RANDOLPH CHITWOOD, M.D.
Chairman, Department of Surgery
Brody School of Medicine
East Carolina University

Transcript of interview on
North Carolina People with
Dr. Bill Friday

July 28, 2000

Dr. Friday: Good evening ladies and gentlemen. Tonight the cameras of North Carolina People are on the campus of East Carolina University Medical School and we are talking with Dr. Randolph Chitwood. We have read a lot about him and he is the founder of robotic surgery. He has made some great news and I need to talk with him in just a few seconds. I know, Randolph, that you have performed a great enormous service here in eastern North Carolina but you did your basic training under Dr. David Sapperson of Duke University. That is a wonderful connection you have there.

Dr. Chitwood: I certainly did and that's one of the things that brought me to North Carolina was Dr. Sapperson at Duke University. I went to the University of Virginia Medical School and Dr. Muller, who had been a classmate of Dr. Sapperson, and he was the chairman there told me I must go down and do it.

Dr. Friday: Father and grandfather both circuit riding doctors in a way, was that a real motivation for you?

Dr. Chitwood: It was but I don't think I realized it much in those days because when I would go on house calls with my dad, they were true country doctors, you know, and my dad had been practicing for many years as did my grandfather and we made house calls but when you carry the bags its not all that impressive but I also saw how much he did for folks up in the mountains and that always intrigued me and then as I advanced I tried to do more advanced technology. I worked for DuPont for a couple of years and then came back to medicine.

Dr. Friday: Well, we are all glad that you did. You are Chief of Surgery here at this wonderful hospital and chief of all that goes on in cardiology, but what about heart disease in eastern North Carolina, what is the manifestation down here?

Dr. Chitwood: Eastern North Carolina has a high incidence of cardiovascular diseases; it is not just heart disease but stroke and diabetes and things that are related to cardiovascular diseases. One of the highest regions in the United States is probably eastern Kentucky and eastern North Carolina and that would be for a number of reasons such as diet and health education, patients going to the doctor later as in most rural regions so you know it is a higher incidence because that is the reason even in the Triangle and early on there was not as much care for these patients.

Dr. Friday: Does the network you developed get more referral now so that you do have a better statistical basis and you see more patients, better diagnosis they bring to you?

Dr. Chitwood: The primary care network that we have developed here and it is the mission of the medical school to see patients primarily and they are referred in here for advanced disease and we are able to not only treat the patient but also educate them about their disease and rehabilitate the patient and also to start data bases so we can see if we are doing good and decreasing the mortality from cardiovascular diseases.

Dr. Friday: You have been on the front pages of the papers with robotic surgery, you have gone all over the world demonstrating and being a part of this experience, now, what is it, what is it we are talking about here? What's so different from the normal chest opening and the work you do in the heart muscle itself?

Dr. Chitwood: Well it's very interesting, when you first think of robots and surgery-they just don't go together, you think of R2D2 type of robot but real robotics is just a tool, another instrument to do heart surgery through smaller, smaller incisions. So what got me interested is I went through heart surgery myself and know what it is like to have a breast bone incision and for me to realize when you operate to make small incisions you need visual aids such as the endoscope that you use for abdominal surgery, knee surgery and so when we first started doing heart surgery through small incisions with these scopes we had large images on screens that we could see and then when it came down to six centimeters and that is just two and one-half inches you get to a point you really can't operate as well through these small incisions. So, what you do is you take it inside the heart so that it is inside the chamber and you operate through a small console which allows you to scale motions, do accurate operations. It is a great magnifier so it is really a stepwise evolution from a breastbone incision to a small incision, sort of like going up Mount Everest where you go to different camps before you get to the pinnacle.

Dr. Friday: It makes you have a very steady hand, does it not?

Dr. Chitwood: Well it does and it's very interesting because it not only takes up any hand tremor that you have. Even if you have the steadiest hand in the world if you are Rembrandt it takes the tremor out and allows you to operate with both hands so that your non-dominant hand is just as good as your dominant hand. It allows you to scale motion so if you are going at one speed you can actually slow up the stitch on the other hand so that you have got more accuracy so there are some electronic advantages with these new computer-driven devices.

Dr. Friday: Let us suppose that you can compare the heart muscle with touch, what has happened before you do that robotic entrance into the heart cavity?

Dr. Chitwood: You have to open the heart for a valve replacement or valve repair; for coronary bypass surgery it is when you are outside the heart but you have to stop the heart and we use traditional techniques but modifications to traditional techniques; you use the heart/lung machine but instead of having big tubes sucking blood where traditionally on the heart/lung machine the heart stops and then you make the incision and you have a quiet heart but the heart is protected as it is kept cold, it is kept arrested so basically it is not metabolizing, it is not using up the energy sources. Of course when you restore the heartbeat the blood supply comes back to your heart and the patient comes off the heart/lung machine.

Dr. Friday: How many of these have you done so far?

Dr. Chitwood: We have done over one hundred twenty valve operations; we were the first in North America to do valve operations like this using these videoscopic techniques; however, the true robotic device such as the DiVinci which we currently use which is a device made on the West Coast, we have got the first FDA approval to do that real robotic surgery in the United States and I am pleased to say we have done five patients thus far in a ten patient FDA approved protocol here at this institution. Of course, prior to that I had done some of these operations in Europe but these five patients and we have five more patients to operate upon in this FDA protocol. All patients have done well and their valves are working fine and in fact I just about twenty minutes ago saw our second patient.

Dr. Friday: Yes and you were kind enough to bring him in and give me a chance to meet him and I must say he looked enormously healthy.

Dr. Chitwood: Indeed he does. He is really having very few problems and he is recovering much faster than he would have. He was only in the hospital four days versus an eight-day stay. Some of these patients get out in two or three days.

Dr. Friday: When you are in the middle of this, is there any type of way that any kind of mechanical failure can happen?

Dr. Chitwood: That's a superb question. Really, a multiple failsafe it would mean that the device would just not activate in the proper sequence which means that it wouldn't be dangerous for the patient. Then what you would do you would just remove the device and then make the incision a little bit larger and do it in the traditional fashion. When you remove your head from the console, the operating surgeon, the device deactivates so those arms don't move at all but yet when you have your head in the console you can move these arms in different ways much like you move a mouse on a computer so if you get into a position where your arm is not comfortable, you can step on a button and you can move your arms back into the comfort zone and then operate again from that position.

Dr. Friday: Your colleague explained to me that three-dimensional capabilities are the secret to this whole business. You can look around, you can look under, and you can look in almost any dimension and it really is a fabulous thing you have come up with here.

Dr. Chitwood: If there is one sense, one of the human senses which you really need, you are having three-dimensional vision with this type valve surgery. You may not have tactile sensation when you feel something there. You could almost do without that as long as you have good visual queues. Of course it would be wonderful to have tactile sensation which we are now working on. It may not be for the next five years but now that three-dimensional vision cameras are very good, about a centimeter and that is less than an inch, of course, but still it is fairly big, we want to get these cameras down to half that size, smaller than a pencil but three dimensional. But you really walk inside the heart essentially when you are looking through one of these scopes.

Dr. Friday: You must be getting calls from everywhere as you have gotten so much publicity about this. What do you do when people call you from New York or Chicago and say they have this condition, how do you handle this?

Dr. Chitwood: Well, many patients that call you are looking for the Holy Grail. They have three valves to be done or five bypasses and two valves. This is a very select population and in time we should be able to do a number of coronary operations and different types of valve operations but I don't think this robot will ever replace the human hand. Patients that call us and want small incisions and they are candidates but we always ask a number of questions, maybe have them send the films to us, and we have done a number of patients. There was a gentleman from Hong Kong we did about two weeks ago and he had a friend on the West Coast who had heard about what we had done and referred him to me and we operated on him and he has returned to Hong Kong-he is an American businessman there. So, the word does spread and if you have the right problem for this particular procedure then it works out well and we are very busy.

Dr. Friday: Could you sit in your surgical suite here and watch the monitor and coach one of your former students doing this surgical procedure in Paris?

Dr. Chitwood: Yes, absolutely.

Dr. Friday: You trust the transmission accurately?

Dr. Chitwood: I trust the transmission of data, my voice, my spoken voice showing where to make an incision and it is sort of like at one of the football games with John Madden. I think the teaching component that you brought up is the absolute key. What we will do is as we get another research laboratory so that we will be able to activate from two sites and see if we do have enough bandwidth on either the Internet or on cyber cable to do these kinds of things. I do envision this more of a teaching tool than one surgeon sits in New York City and operates in Tokyo and Sidney and three or four other places.

Dr. Friday: What is your fertile imagination looking to do next with all of this?

Dr. Chitwood: There are a number of things. I think one thing we've got to develop are smarter robots. Robots are memorized pathways, surgical pathways. You know you get on these airplanes at Raleigh-Durham from the console but basically their powers are due to a lot of computerization and also you are trained on a simulator. Well, you traditionally train surgeons by almost an apprenticeship. With this new era of technology, if we can map what I have done surgically and convert into a real image, or a virtual image that a resident or trainee can actually try to emulate what you have done that is very powerful because you can say how many operations have you done on the console before you go in the operating room. Hopefully in time, maybe twenty years to operate inside the heart with the heart still beating, inside the heart. We now operate on the heart on the outside of the heart with it still beating. Also there is a whole lot of technology associated with growing heart cells and reinserting them into the heart. There are a lot of things that are going to happen and some will happen in the short range and some will happen in the long range. I think in the genetic therapy the sky is the limit and this probably won't come into full play for about twenty to twenty-five years. I think robotics will be a major role in the next four to five years.

Dr. Friday: There are a lot of people writing about you, quoting you as saying that genetics is really the source of problems in cardiac complications most of the time as that is the inheritance factor? Is it that?

Dr. Chitwood: Yes it is, I really think it is. I see individuals in eastern North Carolina who eat fatty diets and really haven't taken care of themselves in a way that someone that is real cognizant of cardiac disease and yet sometimes we do catheterization of their arteries, their bodies are absolutely normal. Then you will see someone has been very meticulous about taking care of their diet, maybe they are a diabetic, maybe they are not, and has this brittle artery very young. So I think first you have the genetic predisposition with environmental factors and I think in the future we will be able to determine which gene you have, which predisposition you have and then maybe we may be able to even look at whatever your specific genetic problems are and tell you risk factors and then make therapy modifications. To many people gene therapy and modifications of anything is worrisome and ethically of concern if it is done in the right way. We have always had to approach ethics in anything in medicine.

Dr. Friday: So if you had a grandpapa or grandmama who lived a long time and mother and dad did, you're in luck.

Dr. Chitwood: And it's a good indication in something that all of us would want and yet I think those who have cardiac vascular disease in their family they might be nervous but they should just take precaution because we have better drugs than ever that prevent these environmental manifestations so you can prevent this and that's what is so important about some of the state initiatives that we are doing.

Dr. Friday: That brings me to that another question. These stories that are all over the papers today about America being the most obese nation. We are couch potatoes and we don't exercise any and we eat the wrong food and are smoking and are very destructive. How much do you teach prevention when you talk to students?

Dr. Chitwood: We teach a lot of prevention.

Dr. Friday: It's not your job, I know.

Dr. Chitwood: It's not a job but really you know because you teach those students, just think what they can do which is sort of like a multiplying effect. You teach two students and they go teach four hundred patients. It is very hard to get people to change their lifestyle. Pain and bleeding will bring you to the doctor but if it doesn't hurt or doesn't scare you, it is very hard to modify your lifestyle. That is why we have taken that as a State initiative. We have a very strong task force in North Carolina for education of the population because we can do something about our health. We are all responsible for our health. The best thing is prevention.

Dr. Friday: How in the world do you keep up with all that's happening in medical science today? I am just bowled over by it.

Dr. Chitwood: Well, I think you have to certainly acknowledge you wouldn't know everything about everything. My wife keeps me informed about a lot of things. She reads the Sunday Times and other things and she will tell me things that I haven't heard about and I have to go read about them.

I think we live in such a wonderful age. This is really a time for information dissemination on the Internet. I sit down and I don't have to have those paper journals around. Now if I want to look up a mitral valve disease, a coronary disease or a cardiac tumor I will sit and simply put in a search word and there are twenty articles that will appear before me as an abstract or image and videos, whatever I need is right there on the internet. When we have the Internet I to come on a wider band width we will be able to communicate from operating room to operating room and I see people in Singapore about three times a year at different parts of the country, and we communicate. So I think that's the way we keep up. But still we only have a little piece of that knowledge.

Dr. Friday: How do you and your colleagues make up your mind what to teach an advanced class of medical students in surgery for example with all of this wealth of information? Do you teach the skill of how to learn or what to watch of substance or do you try to strike a balance somewhere?

Dr. Chitwood: We get to teach two or three things. We teach feeling for the patient and how that individual patient will tell you what their problem is if you can just listen. That is something I learned at home, I didn't learn in my training. What to listen for in a patient's symptomology, then the path of physiology, how this disease became manifested, but basically, what made this little defect cause this person's malady? This is one thing Dave Sapperson taught me. If you don't understand the history of disease and also what makes it happen, you really can't do anything about it. So those are the basics and then therapy, both medical therapy and surgical therapy. When you are training family doctors they are not surgeons or cardiologists, when you try to train family doctors to pick up surgical disease, such as thyroid nodules, breast masses, to be sensitive as to their problems and make early diagnosis, we need to put some useful information in their hands rather than teaching them how to do a coronary bypass operation. So I think that the style is for the group that you are teaching. If you are teaching residents at a higher level, post graduate medical education, then you are teaching them operative skills, you're teaching them more pathology, but you are teaching them really how to do the work of a surgeon.

Dr. Friday: When you are in front of a civic club in say Kinston and somebody raises their hand and says you know, Dr. Chitwood, what about all these things I read about out here that I am supposed do and believe in, how do you simplify this so I can be a better caretaker of myself? We have so much information in all this process.

Dr. Chitwood: Yes, I think you have to drop in two different mindsets. I don't mean talking down to you. I grew up in a small town in the Western part of Virginia and so I was used to talking to folks. My folks were very good at that and so basically I think you have to give them something they can identify with either a friend, a family member. I remember my Uncle Jim had five coronary operations and had a problem and was told he could work it out that it could be solved. You're a young man or a middle age man or whatever and the risk factors for surgical operations are not that high and you should do well. It used to be you could live a full fruitful life. I have done most of my active work here since I have had my coronary bypass operation so you know you have to sort of put yourself in their shoes and talk to them person to person rather than professional doctor to patient. I think in that situation you had better say that I am just like you guys and if I eat the fried chicken I can get coronary disease.

Dr. Friday: The fact that you had this process yourself, it certainly did cause you to discipline how you go about your very work every day and how you recreate.

Dr. Chitwood: Well, that's the hardest thing for me too; how to take care of yourself.

Dr. Friday: I know you like photography and ham radios. You just need to go down in the basement and say that I am closing the door on these other things.

Dr. Chitwood: Yes, I never have the chance to do as much because I am giving so many talks around the country so when I have time I go on the computer obviously with all the imaging stuff and the data. But I went to Tibet, you know, and it's 18,500 feet and you drop off a little weight, and you work hard and you, know, when you get to 18,500 feet it is different. I took wonderful photographs in Tibet, it is an amazing place, and in fact my daughter met the Dali Llama yesterday in Washington with Senator Helms.

Dr. Friday: Oh, how wonderful!

Dr. Chitwood: So when I travel I get a chance to see different things too so some things are on hold and some things I am doing now but now is the time to do this new interesting technology in surgery.

Dr. Friday: What do you see the future of medicine being and what services will be available to the patients? How much more is going to happen? Can this go on and on? Is it endless?

Dr. Chitwood: Well, that's one thing I learned through the history of medicine. If you don't understand the past you will have to refresh yourself and so I think by knowing what happened in let's say between the time of Lister developed that's not much over a hundred years, one hundred twenty years, and you take it to the next one hundred and twenty years, I think we are living in a fascinating time in all of medicine because these times are beginning to get shorter and shorter and shorter, the time lapse between innovation and discovery and I think as we are mapping the human genome, the DNA, to really understand what's encoded in all this, we will understand disease processes much better.

Dr. Friday: Is that another field of medicine, geriatric cardiology so to speak?

Dr. Chitwood: I think so, it is hard for me to turn to introduce you to geriatrics, and it really is. There is a man who is seventy eight years old, I did a mitral valve operation and is that gentleman a geriatric or is he just a kid in a little older body because basically he is a very healthy man. So, there is biologic aging and then there is chronologic aging and I do think that as you get elderly there is no question that things change. Your cellular metabolism changes. You don't just change outwardly but you change inwardly so there are different paths of physiology so there really is more tension and as I come through the baby boomer group I think that this huge mass of people will be in their seventies in twenty years and I think that they will put a big strain on the system and they will have a different type of physiology so it is clearly an important field.

Dr. Friday: This has been one of the most interesting thirty minutes I have spent interviewing anybody. Thanks to you, Dr. Chitwood. Ladies and Gentlemen, I hope you have gained from what has been said here this evening from this really remarkable man and what he has done. Thank you again and good night.