After months of negative news about poorly trained surgeons, class action suits claiming poor communications with shareholders, an FDA review, an article saying that procedure costs were too high, particularly for gynecological operations, and an NBC exposé, the news that stuck and affected the stock (NASDAQ:ISRG) where it hurts seems to be the JAMA article.

The article showed that although the number of robotically assisted procedures is up, their effectiveness is the same as laparoscopic methods but their costs are about $2,000 higher per procedure. That got hospitals to stop and reevaluate their purchases. Shortly after that, the ACOG (American Congress of Gynecologists) suggested that doctors help patients separate marketing hype from reality regarding hysterectomies.

Yesterday Intuitive Surgical reported that quarterly sales were slightly down, and expectations for the next quarter were also lowered.

Intuitive’s shares were downgraded by at least four analysts.