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Mimic Technologies Blog

The Impact of Residents (and Training) on Patients

dV-T Maestro 2Like any new technology, a lot of focus has been placed on ensuring that new users of robotic surgery are adequately trained. Simulation has had a large part to play with this. As the technology has become more mainstream, training requirements have moved from not only training existing surgeons but to ensuring that residents and fellows develop the required skill levels to ensure that they can adapt to the new technologies used in their practice.

Earlier this year we discussed a paper published by the EAU on their curriculum aimed at ensuring that fellows followed a clear curriculum at the end of which they would be deemed to be safe and competent to operate on patients independently. As with many ways of teaching surgery, the procedure is broken into specific steps that the trainee must master before being allowed to carry the whole procedure.

A typical prostatectomy is divided into the 7 following steps: bladder takedown, endopelvic fascia, bladder neck, seminal vesicle/vas deferens, pedicle/nerve sparing, apex, and anastomosis. Typically a trainee will be given a maximum time, of say 30 minutes,to complete one of these tasks during a procedure. Once they have shown that they have mastered the tasks, they will be allowed to move onto another task and eventually to the whole procedure. This is obviously easier to accomplish on parts of the anatomy and procedures that can be standardized.

Until recently, there have not been many studies looking into this practice to see what the potential patient impact could be comparing when a surgery was performed by just the one attending surgeon to one where parts of the case had been handed over to the resident.

Dr. Thiel from the Mayo Clinic in Jacksonville, Florida, has published a paper on just this topic comparing 140 cases where just an attending was involved in the surgery to 232 cases when a resident took over part of the case.

There were no differences in some key clinical outcomes such as positive margins, length of stay, catheter days, readmissions or re-operations when comparing surgeon only to resident –involved cases. There was, however, a difference seen in mean operative time between procedures that were surgeon only cases vs. resident involved (190.4 Min vs. 206.4 Min, P= 0.003)

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The researchers also noted that residents were more likely to be involved with at least 1 procedural step after the purchase of the dV-Trainer.

Mimic believes in this way of training residents which is why the Maestro AR set of procedural curricula we have developed are divided into the procedural steps that a resident will be required to learn. We have been able to marry narrated 3D video content with didactic exercises that allow for a student’s ability to be tested. At the appropriate point, the correct psychomotor skill is inserted to make sure that the student can match the skills required for the procedural step.

Mimic currently has the following available:

  • Right Partial Nephrectomy, Dr. Indibir Gill, USC
  • Hysterectomy, Dr. Arnold Advincula, Columbia University
  • Inguinal Hernia Repair, Dr. Rick Low, John C. Lincoln Hospital
  • Prostatectomy (Si), Dr. Henk van der Poel, Antoni van Leeuwenhoek Hospital/Netherlands Cancer Institute in Amsterdam
  • Prostatectomy (Xi), Dr. Vip Patel, Florida Hospital
  • In Development for Q4 ‘16 Release:
    • Lower Anterior Resection, Dr. Eduardo Parra, Florida Hospital

Click here for more information

 

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The 7 Components of a Successful Robotic Simulation Training Program

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Founded in 2001, Mimic Technologies has been providing robotic surgery simulation training for 15 years. Over the years, Mimic has been involved with one of the most successful surgical simulation launches of all time, with over 2,000 simulators using MSim software worldwide. We estimate that over 30,000 surgeons / residents use this simulation install base each year and that since it was launched, over 6.5 million exercise sessions have been completed.

Many leading academic centers around the world have incorporated Mimic hardware and software into their training programs and there have been numerous publications that were researched and written on Mimic’s hardware and software proving validity.  (A sample of these published studies can be found here.)

All of this experience has allowed Mimic to collect simulation data as well as hands-on experience in successfully implementing best practices to help fully develop new and existing robotic surgery simulation training programs. Over the years, we have found that the most common traits of a successful simulation training program include:

  1. Individuals (trainees) are uniquely identified and results are recorded
    Data is king! It is important for simulation users to create an account and always remember to sign in so that the record of performance over time can show a progression of skill development and maintenance.
  2. Proficiency levels have been discussed and agreed upon
    The study, Best Practices for Robotic Surgery Training and Credentialing, published in 2011 in the Journal of Urology by Jason Lee, et al., concluded that “Rather than being based on a set number of completed cases, robotic surgery credentialing should involve the demonstration of proficiency and safety in executing basic robotic skills and procedural tasks. In addition, the accreditation process should be iterative to ensure accountability to the patient.” Setting institutional standards that have been both discussed and agreed upon will ensure that all clinicians who will be training using simulation are meeting the same requirements. Objective scoring is also helpful to implement a fair and accurate training environment.
  3. Curricula are developed, allocated appropriately, and continuously measured
    According to a 2005 study, Virtual Reality Simulation for the Operating Room: Proficiency-Based Training as a Paradigm Shift in Surgical Skills Training, by Gallagher, et al., “Virtual reality training is more likely to be successful if it is systematically integrated into a well-thought-out education and training program.” Defining specific exercises, mapping out a training path, and continuously checking progress is essential for ensuring that trainees get the most out of simulation to build their skills and move up the learning curve towards proficiency.
  4. Simulation training platforms are easily accessible to trainees
    Also essential for simulation training is ensuring that trainees are able to access the simulator at times that are most convenient and conducive to their learning preferences.
  5. Simulation time is transferable to the real tool
    Face validation shows that a training tool has a realistic look and feel. The 2015 study published in Surgical Endoscopy, Robotic Surgery Simulation Validity and Usability Comparative Analysis, concluded that, “Usability can affect the consistency and commitment of users of robotic surgical simulators.” Before simulation training is implemented, the training tool should be carefully assessed to ensure the skills trainees acquire transfer to the tool they will be utilizing.
  1. Cognitive and psychomotor skills can be validated
    In addition to validating the training tool for Face and Content, the acquisition of both cognitive and psychomotor skills should be validated and proven to make outcomes better. Construct validity distinguishes experienced medical professionals from the inexperienced, Concurrent validity measures the extent to which the simulator correlates with the “Gold standard”, and Predictive validity goes so far as to predict future performance. These types of validation are important to consider when choosing a simulation training tool.
  2. Teams can train together
    The ability to incorporate team training within a simulation training curricula ensure that the trainees will have well-rounded skills such as communication and movement coordination in addition to being proficient in operating the tool they are training for. The study, Teaching Surgical Skills – Changes in the Wind, published in the New England Journal of Medicine by Dr. Richard Reznick, et al., stated, “Virtual reality has the potential to enhance surgical-team training as well as technical skills training. In aviation, teamwork training with simulation has been instrumental in reducing errors. The importance of teamwork in preventing medical error is well recognized, and simulator-based team training has been advocated as a possible preventive approach. Early research results have been promising.”

 

Advances in technology and virtual reality simulation training can make medical training safer, more cost-effective, and efficient and building a successful program doesn’t have to be difficult if similar principles and benchmarks are applied.

 


For more information on how Mimic Medical Education and Development (MimicMED) can help develop your institution’s simulation training programs, click here or contact us at: info@MimicSimulation.com

References:

doi:10.1016/j.juro.2010.11.067

http://journals.lww.com/annalsofsurgery/Abstract/2005/02000/Virtual_Reality_Simulation_for_the_Operating_Room_.24.aspx

http://link.springer.com/article/10.1007%2Fs00464-015-4667-y

http://www.nejm.org/doi/full/10.1056/NEJMra054785#t=article

 

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How Important is Simulation in Medical Training?

by: Christopher Simmonds, VP Business Development & Marketing, Mimic Technologies

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While Mimic has been actively focused on simulation for robotic surgery over the past 15 years, I thought it would be interesting to see how simulation was valued for medical training, in general. While trawling through the internet I came across a study published by the Association of American Medical Colleges (AAMC) in 2011.  The survey was sponsored by a number of other societies including: IMSH, ASPE and AACN. While it is five years old, I do believe it probably still holds true.

The questionnaire was sent to 133 AAMC member medical schools and 263 teaching hospitals in January through March of 2010.  It is interesting to note that the use of simulation increased over time with medical students in both medical school or a teaching hospital environment.  While with residents the reverse pattern was seen to occur with more simulation taking place in the first years of residency than in the later years.

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These observations reflect what we have seen in many of the teaching hospitals using Mimic’s dV-Trainer. Residents are asked to develop psychomotor skills on the simulator before being allowed to migrate to the OR. Many institutions set a specific curriculum with proficiency levels that must be attained before the resident can sit down on the real robotic surgery console and start performing only very specific steps of a procedure.

An interesting part of this AAMC survey looked at how simulation is being used for education and assessment as well as part of a quality improvement program. What sparked my interest was the fact that the researchers differentiated between a number of skills that are very important to Mimic, such as psychomotor skills in addition to clinical thinking/decision making, team training and interpersonal communication skills.

Teaching hospitals were asked to indicate how simulation is used across the three domains of education, assessment, and quality improvement or research. All 64 respondents answered 
this question. Similar to medical schools, overall responses demonstrate simulation is largely used for educational purposes at 87 percent average usage across all competencies, less so for assessment at
 61 percent, and much less frequently for quality improvement and research at only 34 percent.

Teaching Hospital Use of Simulation by selected areas:

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In online questionnaires carried out by Mimic Technologies, we were able to see that over 90% of robotic surgeons had used Mimic simulation products either on Mimic’s dV-Trainer or on the da Vinici® Skills Simulator. This simulation training was primarily for the development of psychomotor skills as part of the surgeons’ initial training on robotics. In our experience fewer hospitals are using simulation for assessment, though we do know of some residency programs who include simulation in their recruitment process. We are also aware of institutions that have implemented a short curriculum that all surgeons need to pass annually to prove that they have the maintained their skill level for the surgical robot.

When it comes to quality improvement the picture is less clear. Given surgeons’ the time constraints, very few hospitals have initiated QI programs that leverage simulation to help improve the skill sets of lower performing surgeons.

As mentioned previously, this paper is five years old and I am sure the situation has continued to evolve. The implementation of the affordable care act is shining a spot light on patient outcomes and thus indirectly on variations in surgical performance. We can see that many institutions are trying to see how they can help improve the outcomes of their lower performers and we believe simulation will have a key role to play.

 

 

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Variation in Surgical Volumes by Surgeons

A Case Study of the BAUS Audit on Prostatectomy

    baus prostatectomy baus prostatectomy2

Recently, there has been ongoing debate around the impact of case volumes on surgical outcomes.  A previous blog post (The Cost Debate in Robotic Surgery and the Impact of Skills) discussed a 2013 study published in the New England Journal of Medicine by Dr. John Birkmeyer, et al, which looked at skill levels between surgeons and identified that surgeons in the lower quartile completed three times fewer operations compared to surgeons in the top quartile.

In December 2012, the UK Government outlined plans to publish surgeon-level outcomes data, taken from national clinical audits, in ten specialty areas, which included Urology. This is known as the Consultant Outcomes Publication (COP) programme.

The British Association of Urological Surgeons (BAUS) has since published a number of audits on surgical outcomes in areas such as Prostatectomy, Nephrectomy, Stress Urinary Incontinence, and Urethroplasty. These audits are available for the general public to review the volumes and outcomes of a wide variety of surgeons.

The 2015 Prostatectomy audit, which looked at 2014 cases was published in September 2015 and the results are summarized below (as published on the BAUS website).

  • The data collection period was from January 1, 2014 to December 31, 2014
  • 6,161 cases were submitted in total, of which 5,814 were from England; these 5,814 cases came from 147 consultants at 62 sites, and include 230 private patients from 37 consultants
  • Hospital Episode Statistics (HES) for 2014 indicate that there were 6,651 radical prostatectomies undertaken in England, so data was collected from 87% of the radical prostatectomies undertaken in England in 2014
  • 5% were robotic assisted, 26.7% laparoscopic, 13.4% open and in 1.4% of cases the technique was not recorded
    • Median number of cases per consultant: 32 (range 1 – 157)
    • Median number of cases per center:  85 (range 1 – 250)
  • The overall transfusion rate was 7% – for England only, 2.6%. In England only, the transfusion rates by technique were: open 5.4%, laparoscopic 0.8% and robotic 2.9%.
  • 5,174 of the entries recorded whether there had been adverse events. The total post-operative complication rate was 5% (491 / 5174). Of these 491 cases, 364 recorded the Clavien Dindo grade (i.e. 127 or 26% did not). Complications classified as Clavien Dindo Grade III or above were seen in 1.6% of cases.

“Another interesting point to note was that there were differences in surgical positive margin rate between the three approaches,“ says Mr. Ben Challacombe MS FRCS (Urol) Consultant Urological Surgeon & Honorary Senior Lecturer, Guy’s Hospital & King’s College London. “Robotic surgery had an average of 13% while both the open and Laparoscopic approaches were at 19%.  The length of stay was also seen to be lower for the robotic approach at a median of one day post operative”

We decided to go into each of the individual surgeons recorded on the web site and try and see if we could give any further insight into volumes carried out by the differing surgeons. Given that 12% of the cases do not have complications rate reported I did not try and see of there was a linkage between volume and complications due to the incompleteness of the data set available.

There were a number of interesting patterns.

Volume by procedural type:

baus table 1

As the table shows, more surgeons did Robotic cases and on average did more cases per year than the other approaches. We therefore decided to an analysis of the difference in procedures between the top and bottom quartile. A quartile was based on the number of surgeons doing the procedures so for example in the robotic cohort we compared the volume of the top 21 surgeons against the bottom 21 Surgeons.

The table below highlights the differences:

baus table 2

25% of the surgeons (37) with the highest volumes carried out over 50% of the cases. Interestingly the concentration was greatest in Open surgery where they carried out 69% of the cases. At the other end of the spectrum 37 surgeons with the lowest volumes only did just below 9 cases each or 5% of the total volume.

This picture is made slightly more complicated as clearly some surgeons will do more than one technique. In this sample 106 of the surgeons (73%) used only on technique while 36 used two techniques and three surgeons used all three techniques.

The overall surgical volumes increased as the number of techniques used increased. Those using one technique averaged 39 cases in the time period, those using 2 averaged 45 and those using 3 averaged 49 procedures. It is only natural that this occurs as surgeons move from one technique to another or believe that different patients are better suited to different techniques.

One of the big advantages of the 21st century is that data from surgical performance is becoming more transparent.  This transparency is going to allow medical professionals to have visibility on a number of factors that affect patient outcomes, which will allow them to put in the correct protocols to ensure that the highest quality of care is always delivered. We believe that the increasing amount of data is showing that the use of validated simulation protocols and curriculum can ensure best results for patients.

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Implementing Robotic Surgical Training: Thoughts from the French Academy of Surgeons

french academie

On November 13, 2015, a panel of experts in robotic surgery met at the Académie Nationale de Chirurgie (ANC) in Paris to discuss training in robotic surgery. The meeting was moderated by Professor Michel Huguier and the speakers included:

  • Professor Rolland Parc, Conseil de l’Ordre des Médecins
  • Professor Jacques Marescaux of IRCAD (the institute for research into cancer of the digestive system), Strasbourg
  • Professors Jacques Hubert and Laurent Bresler of the School of Surgery at Nancy
  • Professors Xavier Cathelineau and Guy Vallancien of the École Européenne de Chirurgie (European surgical training centre), Paris
  • Professor Jacques Belghiti from the HAS (the French national health authority)
  • Dr Denis de Valmont from the insurance company SHAM
  • Dr Yves Allioux of the Caisse Nationale d’Assurance Maladie (CNAM)

The full day session included discussions and presentations on the current status of robotic training in France as well as an overview of the adoption and current state of robotic surgery in a number of key specialties from Urology to Thoracic.

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Their group identified some fundamental needs:

  1. Training requirements should be based on the established protocols for training in surgical robotics (drawn up by the teams from Nancy, France)
  2. It is essential to anticipate the arrival of new robotic platform
  3. It would not be helpful to increase the number of training centers. What is required would be several centers of excellence who are well equipped in platforms and personnel, with good reporting systems or registers.

The guiding principles of modern computer-assisted surgery, and thus of robotic surgery, should be the following:

  1. It is assumed that the clinicians should know how to operate and be competent in their surgical specialty
  2. Surgeons need to become familiar with the all aspects of the computer-assisted system
  3. Success will only be achieved through partnership with the manufacturers
  4. However, maintaining professional ethics and independence and avoiding all conflicts of interest is essential
  5. Being able to justify scientifically the evolution of treatment approaches thus being able to satisfy financial policymakers, and to defend surgeons against whom the HAS starts disciplinary proceedings.

Conclusions from the discussions:

The training in robotic surgery currently provided by the manufacturers is not a legally binding qualification. Their only obligation, as with any equipment manufacturer, is to explain to the purchaser how their product works. This training, according to published literature, is generally too short, and does not include any assessment of surgeons’ ability to use these robot systems.  The responsibility of monitoring this training should, therefore, fall to the scientific societies and the universities in partnership with the manufacturers, and should include the evaluation of teams who will be tasked with these, using these new technologies. Training in robotic surgery can be provided by both public or private institutions, bearing in mind that it requires a substantial investment in equipment. It appears that university budgets alone will not be enough to meet this investment, and that public institutions could enter into partnerships with the private sector to meet the demand.

Robotic surgery is put into practice by surgeons and their teams, and their training should cover 5 areas:

1 – Surgical training is the remit of the existing schools of surgery

2 – Basic training in the use of a “robot” is common to all specialties that plan to use the system. It should be validated by a document certifying that the surgeon attended a course of basic training involving learning about the machine and the relevant techniques, with time on a simulator and on the robot in “dry lab” and “wet lab”. This stage of training should finish with an assessment

3 – In robotic surgery the surgeon is removed from the operative field, and there is, therefore, a loss of visual communication with the rest of the team. This makes training of the other members of the surgical team (team training) indispensable

4 – The clinical training specific to each specialty and procedure will be carried out in centers that have robots and having “proctors” (“Advanced Courses”)

5 – Surgical practice involves lifelong learning, which requires that the surgeon maintain his skills throughout his or her career. The question of re-certification, like that imposed on aircraft pilots following a period of inactivity or when they don’t practice their skills on a regular basis, does not currently exist in medicine. It is likely that in future the development of simulators will enable surgeons in these situations to refresh or maintain their technical skills.

 

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