By Rob Stein
Washington Post Staff Writer
Wednesday, July 6, 2005
Ries Daniel was waiting in his hospital room the morning after bladder surgery when the door finally swung open. But it wasn't his doctor. Instead, a robot rolled in, wheeled over and pivoted its 15-inch video-screen "head" toward the 80-year-old lying in his bed at Baltimore's Johns Hopkins Hospital.
"Good morning," said a voice from the robot's speaker. It was Louis Kavoussi, Daniel's urologist. His face peered down from the screen atop the 5 1/2 -foot-tall device dubbed Dr. Robot. "So, how was your evening? No problems?"
Studying his patient through an image beamed back to his office by Dr. Robot's video camera, Kavoussi was concerned because Daniel had run a fever overnight and developed a cough. "You're not looking as good as yesterday," said Kavoussi, zooming in the camera for a closer look after having focused on Daniel's chart moments before.
"I didn't have my martini," said Daniel, managing a smile.
"Well, let's see how you are feeling later on today," Kavoussi said . "If you're feeling better, we'll send you home, all right?"
After telling Daniel that he was ordering a chest X-ray and other tests, Kavoussi tweaked a joystick to maneuver the robot back to the hallway.
Such robot-assisted exchanges are being repeated in dozens of hospitals across the country by doctors who use the machines to make their rounds, monitor intensive-care units, respond to emergency calls and consult with other physicians.
Proponents say this and other new "telemedicine" technologies are allowing doctors to use their time more efficiently and serve more patients, often at odd hours or in remote places where the sick would otherwise have a hard time seeing a doctor.
"There's a tremendous amount of medical care being provided from a distance today through technology like this," said Jonathan D. Linkous, executive director of the American Telemedicine Association.
Skeptics, however, fear that the technology is further depersonalizing health care, accelerating the trend of doctors spending less and less time with their patients, and eroding what remains of the doctor-patient relationship.
"This is a triumph of the model of medicine that has abandoned the idea of personal interaction and providing comfort in favor of a model of the patient-physician interaction as essentially an exchange of information," said David Magnus, a Stanford University bioethicist. "You can see a face, but there's no touch, no laying on of hands, no personal contact. We're increasingly isolating people in a sea of technology."
Robots are turning up in more medical roles. Some help surgeons perform procedures, especially those requiring extreme precision. Others ferry supplies and equipment around hospitals and even dispense medication. Pittsburgh researchers are testing the Nursebot to lead nursing home residents to physical therapy sessions and remind them to take their medicine. GeckoSystems Inc. of Conyers, Ga., plans to soon begin marketing its CareBot to help nurses, doctors and relatives monitor and care for the elderly at home.
Face-to-face encounters between doctors and patients are increasingly giving way to technology in other ways, with the goal of avoiding frustrating telephone tag, long drives to the office and time wasted sitting in waiting rooms.
Physicians are turning to e-mail to reach and respond to patients. Hospitals, clinics and doctors groups are setting up secure Internet portals allowing patients and doctors to consult electronically.
In the District and almost every state, including Maryland and Virginia, patients also are "meeting" with their doctors from afar through dedicated telemedicine networks. They directly link major medical centers, such as the University of Virginia Medical Center in Charlottesville, the University of Maryland Medical Center in Baltimore and Children's National Medical Center in the District, with distant sites.
The networks provide care to patients who do not have easy access to physicians, such as people who live in poor inner-city areas or in remote rural regions where specialists are rare. Prisoners are another group that may benefit.
Psychiatrists conduct regular therapy sessions using video teleconferencing. Surgeons examine patients' incisions via video hookups after they return home. Dermatologists diagnose rashes or lesions from images snapped with picture phones or transmitted live by video cameras.
"We've saved a lot of lives," said Joseph C. Kvedar, director of telemedicine at Partners HealthCare in Boston, who runs a weekly long-distance dermatology clinic for residents of Nantucket Island. "We've picked up a lot of skin cancers."
The need, proponents say, is increasing as the population ages and further strains a system already experiencing a shortage of doctors and nurses.
The approach may be especially useful for caring for the increasing number of elderly people trying to remain in their homes. Some nursing services are installing video phones for clients, some equipped with stethoscopes and other devices that patients can use to regularly send crucial medical information, such as heart rates, blood pressure and blood sugar levels.
"Many of the devices that physicians use have now been adapted for the electronic superhighway," said Ronald S. Weinstein, director of the Arizona Telemedicine Program.
Many experts speculate that, in time, robots will diagnose cases, and patients will consult with doctors via futuristic versions of the BlackBerry that will automatically transmit medical records and real-time data, such as blood pressure readings.
"I think we'll get to the point in the future where the use of robots and robotics and computer-aided diagnosis and treatment will transform the delivery of medical care," Linkous said. "We're not there yet, but we're going down that path very rapidly."
Studies have found that the quality of care delivered via telemedicine tends to be at least as good as that given in person, and in some ways is better, the proponents say. Patients often get more time with doctors and leave the hospital sooner. For the most part, patients say they are happy, sometimes even preferring the remote interactions to a face-to-face encounter.
"Our satisfaction surveys have shown that everyone is pleased with the service as long as the technology is working," said Elizabeth Krupinski, who evaluates the Arizona program. "Even in psychiatry, patients find it is intimate once they get beyond the fact that they are talking to a TV."
While acknowledging the possible benefits, skeptics worry that technology will be used as an inferior quick fix for doctor and nurse shortages and as a way to save money at patients' expense. Doctors seeing patients via video could easily miss subtle but important clues, such as a patient's posture, a slight tremble or even how someone smells.
"You can get readouts, but you can't get a sense of a patient's restlessness in bed or perhaps fine palpitations or the atrophied forearm that may be a clue to something important," said Ruth B. Purtilo, a bioethicist at the Massachusetts General Hospital in Boston. "A skilled physician can look well beyond the vital signs."
Physical touch remains an important part of the healing process, particularly for the elderly, several experts said.
"I work in a nursing home, and these people are desperate for touch," said Julie Connelly, who co-directs the program on humanities in medicine at the University of Virginia. "Many are widows or widowers. They have lost a lot of their options for getting a hug and being touched. Sometimes you just need to massage them rather than giving them pain medication."
The proponents of telemedicine argue that the technology is often used to supplement, not replace, personal visits. It will enhance care, they say, as long as it is used judiciously.
"You wouldn't want to tell someone for the first time that they have cancer this way," Kvedar said. "But the robots are pretty good, and coming down the road is video e-mail and all sorts of ways you can convey emotion. . . . And the fact of the matter is, there are many health care interactions that are fairly mechanistic and routine."
More than 35 hospitals are using the same type of robot roaming the halls at Johns Hopkins, paying $120,000 to buy or $4,000 a month to rent each unit. For $5,000, doctors can install a control station in their office, home or clinic.
"This allows the doctor to literally be in two places at once, which means they can be at the patient's bedside much more frequently and immediately," said Yulun Wang, chief executive of InTouch Health Inc. of Santa Barbara, Calif., which makes the robot.
Kavoussi, the urologist at Johns Hopkins, has conducted studies evaluating the robot, which he said have shown that it improves efficiency and that patients like it as much as face-to-face meetings.
"The only thing that is lost is nostalgia," said Kavoussi, who is on the company's scientific advisory board and a stockholder. "We all miss the cars from the 1950s, but the reality is they burned a lot of gas and took a lot of resources and were expensive to make."
Daniel and another patient Kavoussi "visited" the same day said they could see the advantages of the robot and found the experience interesting. But both added that they prefer to see their doctor in the flesh.
"I don't object to it," Daniel said, but "I think person-to-person is better than person-to-machine. When the chips are down, I want the doctor."