Heads above the parapet

In his shortlisted essay for the 2020 John Henahan Prize, Dr Liam Bourke asserts that doctors and technology exist together in symbiosis


Posted: Saturday, August 1, 2020

Dr Liam Bourke

“One machine can do the work of fifty ordinary men. No machine can do the work of one extraordinary man.” – Elbert Hubbard.
We clinicians, as a matter of course, often poke our heads above the parapet. Arguably, this is most evident in the field of ophthalmology. Through our efforts we attempt to be extraordinary, so that our patients can partake in the ordinary. The ingenuity of pioneers like Sir Harold Ridley, having the swiftness of mind and boldness of character to attempt the first intraocular lens implant in 1949, underpin this remarkable attribute.
Advances in technology are undeniable, as is our ever-growing dependence upon it. Again, this is probably most apparent within the ophthalmic specialty. Our development of robotics as a human race, and more specifically robotics in medicine, is astonishing.
Ophthalmic surgery is relatively unique in its demand for dexterity with minuscule tissue structures within a limited surgical area. This has necessitated the requirement for superior levels of function. Robotic technology offers significant improvements in movement control and precision, tremor cancellation, enhanced visualisation, increased range of motion, and distance sensing. This technology can now offer three-dimensional views with superior instrument manoeuvrability and decreased error outcomes. Howard Larkin befittingly authored an article in the April issue of EuroTimes titled ‘Robotic surgery getting closer’. He outlines the recent development of the automated cataract platform, IRISS (Intraocular robotic interventional surgical system), by Dr Jean-Pierre Hubschman and his team at the Stein Eye Institute and the Advanced Robotic Eye Surgery Lab at UCLA. The IRISS system extracts the lens nucleus and cortical remnants after 3D construction of the eye via pre-operative OCT scanning. Specifically, planning includes ascertaining the trajectory of instrument tips in an effort to reduce complications such as capsule rupture. In a study involving porcine eyes, no posterior capsule ruptures were noted and completion time of lens removal averaged less than five minutes. Dr Hubschman and his team expect a prototype to be ready for human trials in less than five years.
However, it is my firm belief that clinicians will never be replaced by a robot to perform cataract surgery. I view the two as existing together in symbiosis, providing a service that is technically more astute while having the clinician in ultimate control and offering important human interaction. This sentiment is shared, it would seem, not only by surgeons, but by the individuals who are constructing these robots. Another interesting and informative article in the aforementioned publication highlights this. It was penned by consultant vitreoretinal surgeon, Dr Leigh Spielberg, and is titled ‘High-precision treatments with robotic assistant’. Although this article mainly alluded to the use of robotics in vitreoretinal surgery, pertinent points for all ophthalmic surgery are explored. The article specifically mentions a Dutch company, Preceyes, that has developed an intuitive robotic assistant that has improved precision by almost completely eliminating hand tremor. Accuracy has been increased ten-fold allowing for intraocular precision of ten microns or less. What struck me most however, was the comment made by Preceyes’ Chief Medical Officer, Dr Marc de Smet, in relation to the purpose of the robot: “The robot supports the surgeon by improving existing surgery and enabling the development of new, high-precision treatments.” He stresses that the intention of the robot is not to replace the surgeon or even to perform surgeries independently. It is to be viewed as an ancillary tool, reducing surgeon stress and allowing for improved surgical outcomes.
Recent events have highlighted the sacrifice and commitment that clinicians make. The outbreak of COVID-19 has called all healthcare professionals to task and the global reaction has been overwhelming. Here at home, we have had Irish doctors returning from all corners of the globe to assist us in our national effort. Certain technologies are being used worldwide to great effect, even if their use is morally questionable. These include the assignment of QR (quick response) codes to individuals depending on the status of proximity to known COVID-19 cases, in countries such as China. This allows for near-constant tracking of people, in an effort to localise the virus’ spread and damage.
In spite of all this amazing technology, along with our advancements in robotics, it is ultimately the clinicians and healthcare workers who are on the front-line and delivering care to affected patients, sometimes at their own peril. Li Wenliang, a fellow ophthalmologist and now world renowned ‘whistleblower’ who has been ‘martyred’ by the Chinese communist party, epitomises this intrinsic advocacy. It is this human sacrifice, interconnection, and empathy that is irreplaceable. It is what defines the medical profession and our duty as doctors. These human traits cannot be forged on computer screens or in factories. These inherent attributes, what defines the clinician, are invaluable and cannot be replaced.
* Dr Liam Bourke is a Senior House Officer surgical trainee working in Cork University Hospital,Ireland