by John Lenihan, Jr., MD, FACOG
In the recent past, most surgical training programs were modeled on the Halstead Axiom of “See One, Do One, Teach One.” This was particularly true for robotic surgery training since many programs were overloaded with teaching traditional open and minimally invasive surgery skills to their students. Also, many educational leaders weren’t sure about the future of robotic assisted surgery. Was it just a passing fad? It seemed too expensive for surgical training. Maybe there were only certain situations where it would be useful. How do we fit it in?
Over the last 15 years, the evolution of robotic assisted surgery has become much clearer. Intuitive Surgical’s daVinciÒ System is now the preferred approach for many complex abdominal and pelvic procedures. And with many new robotic platforms entering the market in the next one to two years, robotic assisted surgery is predicted to grow at 24.4% per year over the next 7 years increasing in value worldwide from $5.5 BN in 2018 to greater than $24.5 BN by 2025.1 In addition, medical students are now choosing residencies that can provide them with robotic surgical training over ones that can’t. Most surgical residencies are now starting to develop training programs that include some exposure to robotics. We surveyed many different programs and found that the requirements for robotic training are all over the map. Most programs require taking the Intuitive Surgical on-line course, and then attending some didactic lectures, while others require VR simulation but the curricula very greatly,2 and some let the resident first assistant train on robotics yet the training can be very unstructured for this role and many do not include team training at all. Most programs do offer some sort of letter stating their residents are qualified to perform robotic surgery when they graduate, but the criteria are very nebulous.
In the early 1980’s, the Dreyfus brothers at the University of California, Berkeley, proposed a model for training that can be applied to almost any discipline.3 The Dreyfus Model of Skills Acquisition differentiates stages of learning from novice to master and describes the steps necessary to attain each step. The key of this model is that the students are required to completely master one step before being able to advance to the next step. This concept has been called “Training to Proficiency.” To become proficient, one must be able to pass a skills test consistently, not just once. Several studies have validated this approach to learning.4 If this model is applied to a robotic training program, ideally residents should master each step by demonstrating proficiency before moving on to the next step. This equates to being able to pass a simulation exercise at least twice consecutively. Most programs also require three to five total passes of each exercise to demonstrate proficiency. Most residents today, however, graduate as “competent,” or in other words “just safe.” They don’t actually become proficient until long after graduation when they have many more cases under their belts. It would be better to try and achieve proficiency prior to graduation.
Dreyfus Model of Skills Acquisition
This is what an ideal Robotic Surgery Training program might look like:
- Students take an Innate Ability Assessment with VR Simulation prior to starting residency. This will allow program directors to predict how long it will take a student to achieve proficiency in their training curriculum.
- A VR curriculum will need to be passed to proficiency prior to gaining access to cadavers or the OR. Basic training and first assist training will be required for R-2s to become bedside assists. Curriculum progress and scores will be available to students and faculty 24-7 in real time on a cloud portal. Team Training will also be a required focus.
- R-3s and R-4s will be required to have more didactics and pass more advanced simulation to get on cadavers and eventually on live patients as console surgeons.
- Partial or complete surgical procedures will be video reviewed by faculty to evaluate GEARS Scores as well as surgical technique and knowledge.
- This program will be standardized for all new robotic platforms.
By establishing clear, proficiency based benchmarks for residents to master prior to gaining actual surgery time in the OR, we are moving towards a more standardized and reproducible teaching process that is long overdue. In today’s world, it is the only ethical choice.
- Lenihan JP, Brentnall M. Seeking the Ideal Robotic Training Experience: A Comparison of Four Different Robotic Surgery Simulation Training Programs: presented SRS, Stockholm Aug 2018.
- Tam V, Zeh H, Hogg M. Incorporating Metrics of Surgical Proficiency into Credentialing and Privileging Pathways. JAMA Surg. 2017;152(5):494-495. doi:10.1001/jamasurg.2017.0025.