The Paradox of Exceptionalism: Setting Priorities Straight

Surgical innovation is exponentially accelerating. Prabhu and Rosen describe the phenomenon of rural hospitals and surgeons in the United States increasingly adopting and demanding surgical robots.¹ Given the high costs associated with robotic surgery, they rightly mention the tense balance between “constant financial pressure juxtaposed against unsustainable health care spending, until the so-called bubble finally bursts.“¹

The United States is the single-largest health care spender in the world, spending nearly four trillion US dollars on health (over US$10,000 per capita) each year, at least double that per capita of most European countries. Meanwhile, life expectancy and health metrics in the United States trail other high-income and many upper-middle-income countries. This paradox is well-known and is in part because a quarter of health care spending in the United States, nearly one trillion US dollars, is wasted each year. In comparison, Costa Rica spends <US$1000 per capita on health care each year yet its population has a higher life expectancy than Americans. Moreover, that wasteful spending could provide free access to primary care for all low- and middle-income countries, or over six billion people worldwide.

Robotic surgery has its role in large tertiary and teaching hospitals where high volumes, shorter length of stays, and lower per-procedure costs can be achieved based on economies of scale and volume-outcome relationships. However, the pervasive, inefficient, and harmful trends observed in today’s health care “market” in the United States should remain a large concern in addition to the repercussions of direct-to-consumer marketing or attempts to attract surgeons to rural areas through unsustainable robotic expansions, which ultimately become a gimmick rather than a gift to rural populations. Unless we reprioritize the delivery of higher quality care at a reduced cost, robotic surgery will not deliver on its promises to better care for our patients.