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Mimic Technologies Blog

How Long Should a Trainee Practice on a Robotic Simulator?

This is probably the most frequent question asked when people are trying to understand the impact of investing in a simulator for their robotic surgical program. Of course, there is not one answer to this question as training objectives can vary significantly depending on the trainee’s discipline, level of surgical experience, and standards set by a hospital’s robotics committee. However, regardless of the training objective, a trainee should not be judged by “how long” they have trained, but by whether training data indicates “proficiency”. However, rather than boring you with published articles on what it means to be proficient, I will share some generalized data with you that will help answer this question.

I have been able to analyze the utilization at some of our high usage centers on both dV-Trainers® and da Vinci® Skills Simulators. While the overall usage is higher on the dV-Trainer®, the utilization distribution is the same across both platforms. These systems represented 705 different users who spent over 2,600 hours on the systems.

The average utilization of the system is just under 4 hours per user. I, therefore, chose to split the users into three groups: those who spent more than 10 hours on the system, those who spent between 4 and 10 hours, and those who spent less than 4 hours.


As you can see, the vast majority of people spent less than 4 hours with approximately 1 in 4 spending less than an hour.

However, if you look at the impact on the utilization you will see that the smaller group of dedicated trainees (those that trained for more than 10 hours) dominate the total simulation usage.

How does this help answer the original questions? One interpretation is that if someone does not spend more than 4 hours on a simulator, they cannot be seen to be serious about training. If they spend over 10 hours, then they are clearly more interested in developing the right skill level. Interestingly, 10 hours is the amount of time that the Urology Department at Hartford Hospital felt was the optimum time residents should be spending on simulation based on their 2015 study (Read the full study here). The answer could therefore be, “at least 10 hours should be spent on simulation training or as long as it takes you to become proficient”.

The real answer is that it will vary by individual and will be partly based on their level of interest and their innate ability. In 2014, a paper was published by Andrea Moglia from Pisa on the innate ability that medical students might have for robotics (Read the full study here). The paper was able to show that 6.6% of the student population of 125 had a significantly higher score than the median and were as good as expert surgeons the first time they sat down on the console. At the other end, there were 11% who clearly had no aptitude at all. It should be expected that users with innate ability will require significantly less training time than the average user, but the time needed will be dependent on the curricula and the proficiency thresholds that have been set by their institutions. The time an individual will need to spend on a simulator to gain proficiency will therefore be driven by a number of factors, including their own motivations, their innate ability, and the proficiency standard set by their institution.

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The Relationship Between Robotic Surgical Technical Skill in RARP and Patient Outcomes – 3 Abstracts From AUA 2017

One of the questions we have been studying and trying to better understand is the relationship between surgical skill and patient outcomes. The rough rule of thumb has always been to ask a surgeon how many of these procedures he or she has done. The logic is that the more surgeries they have performed the better they are likely to be.

Three abstracts were presented that looked at this particular subject at AUA 2017. Two of them leveraged the Michigan Urological Surgery Improvement Collaborative (MUSIC) and one was from a single center study looking at a small cohort of patients from a single surgeon.

High level conclusion:

All three abstracts concluded that there was a relationship between the technical skill of a surgeon and selective patient outcomes. These varied from improved continence at 3 months to reduced urethral catheter replacement for more technically skilled surgeons. There were also suggestions of improved readmission rates as well as decreased blood loss though this was not consistent across all abstracts.

Two of the abstracts were as follows:
Technical Skill Assessment of Surgeons Performing Robot-Assisted Radical Prostatectomy: Relationship Between Crowdsourced Review and Patient Outcomes (Paper# PNFBA-02: Best Abstract – Khurshid R. Ghani et al., Ann Arbor, MI. Read the full study here)

Surgical Skill and Patient Outcomes After Robot-assisted Radical Prostatectomy (Paper# PD58-06: James O. Peabody et al., Detroit, MI. Read the full study here)

Both of these abstracts leveraged the MUSIC database and asked 29 surgeons to provide a video of a case and both used a clip of the vesicourethral anastomosis. Both abstracts also were able to look at results against 2,256 patients. In both instances, the surgeons were reviewed using a Global Evaluative Assessment of Robotic Skills (GEARS) that divided them into quartiles and compared results of the top 25% (Most Skilled) with the bottom 25% (Least Skilled).

The difference between the two papers is that one used the C-SATS platform and crowdsourced the evaluation using 285 reviewers while the other leveraged a group of 56 surgical peers. There is not enough detail in the abstracts to understand the nuance and difference between the reviewers and the scoring achieved.

The results for the crowdsourced study can be seen below:

While the results from the peer reviewed study are seen below:

Given that there is an overlap in a number of the authors in both abstracts, it will be interesting to see if a paper is published that tries to explain these differences.

The third paper was:
Surgical Technical Performance Impacts Patient Outcomes in Robotic-Assisted Radical Prostatectomy (Paper# MP51-15: Mitchell G. Goldenberg, Toronto, Canada; S. Larry Goldenberg, Vancouver, Canada; Teodor P. Grantcharov, Toronto, Canada. Read the full study here)

This looked at 28 case matched patients from one surgeon over a 7 year time period and was reviewed by one surgeon. They also used the GEARS scoring system as well as the Robotic Anastomosis Competency Evaluation (RACE) and the Generic Error Rating Tool (GERT).

They were able to see a correlation between patients who did not achieve continence at three months and the number of errors that occurred during the bladder neck dissection.

Fundamentally these abstracts show that surgical skill matters. The more a surgeon can develop their technical skill set away from a patient, using validated simulation curricula that is driving to proficiency, the better it will be for the patient as well the hospital as fewer readmissions will lead to lower overall costs.

For more articles from the Journal of Urology and AUA, click here. For more validation studies about Mimic products, click here.

Focused on assisting hospitals to better maximize their investment in robotic surgery, Mimic has over 15 years of experience providing tools and support for robotic surgery training and program support. Contact us today to learn more.

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Interesting Studies from AUA 2017

In May, Mimic joined top urologists from around the world in attending the AUA Annual Meeting in Boston. Among the rich content and papers presented, here are 3 especially interesting robotic surgery training and simulation takeaways from papers presented at AUA 2017:

1. Trainees take between 15% and 120% longer than expert surgeons when carrying out procedural steps (Paper#MP51-04; Muammer Altok, Mary Achim, Surena Matin, Curtis Pettaway, John Davis, Houston, TX).

2. Novices position their arms in a less ergonomic fashion than expert surgeons (Paper#PD46-06; Kenta Takayasu, Kenji Yoshida, Tadashi Mastuda, Osaka, Japan).

3. Viewing a patient-specific simulated 3D model of a kidney tumor helped novices in identifying tumor locations (Paper#PD46-12; Rai et.al.).

1. A Decade of Robot-Assisted Radical Prostatectomy Training: Time-Based Metrics from Fellows and Residents (Paper# MP51-04, Muammer Altok, Mary Achim, Surena Matin, Curtis Pettaway, John Davis, Houston, TX)

A common way to train fellows is to allow them to carry out steps of the procedure and as they build up confidence, they eventually migrate to the complete procedure. This paper looked at the difference in time at various stages of the procedure between experts and novice surgeons and graded them by quartile. Overall fellows and residents were involved in 1,622 cases. The increase in time to complete the segments varied from 15% (E-PLND) to 120% (dorsal vein complex) depending on the part of the case being carried out as can be seen in the table below:


A Grade 4 to 5 success rate was achieved in 95% of the cases. Modern training in robot-assisted surgery is evolving towards curriculum-based training that includes didactics, dry-lab exercises, wet-lab operations, surgical assistance, and ultimately console performance under careful supervision. After a decade of training 4 clinical fellows and up to 12 residents per year, this study transformed their step-wise time metrics into a simple table to use to benchmark performance. A non-validated qualitative feedback was also recorded. Read the full study here.

2. Analysis of the Posture Pattern During Robotic Simulator Task Using Optical Motion Capture System (Kenta Takayasu, Kenji Yoshida, Tadashi Mastuda, Osaka, Japan)

This study was essentially looking to see if the relative position and movement of the shoulders, elbows, and wrists was different between novice and expert surgeons carrying out two Mimic simulation exercises. The table below shows there was in fact a significant variation:


We have often seen that there is a difference in economy of motion between expert surgeons but this is another way of looking at the same phenomena. In addition, there are differences between novices and experts in the positional relationship between the elbow and wrist and joint angle of the upper limb, indicating that experts may have less posture stress. Read the full study here.

3. Virtual Simulation Improves a Novice’s Ability to Localize Renal Tumors in 3D Physical Models – a Multi-institutional Prospective Randomized Controlled Study (Paper#PD46-12, Rai et al.)

This is an interesting paper that evaluates if bringing patient-specific 3D models into a simulated environment helps in identifying tumor location. One hundred medical students were put through the protocol below where they were exposed to a CT scan, half then looked at a 3D model on a dV-Trainer and half went to look straight at a physical model.

Those who had also looked at the 3D virtual representation on the dV-Trainer more accurately visualized the tumor location on the physical model. Read the full study here.

For more articles from the Journal of Urology and AUA, click here. For more validation studies about Mimic products, click here.

Focused on assisting hospitals to better maximize their investment in robotic surgery, Mimic has over 15 years of experience providing tools and support for robotic surgery training and program support. Contact us today to learn more.

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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)

blog tabe

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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