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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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Better Teamwork Leads to Better Outcomes in the OR

Surgery has often been referred to as a team sport. The role of the surgeon is undoubtedly critical but so is the role of the entire team in ensuring patient safety and positive outcomes.

This is especially true in robotic surgery where the main surgeon is no longer at the patient’s side but is seated at a robotic console outside the operative field. The console-side surgeon now relies heavily on a first assistant or patient-side surgeon. The first assistant is a skilled laparoscopic surgeon whose prime objective is to work as a team with the robotic surgeon to maximize efficiency during the procedure.

A recent study titled, “Impact of Assistant Surgeon on Outcomes in Robotic Surgery,” by Dr. Rishi Nayyar, et al., published in the Indian Journal of Urology found that, “with increasing experience of patient-side surgeon and associated console surgeon, who form a consistent surgical team, the mean operative time for all robotic procedures shows a consistent trend of reduction across all surgical types.” (Click Here to Access the Full Study)

Typically, better outcomes in robotic surgery are associated with only the console-surgeon. According to Dr. Nayyar’s study, there is no existing objective evidence regarding the impact on outcomes with the experience of the assistant surgeon in robot-assisted surgery. Therefore, the goal of this recent study was to objectively verify the hypothesis that the experience of patient-side assistant in robotic surgery affects intraoperative outcomes.

During the study, a total of 100 cases of robot-assisted laparoscopic pyeloplasty were analyzed and on comparing outcomes between the 1st and 2nd halves of the assistant experience, the mean operative time reduced from 102.50 min to 82.80 min (P = 0.001) and mean blood loss reduced from 72.00 ml to 63.90 ml (P = 0.91). (See table below)

outcomes

As the study suggests, a console-surgeon and first assistant to who work consistently together make a better team and positively influence the outcome of the procedure. Mimic’s Xperience Team Trainer (XTT) was developed specifically for this reason.

The XTT simulates the patient-side and connects with the dV-Trainer that simulates the console side, thereby allowing both the console and the patient-side surgeons to train in tandem with virtual reality simulators. Routine tasks are executed crisply and efficiently while also working on communication between both surgeons.

A 2015 study done by Dr. Jacques Hubert, et al., published in Surgical Endoscopy confirmed face, content, construct, and concurrent validity of the Xperience Team Trainer as an assessment tool of robotic surgery bed-assistance skills for the patient-side surgeon.

This study also emphasized the importance of teamwork between the patient-side and console-side surgeon in robotic surgery, which may change the paradigm of robotic surgery training in the near future. To read a past post about this study, click here.

 

Nayyar R, Yadav S, Singh P, Dogra PN. Impact of assistant surgeon on outcomes in robotic surgery. Indian J Urol 2016;32:204-9

 

 

 

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Predictive Validity of Simulation Training for Robotic Surgery and Other Modalities

The big question that many doctors and hospitals continually ask themselves, “will this time I spend on a simulator actually end up having an impact on my patients?”, plays a big part in how training is structured. In terms of validation, correlating time spent on a simulator to improving patient outcomes is referred to as predictive validity.

The first research study to look into this for robotic surgery was published by Dr. Patrick Culligan in 2014, which developed the “Morristown Protocol”.  Using the Morristown Protocol curriculum, Dr. Culligan, et al., demonstrated predictive validity by setting an expert-based proficiency benchmark and asking 14 attending surgeons to complete a curriculum of 10 exercises to this same level of proficiency as the experts that were benchmarked. After completing the simulation training, the attending surgeons were able to complete their first robotic hysterectomy case within the same or better parameters as the experts. These parameters included things such as operative time, blood loss, and technique as assessed by experts. While this study was done using Mimic software, the simulation training was carried out using the Intuitive Surgical Skills Simulator hardware.

The table below gives the data for the experts as well as a control group of surgeons who had privileges at the institution but had not spent any time on a simulator for training:

table1

More recently, Dr. Gokhan Sami Kilic of the University of Texas Medical branch at Galveston carried out a study that looked at the impact of simulation training on surgical outcomes for Hysterectomies that not only looked at robotic surgery but also included open surgery, laparoscopic, and vaginal approaches to Hysterectomy.

Unlike Dr. Culligan’s study, Dr. Kilic also focused on residents as opposed to already trained surgeons. The average age of the surgeons who went through the Morristown protocol was just under 50 years old. Dr. Kilic’s study, however, was focused on surgeons who were in their residency and were grouped in PGY2, PGY3, and PGY4, typically under the age of 40.

This study looked at patient outcomes such as estimated blood loss, postoperative hospital stay, intraoperative adverse events, and mean operative time. The study was retrospective and covered a period from 2009 to 2014.

Simulation was introduced in 2010 at the institution for all modalities except robotics. Robotics was introduced in 2011 with the acquisition of Mimic’s dV-Trainer. The simulators were from a wide range of manufacturers in addition to Mimic including, 3-Dmed and Limbs&Things. Residents followed a structured simulation-based training program for Total Abdominal Hysterectomy (TAH), Vaginal Hysterectomy (VH), Total Laparoscopic Hysterectomy (TLH) and Robot Assisted Hysterectomy (RAH).

In total, 1,397 patients were included in the study and 41% (n = 576) underwent TAH, 22% (n = 305) underwent VH, 20% (n = 272) underwent TLH and 17% (n = 244) underwent RAH.

The patient populations did demonstrate some variations between the modalities and there were no statistically significant variations in relation to age, BMI, parity, or the number of previous surgeries.

The results can be seen in the table below

table2

As you can see in the table, the average estimated blood loss before and after simulation-based training was significantly different in TAH and RAH groups, but no significant difference was found for VH and TLH. The mean of length of hospital stay was also significantly different before and after simulation-based training for each technique.

It is interesting that there was no statistical impact for OR time, though perhaps understandable as OR time is more related to overall team performance and thus requires team simulation as opposed to surgical skill.  Intraoperative complications did not seem to be impacted either by simulation, though they did trend downward in the robotic cohort.

Although the study was not intended to look at this specifically, it does seem to indicate that while robotic surgery might have marginally longer operative times it does seem to have a lower level of intraoperative complications, lower blood loss, and the lowest length of stay along with Vaginal Hysterectomies.

At Mimic, the dV-Trainer was developed with the objective of helping surgeons master the da Vinci ® robotic system allowing them to improve outcomes for patients. It is great to see a research study that validates in this general direction not only for robotics but for other modalities that incorporate simulation training as well.

 

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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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