That leg brace graduated first in its nursing school class!
November 3, 2011 -- Recent media about the increasing role of robots and lay persons in health care has persisted in referring to those novice health actors as "nurses." Today a TechNewsDaily item on the CBS News website described some machines Toyota is developing to help those with mobility problems--including computerized leg braces--as "robot nurses." On March 18, an Associated Press story reported that "Purdue University researchers are developing a gesture-driven robotic scrub nurse prototype that may one day relieve the nurse of some of her technical duties or replace the scrub technician who is at times responsible for fulfilling those tasks." The piece repeatedly calls the machine, which currently recognizes five hand gestures, a "robotic scrub nurse." But those robots are not thinking health professionals with years of college-level science education. On February 17, Forbes health blogger Michael Millenson described efforts to use IBM's question-answering machine Watson as a "physician's assistant." The post suggests that IBM consider "a pleasing, deferential, higher-pitched voice, the experienced and trustworthy nurse who knows her stuff, but also knows her place." The headline: "Watson: A Computer So Smart It Can Say, 'Yes, Doctor.'" Millenson claimed that he was just using "droll, tongue-in-cheek understatement" to suggest that physicians might respond better to the "deferential manner" in which nurses have traditionally treated them. But his piece exploits the handmaiden stereotype, and the headline is a weak joke about this "smart" computer being used in a role that consists mainly of saying "yes, doctor." The media seems to assume that anything or anyone who assists in health care can be called a "nurse." A current lobbying campaign by the U.S. long-term care industry to protest potential federal budget cuts includes an ad that blares: "Today, you're an accountant. Tomorrow, you're dad's nurse." Actually, no, you're not. We urge all these media creators to avoid glib statements that suggest nursing consists of performing a few simple tasks.
Robotic Nurse Assist
Today's TechNewsDaily story, posted on the CBS News website, was written by Samantha Murphy. The short item describes four new robots that Toyota has just unveiled and that the company hopes will help those with trouble walking, including paralyzed patients. Two of the robots (the "Independent Walk Assist" and the "Walk Training Assist") are sensitive computerized leg braces that help people return to normal walking. The third robot ("Balance Training Assist") is a two-wheeled device on which patients stand and play video games to strengthen their muscles. The fourth and most advanced robot ("Patient Transfer Assist")--and the only remotely humanoid one--helps caregivers move patients with a "combination of weight-supporting arms and a mobile platform." Given the functions of these machines, the article text does not suggest there are any "nurses" here. Instead, it merely notes that the robots are "designed to provide support in nursing and health care," which is fine. However, the CBS News headline is:
Toyota "robot nurses" to aid the disabled
We could sort of see someone who doesn't know much about nursing--like the vast majority of humans on the planet--thinking that the fourth robot is a "nurse." But the leg braces? Really? Could we also say that a cane is a "nurse"? A syringe? A Band-Aid?
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This "robotic scrub nurse" can recognize five hand gestures
The March 18 Associated Press story also had a troubling headline, at least on the Fox News site: "Robotic Nurse in Development at Purdue." But this piece also has a slew of "robot nurse" references in its text. The article reports on the work of Juan Wachs, an assistant professor of industrial engineering, and other researchers who are developing a "gesture-driven robotic scrub nurse prototype" that may some day relieve the nurse of some "technical duties" or "replace the scrub technician." The researchers hope the robot can "assume two tasks that are monotonous but extremely important for a scrub nurse or tech -- passing the instruments to the surgeon and monitoring the number of instruments being used -- but faster than a human," so as to "help reduce medical errors such as leaving instruments inside a patient's body."
Another Wachs project to assist in surgery is "Gestix," a "vision-based technology that would allow surgeons to search through images in an electronic medical record database by simply moving their hands in front of a large computer screen, as Tom Cruise famously did in the 2002 Steven Spielberg film 'Minority Report.'" The piece explains that this would allow a surgeon to "browse through records on his own without leaving the sterile field" instead of "having to rely on nurses to browse through electronic medical records once an operation starts -- allowing room for error and delays." The piece mostly reads like Wachs is on a mission to help surgeons nurse-proof the OR; there is barely any suggestion that these machines help nurses, even though they are designed to do nursing tasks.
Anyway, the team working on the "robotic scrub nurse" has developed software that now recognizes five hand gestures at 95 percent accuracy. That basically means the robot arm is usually able to, for example, see a surgeon hold up two fingers and pass the surgeon a pair of scissors. In fact, plans are underway at Purdue to offer a bachelor of science degree in recognizing the five hand gestures (OK, not really).
The piece focuses on the mixed reactions of local physicians to advances in surgical robotics, though of course no nurses are consulted--that would be like asking the robot what it thinks! The piece leads off with a short section about the work of "Dr. Daniel Wickert," an OB-GYN who uses the da Vinci Surgical System, a $1.5 million robotic surgical device, at St. Elizabeth East, a local hospital. The article explains that Wickert can use four robotic arms during surgeries like hysterectomies, which allows smaller incisions, so patients can recover more quickly. Wickert seems excited about advances in surgical robotics, noting that we "are at the beginning of where robots . . . will take us." We wonder if his enthusiasm would dim if the media constantly referred to the machines as robotic surgeons and suggested that they might soon replace him!
On the other hand, the Wachs robotic prototype "already has its skeptics."
Dr. Ruban Nirmalan, a general surgeon with Indiana University Health Arnett, said a robotic scrub nurse would not only need to be fast and recognize the surgeon's voice and hand gestures flawlessly but be able to "think" and modify its sequence to keep up with a dynamic case. "If a robot can do the (basic) tasks it may be helpful in some simple, routine operations," he said. "However, I'm skeptical that we have the technology available now for a robot to accomplish all those tasks. Asking a robot to think for itself, and do it well, will be the biggest hurdle for this device."
This amounts to a suggestion, however oblique, that nursing actually involves "thinking" and that it is more complex than just handing surgeons a few objects and counting. That's not bad, but it's telling that it had to come from a surgeon rather than a nurse. Can you imagine an article about a "robotic surgeon" that consulted no surgeons? And of course, while Nirmalan recognizes that supplying instruments in a dynamic surgery is not simple, his comments don't begin to convey the real complexity of OR nursing, which involves skilled monitoring of patients and the whole enterprise, as well as advocacy and management tasks. Robots cannot tell physicians when they are doing the wrong operation on the wrong patient. Robots cannot call security to remove a drunk surgeon from the operating room. Robots are not patient advocates.
However, the piece does not completely ignore those whose work the new robot will supposedly be doing. No nurses weigh in, but the piece does close with quotes from Dorothy McClannen, "professor of surgical technology and program chairwoman at Ivy Tech Community College" (maybe that sounded more impressive than a title with the word "nursing" in it). McClannen is not worried that the new technology will "replace" certified surgical technologists (scrub techs) because "their job is just way too complex. People think they just pass what the surgeon asks for but it's so much more than that."
The piece does not say what that more is, and of course, no one asks whether anyone who is not a registered nurse--human or otherwise--should be playing such a vital role on the OR, whatever the cost savings may be. In any case, the article fails to convey anything like the full scope of what OR nurses do. It may be that those responsible for such media articles and in some cases the technologies themselves have only the fuzziest idea of what nursing is, so they think these machines are actually within range of doing all or most of that work. Or maybe they at least have some sense that RNs do more, but believe that the term "nurse" can also be applied to any person or thing that provides assistance in a health care setting. That is a common problem with the term "nurse," which people do tend to use very broadly to include any kind of unskilled tending (e.g., "nursing my beer"). In any case, the frequent use of phrases like "robotic scrub nurse" undermines nurses' efforts to persuade policy-makers and the public to give the profession the resources it needs to save lives and improve outcomes.
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So smart it can joke, "Yes, Doctor"
Michael Millenson's post on his Forbes blog begins with that great headline: "Watson: A Computer So Smart It Can Say, 'Yes, Doctor'." Millenson sets the flippant tone right away, asserting that "Game Show Watson wants to be a doctor. Well, almost." He explains that after the computer's "commanding victory on Jeopardy," creator IBM will be exploring whether its "combination of advanced natural language processing and sophisticated algorithmic decision-making capabilities" can be useful in health care. Millenson uses a quote from 1965 by the IBM CEO Thomas J Watson, Jr., son of the CEO for whom the computer is named, that is actually more progressive than the media discussed in this analysis:
The widespread use [of computers] . . . in hospitals and physicians' offices will instantaneously give a doctor or a nurse a patient's entire medical history, eliminating both guesswork and bad recollection, and sometimes making a difference between life and death.
A doctor or nurse? Like they could benefit equally from technology, almost as if they each have "life and death" duties to the patient, rather than one being the mindless servant of the other?
IBM's current plans for Watson include working with Columbia University and the University of Maryland to "create a physician's assistant service that will allow doctors to query a cybernetic assistant," and with Nuance Communications, which will add voice recognition. Millenson suggests that the "'physician's assistant' designation should assuage a profession long suspicious of any brain other than its own." He cites a 1973 Wall Street Journal article about the growing role of computers in diagnosis and treatment plans that said "many physicians are openly hostile to the whole concept of computer medicine, fearing that the machine may one day usurp duties." And he quotes current Harvard Medical School physician Warner Slack, who reminds physicians that they're "not merely human memory sticks" and says that "any doctor who can be replaced by a computer should be." Millenson notes that the University of Maryland physician working on the Watson project "reportedly refers to the computer as a peer, as in 'Dr. Watson.'" Millenson concludes:
But just in case, I have some advice for IBM. Its technology team gave Game Show Watson a rich, pleasing baritone voice. Physician Assistant Watson? Forget the sound of a world champion Jeopardy star. Instead, think about a pleasing, deferential, higher-pitched voice, the experienced and trustworthy nurse who knows her stuff, but also knows her place. Watson, can you say, "Yes, Doctor"?
Obviously Millenson's main subject is physicians' eagerness to protect their turf and their insecurity about new technology encroaching on it and possibly threatening their power. The "human memory stick" bit is also a fair description of a trap that some physicians may fall into, becoming obsessed with their own knowledge and status to the point that patients (and colleagues) seem to matter little. That's all fine as far as it goes. Nurses too should be open to new technologies that can help them, and not reject them out of hand. Any nurse who can really be replaced by a robot should be. But nurses can't be replaced by robots, and that's the problem with so many "robot nurse" articles.
In any event, some readers evidently objected to the concluding paragraph, with the nursing reference. Millenson responds to them online this way:
Alas, droll, tongue-in-cheek understatement is not always read that way. For the record, this is not misogyny, it is a commentary on the fact that physicians don't like their autonomy challenged by either humans or machines, and just might (might) accept a machine only if it acted in the deferential manner to which they have become accustomed to being treated by nurses. My feminist physician and nurse friends got the reference immediately and thought it was spot on. Obviously, not everyone read it the same way.
We agree with the modest Mr. Millenson that his post is tongue-in-cheek, but we're not sure what's understated about it. Alas, it's a pretty obvious joke about physicians' being more open to machines like Watson if they are de-fanged by being presented as "nurses," those "deferential" females who don't challenge physician authority no matter how "experienced" they may be or how much "stuff" they may know. Millenson contrasts that idea with Watson being treated as a physician "peer," and with the "sound of a world champion Jeopardy star," meaning that nurses are not peers and they don't sound like champions of anything, unless you can be the champion of saying, "Yes, Doctor."
We're not sure if this is misogynist, exactly, but at best it trivializes the problem of excessive physician power and nurses' traditional difficulty in challenging it to protect their patients. At worst, the nursing reference is simply exploiting the handmaiden and angel stereotypes to make a weak joke. Sure, the piece pokes fun at physicians, but it gives readers no reason to doubt that nurses really are deferential female servants who are happy to assent to anything physicians want, "who know their place." Of course, it's true that physicians still have more power and many nurses remain intimidated.
But nurses are autonomous professionals with years of college-level education, and many challenge physician care plans as part of their duty to advocate for patients. Millenson's reference to "know[ing] their stuff" does not convey much of this; he could be referring to knowing whether a bed is available or where a certain type of drug is kept. And of course, even suggesting that this robot could be presented as a nurse is not helpful, given all the other media about robot nurses, though in fairness the piece does also discuss whether Watson should be treated as a physician. Incidentally, it is curious that a piece all about physicians protecting their turf would say nothing about the advanced practice nurses whose increasing role in health care seems to have panicked some physician lobbying groups; many of those nurses certainly do not seem to "know their place."
"Today, you're an accountant. Tomorrow, you're dad's nurse."
This month a number of different posters appear in the Washington, DC Metro system as part of an extensive "Care Not Cuts" campaign, a public lobbying effort by the U.S. long-term care industry to protest reimbursement cutbacks Congress is considering, as the "supercommittee" works on what to do under the recent budget deal with President Obama. One ad features huge text reading: "Today, you're an accountant. Tomorrow, you're dad's nurse." The poster also shows a syringe with a needle and what seems to be a pencil. Much smaller text notes that 78% of post-acute care and nursing home care patients would be affected by cuts in Medicare and Medicaid funding.
But no, actually, you're not his nurse, dear accountant. Most of those who see the ad are likely to envision suddenly having their serious careers and lives disrupted by having to perform unskilled drudgery for poor Dad because federal budget cuts have forced him out of his long-term care facility. We could interpret the ad text as a comment on the accountant's lack of qualification to be a "nurse." But it seems pretty unlikely that many would read much more into it than that the accountant is not used to having to perform nursing duties like giving medications. We suppose it's good that nursing was not represented by a bedpan, though it's possible that the syringe and pencil are subtle proxies for other aspects of being Dad's "nurse" that many would find very unpleasant. The long-term care ad reminds us of a 2006 CVS television ad in which a pharmacist suggested that he had turned a patient's spouse into a "nurse" with a few hours of training in how to give medications; CVS later worked with us to modify the ad.
One last thing: what's with the pencil in the Metro ad? Because nurses use pencils, like first graders, when they record the medications they are giving? Could the pencil be a reference to the fact that nurses do have to go to school and learn things? That seems like a stretch. Clinical nurses do spend a good deal of time on charting and administrative tasks. And nursing advocates, scholars, teachers, and students write extensively. But believe it or not, these nurses usually use computers and pens, just like other adults!
The problem with describing any assistive thing (person or machine) in a health care setting as a "nurse" is that it degrades public understanding of nursing, suggesting that nurses are basically unskilled helpers, doing whatever simple tasks physicians direct, learning to give medications or take care of Dad in a few hours, recognizing that two fingers means scissors, or writing little notes with their No. 2 pencils, rather than the college-educated professionals they really are. That makes it harder for nurses to get the resources they need to do their actual job, which is using advanced skills to save lives.
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