On the path to proficiency based robotic surgery training

Surgeons across the globe have been trained to perform surgical procedures by the Halstead Method of “See One, Do One, Teach One” since the early 1900’s. This process relies on didactic teaching and observation of skilled surgeons by young learners who then go on to develop and improve their skill on live patients. Despite this process being well entrenched in our current system of medical education, it is far from practical, reliable or ethical in today’s world. Imagine if young pilots just learning to fly were given the keys to a multi-engine jet airliner full of passengers! The training of pilots requires proficiency based training, much of which happens in a safe simulation environment where a mistake does not result in any significant damage or loss of life. Recent data from the FAA indicates that the average commercial pilot receives >1500 hours of training before being allowed to pilot a commercial aircraft. The fatality rate for an aircraft passenger in the United States is 1 out of 1,000,000.¹ A surgeon begins operating independently after about 15 hours of training, and the published mortality rate for all surgical procedures in the USA is 30.9 out of 100,000 procedures.² Pilots are expected to be proficient from day one; shouldn’t patients expect the same from their surgeons?

Simulation has improved over the past twenty years and now most young surgeons are being trained on some sort of simulation. Initially, this was mostly in the form of inanimate models and box trainers; but now VR simulation is starting to take center stage. Many recent studies have demonstrated the advantages of high fidelity VR simulators such as the Mimic dV-Trainer® when compared to traditional box trainers.³  Outcomes of training on VR simulators have been shown to be equivalent or better than standard dry lab trainers. Also, there are obvious advantages with VR simulation, including performance assessment using objective scoring metrics, lack of need for direct observation by a faculty trainer, and the elimination of student self-reporting. Now the question becomes: what is the best way to train on a VR simulator?

Our poster presented at the 2019 ACS Surgical Simulation Summit analyzes four different training protocols in an attempt to track trends and help our customers develop more effective training curricula. One finding was that consistent ongoing programs tended to have better success than shorter more labor intensive programs. For example, one program required only 1 pass on 22 exercises and had a 70% pass rate. Another program required 2 consecutive and 5 total passes on 13 exercises and only had a 31.7% pass rate. Recently, there has been a lot of attention given to the educational model developed by Dreyfus and Dreyfus at University of California Berkley in the early 1980’s.⁴ This model describes four basic characteristics that students master in their quest to acquire a new skill, such as flying an airplane or performing surgery. This progression takes a student from being a novice to becoming competent, eventually proficient, and sometimes to the level of mastery obtained by experts. A competent surgeon at graduation should be safe in the OR, but a proficient surgeon should also be able to match levels of surgical efficiency consistent with their community and national standards. A recent publication by the American College of Surgeons reported that 26% of graduating surgery residents did not feel competent to perform one or all of the five most common general surgical procedures taught in residencies.⁵ It’s time to standardize surgical training curriculums using validated VR simulation exercises that must be passed a sufficient number of times to ensure at least competency (safety) for all surgical trainees prior to allowing them to operate on live patients. In 2019, this should be an ethical imperative!

by John Lenihan Jr., MD, FACOG

1. 1. FAA Air Carrier Fatalities, 2016; https://www.faa.gov/about/plans_reports/Performance/quarter_scorecard/.
   2. Quick Stats: Published Death Rates for All Surgeries in the USA for Adults > 45 Years Old; http://www.cdc.gov/nchs/nvss/mortality_public_use_data.htm.
   3. Correlation of Virtual Reality Simulation and Dry Lab Robotic Technical Skills; Newcomb LK, Bradley MS, Truong MS, Visco AG, Siddiqui NY:  J Minim Invasiv Gynecol. 25(4), June 2018, 689-696, https://doi.org/10.1016/j.jmig.2017.11.006.
   4. Dreyfus, Stuart E.; Dreyfus, Hubert L.(February 1980). “A Five-Stage Model of the Mental Activities Involved in Directed Skill Acquisition”(PDF). Washington, DC: Storming Media. Retrieved June 13, 2010.
   5. http://skepticalscalpel.blogspot.com/2017/06/some-general-surgery-residency.html.