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Science

Gall Bladder Removed In France By Doctor In New York 206

Posted by timothy from the wait-till-it-hits-dentistry dept.
cybaea writes: "In this article, the BBC reports on the first successful major telesurgical operation. Doctors in the United States removed a gall bladder from a patient in eastern France by remotely operating a surgical robot arm." Note that this was using a "high speed optical link," not competing with email, viruses, or other things being sent on the Internet. Update: 09/19 17:05 PM GMT by T : Uh, that's "gall bladder," not "tumor." From this distance they look the same to me.
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Gall Bladder Removed In France By Doctor In New York More

Gall Bladder Removed In France By Doctor In New York

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  • I think this is funny. There is no mention of a Tumor in the article or the submitters comments, yet it appears as a headline. A gall bladder is an organ, not a tumor.
  • What good is it if they cant play Quake while fragging gall bladders?!

    a dedicated link is bad in that situation. One on One can get pretty boring after a while.

  • Woah (Score:1)

    by skrowl ( 100307 )
    I don't want a doctor who can't tell the difference between a gall bladder and a tumor operating on me!

    At any rate, this is very interesting news. I hope they use pretty strong crypto to protect the communications. This would give new meaning to Denial Of Service if the stream were interecepted and modified.

  • I heard... (Score:4, Funny)

    by Rude Turnip ( 49495 ) <valuationNO@SPAMgmail.com> on Wednesday September 19, 2001 @12:01PM (#2320459)
    that the surgeon yelled out "First Incision!"
  • I'll be really impressed when a doctor in Paris helps survivors of the WTC...

  • So... (Score:2)

    by tshak ( 173364 )
    If someone performs a DDOS on a lot of major POPs PNAPs and it inturrupts communication and kills the patient is the script kiddie up for murder?
    • Yes. But no one would use the Internet for this type of thing anyway.
      • >> Yes. But no one would use the Internet for this type of thing anyway. <<

        Hackers can bust into just about anything if the circumstances are right.

        I can imaging an arm coming out of somebody's ear, and them yelling, "Those d*** hackers!"

        However, that may be a boon to basketball: slam-dunks without ever jumping. White men have a chance now :-)

  • Ouch (Score:3, Funny)

    by SilentChris ( 452960 ) on Wednesday September 19, 2001 @12:02PM (#2320464) Homepage
    "by remotely operating a surgical robot arm"

    Boy, a buffer overflow during that would be a bitch.

    • Re:Ouch (Score:5, Funny)

      by fobbman ( 131816 ) on Wednesday September 19, 2001 @12:16PM (#2320577) Homepage
      A tragedy was narrowly averted when the surgeon was in the middle of an intricate micro-stitching and a casino pop-up ad obstructed his view. Thank goodness a forward-thinking assisting had their hand on the mouse ready to "X" it outta there.

    • Seriously, I have to doubt the usefullness. A robotic arm with remote control options can't be cheap, and if I were on the table I'd much rather the doctor just hopped on a plane and came to me.

      The idea of having the cameras in place so doctors could watch (and discuss) live surgery in far away places would be cool. But c'mon, a robotic arm doing surgery?

      It just doesn't seem like this is a good use of money, especially when you account for the extra risk to the patient.
      • But this could usher in a new world of combat surgery. Think of a situation in which it may not be *safe* for a doctor to be. Or, that the doctor could perform an operation on a patient at location "A", then minutes later at location "B" (thousans of miles away).

        Granted this is still a 'work in progress', but it's exciting stuff.

      • Re:Ouch (Score:2)

        by znu ( 31198 )
        This probably isn't such a big deal for routine things, but there are some cases where there are just a small handful of doctors who can perform a certain procedure properly. They can't spend all their time flying around the world, and the patients aren't always in good traveling condition. Once this technology reaches maturity, you'll be able to get treatment from any specialist you need at any hospital. Remember, these machines will keep getting cheaper. Doctors, if anything, get more expensive.
        • I'll even up the ante on that one then and say that eventually this will lower the cost of doctors as cheaper, but still quality surgeons from other countries can perform operations.


          Of course, knowing the insurance industry, HMOs eventually won't cover your operation unless it is from a cheap country.

      • The robots will be in the $100k range (currently much more) within years, and a plane ticket to Europe at the last minute would cost $2-3k at a minimum. factor in the time, and the possibly critical state of the patient, and you can cover the expenses with a dozen patients...
      • I don't question the usefulness. I *do* question how judicious the doctors were in performing the demonstration. This procedure was almost certainly not a life-or-death one that could only be performed by specific doctors in the U.S. So performing it in this fashion *must* have exposed this patient to some risks, even if there were qualified doctors on the patient's side of the ocean overseeing the work, else this story would not be newsworthy. The doctors therefore exposed a patient to some risk just for a proof-of-concept, a publication, and a lot of P.R., when the proof-of-concept could have been done by operating on a pig, or just demonstrating the requisite dexterity in some other fashion. I guess this is just another case where the vanity of surgeons conflicted and overrode the safety and interest of the patient involved. What would the press release have looked like if the patient had died, I wonder.

        • Well, I haven't read the article so I may be mentioning something that was mentioned in it, but those things you suggest doing first (operating on animals and proving dexterity through some other experiment) HAVE already been done... that's why it was not unreasonable to do this on a real live patient with a condition that was not difficult to treat (i.e. a condition that any surgeon could perform, and which was not a technically demanding operation). I mean, you wouldn't want this being done on a patient that needed microsurgery or a heart transplant as your first trial.

        • I'm sure the patient was informed of and elected to go through with the risks of this procedure. Some people, myself included, are willing to take some risks in order to advance science, especially medical science. I am also doubtful that they haven't already done animal experimentation with this device.

      • Re:Ouch (Score:3, Insightful)

        by krlynch ( 158571 )

        One eventual goals (and one of the reasons that the USDOD is paying big bucks for this kind of research) is to send these types of systems into "dangerous" areas where you wouldn't want to risk the safety of a specialist, or can't afford to send a specialist (major natural disasters, military campaigns, space explorations, remote research stations, etc.). It is unlikely that you will see many more gall bladder removals done in the middle of France with this technology. But you ARE likely to see, for example, soldiers patched up very close to the battle field, or researchers having cancer surgery done in the depths of the Antarctic winter when it is just too dangerous to try and either fly the patient out or the doctor in.

  • Imagine if hackers (script kiddies anyway) got ahold of this thing. It'd put a whole new meaning on getting 'hacked up'

  • Telecommuters (Score:2, Funny)

    by spudnic ( 32107 )
    I can just hear all the surgeons begging their bosses to let them telecommute from home now.

    • now doctors can do whaat techies have done for quite a while.. something explodes in the middle of the night, you get up, dial in, fix it, all while naked and watching ricki lake!
  • I mean, sure, the optical network isn't connected to the 'net *yet*. Just wait until the orderlies figure how to make a bridge, and load up counterstrike....

    "Um, sorry ma'am, your husband didn't make it. The lag was too great, and those bastards kept ping flooding us. But don't worry, my clan and I will get them next time! D0ct3rz r00l!"
    • You owe me a lifesaver with your closing h4x0r phrase. I was balancing it on my tongue while reading and spit it out laughing at that point. Kudos.

  • Better Picture of Robot in action (Score:4, Informative)

    by FortKnox ( 169099 ) on Wednesday September 19, 2001 @12:03PM (#2320478) Homepage Journal
    Here's [yahoo.com] a pic of the robot in action. Looks like that gall bladder was pretty big, or the frenchwoman isn't what I'd call "underweight".

    Notice the three large arms sticking in? Gall Bladder surgery is usually arthroscopic. So, long distance surgery does have the drawback of more/bigger scars.
    • Actually, gas is infused to expand the abdomen during the surgery, so the patient may not be that fat. Also, those three robot arms look to be going into ports about the same size as used in a typical laparoscopic procedure. (I don't think you really mean arthroscopic...that means scoping a joint....and the most gallbladders aren't found inside joints).
    • Also note that doctors and nurses in the background aren't wearing surgical gloves. Maybe there are gloved surgeons standing by, but this pic gave me the impression that had the robot malfunctioned (perhaps due to a power failure) the surgeons would first have to scrub and get gloved-up before jumping in to help the patient.

      As to the aparent weight of the patient, I think its more likely that the patient was pumped up with CO2 which is typical for laparoscopic gall bladder surgery [lubbocksurgical.com].

    • First you can' judge her size or the gallblader size based on the size of the stomach in the pic. During LAPRASCOPIC (see below) surgery, you insert the instrument, place a surgical tie around it and then inject an inert gas to expand the abdomen as much as possible so that you can shine light on the area you are operating on.


      Second. Your statement should have read "Gall bladder surgery is usually Laproscopic". Arthroscopy is using a laprascope to look at a joint (note: arthro = join. i.e. arthritis =joint inflamation). And yes, looking at that picture, it WAS laprascopic. I've assisted (i'm a surgical PA) on numerous laprascopic operations, and those look EXACTLY like the ones i've used. Nothing really unusual from the pic.

    • Normally the abdomen is inflated with CO2 for this type of surgery. So her stomach may not normally be beachball shaped.

      -Eric
    • I had this same surgery last year, they go in through your navel and 2 other places, they also inflate your abdomen with dry nitrogen (I guess I must have looked like that :-), you have to walk a lot afterwards to help your body expell any that's left over



      It's the only surgery I've ever had and it was a breeze - I walked home within 24 hrs



      The fun part was when the doc removed the drain he'd left in a few days later - he said "this may feel a bit funny and it might hurt" - hit hurt like hell, but it felt ssooo wierd (all that stuff moving inside you as it came out) I couldn't stop laughing even though it hurt so much .... now I know how that guy felt in the 1st alien movie ....

  • Pointless (Score:3, Insightful)

    by LordNimon ( 85072 ) on Wednesday September 19, 2001 @12:03PM (#2320483)
    I thought the whole point behind going to a specific doctor for a procedure was that he's far more knowledgeable about it than anyone nearby. Removing a gall bladder isn't exactly cutting-edge medicine.

    But I would never go for this. Part of the advantage of having such a capable physician is that if anything goes wrong, he can take care of it. The robot arms restrict his options and make it more difficult to work in an emergency.

    Not only that, but this involves a reliable high-speed connection. The only time this technology would be truly useful is if you were in the middle of nowhere and needed an operation. But if you're in the middle of nowhere, you'll never be able to get a reliable high-speed connection!

    • I thought the whole point behind going to a specific doctor for a procedure was that he's far more knowledgeable about it than anyone nearby.

      What do you expect, a brain surgery to be performed the first time this technology is actually used? You have to start somewhere. A standard procedure of taking out a gall bladder is a good way of proving that telesurgery is possible.
    • No, removing a gall bladder isn't cutting-edge, but when you're testing technology such as this, you want to keep the procedure itself relatively simple...that way, any mistakes aren't life threatening, and if there are suddenly problems with the communications link, a local surgeon can take over.
    • I thought the whole point behind going to a specific doctor for a procedure was that he's far more knowledgeable about it than anyone nearby. Removing a gall bladder isn't exactly cutting-edge medicine.

      Seeing how this is the first time this kind of thing has been done, I think that is why they chose a simple operation. Removing a gall bladder is easy and rarely fatal.


      But I would never go for this. Part of the advantage of having such a capable physician is that if anything goes wrong, he can take care of it. The robot arms restrict his options and make it more difficult to work in an emergency.

      There are other surgeons in the room in case something did go wrong. It is not as if they just stuck the woman in a machine and then went out for coffee.


      Not only that, but this involves a reliable high-speed connection. The only time this technology would be truly useful is if you were in the middle of nowhere and needed an operation. But if you're in the middle of nowhere, you'll never be able to get a reliable high-speed connection!

      There are highly specialized surgeons that are not available in every country, even in technologicly advanced ones. Once all the bugs are worked out, which might be decades from now, these surgeons will be available to anyone. Also, with any luck, high speed connections will be much more commonplace, even in remote areas.

    • Dude, 15 years ago gallbladder removals were done by open surgery.

      Then the laparoscopic techniques became widespread....it was a good thing.

      Loads of abdominal ops can be done laparoscopically now, the result is less time post-op in recovery, less scarring, and a nice neato operation.

      Plus you get to use the word insufflate and not laugh.

    • As with any development, you try it first on the simple case to prove that it can be done. Once you have the kinks worked out, then you go for the more complicated stuff. Simple Engineering 101.
    • This is a first, and it's a prototype, and I wouldn't want my gall bladder removed by a guy an ocean away drinking coffee, worrying about a building falling over... BUT...

      Someday I may be in the Arctic...
      Or on a plane
      Or in space
      Or whereever... the point isn't *how* it was done, the point is that we *can* do it...
  • It seems that doctors in NYC would still be too busy with WTC related stuff to worry about French gall bladders/tumors. Or has it slowed down enough in the hospitals for doctors to do cool stuff like this?
    • What many people still don't understand is that the doctors in NYC geared up for one of the worst catastrophy's in American history and then waited... and waited... and then had nothing to do.

      Doctors don't treat the dead. I believe they only retrieved something like 5 or 10 living bodies from the pile. And that was all in the first 24 hours.

      So in short, they never were busy. Every hospital in the tri state area geared up and expected to get flooded with casualties, but then, they never came. I guess after a day or so, hospitals started to stand down from their heightened state of alert. Now they've got time for research once again.
    • The sad reality, from what I've heard, is that there are lots of doctors standing around because with nobody being yanked from the rubble, there's simply nobody to treat (beyond some acute stuff on the first day, of course).

      Besides, they probably had this all set up long in advance, and kept to their timeline in keeping with all the "get back to work" directives being floated about.

    • Sadly, as many of the NYC ER docs have said, there really wasn't a flood of severely-injured-but-savable people into the area hospitals. Injury apparently was largely an all or none phenomenon.
    • the sad thing is, brah, that it never was that busy in the hospitable. Doctors kept waiting for patients, and after the initial flow no one came...no ones been rescued in days. Truly sad.
  • The article refers to this article [nature.com] at Nature [nature.com]

    Very interesting, this may enable for people in thrid world countries to have access to the best surgeons in the world. It may also allow operations on the ISS at some point. I'd expect to see developments where surgeons from multiple sites coordinate work on a single patient at a remote site.
  • They were probably competing with viruses of both kinds. You really have to have a sterile environment both over the network and in the operating room.

    More bizarre thoughts:
    Will doctors sue for carpal tunnel? Will doctors sue for carpal tunnel after performing remote surgeries on carpal tunnel patients? (The ultimate in irony)

    Can doctors now prescribe medication remotely? And if so, can I just buy 10 different masks and walk in with each saying "Yea, 100 Vicodin to go please..."

    Do the robot arms have bad handwriting as well?

    Will the nurses now look like Seven of Nine and give me sponge baths?

    Will dentist robots be bugging me now about how bad my brushing habits are, even though I never have cavities?

    And finally, will all the script kiddies be hacking into those remote boob-job surgeries? I hope they get grossed out and short circuit their 31337 keyboards with vomit, cause it's not for the squeamish.
  • This surgery should be encouraging news for NASA.

    They're is doing research along this same theme. They someday want robots to be able to be controlled either from the ground or the space station by a person wearing a VR suit. The human can see a 3d image of what the robot is working on and they're working on having the bot transmit some kind of feel (a sense of touch) back to the human. Advantage to this is the ability to make the robot fit into small or dangerous areas and not subjecting a live person to danger.
  • not competing with email, viruses

    Yeah ! Those emails and virusses are major bandwidth killers ! Because of them, it takes ages to download mp3s and AVIs on my 56k modem. Must be. Down with email !

  • How do you sue for malpractice? In France or the US of A?

    ~Sean
    • This would be cool: in the future, when robots are doing this sort of thing and have all amazing AI (and of course I will have my flying car and aluminium house), you can sue the goddamn robot because undoubtedly in the future the civil libertarian fuckheads will have lobbied for equal rights.

      Or would you sue the connection provider? The legal hassle would be horrendous. One side trying to prove that the other screwed up. Christ it would go on forever.......sue the creator of the arm (if the arm didn't have AI)?

      OK, I am talking of arms having AI so it's time for my medicine.

  • Make sure the tech team at your local French hospital apply all patches to the communication software or else you might get operated on by a script kiddie from China.

    I don't care what internet this runs through, I want a real doctor in the room with me.
  • "from the wait-till-it-hits-dentistry dept."

    I bet the brittish can't wait until this hits dentistry.

  • medical transcript... (Score:5, Funny)

    by turbine216 ( 458014 ) <turbine216 AT gmail DOT com> on Wednesday September 19, 2001 @12:13PM (#2320560)
    here's the just-released transcription of the communciations between the surgeon and the patient:



    DOCTOR: how r j00 feeling?

    PATIENT: ok

    DOCTOR: duz this hurt?

    PATIENT: ouch

    DOCTOR: roflmao

    PATIENT: :(

    (PATIENT signed off at 08:36 AM EST)

    DOCTOR: hello?

    DOCTOR: r u there?

    DOCTOR: kewl
    (DOCTOR signed off at 08:38 AM EST)

  • Ghoulish removal of Gaul's Gall-bladder.
  • Can you imagine doing this for knee surgery, or something else that doesn't require general anesthesia? I don't know about you, but I don't think I could deal with watching a robot operate on me.
  • Think about how you get charged for every... little... thing... when you have to go to the hospital.

    And now you have to pay for all this too? Ack! Do they have an attachment on that arm to allow the Billing Dept to remotely remove your wallet while they're at it?
  • I mean, just when the doctor manoeuvres the arm to remove the bladder, its hit a zillion times with some bizarre M$ concoction, and a warbled command is sent to the arm in Europe. I shudder to imagine the consequences.
  • Americans would do anything do get to know French women more intimately ...
  • So what happens if the robot arm fails mechanicaly, like a busted ball bearing or something??

    Just wondering.

    pressure/grep

  • then the possibilities are limitless.

    Check out: http://www.fu-fme.com/

  • Lag (Score:3, Informative)

    by Reality Master 101 ( 179095 ) <.moc.liamg. .ta. .101retsaMytilaeR.> on Wednesday September 19, 2001 @12:29PM (#2320664) Homepage Journal

    If you figure 3000 miles both ways, then we're talking a minimum 0.03 seconds of lag. When you figure all the overhead, plus you don't get perfect speed, that could be a 0.1 seconds. That seems pretty significant if you are doing delicate surgery. It would be even worse if it was across the world.

    As John Carmack once said, "The speed of light sucks".

    • According to the story, the experienced lag was about 200ms, which equates to a sucky dialup Quake ping. They also mentioned that the maximum acceptable lag for the job was about 330ms - a nearly unplayable Quake ping.

      The obvious conclusion is that surgery is easier than Quake, right? :-)

  • ...good thing you're not the surgeon then.

    - A.P.
  • some Mindstorms hacker builds one of these out of Lego?
  • This will be really useful for the Antarctic population, given the track record for their surgeons becoming ill during their tenure.
  • for rampaging killbots to perform surgery on me without the errors that human intervention providers. Who needs a doctor on the other end of the world when the killbots will do it for ya, faster and better!

  • ...no, it is not a tumor!!!
    This tech seems pretty cool, but I don't know how much I'd trust it. What if a hacker got into the network somehow and started toying around with my innards? I don't think I'd like that.
  • I don't think the nurses or other doctors were all that impressed.

    "Look at him, he's totally camping the pancreas!"

  • Note that this was using a "high speed optical link," not competing with email, viruses, or other things being sent on the Internet.
    Other "things" being Code Red, Code Red ][, Code Blue, Nimda, and other features of MS IIS...

    It would be nice for critical applications, such as surgery, critical teleconferencing, ... downloading KDE 2.X..., to pay a couple bucks (X 10) and be on a dedicated route to the other end. Over the Internet, I mean. For the vast majority of Internet usage the passive routing is fine but for a small percentage, it is too happenstance to be trusted. What would it take (besides Internet][, I mean) to have a dedicated route option?

  • "Mike broke the Hub-ble. Mike broke the Hub-ble"

    Don't mark me down if you don't get it. Yes, it relates to the story.
  • The robot responds to verbal commands like ``move up'' or ''move down''

    I sure hope it's more accurate than some of the speech recognition tools I've used.

    • Doctor: "Move up"
    • Robot: "COMMAND NOT RECOGNISED"
    • Doctor: (clears throat) "Moooovvvveee up"
    • Robot: "COMMAND NOT RECOGNISED"
    • Doctor: "Moof up"
    • Robot: "COMMAND RECOGNISED: REMOVING GENITALS"
    • Doctor: "Oh crap."

  • Wireless? (Score:3, Insightful)

    by scott1853 ( 194884 ) on Wednesday September 19, 2001 @01:19PM (#2321161)
    This would be really good if they could setup the system in something the size of an ambulance so people can be fixed up without having to make them endure a helicopter or ambulance ride to the nearest hospital. So is 802.11 ready for this?

  • Shouldn't that be a... (Score:3, Funny)

    by szcx ( 81006 ) on Wednesday September 19, 2001 @01:23PM (#2321201)
    ... Gaul bladder?

  • Ping? (Score:2, Insightful)

    by UserChrisCanter4 ( 464072 )
    It said in the article that the doctor was pulling a 200ms ping, and that the maximum acceptable latency was 330ms.

    Now I'm not trying to troll or be funny here, but that's a pretty lousy ping, especially for a direct fiber link.

    I don't know about anyone else, but Quake is damned near unplayable with a 330 ping. We're talking about life and death situations here... If I can't accurately rail someone with that kind of latency, I certainly wouldn't want to be trying to move my scalpel without knicking the femoral artery.
  • When this moves to the internet.. What about packet loss.. or some jackass on your network using morpheus.. "DAMN PACKET LOSS!" Well, he won't need that kidney.

    DOH!

  • Medical arrogance. (Score:3, Interesting)

    by Rothfuss ( 47480 ) <chris.rothfuss@g ... minus herbivore> on Wednesday September 19, 2001 @01:39PM (#2321329) Homepage
    This is an absurd abuse of technology to further a doctor's career. There is no chance that this surgery was in the best interest of the 68 year old patient. Gall bladder surgery is reasonably common and could have been performed by any of a number of local doctors. This was *all* about getting a publication - which is sick. And I don't want to hear about how this technology will revolutionize anything, because the amount of logistical preparation needed on both sides will always make it easier to just fly a specialist to the scene and have her/him operate on the patient.

    The best quote from the article...

    "The time delay between the surgeon's movements and the return video image displayed on screen was less than 200 milliseconds. The estimated safe lag time is 330 ms."

    Estimated safe lag? As determined by who? The NIST? The AMA? Probably the doctor, immediately after hearing that the time delay was 200ms.

    -Rothfuss
  • The most compelling thing is that this surgery was of the "minimally-invasive" variety. That is, the incision was only about 1/4".

    I argue that the market for a transatlantic surgery pales in comparison to having the exact same set of surgical stations within a few feet of one another. The real value is the minimally-invasive part of the equation, rather than the fact that they made a gee-whiz surgery over thousands of miles.
  • This has already been done. IIRC open heart surgery was preformed on a guy in an Oriental country (I forget which) over the Internet2 by someone at KUMC (I believe it was KUMC). I saw that on Discovery this Spring. I don't have details for you. Hopefully that will be enough to find it yourself.
  • While the usefulness can be debated, it's breakthroughs like this that help restore faith in human beings, after witnessing the harm they can cause.

  • ...can warn the medical team on the other side of the ocean if it was running out of surgical tape or other key materials.

    Duct tape can easily replace a empty surgical tape dispenser. Rubber cement, Swingline staplers and binder clips are pretty common, so the robot will be able to refill with the "next best thing" in case of a supply shortage.

  • Doctors in the United States removed a gall bladder from a patient in eastern France by remotely operating a surgical robot arm.

    What we need is remote control firefighters, that can enter burning buildings and put out fires from the safety of the command center a couple blocks away. A much harder problem, due to the necessity to climb stairs and all, but maybe you could make a helicopter version which could break through the upper story windows?

  • I'm in the ATM business (Asynchronous Transfer Mode, not Cash Machines, though we do them too), where Telemedicine has been a staple of hype vendors for decades. At least in the US, telemedicine is not realistic except for a few contrived situations, mainly because medical licensing is done on a state-by-state basis, at least for dramatic silly things like this. Usually anywhere that can afford robot doctors are high-tech enough big-city big hostpitals that have real doctors. There is a realistic case for remote support, which is a (human) doctor in one city where the patient is talking to a specialist in another city and sharing pictures back and forth. There may be emergency medicine situations where a paramedic needs to consult a specialist, but that's usually a wireless situation. If it weren't for the structure of the medical insurance systems dominating US medicine, there might also be applications for a nurse with a camera at a small office working with a doctor who's telecommuting from some other location, but the main situations where that makes sense are rural areas that don't have the right kind of doctor within an hour or two drive.

    (In a non-insurance-dominated free market, people could pay for what they wanted, which would probably include cost-effective non-bureaucratically-oriented structures like that. And in a socialized-medicine market, you'd probably have either lots of doctors, if you believe its proponents, or not enough money for experimental technology, if you believe its opponents, or less restriction on what the medical service can do as long as it saves the service money.)

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