Dr. Rafael Barrera was making routine rounds on a recent Thursday afternoon, tending patients in the surgical intensive care unit at Long Island Jewish Medical Center in New Hyde Park.
As he moved from bed to bed, he observed surgical incisions and checked the beeping and blinking monitors that provided an array of medical information: heart rate, blood pressure and pulse. He consulted with doctors and chatted with nurses.
Yet, Barrera, the ICU's director, was physically nowhere near LIJ, but 300 miles away in Hanover, N.H., where he was studying for a few days at Dartmouth College. While on the campus, he was also in the high-intensity, life-and-death struggle of a major intensive care unit -- teleported there into a robot called RP-7i.
The 5-foot, 5-inch automaton on wheels is operated by Barrera from a laptop. His image is beamed in real time onto the robot's screen, which serves as its head. Barrera's voice emanates from a speaker.
It is a futuristic blending of human and machine.
Robots are becoming an inescapable presence in health care, arriving in all shapes and sizes. Big ones, small ones and a growing zoo of those with fur. Robots are not only a presence at patients' bedsides, they help perform surgery and fill prescriptions -- assist doctors in the operating room. And they are increasingly controversial.
Some have caused concerns among humans worried about job security. Ethical debates have flared over so-called companion robots designed for the elderly, and therapeutic ones destined for nursing homes. Robots, some experts say, will never take the place of nurturing human relationships. Designers simply want less prejudice directed toward the machines.
"We have to get away from this Asimovian idea that robots are competitors," said Dr. Michael Treat, a former Manhattan surgeon, now a full-time robot designer. In "I, Robot," the late science-fiction author Isaac Asimov portrayed them as sinister.
"Robots have to be integrated into what we do. They are not competitors and they are not going to take over the world," Treat said.
An asset for hospital
Pragmatism drove LIJ to add a robot to its staff.
"We chose to use the robot because it is cost-effective," Barrera said. The robot allows a 360-degree view of a room and is capable of traveling at a speed of 2 mph.
When he needs a better view of a patient, Barrera can extend the "neck" attached to the screen-head.
Unlike Skype or communicating visually through a cellphone or iPad, the robot has height and mobility, bringing the user to the brink of a boundary crossed only in science fiction in the past: having a presence in two places at once.
Barrera said the system is officially known as a remote presence, a product of InTouch Health in California, which makes a family of similar robots.
"I have the software in the laptop and I can mobilize the robot anywhere I want to go in the hospital," said Barrera, who added that he can wheel himself onto an elevator when having to travel to another floor. But because the robot has no arms, Barrera has to ask for human assistance in summoning the elevator and selecting where he wants to go.
"If there is a private conversation I need to have with someone, I can do that. We can go somewhere private and have that discussion, and this is face to face and it works so much better than a telephone."
Patients are mildly surprised but generally unnerved when a robot wheels up to their bed.
"It was like ET visiting the first time I saw it," said Barbara Casey of Massapequa, who was hospitalized for 14 months for a series of surgeries.
She woke up after her initial operation and saw a robot peering down at her.
"I could see Dr. Barrera and he was seeing me and it was good to know that he could check on me and not be there," Casey said. "There was a time when doctors made house calls. I guess now they make robot calls."
Barrera has reported on the robot in medical literature, noting its usefulness in patient care.
"We have published twice about the robot," Barrera said. "We have asked patients and their family members what they think about it and they say they are very comfortable with it."
As pleasant as the robotic experience has been for Barerra, robots elsewhere have been met with resistance. The fear that a robot can usurp a human's job has been daunting for developers designing devices endowed with sophisticated artificial intelligence.
Concern about jobs
Treat, a former surgeon at New York Presbyterian Hospital and founder of Robotic Systems & Technologies Inc., in the Bronx, learned firsthand that robots are not always popular when they compete in the human health care workforce.
He created Penelope, a robot introduced to New York Presbyterian's operating rooms in 2005. But because the robot was designed to function as a scrub nurse -- handing surgeons instruments during an operation -- tensions grew over Penelope's presence, Treat said.
"There was nursing opposition to it, definite pushback that you are invading sacred territory," he said.
Penelope is a robotic arm Treat invented to be uber-responsive to voice commands: Suture. Scissors. Retractor. Hopkins clamp. The robot retrieves instruments and passes them to the surgeon.
"The operating room is one of the most conservative institutions in the world and it's very hard to innovate [with robots]," he said.
The da Vinci Surgical Systems, for example, which are used to perform a broad array of surgeries, are the only general surgery devices used in U.S. hospitals. The machines are manufactured by Intuitive Surgical Inc. in Sunnyvale, Calif.
Treat and his collaborators have redesigned Penelope to be a whiz in hospital sterile supply processing departments. Penelope is at New York Presbyterian and being tested in another Manhattan hospital's supply department, Treat said.
The processing department, also known as central supply and sterile supply, is in charge of sterile and nonsterile surgical equipment. The department oversees cleaning, preparation, and most of all, counting equipment after an operation.
"At the end of an operation, when you are closing up patients, you have to count all the instruments. There may be 50 to 100 of them, and I can tell you from experience most times the count is wrong because the initial inventory on the tray is wrong.
"If you count 11 Kelly clamps and there are supposed to be 12, the burden of proof is on the surgeon. Then you have to disturb the wound to make sure there is nothing left behind."
A robot, he said, can accurately count all day and, because it possesses embedded intelligence to recognize every instrument, it will never make a mistake.
At Winthrop University Hospital in Mineola, Walter Rx has been on the job for 13 years and has never erred filling patients' prescriptions.
Walter is a prescription-filling virtuoso -- 4,000 doses a day, seven days a week, 365 days a year.
"Theoretically, it is taking away jobs, but it is improving efficiency and accuracy," said Steven Gerson, Winthrop's assistant director of pharmacy.
Gerson said Walter's presence has allowed the pharmacy to deploy its technicians to other key roles in the pharmacy. Medication retrieval and restocking are left to the robot.
In 13 years, Gerson said, Walter has missed only three days of work due to down time for maintenance.
Programmed to comfort
Beyond robots that perform work there are others that designers hope will perform more nuanced roles involving direct patient care, such as easing anxiety -- and therein persists an ethical debate where some say robots have gone too far.
Paro, a furry robot that looks like a baby harp seal, is actually a $6,000 stuffed animal containing microphones, 32-bit processors and sensors arrayed throughout its fur. The sensors enable it to respond to human touch.
Studies have shown that it can help lower agitation in people with Alzheimer's disease when the fur is stroked.
Paro can also recognize human voices and track a person's motions. If someone is mean to Paro, it will react with a whimpering sound and shut down.
Invented by Japanese robot designer Takanori Shibata, Paro is a therapeutic robot for dementia patients as well as a companion for healthy elderly people and children with autism. It was approved for therapeutic purposes in this country by the U.S. Food and Drug Administration in 2009.
"This is actually the eighth generation of Paro," said Christine Hsu of PARO Robots U.S. Inc., in Schaumburg, Ill. "It was first developed 20 years ago and commercialized in 2003 in Japan."
As a companion robot, Hsu said, Paro can take the place of a dog or cat for people who live in places that forbid pets. Paro has big dark eyes and makes actual baby harp seal sounds. Its softness, she said, is part of its seduction.
The robots are being sold to nursing homes as a type of pet therapy for residents.
Dr. William Thomas, a leading advocate for improving U.S. nursing homes, said foisting robots onto older people is inhumane.
"What elders and their families are paying for in long-term care is people-care. To outsource this care to a machine covered in fake fur is outrageous."
"This is basically a rug with a computer inside of it," said Thomas, founder of the Center for Growing and Becoming in Ithaca.
Hsu said Paro is part of a revolution in robot technology, which has exploded in Japan, the global leader in robotics and applications in artificial intelligence.
S. Shyam Sundar, a robot expert at Pennsylvania State University, said robots will likely become more commonplace in the not-too-distant future, filling roles many people find difficult, dangerous or distasteful.
"Robots are important because they can richly complement our lives by doing things that we don't want to do, especially on a continual basis," Sundar said. "They can assist us without getting tired or bored. They can provide care to seniors. They can teach social skills to autistic kids."
Barrera, meanwhile, has found that he can be in another country via robotic technology without leaving Long Island.
As a physician who performs free surgeries in Ecuador for children with cleft lips, his pressing obligations here don't leave much time for extensive follow-up care -- at least not until the hospital acquired a robot.
"Now I can be with my patients in Quito," said Barerra, who visits their bedsides while half a world away.