Is surgical training stuck in the past?

When we look back on the last century, the pace and number of advances in our ability to treat disease and injury is truly astonishing. The exponential growth of technology has contributed to this greatly, as we see new advances often come in the form of new technologies. Amazing innovations in the fields of endoscopy, catheterization, robotics, imaging, navigation, 3D printing and more allow us to do things that were previously not believed to be possible. While these advances have opened the door to new life-saving options, we have failed to recognize the complications they have brought with them.

In general, these new technologies are far more complicated than simpler techniques from the past. But the real challenge is not simply that technology is more complex; it’s that these solutions are being released into a system of medical training that has not changed in over a century and continues to place constraints on surgeons. This problem, or training gap, is only increasing over time, and ironically, technology is also one of the only ways to address it. Closing the training gap with technology requires more than expensive simulators though; it requires looking at more accessible and cost-effective solutions that democratize surgical training for every surgeon.

Take a moment to recall the apprenticeship training model we went through as trainees. Cases were dictated by the schedule of the attending you were assigned to. While ideally, you’d be performing aspects of the procedure yourself, you likely spent a good portion of that training holding retractors or just watching. As you climbed in seniority, from time to time, you were given the opportunity to take the lead in certain key parts of the case.

This system served our medical community well for many years, but medicine and surgery are changing rapidly — almost too quickly to keep up — and these dynamics are leading to an unsustainable situation. This growing training gap is a simple math problem wherein the number and complexity of procedures that a trainee must learn is always increasing, but the time that they have to learn them is less than ever.

Why do they have less time?

There are two major factors to consider: work-hour restrictions and growing administrative responsibilities. New work hour restrictions that limit residents to work a maximum of 80 hours per week, which, while completely reasonable, have lost residents around a year of hands-on training time. Additionally, some studies have shown that 50 percent of a resident’s time can be spent on the computer entering information into EMR systems. There is simply not enough time for residents to get the level of hands-on training needed.

In 2017, Dr. Brian George and his collaborators published, “Readiness of US General Surgery Residents for Independent Practice,” in Annals of Surgery. This groundbreaking study measured the ability of residents to operate autonomously throughout their training up until graduation. The results were alarming, to say the least. At the time of graduation, about 30 percent of residents were still unable to operate independently. This phenomenon is leading to a vicious cycle in which these young, undertrained attending surgeons are still spending their time training themselves instead of operating at a level where they can train the next round of young residents counting on their coaching and education.

New surgical technologies are becoming a more prominent contributor to this training gap and pose challenges not just for residents, but for surgeons out in practice as well. For example, take surgical robotics which is an incredibly exciting technology and field that may unlock the potential for treating conditions that were previously untreatable. Learning to use, however, is not simple. Numbers vary between studies, but in general, a surgeon needs to perform at least 25 cases to perform at a basic level of safety, and around 75-80 to achieve optimal proficiency.

Typically, the training for new surgical techniques that use medical devices is the responsibility of the device company. Being flown to a training session or having access to training courses is the standard approach. But the reality is that these learning opportunities are short and infrequent. I noticed the space between attending a course and first in-patient use can be anywhere from four to six months. In addition, there often is very little opportunity to practice in between. At most, we’re given a video to review. Given such constraints, surgeons who want to use a new medical device might “wing it” a little bit. They might have someone read the technical guide aloud during a procedure, or have a sales rep walk them through a case.

New medical devices and technologies have also created counter-intuitive training challenges that appear because these new technologies are too good at what they do, meaning the surgeon needs less help from residents and the medical team. As described in his excellent analysis of robotics surgical training, Mathew Beane points out that because surgeons now are able to perform these procedures near complete independence, residents don’t have as important of a role in the case, as they would in an open surgery. This leads to a lack of engagement and participation that perpetuates residents graduating with very little, if any, actual hands-on experience.

Research continues to note how simulation technologies can be a solution to this problem. Simulation allows trainees to practice procedures before treating patients so that they have a safe place to make mistakes and work their way up the learning curve at their own speed. Simulation also has the ability to standardize training, so that we can quickly disseminate best practices and techniques from governing professional bodies, through the cloud down to a simulator. Finally, simulators can accurately assess a surgeon’s objective technical skill. In this way, we can actually ensure that we are training quality providers who can safely and effectively care for patients. The field of simulation is evolving through the recent introduction of breakthrough immersive technologies, such as augmented and virtual reality, that increase access to training for all members of the surgical team.

Aviation has been using simulation successfully for decades, so why aren’t we doing something similar in the medical world? It may be time to fight fire with fire. Technology, specifically immersive technologies and simulation, can solve a critical problem that other technologies have created.

Justin Barad is an orthopedic surgeon and founder and CEO, Osso VR.

Image credit: Shutterstock.com

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