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The Unintended Consequences of Robotic Surgical Practice for Resident Surgical Capacity
Matthew I. Beane, MS, PhD Student.
Massachusetts Institute of Technology, Cambridge, MA, USA.
BACKGROUND: Robotic surgery has seen rapid and pervasive expansion in Urological surgical work, with significant implications for the performance of core procedures such as prostatectomy, nephrectomy and partial nephrectomy. The implications of this technology for resident education are less well understood. Though many theory- and lab-driven efforts have been initiated to improve training in robotic surgery for medical residents, to date we do not have any empirical study of the ways in which residents learn (or fail to learn) how to operate with the daVinci system in the context of actual residency programs. Insights in this direction could help ground and improve efforts to maintain a healthy and growing base of qualified robotic surgeons.
METHODS: The author took near-verbatim, time-stamped observational notes on over 150 open, laparoscopic and robotic urological procedures at four top-tier teaching institutions in the New England Section of the AUA. IRB restrictions mandate anonymity for all participants’ and their institutions. He likewise recorded and transcribed interviews of attending surgeons, residents and surgical staff in urology programs at these institutions. Finally, he performed confidential interviews with attending surgeons and residents in urology programs at 15 additional top-tier teaching institutions throughout the United States. Each attending selected two residents to be interviewed - one that they assessed as learning robotic skills rapidly and extensively, and one that was average or below average in this regard. The researcher was blinded to this assessment until after resident interviews were complete. Standard techniques for analyzing qualitative data were applied to induce findings.
RESULTS: Best-in-class robotic surgical practice greatly inhibits the effectiveness of traditional dwell-time focused methods for learning surgical technique (e.g., “see one, do one, teach one”). Residents typically get two four-month rotations of exposure to robotic surgical work, and in an average procedure get 10 to 20 times less time on surgical task as in the equivalent open procedure. Given their ability to perceive very minor quality deviations, top robotic attendings regularly reduce the learning value of this time through “helicopter teaching:” intervention and supervision so frequent that it significantly delimits opportunities for residents to struggle at the edge of their surgical capacity. All 18 residents assessed as exceptionally competent reported learning through three organizational processes: early exposure to robotic surgery (e.g., pre-residency research), extensive digital rehearsal (e.g., simulation, online video) and - most crucially - rotations at institutions with less robotic surgical expertise and profitability pressure. Only two residents assessed as average highlighted these processes.
CONCLUSIONS: While adoption of robotic surgical technology has expanded the pool of surgeons willing to perform minimally-invasive procedures, current usage and instruction practices may be unduly constraining the flow of competent robotic surgeons into the profession. To the extent that this is accurate, institutions, the surgical profession and vendors should consider redesigning organizational processes, surgical practice and surgical systems themselves in order to better capitalize on the learning modalities evident in the everyday practices of top surgical students.
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