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GUEST EDITORIAL
Year : 2019  |  Volume : 7  |  Issue : 1  |  Page : 1-3

Live surgical broadcasts: Are there some lessons to be learned from the Johnson and Johnson's articular surface replacement hip implant case?


1 Department of Ophthalmology, Hindu Rao Hospital, Delhi, India
2 Department of Medicine, Deep Chand Bandhu Hospital, Hindu Rao Hospital, Delhi, India

Date of Web Publication12-Mar-2019

Correspondence Address:
Jatinder Bali
Department of Ophthalmology, Hindu Rao Hospital, Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcor.jcor_88_18

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How to cite this article:
Bali J, Bali RT. Live surgical broadcasts: Are there some lessons to be learned from the Johnson and Johnson's articular surface replacement hip implant case?. J Clin Ophthalmol Res 2019;7:1-3

How to cite this URL:
Bali J, Bali RT. Live surgical broadcasts: Are there some lessons to be learned from the Johnson and Johnson's articular surface replacement hip implant case?. J Clin Ophthalmol Res [serial online] 2019 [cited 2019 Jul 17];7:1-3. Available from: http://www.jcor.in/text.asp?2019/7/1/1/253994




  The Johnson and Johnson's Case Top


The Indian government recently accepted the report of an expert committee which awarded compensation to patients who received Johnson and Johnson's articular surface replacement (ASR) XL Acetabular and ASR Hip Resurfacing Systems. This implant was made by its subsidiary DePuy and was associated with complications and increased revision surgeries. Out of the 4700 sold in India, only 1032 were traced. At least four patients were reported dead in this Indian cohort.[1] Newspapers, which traced the implant recipients, reported that the recipients were required to pay only for the implant; the cost of the surgery or getting the surgeon from abroad was waived off. There were live surgeries which were advertised.[2] This case has thrown up a few questions which we, as practitioners, need to examine.


  Live Surgery Demonstrations and Broadcasts Top


We will be focusing on the live surgery demonstration and the current trend of live surgical broadcasts (LSB) from different hospitals/centers to a live audience in a conference or meeting of professional bodies/associations. The first LSB was made in 1996 from California to Buenos Aires by Gandsas et al. when they broadcast three laparoscopic procedures using the Internet.[3] Several other advances were soon reported including live broadcast to handheld devices.[3],[4]


  Surrogate Advertising Top


LSBs have acted as advertising opportunities for operating surgeons, operating institute/center, society organizing the meeting, the trade, and the manufacturer. Ancient gladiatorial championships, reality television, and live surgery satisfy a basic voyeuristic human instinct. It spawned a culture of “champion surgeons” and new age technology. The competition between the surgical centers to display the newer machines they acquired ramped up the importance of this advertising exercise.

When liquor advertising was banned, there was rise of surrogate advertising. Similarly, LSB was and still is a means of surrogate advertising for both the champion surgeon and the center. The assertions made at some of these live events bore no semblance to the evidence available in the public domain. It was argued that watching surgeons operate, “seeing” the difficulties, tackling the mistakes as they occurred was valuable experience in real-life situations.

Others argued that the surgeon could explain the procedure and its attendant issues much better after the surgery had been completed. The need for making a spectacle of somebody's pain did not appear to add any value to the learning experience. Moreover, you had to wait for a complication to happen to teach you something.


  Live Surgery Demonstrations and Broadcasts Against Prerecorded Videos Top


Currently, there is scarce evidence to support live surgery as an educational tool. There is no evidence to suggest superiority of LSBs to prerecorded surgical videos. The latter seems to have the added benefit of frame-by-frame analysis and video editing and labeling which may convey the information better to the audience.[4] McIntyre et al.[5] and Gul et al.[6] compared the student responses in the operating room (OR) to those watching live transmissions. The restrictions imposed in OR and the lack of a clear vantage point was a clear deterrent. However, no head-to-head comparisons with the current gold standard of prerecorded surgery with live surgery have been made with any randomization. It has been presumed that live surgery is beneficial to the profession without clear evidence for the same.

LSB is an exercise in cognitive domain where knowledge is acquired. To have an effect on physical/kinesthetic domain, practice or simulation is required. When you watch the bowler bowl, you do not acquire the skill to spin or swing a cricket ball unless you do it yourself. All coaching is done with recorded videos across all sports. Live sports events may not add too much to the repertoire of a practicing sportsman.

Who would like to learn landing with an aeroplane loaded with passengers with live streaming of the event? You would like it the least if you were a passenger in the aircraft. The aviators today learn a lot from the simulators before they even start flying. No new aircraft goes up in a test flight fully laden with passengers with broadcast from the cockpit. We never see two competing airlines showing what their pilots can do or the kind of new machines they have just bought.


  Patient Safety Top


Before advent of broadcasting, Chatelain et al., while studying 104 coronary angioplasty live demonstrations, reported that complication and success rate of live surgery was inferior to published data.[7] It is a surprise that different professional bodies carried out further work on LSBs without really addressing the issue of beneficence and nonmaleficence. The 2007 death of a cardiothoracic patient, soon after a live demonstration, is all too fresh in our minds. In fact, some surgical subspecialties, for example, the American College of Obstetricians and Gynaecologists and the American College of Surgeons stopped all live surgery transmissions within their meetings after this mishap.[8] Some solace can be had from the fact that some authors have reported similar results in both LSBs and controls. In 2005, Schmit et al. published a study of 168 endoscopic retrograde cholangiopancreatography procedure LSBs to 168 controls and reported no significant difference in duration of procedure, complications, and success rate. However, procedure was delayed in 10.7% and general anesthesia had to be used significantly more frequently for the live procedures (87.5% vs. 44%).[9] Several other short studies may be cited, but the scope of these studies is rather limited because they never reported on long-term prognosis. Furthermore, please remember that “no-proof-of-harm” is not the same as “the-proof-of-no-harm.”

There have been instances when surgeons refused to accept failure or resorted to heroic measures just to prove that the complications were trivial even if they were not or people in the audience objected to something unethical or unscientific. The surgeon is under stress to complete the surgery smoothly to prove that his skills are extraordinary. Sometimes, even hand tremors have been observed and commented upon by the audience. The moderator has an unenviable job to act as a buffer between the audience and the surgical team. In such a situation, the objectives of such an exercise can be anything but learning.

The aim of any treatment, especially if a surgery is required, is to benefit the patient/s or at least avoid putting him at risk of harm. This principle “Primum-non-nocere” is held with great esteem in medical ethics. In “Epidemics” in the “Hippocratic Corpus,” there is mention of “to-do-good or to-do-no-harm.” In live surgery, the surgeons are under stress. Conversing with a live audience while operating impacts the surgeon's attention. The general law prohibits multitasking in routine tasks such as driving because there is evidence that it impairs concentration and that accidents were associated with mobile phone use. The microphone with a live audience must be at least as distracting in precise live surgery with a sentient human at the other side.


  Informed Consent Top


Nowhere in the informed consent process is the patient expressly informed that the surgeon's attention may be divided or that he may be under pressure to complete the surgery. In case of the Johnson and Johnson's ASR hip implant, the patients were offered surgeon's operating fee waiver and they paid only for the implant. In some cases, the patients are offered the implants free. This subverts free will of the patient and impinges on his autonomy to take the decision. In some extreme situations, it may even border on inducement and coercion, especially in case of poor, economically weak patients. This is ethically incorrect. The inherent conflict of interest is apparent. A potent mix of advertising, sponsorship, and professional surgical showmanship along with the high audience recall of the products are driving these live surgery spectacles. The operating center wants to advertise its facilities; the champion surgeon, his skill; and the companies, their new-generation products.


  Guidelines and What They Do not Address Top


Several professional bodies have come up with guidelines for live surgery, while others have banned the practice altogether, for example, the American College of Surgeons. The guidelines issued try to tackle jet lag, foreign surgeons, unfamiliar equipment and instruments, unfamiliar operation rooms, and the use of moderators at crucial points in the surgery. Many advocate the procedure being conducted within the precincts of the surgeon's own institution. However, none of the professional association guidelines justify the need for live surgery. Hence, these guidelines are not scientific. There is no valid ground to support the live surgical demonstration when the same or results can be achieved objectives with less risky prerecorded surgical video edited to the satisfaction of the audience's expectation.


  Conclusion: You Decide Top


It is important to set our house right today, so that a similar incident does not come back to haunt us. There appears to be a need to put an end to this needless exhibitionism. This sacrifice at the altar of commercialism/consumerism may eventually correct itself with juridical interference much to the consternation of the practicing healers. We must understand that playing with fire merely for entertainment may end up burning our hands and our professional reputations.

Is it too late to expect a debate on the ethics of live surgical demonstrations and concrete actions thereon?



 
  References Top

1.
Raghavan P. J&J's Subsidiary Hip Replacement Row: A Detailed Timeline of Events That Hit This Global Giant. The Economic Times; 2018. Available from: https://www.economictimes.indiatimes.com/industry/healthcare/biotech/healthcare/jjs-subsidiary-hip-replacement-row-a-detailed-timeline-of-events-that-hit-this-global-giant/articleshow/65664114.cms. [Last. [Last accessed on 2018 Dec 10].  Back to cited text no. 1
    
2.
Kaunain S. An ICIJ-Express Investigation: J and J Advertised their Surgeries ‘Live’, Then it All Went Wrong. The Indian Express; 2018. Available from: https://www.indianexpress.com/article/india/an-icij-express-investigation-jj-advertised-their-surgeries-live-then-it-all-went-wrong-5474611/. [Last accessed on 2018 Dec 10].  Back to cited text no. 2
    
3.
Gandsas A, Pleatman M, Altrud R, Migliarini G, Silva Y. Live broadcast of surgery through the internet. Lancet 1996;348:1314.  Back to cited text no. 3
    
4.
Brunckhorst O, Challacombe B, Abboudi H, Khan MS, Dasgupta P, Ahmed K, et al. Systematic review of live surgical demonstrations and their effectiveness on training. Br J Surg 2014;101:1637-43.  Back to cited text no. 4
    
5.
McIntyre TP, Monahan TS, Villegas L, Doyle J, Jones DB. Teleconferencing surgery enhances effective communication and enriches medical education. Surg Laparosc Endosc Percutan Tech 2008;18:45-8.  Back to cited text no. 5
    
6.
Gul YA, Wan AC, Darzi A. Undergraduate surgical teaching utilizing telemedicine. Med Educ 1999;33:596-9.  Back to cited text no. 6
    
7.
Chatelain P, Meier B, de la Serna F, Moles V, Pande AK, Verine V, et al. Success with coronary angioplasty as seen at demonstrations of procedure. Lancet 1992;340:1202-5.  Back to cited text no. 7
    
8.
Challacombe B, Wheatstone S. Live surgery: Essential surgical education or putting patients at risk? Bull R Coll Surg Engl 2010;92:224-5.  Back to cited text no. 8
    
9.
Schmit A, Lazaraki G, Hittelet A, Cremer M, Le Moine O, Devière J, et al. Complications of endoscopic retrograde cholangiopancreatography during live endoscopy workshop demonstrations. Endoscopy 2005;37:695-9.  Back to cited text no. 9
    




 

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The Johnson and ...
Live Surgery Dem...
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Live Surgery Dem...
Patient Safety
Informed Consent
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Conclusion: You ...
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