Week 1 - Tian

Harvey Tian

Clinical Immersion NYC - 2013

The first week at the hospital has been akin to drinking from an open fire hydrant. The sheer amount of information to learn has been non-trivial to absorb, but fortunately, this was counter-balanced by my excitement to be in one of the largest and most active hospitals in NYC. After thoroughly reviewing various common medical terminology, jargon, and the anatomical positions of the human body, I was set to hit the ground running.

This summer, I am working with my clinical mentor, Dr. Ashutosh Tewari, a highly esteemed and widely recognized urologic surgeon in the New York Presbyterian Hospital. As a professor in the department of urology here at Weill Cornell Medical College, Dr. Tewari also carries on a considerably sized research team of which I will be a member for my 7-week stay.

On the very first day, immediately proceeding our 10:00AM introductory meeting given by Dr. Wang and Dr. Frayer, I scrubbed up to go into the OR to familiarize myself with Dr. Tewari's work by watching 3 prostatectomy surgeries back-to-back-to-back in a 5 and a half hour marathon. I was fortunate enough to have been accompanied by a medical student and resident in Urology whom both belong to Dr. Tewari's lab and were kind enough to walk me through the procedure displayed on the OR monitors as Dr. Tewari performed the operations. With the help of the medical student and resident, I was able to rapidly understand the processes of the robotic prostatectomy using the Advanced Robotic Technique (ART).

Having performed over 5,000 prostatectomies using the ART system and serving as the director of both the Prostate Cancer Institute and the LeFrak Robotic Surgery Center at NYPH, Dr. Tewari's makes the procedure look almost easy. However, with the help of the urology resident in the room, I was able to gain an appreciation for just how much skill was necessary to successfully perform a prostatectomy with ART. There are 4 robotic arms, two of which are controlled by Dr. Tewari, and two more controlled by a urology resident in training and together, which through a minimally invasive technique involving only 4 small quarter-sized incisions on the patient's abdomen, can perform the entire procedure. Furthermore, the robotic arms not only lack tactile sensation, making suturing within the patient extremely difficult, but perception of depth is dependent on the inserted camera sending separate images into each eye-piece of the surgeons. 

In the same accord, the engineering features of the da Vinci robotic surgery instrument were equally impressive. The pincers on the robotic arms are capable of heating up to temperatures fully sufficient to cauterize flesh and blood vessels within 1 second and yet able to cool back down to immediately touch neighboring locations within the patient without any harm also within 1 second. Each arm has a predefined purpose and surprisingly is disposable after a maximum of 10 procedures. A chip inside each arm identifies and logs each procedure and requires the arm to be replaced upon the 11th procedure to stay within the company's regulations.

With such expensive equipment, not every hospital around the world can afford to have the da Vinci system. Furthermore, this causes certain inter-hospital political ramifications in other nations such as the United Kingdom as explained by the urology resident from Great Britain. In the UK, hospitals are regulated by the government and the amount of patients that they can see are based upon the data that they provide for prior years thus, if there are 3 hospitals for a city and one of hospitals acquires the da Vinci system, the remaining two hospitals are pressured into purchasing the da Vinci system as well even if they are operating it at a loss, otherwise the number of patients that they lose to a hospital which does have the da Vinci system could be far more detrimental to the hospital's business.

Throughout the rest of the week, I watched one more procedure to solidify my understanding of the robotic prostatectomy and then scheduled 30 minute meetings with each of Dr. Tewari's group members on his research team to explain both my background and begin to probe into where I may be a  good fit in terms of my expertise and available projects.

All in all, it's been a very fast paced week and I'm thoroughly enjoying the hospital environment.