, whether it's a debug log or the ability to change things and see what breaks.

It's really hard to fix something you can't see. So do you think that surgeons will ever be completely replaced by technology? Well, I've been wrong about a lot of things that I thought in the past. I thought that we wouldn't even need surgeons for some types of things by now in terms of corrections possible by molecular biology. So I'm probably going to be wrong about this. But I do think it's extraordinarily unlikely that a non-active human being will be performing surgery without direct intervention. I think those possibilities exist more in the realm of diagnostics, where algorithms in theory can provide answers to questions that we might not ordinarily think about as a practitioner of medicine. But in terms of actually doing a procedure, it requires so much in terms of the next move you're going to do, in terms of risks and assessment, little tiny things that you

don't even think about if you're not in the field and actually doing this. I just don't see that happening, and certainly not in the next 50 years. I'd be happy to be wrong if it really works, but it seems unlikely. Do you ever put anything with a battery inside of a person? Well, there are lots of battery-operated devices that are used, such as pacemakers and defibrillators. I've done a lot of the pacemaker implants in the past. Those are pretty much the standard sorts of things. There are some other types of devices now that may have to do with neurostimulation

and possibly the correction of ear problems where small devices and small batteries may be implanted actually. But there's not a lot more beyond that right at this time. So do you do brain surgery? I do not do brain surgery. I had to check. But you also do other implanted devices, maybe without batteries, joints. Is that right? No, I don't do joint implants. I certainly work with and know people who do that. But

joint implants are not something that would be standardly performed by a general surgeon. Oh, okay. Oh, an orthopedist, I bet. Right. So how do these things get paid for? I mean, those intuitive surgical robots are expensive. They're really neat and they're fabulous. But where does the money go and how does that work? Well, I don't know the specifics of the reimbursement and how that works, but most institutions that are doing this are eating a lot of the cost of the robots at this point, I think.

I think that there is a lot of cost that cannot be overcome by the number of cases that they do. And there are a lot of the surgical procedures that are performed that are not necessarily superior by the robotic approach, that are just done that way in order to accumulate case volumes, but they don't get special reimbursement for it. So you're talking about a robotic machine that's upwards of $2 million with a huge maintenance cost that is ongoing every year in order to support that. So a lot of the institutions will market their procedures and market their program, a robotic program. You'll see billboards all over the place for them trying to increase their usage and get patients to come in because they have that expertise. But if you actually drill down to find out what procedures truly are better by the robot, it's going to be a small subset and

probably not enough to support the machines. Has there been enough use of it? Have there been enough case studies that the machines do or don't have a better quality of life? It's not just quality of life. What's the other measurement for success? Well, outcomes, any kind of outcomes, quality of life, the number of days that a patient's in the hospital, the recovery times, all of those things are important. The real issue in terms of the studies are, as with many, many studies, I think, in medicine now. You have to be inherently suspicious that the study is funded

somehow backdoor by either institutions or companies that have provided the information. One of the real problems in medicine is that you don't see the negative studies, the outcomes of the negative studies. They just don't get published. So when you look at comparative studies, you may only be seeing the studies that have provided apparent benefit and not the studies that have said, well, there really isn't any big outcome difference. Similar findings for some very basic procedures are the standard old hernia repair versus a laparoscopic repair, where if you look at the studies, it's very difficult to really sort out whether the laparoscopic repair has incredible advantages that everybody has marketed or whether it really doesn't have such advantages and may actually have some disadvantages. For instance, there are studies that have shown that comparing

a standard incisional repair of a hernia to a laparoscopic hernia repair, that the outcomes were basically the same, but the laparoscopic hernia repair, that the outcomes were basically the same, but the laparoscopic hernia repair was the only one that had potentially dangerous complications. That doesn't get published. So there's always issues as far as the outcomes. Well, that's kind of terrifying. I'm not sure I wanted to know that. I figured laparoscopic was always better. Yeah, that's not actually true. And even though I do a lot I figured laparoscopic was always better. Yeah, that's not actually true. And even though I do a lot of major laparoscopic surgeries,

I have chosen not to do laparoscopic hernia repairs. And I specifically tell my patients that that's a possibility and describe to them why I've chosen not to do that. So that's something people can think about, and if they want to have it done, they can have it done. I completely understand about the studies. It seems like when I work with processors, whenever I read their sheets and information,

their processor is always the fastest, bestest, and cheap. Every single vendor has that. And I'm not quite sure how they do the baselines to get it always to be the best. So definitely know where your information comes from is important. Although now I'm still cranking my brain around which surgeries should I have which way, and I never want to have any surgeries ever so maybe I shouldn't spend too much time on that. What makes for a good device in your opinion a good medical device? Well a good medical device is in particular let's start

with a laparoscopic procedure it's something that is intuitive to your hand position, ergonomically satisfactory and comfortable. It's really interesting with the laparoscopic procedures because when you do a long procedure with these laparoscopic procedures, you oftentimes are so involved in the operation and what you're doing and the critical nature of the work that you forget about yourself. So it's very common to have a lot of sore joints and muscles when you finish the procedure. And that's usually because you're trying to hold the instrument in an awkward way because of the demands of the configuration of the hand hold or some other thing trying to put traction pulling.

So the instrumentation that's going to be most successful is the one that you have to think the least about that is more standard to your own use that you would use just sort of anywhere else in terms of your activities. When you say long, what do you mean by long? Could be hours. So multiple hours standing in a physically awkward position doing intensely correct and mental work that's correct and you're you're you know you're always working as a surgeon you tend to be able to sort of disconnect in a way from the fact that you're actually working on a human being and that that person is a has connections to families and all kinds of other things i mean it's an it's an interesting separation that I've thought about a lot. You have to be able to do that disconnection and more or less work like you're working on a remote. Like a robot, like a gadget. Something like that. You become more gadgetoid, right? So

some procedures take a long time. And usually the ones that take a long time are involved for a variety of anatomical reasons. And you cannot just have a sandwich and let the patient sit there or something, although you've all heard stories to that effect, I suspect. So it's an intense thing. Once you start, you have to complete and you're looking to complete it effectively. So the devices that you use have to work without a lot of compromise. You can't have, oh gee, this didn't work, let me have another one or something like this. You also have to have

within the proximate area of the operating room backups in case there are problems because there's no device that I know of that's technically perfect. There's no just rebooting a device because it isn't working right now or resetting something because it's a little broken or even just changing the batteries is probably not something you want to break your flow when you're three hours and into a four-hour operation. That's true but all of those things do happen on some level. There are some types of instruments that do function with batteries. Some of them are reusable devices. One of the critical components in doing most of the procedures that are intra-abdominal with laparoscopic approach is a cutting and sealing device that's used for dissection and hemostasis.

And there are many of those that are provided, and that's where companies do a lot of what you said. Each device company says that my device is better, and here are the reasons. Because of the thermal delivery, because of the lateral spread of the thermal delivery, because of the precision of the tips, there are a whole bunch of things like this. Let's go back to cutting and sealing. Are we talking laser scalpels and glue guns? Now, there are actually devices that are the most common one that we use is an ultrasonically driven device, which allows cutting and simultaneously cutting and sealing of tissues.

So you simply grasp something and you pull the trigger and hold it and it, by ultrasonic means, heats the tissue, seals it, and divides it. Then there are others that are purely thermal activated. Both of those. I'm sorry. So you're telling me that you have a Jedi sword. Yeah, that would be cute. It's sort of like that, but it's a very small tip. So you're actually controlling a very small area at a time. But it is remarkably, remarkably useful. For example, there's a type of procedure where we would need to, say,

remove an adrenal gland, which sits just on top of the kidney. It's very, very remote from any anterior approach and only awkwardly approachable posteriorly through standard incisions. This is an operation which used to require a very large incision and lots of work. Now, it's predominantly performed laparoscopically, and the instrumentation using this ultrasonic instrument allows you to essentially do the operation without placing any stitches, only a few clips, and you have to know the anatomy, obviously, and getting there is still tricky, but it's still virtually an outpatient procedure. A patient may go home in a day or two after having had this procedure done.

And it was not possible to do that operation without this instrument that could cut and divide, certainly not in the context of a rapid procedure. It gives you great control. You don't have to interrupt, place clips, and do other things that would be necessary normally. That's really exciting. I mean, those are the devices that I want to say I made. You know, the things that actually take somebody's life and make a big difference. Do you talk to many device manufacturers about what you need and how their things work, or do these things just come to you through the hospital?

Well, it's interesting. There's a combination. There are always people, representatives who want to meet with you and discuss their device. So, for instance, what I typically use in the procedures we were talking about before is a harmonic scalpel. There are competitors who present themselves periodically for discussions regarding their instruments. I've used all of those, and there are some advantages and disadvantages to each. So a lot of times the hospital, in order to accommodate the surgeons, will have to have both types of instruments available, which makes it that much

more complicated in terms of what you want and whether you're going to get that or not. The devices that we use also are staplers. Those are very commonly used. Oh yeah, I have one on my desk. Yeah, I think ours is a little different than that. These were originally developed, I think, by the Russians and then taken over and developed by the companies here and in Europe. But the stapling devices have been critical to rapid performance of procedures in a safe fashion. And they've been incorporated also into the laparoscopic approaches. So there are stapling instruments which are used for resections, intestinal resections and such routinely. The stapling devices have changed dramatically

over the time that they've been available, and they have become incredibly more safe and reliable in their usage. They've also become more adaptable inside. They've become smaller. And smaller, what do you mean? I'm thinking about a laparoscopic port is like a centimeter wide, and so the staples have to go through there.

Right. The instrument is a long instrument with the device being the delivery tip being usually a flexible articulated tip so that you can deflect it in a certain angle so that you can provide positioning. You can rotate it. It's all through a tube. The tube has to be at least 12 millimeters for most of the stapling devices. There's not any that I know of that are a lot smaller than that. When these device manufacturers come in and they have, you know, their harmonic scalpel, that's so cool. And their competitors maybe to show you how much theirs is better. How do they give you something to test it on? I mean, do they just cart around a

body? That seems horrible. Yeah, that's not likely, obviously. But they do often bring in some sort of tissue, like a piece of steak, some meat or something, that you can actually test the instrument on and can demonstrate how it cuts and seals the tissues. Also, there are a lot of... And you get lunch. There are also a lot of labs that you can go to, that the companies will provide, that you can go to a lab in a high training lab. They will actually have animals that you work on.

Atmel has a number of training labs, but usually they just give out dev kits and let us play with their gadgets. I don't think there's any stakes involved. No, it's a whole different deal, and obviously it's a lot more when you're actually going to physically do this on a patient. One of the things that may be somewhat different for most patients, I mean for most physicians than the technical people who put these instruments together, is that you are working with a human being, a patient. You've had to sit down, look the patient in the eye, and say this is what I think is best for you. These are the outcomes we expect. These are the possible complications. Most of the time as a surgeon, when you're discussing some of this with a patient prior to any operation, you've been in the office with the patient and with the family,

directly discussed what you're going to do, why it should be done, given them opportunities to ask all the questions. But it's you as a surgeon taking care of a human being, a patient. I suspect that sometimes some of the people in the technical world may forget that. They may not have exactly that same approach. So when the patient's best interests are there, the technical people have to realize that they're not trying to sell the doctor on this. They're trying to sell to the consumer, the patient. It's the patient who's the final product, and it's the outcome of those procedures that's critical.

So going around that and trying to just sell a product is great if you're a company, but the bottom line is the patient and that outcome. It's awkward. I've worked on medical devices and the engineers often are pretty connected to, I'm doing something that makes a difference. I'm doing something that can save a life. But then the marketing folks tend to try to figure out how to sell it. And you can't sell it to the people who are sick and hurt. You have to sell it to the hospital administrators.

And they require an entirely different set of enticements. And even the surgeons need to say, yes, this is the one I want, so that the administrators will buy it. And so it gets marketed to the surgeons as nifty and new and sweet, but not necessarily better. And it's hard to, it's another case of you have to follow the money is who pays for this. That's who's going to get marketed to even if they aren't the ones that are the real goal and consumers. It's kind of like the robots. Those get sold to the hospital.

The hospital has surgeons trained on them, but does it make a better end condition for the user the the actual patient user the person who's who's hurts and it's a huge burden of responsibility for the surgeon to say yes i want to use the nifty new gadget and by the way this is on a real life human being so maybe i don't want to use i want to use something I know really works. How do you try anything new? Yeah, well, that's kind of tricky. I mean, the marketing that we see is usually, at least the marketing that I see,

is usually the representative is coming to me to try to sell me on the idea so that I will then put pressure on the administration, the operating room, to consider getting these instruments. But now, as everybody knows, there's an incredible amount of pressure financially for all of the institutions to survive, which may be even worse in the near future. So you have to be very selective about what you're doing, and there has to be real justification for going from one instrument to another, the certification that it's going to actually benefit somebody, and it's not just another way of doing it that's going to cost more and basically be redundant, requiring in addition more backup in terms of the manipulations within the operating room. You picture an operating room nowadays, you have a large amount of instrumentation in there between the

anesthesiologist. If you're doing laparoscopic procedure, you have a stack of machinery that's involved in all of the maintenance of the intra-abdominal condition that you need, as well as controlling things. So all of that instrumentation is always being challenged by some other company. I don't know exactly how the mindset develops that allows development of things in the future without having specifically addressed the cost factor. So that's going to be a real critical thing for all companies. Everything that happens is going to have to say,

okay, this is not just somewhat better, this is a lot better, and this is not necessarily just going to be a matter of a change of instrumentation, but it has to cost less and be reliable. Those are going to be critical things in determining the future, I think. And that's tough because new technology costs more because you have to make up the NRE, the non-recurring engineering, the cost of actually building it the first time. The first instrument costs a million dollars.

The second one only costs a dollar. That sort of initial investment has to be made up somewhere, and that's difficult. If you're trying to make it better and cheaper at the same time, you don't usually get everything at once. Yeah, that's very tricky. And so durability of instrumentation may be part of that. That's one of the reasons that the harmonic scalpel has succeeded in the way it has, is it's

a very durable instrument. Seems to have been reliable within its known limitations. It's hard to escalate from that to something else that just does pretty much the same thing without showing that there's a substantial cost benefit and it's an equally successful instrument. In terms of development of instruments and what we as surgeons need, a lot of that has been driven by the surgeons themselves saying, well, I need to have this or that. I actually had a circumstance where with a major company at one point, I sat down in the coffee room and drew a diagram of what I thought something had to be done to make

this instrument perform in a more satisfactory way, would allow something very different to be done. And remarkably, within about six months, that development actually came out. Excellent. And I approached the representative that I discussed, and it turned out that that information had been carried back to the company and that there were he was suspicious that some changes had been made in terms of my

recommendation so it was kind of interesting well that's cool except for the part where they didn't pay you a bazillion dollars yeah I thought about thought about that. What is the next drawing? Tell us. We won't tell anyone. Yeah, I don't have one right now. Do you have a wish list? I mean, not specific things, but what do you want to see from technology in the future? Cheaper, I got that yeah that's that's always uh a challenging question because if i knew the answer to that i would be talking to companies myself right so uh that's it's hard it's hard when you're a practicing physician to be really in the game of what you're doing on a day-by-day basis and thinking up things that would really be critical. My real wish list has to do more with the molecular biology aspects of things

than mechanical, so it's a little bit hard to provide you with a list of things that I would like. Well, then tell me about your phone. You have an iPhone. Ah, yes. But it's special. Tell me, what is the, show me the iPhone. Tell me what it does.

Well, the iPhone that I have just has a case on it like anybody's protective case, except that this one has an EKG monitor pad on it that allows you to just put this in the hands of an individual, and it will show at least a one-lead electrocardiogram tracing. That allows you to determine a rhythm at least and specifically detect whether there's some unusual tachycardia. It isn't like a fully KG, but it does give you the idea that the iPhone could certainly support a lot of technical monitoring things that you might create if you were going to have a wish list of things that would allow somebody to determine what's going on inside the body,

some sort of transdermal instrumentation or other monitoring that would be incorporated readily into that, which would become available then not only to the physicians but to patients if they were doing self-monitoring. So this EKG thing, it's got the two metal bits on the back and you touch them and then it draws that thing we've all seen in a medical drama, the little mountain thing that goes up and down. And this one doesn't beep, which I found great because I hate the beeping. And you can hand it to someone who's having palpitations and it will show something and then you could take that to your doctor and say look i'm not crazy i really do occasionally have these weird spaz outs right no question about that it would work just like that uh i i'm not exactly sure

this when i acquired this this had to be by a physician so so having one, you had to have that qualification. Used by a physician or prescribed by a physician? Well, now I think they've escalated it to where it can be prescribed by a physician. I'd have to actually check that with the company. But this is by AliveCorps, which is the company that provides it. I actually had some communication that was going on long before they released it and wanted to be sort of on the forefront of having that capability. So as soon as they had that out, which I think was released first in Europe,

then they provided that access. I think they have liberalized it now to where it can be prescribed for a patient by a physician. I don't know whether people can just go buy it themselves. So can I get a prescription? It was really cool. Yeah, you can do that. I mean, sure. Well, I meant for you, but I don't think that's going to work.

I don't think there's any reason not to do that, really. But it actually stores the information, so you can add notes to it, the circumstances that occurred at the time of the recording, and you can have it on this particular patient. And then it's, I believe, stored elsewhere for remote access subsequently. And I totally agree that the iPhone and other small devices like that are a great way to have the pocket physician, maybe not the whole physician,

but little bits of information like that. You were saying transderma. What do you mean by that? Well, there are a lot of devices that you put on, for instance, monitoring the pulse and the O2 saturation that you can put on people's fingers to monitor them. That's commonly done for anesthesia monitoring and in ICUs where you're checking continuously the O2 saturation and the pulse. Even if you just walk into an ER right now, they pop on the O2 monitoring.

Actually, you can go down to your local pharmacy and pick up one yourself that you can put on your fingertip and monitor your PO2. They're not that expensive now. So similar devices that might be able to, quotes, look into the blood flowing beneath the skin and actually detect or determine what the state of that is, like take glucose, for instance, that you could do some peripheral monitoring of the glucose level. Obviously, it would be very good for diabetics. There are other things that you might imagine would be useful in terms of physiologic monitoring. That's going to require a combination of high-tech stuff and some way of interrogating the tissues that's reliable.

Or even some sort of chemical monitoring. I've been fascinated by the little MEMS sniffer systems that check out different molecules and report whether they're there. Yeah. And I believe there's a tricorder XPRIZE going on, that if you build something that they consider that's tricorder enough, Star Trek-y enough, you win a big prize. It seems like the iPhone is a good basis for this.

That would be a pretty good system, and there's already everybody's cranked up for doing apps for it, so it would be a great add-on. And I believe your son works in medical technology. Right. He's done a number of things that had to do with intravascular assessment for operative interventions and also evaluating the eye. There are a number of ways that all of those things can be result in significant reductions in the patient's exposure to harmful interventions. Additionally especially with the instrumentation that's being done by the intravascularly it reduces substantially the risks of having harm by radiation,

both to the patient and to the interventionist who's doing the procedure, because typically a lot of the intravascular procedures require a lot of radiation exposure. Even though they try to minimize that, the cumulative effect on the surgeon over a long period of time is substantial. Do you do those sorts of surgeries? I did. I don't. I used to do a lot of vascular surgery, but my emphasis now is on cancer surgery and I have moved away from that. But I did probably 20% to 30% of my practice previously was vascular surgery. And one of the reasons that I started to move away from that

was that there was this tremendous shift toward the intravascular, endovascular approach, which did require a lot of radiation exposure. And the whole shift of the vascular surgery field has moved towards intravascular procedures. All right. As we were talking before the show, you said something pretty remarkable. So I'm going to quote this part. The difficulty with rare things is that there are so many of them. And is this a presentation

of a common problem or a common presentation of a rare problem? These are very common ideas with software developers trying to figure out bugs. I mean, I guess you're trying to figure out bugs in humans too. But when I debug software, I usually get to try again with the main cost being my loss of time, not anything worse. What you have to deal with it with much greater consequences. What advice do you have for those of us who get to try again? Well, from my personal approach as far as the practice of surgery, you're always trying to decide, first of all, whether the patient has something that can be or should be fixed or repaired or bettered by a surgical intervention. Or whether something is simply mimicking that. And you don't want to be doing procedures if you don't need to. You don't want to do the wrong procedure when you do need to do a procedure.

And there are a lot of things which are complicated by multiple issues with the patient. So patients have multiple comorbidities. They present with something that looks like it's surgical, but it may not be. I'll give you a couple of examples so you have some idea. It's not uncommon for me to see a patient in the office who has had some kind of abdominal pain. They've had a study that shows that they have gallstones. Well, not everybody who has gallstones needs surgery for the gallstones. I don't just routinely operate because somebody has gallstones. It has to be that those are

causing a problem. And not everybody who has abdominal pain and has gallstones has the pain because of the gallstones. So sorting that out gets to be somewhat challenging. Not everybody who has a hernia needs a hernia operation. There are some who do and some who don't. There are many patients who come in with lots of symptoms, and you're trying to sort through them to try to figure out what really needs to be done. You're sort of on the end of a long story, and you're trying to figure out whether an intervention needs to take place at that point. Nobody comes to the surgeon first. Generally speaking, that's not true.

And so that's one of my questions to my patients usually when they come in there, what brings you to a surgeon? It's not taken lightly by patients usually, and nor is it taken lightly by the surgeon. But you want to make sure that if you're going to do something, it has to be done for the right reason. So it's always tricky to go back and try to sort this out in patients who have something other than a classical presentation and classical findings and try to address it in an appropriate fashion. Come back to your question. What advice do you have for us?

Well, I mean, the real endpoint is the patient. And when people are trying to figure out what's going on with a technology, you have to figure what your role is in the development of better care for the patient and why you're really doing something. What is the goal of the question you're attacking? Is it something that you're just trying to outdo another company, another instrument, or is there something really remarkable about what you're approaching? I'd go for the real game breaker and try to figure out what can make a

substantial difference in a safe fashion and always keep a focus on the fact that this is, if you're in the medical business, you're dealing with the patient and the end point is the outcome of that patient's final procedure. And there you have it, Dr. White telling us to dream big. I'm really happy we got the chance to talk about technology and surgery and medicine. Thank you for joining me. Do you have any other thoughts you'd like to leave us with? No, but I do think that the critical role technology has played

is the ultimate change that we've seen over the last 10 to 15 years in medicine. I think technology will continue to be an important part of the future, making things safer and less expensive, ultimately, if done properly. I hope you'll consider coming back to talk to us about our shared interest in epigenetics and how that's like the software that runs on our DNA hardware. Thanks. I look forward to that. Thank you all for listening. I hope you enjoyed this episode. If so, go write an iTunes review right now.

I'd really appreciate it. On the other hand, send criticisms, questions, or comments to show at makingembeddedsystems.com or hit the contact link at embedded.fm. Finally, I want to extend a big thanks to our producer, Christopher White, for being willing to sacrifice his family to our podcast.