Robots can help medicine, but the training of surgeons needs to change

Robotic surgery can help medicine. Treatments with robots are more effective and shorter than classic treatments. But in order to benefit from the benefits of robotics, changes in physician education are important. Appropriate training is the basis for efficiency and quality in robotic treatments.

The da Vinci robots helped remove the prostate and kidney

On September 24, Dr. Paweł Wisz, MD, along with Dr. Stefano Puliatti – head of the Urology Clinic at the University Hospital in Modena (Italy) and Dr. Ruben de Groote from the OLV Hospital in Aalst (Belgium) performed 6 procedures with the support of 2 da Vinci robots – 5 radical prostatectomy (prostate removal) and 1 partial nephrectomy (kidney removal).

The event was to present the effectiveness and quality of treatments performed with the help of robots. The treatments lasted about 1,5 h – 2 h on average, which is a global standard. All doctors are associated with Orsi Academy, which is the largest training center in Europe, where optimal models for training surgeons in the field of robotic procedures have been developed, guaranteeing high efficiency and quality in the procedures performed.

Robotic surgery – what is it?

Despite its short history in surgery, robotic surgical technology has already proven its numerous benefits, including visualization, excellent dexterity and precision in minimally invasive procedures. Currently, the most widespread and dominant robotic system used in surgery worldwide is the da Vinci system by Intuitive Surgical. The technology has been developed for over 20 years, we already have 4 generations of these platforms, 6,5 thousand. installation of da Vinci robots in the world in 67 countries, 8,5 million operations performed, 24 thousand. scientific publications, including 3 last year alone, more than 30 articulating surgical instruments as well as advanced and intelligent suturing and sealing devices, energy tools with variable clamping force and accessories.

However, the evolution of robotic surgery is far from over, and many potential competitors are now preparing their solutions for commercialization. In Poland, we already have 16 authorized da Vinci systems, the first installation of the Versius system (CRM Surgical) has appeared, the ExcelsiusGPS systems from Globus Medical (for spine treatments) and the CorPath GRX system, developed by Siemens for cardiological treatments, are already present. Siemens is developing the system very intensively and by the end of this year we expect the system to be certified for large vessels, and work is underway on a system for treating strokes.

The estimates based on the results of a study conducted specifically for the purposes of the PMR and Upper Finance Group report show that in a country the size of Poland, there should be about 50 robots by the end of 2025, with the help of which nearly 15 jobs will be performed. treatments per year. At the end of 2021, it may be approx. 2,5 thousand. procedures. It is worth noting that the market dynamics would be even higher if a dedicated program of financing these procedures by the National Health Fund was introduced.

According to the report, in the years 2021-2026 the average annual increase in the value (CAGR) of the robotic surgery segment will amount to as much as 23%.

In the face of this dynamic development, it is impossible to ask the question: how to support the building of real skills of doctors working with the use of technology, how to verify their level and how to disseminate them?

Pandemic and the possibilities of training surgeons

The pandemic significantly reduced the availability of surgical treatment. Information about a smaller number of operations that were performed in 2020 is no longer new. However, little is said about the fact that this situation also had a negative impact on staff education, training, especially in the field of surgery, and the staffing gap has widened, and it is impossible to fill it without resorting to new solutions based on technologies, surgical robots and artificial intelligence.

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With the advent of robotic systems, there was also a system for certifying surgeons by manufacturers of robotic systems. It is worth noting that the certification carried out by the manufacturers of robotic systems is only a condition that allows you to work with these tools, and it is not a determinant of achieving an appropriate level of medical skills. The training offered by the manufacturers covers only the conscious and safe use of the systems, and does not cover the scope of the necessary medical training and the experience required to practice surgery.

In order to use the potential of technology, it is worth facing some myths and abandoning the belief that for the operator’s skills the key issue is to certify only the number of operations performed. Research indicates that the best predictor of surgery safety is the actual skill of the operating surgeon.

Hence, the attention of hospital managers should focus on issues related to ensuring appropriate development paths for surgeons, keeping data registers and their analysis, and then implementing solutions improving efficiency and quality. All this to create medicine based on values ​​for patients.

Robotics will revolutionize physician education

In Poland, robots began to develop in operating theaters relatively late due to limitations in access to technology. We can regret it or we can take advantage of it and learn from the best experiences of those who have been on this path for over 20 years. The introduction of technology in the form of a robot to the operating theater creates the possibility of a revolutionary change in the way of educating the staff. As part of the projects developed at Orsi Academy in cooperation with European and global scientific societies, research work has been developed for several years, the result of which is the creation of an optimal training program for robotic surgeons.

Orsi Academy is the largest training center in Europe, where optimal models for educating surgeons in the field of robotic procedures have been developed, guaranteeing high efficiency and quality in the procedures performed. Based on this model of education, doctors at NEO Hospital were selected. NEO Hospital is the only hospital in Pollska that cooperates with Orsi Academy.

The first joint activities were presented in Rzeszów, where 6 procedures were performed under the supervision of Dr. Wisz with the support of 2 da Vinci robots – 5 radical prostatectomy and 1 partial nephrectomy.

The training of surgeons needs to change

Training the surgeon should detach from the operating theater and the patient, thereby deviating from the traditional teaching model. Surgery on patients cannot be the basis of a training strategy. You need to shift to a mindset about training surgeons, where learning about procedures and technical skills until the right skill level is achieved takes place outside the operating room. This approach to training is not based solely on the volume of treatments performed. It is based on teaching skillful, targeted operation and offering the trainee supervised operational experience that gives him the opportunity to integrate already acquired knowledge and technical operational skills, but in a real context.

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Direct feedback from qualified instructors along with the possibility of purposeful (not just repetitive) practice are essential elements of mastering the technique. These strategies are best implemented in laboratory and simulation conditions, in dedicated training centers. This training approach provides an excellent set of operational skills, but must be backed up by measures of the level of effectiveness achieved vs. a benchmark level that has been validated as required for the skill, i.e. based on specific metrics.

Carrying out an operation according to a predetermined pattern provides a level of confidence that certain skills have been acquired (not just understood). The more technically demanding operational procedures become, the greater the need for carefully structured training programs that offer skill maturation in a safe environment. Surgeons using advanced technologies such as surgical robotics are well aware that the number of surgeries performed does not necessarily determine operational skills and that performance / effectiveness ratios that represent a skilled skill should be sought quickly. It is a more effective, efficient, objective, transparent and equitable approach to training operational skills.

Case study on the example of radical prosotatectomy (robot-assisted surgery (RAPR)

What was the operation performed with the robot like?

First, the characteristics / pattern of the robotic radical prostatectomy (RAPR) procedure (operation) were established. A group of 5 experts – four urological surgeons and a behaviorist – formed the group that characterized the procedures. The surgeons had over 10 years of experience in the practice of RARP (radical robotic prosotatectomy). A panel of 19 experts from 10 countries then verified the key indicators through a modified process. The median number of RARP cases conducted by these panel experts was 1500 and the median age of the panel experts was 49 years.

The groundbreaking meeting took place in Marseille, on September 5, 2018, just before the development of the robotic surgery market in Poland began in earnest.

First, the concepts of the “PBP” training program (proficiency based progression) were presented.. The reference measures for the robot-assisted radical prostatectomy (RARP) procedure are also presented, i.e. what reference values ​​and parameters should be achieved by the surgeon for the procedure to be performed correctly, taking into account all the benefits for the patient. Procedure phases, steps, bugs, and fatal errors were outlined and covered by the Delphi panel. Following this discussion, the proposed indicators were edited in real time and a vote was taken to establish the level of consensus on the indicators.

12 key phases of the procedure were defined, consisting of a total of 81 steps. Also 87 errors and critical errors, characteristic of this procedure, were defined.

The second step was to examine the importance of physician certification. The study involved 24 people, 12 experienced surgeons (median age 59) each of whom had more than 500 operations, and 12 novices (median age 36) who each performed less than 10 operations. Each group was divided into 2 subgroups – surgeons who had previously undergone a PBP or proficiency-based progression program or who had not. All surgeons were robotic surgeons.

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The results of the study were surprising, as in the critical phases of the procedure, novices performed better than experienced operators who did not undergo the PBP program, ie proficiency-based progression. Experienced operators who underwent proficiency-based progression did the best in each phase of the operation.

The PBP, or proficiency-based progression program, has been evaluated and subjected to extensive testing. In one of the newest ones, a meta-analysis of the results was performed. Compared to the traditional training, the participants of the PBP training obtained significantly better results. PBP training reduced the number of executive errors by 60 percent. and shortened the treatment time by 15 percent. and increased the number of correctly performed steps in the treatment procedure by 47%.

Artificial intelligence to help healthcare

Artificial intelligence can help in solving problems related to the deficit of medical staff, among others due to the change in the model of staff education. Thanks to the development of artificial intelligence, dedicated training centers have been created, in which, thanks to simulators similar to those in aviation, we can carry out virtual operations and simulate individual stages of operations, including complications.

Such a model of education shortens the education curve, but also allows for a deep standardization of the process and better preparation for treatments, which translates directly into benefits for patients.

Coalition for the development of medical robotics

On September 24 this year, by the decision of the board of the Polish Federation of Hospitals, the Coalition for the development of medical robotics was established, which is to become a center of expert knowledge on medical robotics, a place where clinical partners, industry and science meet and cooperate in the field of training, research and development and analysis data in order to best implement robots into medical practice.

The key goals that the coalition sets itself are:

1. Educational tasks based on knowledge sharing programs, 
2. Cooperation for the development of human resources, program development, study visits, case observation, internships
3. Data analysis to precisely determine the benefits of robotic surgery, both from the perspective of the clinical effect for patients and the calculation of costs and economic benefits of using this technology, developing a proposal of tools supporting the development of medical robotics. 

The Polish Federation of Hospitals (PFSz) is a nationwide organization of employers associating hospitals regardless of their ownership structure, size or model of operation. PFSz was founded in 2011. It associates directly over 280 hospitals, and through agreements with local and sectoral hospital unions, it functions as an umbrella organization for over 500 hospitals in total.

The main goal of the Federation is to improve the operating conditions of hospitals. PFSz works for better financing of hospitals, increasing the importance of hospital management, the safety of patients and hospital employees, as well as for quality, good management practices, education and good legislation.

PFSz represents Polish hospitals on the national and international forum. PFSz belongs to the European Federation of HOPE Hospitals, which associates over 80 percent. hospital resources in the European Union. PFSz cooperates with the International Federation of Hospitals IHF – the only global organization of hospitals.

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