The applications of robotic technology in surgical practice have grown exponentially over the last 15 years. Popularity was initially limited to certain surgical specialties, but in the last 5 years, nearly the entire spectrum of surgical practice has adopted robotic technology.1–14 Because this expansion includes academic medical centers, surgical trainees are increasingly exposed to this technology. However, a recent review of current resident-specific curricula for robotic technology revealed minimal standardization and a lack of cognitive components.15 As educators examine the robotic surgical environment more closely, they have begun to question how this new technology might resist integration into today’s apprentice-based learning environment. For example, early studies suggest that despite increased exposure to robotic technology, residents have a negative initial impression. In a 2014 study, 46% of 192 general surgery residents responding to a national survey felt that robotic-assisted surgeries interfered with resident training. That study is also one of many that have suggested that exposure to robotic-assisted surgical procedures is increasing in general surgery residencies6,16–18—over 96% of respondents noted the presence and ongoing use of robotic technology in their training programs.
Robotic technology appears to be increasingly popular among general surgeons working in academic settings, so it is unclear why the popularity among residents does not align with this view. One reason for the residents’ negativity may be the decreased hands-on operative experience in this new robotic environment. For example, introduction of robotic technology at a gynecology residency program resulted in significantly fewer procedures available to residents.19 Similarly, in a study of general surgery residents, 63% reported participating in a robotic operation, but only 18% reported accessing the operative console18 (the unit, separate from the robotic arms and the operating table, that enables the surgeon to manipulate the robotic arms; the console includes the operative controls and a screen that displays a three-dimensional view of the operation). Although the number of robotic-assisted general surgery cases is increasing, it appears that the resident’s role is often limited to exchanging instruments at the bedside or intermittently suctioning excess fluid using an assistant hand port.
The integration of robotic surgery into surgical education is often compared to the integration of laparoscopic and endovascular surgery, which occurred without significant challenges over the past three decades. Similar to laparoscopic and endovascular technology, robotic technology aims to assist physicians with complex surgical tasks by minimizing human error while increasing the technical ease of performing surgical interventions. However, one distinguishing feature of robotic technology is the independence it gives to a single operating surgeon. A single operating surgeon can control four robotic arms, including the camera, multiple instruments, and electrocautery devices. This independence is undoubtedly beneficial where resources are limited, but in the training environment, serious challenges emerge. In the traditional training environment, the physical involvement of residents is essential to provide the operating surgeon adequate visualization and assistance with retracting tissues. This natural dependence on residents to create a manageable and functional surgical field decreases with robotic technology.
The purpose of this study is to understand how robotic surgeons are approaching the integration of robotic surgery into resident training at their academic medical centers and to identify challenges and make recommendations. We hypothesized that our findings would reveal that today’s surgeons use different approaches to integrate robotic technology into surgical training, and that regardless of diverse viewpoints and methodologies, the challenges that emerge would reflect consistent themes.
Study design and participants
We conducted semistructured interviews over three consecutive days (March 22–24) at the 2017 annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons in Houston, Texas. We approached conference attendees randomly at separate locations throughout the exhibition hall and surrounding conference venue. We limited participants to active practicing surgeons who used robotic technology and worked with residents or fellows in the robotic operative environment. We excluded nonsurgeons and surgeons not using robotic technology. C.A.G. and K.M.M., both surgical research fellows, conducted the interviews. They approached attendees covering a broad age spectrum with the goal of obtaining input from participants with different levels of faculty experience. There were no time restrictions.
The semistructured interview questions were designed to solicit information about surgeon experiences with robotic technology and interactions with residents or fellows in training, challenges they have encountered, and recommendations for improving integration. The authors, who have a wide range of expertise in education and surgery, developed the interview script together (see Supplemental Digital Appendix 1 at http://links.lww.com/ACADMED/A671). (C.A.G. has a master’s degree in arts and education with a focus on health professions education from the University of California, Berkeley, and led the design and implementation of the robotic curriculum for the Department of Surgery, University of California, San Francisco; K.M.M. received a training grant from the National Institutes of Health [NIH] to take courses in research design; H.W.H. has received NIH funding for multiple research projects; P.S.O. has more than 10 years of experience with medical education research.) Questions were open-ended and broad to avoid presumptions about the robotic environment. Interviewers approached conference participants and asked if they were practicing surgeons using robotic technology. If they said yes, interviewers asked if they were willing to discuss their experiences. Initially, participants were asked to describe their experiences with surgical robotics and integration of these skills into resident training. To provide a degree of structure to the conversations, interviewers had a list of subtopics to use as discussion points, including the following: additional information about trainees, the operative environment, training materials, greatest challenges, comparison with other surgical approaches, and recommendations for improved integration of robotic technology into resident training. Interviews were considered complete once all subtopics had been addressed. Interactions and participant responses were documented with written notes and audio recordings. All written notes and summaries of audio recordings were anonymized.
Qualitative data analysis
To analyze our data, we used a form of qualitative analysis called progressive focusing,20 an analytical process that includes listing concepts reflected in notes and examining relationships between them.21 Specifically, we reviewed notes and recordings from participant responses at three points in time: immediately after the interview, the evening following a day of interviews (which took place on three consecutive days), and the week after the conference concluded. We created progressive summary documents with narrowing focus. Qualitative content analysis of the summary documents and audio recordings revealed four consistent themes discussed in the interviews. We summarized each theme based on the challenge it presented and then used these results to make an associated recommendation. Additionally, in response to a participant’s suggestion, we posted a question on a closed forum online to gather additional data to authenticate the results from the qualitative analysis.22
Quotations supporting these themes were recorded both from interviews and from more than 50 responses to the prompt we posted on a monitored social media platform for robotic surgeons: “For those teaching residents … could you give pearls, perspective, safety tips?”23 The University of California, San Francisco IRB approved this study as exempt.
Over three days of a national surgical conference, we conducted 24 interviews with eligible attendees. Our analysis of the interview data indicated that the first and most consistently cited challenge respondents faced when integrating robotic technology into resident training was the ongoing learning curve of surgical faculty using this new technology. By using thematic analysis, via progressive focusing,20 we identified an additional four themes highlighting challenges specific to robotics. Within each theme, although participant opinions and responses differed greatly, we identified a single associated recommendation (Table 1). Representative quotes supporting each theme are summarized in Table 2.
Theme 1: Technique versus tool
The first theme highlights tension between two areas of learning: surgical technique and the robot, the surgical tool. The faculty surgeons who participated in our study learned to use robotic technology after completing their surgical training. In other words, they had mastered the cognitive and technical skills needed as a surgeon; learning to use the robot was essentially supplemental to their foundational surgical knowledge. Today, integrating robotic technology into residency occurs at a very different stage of the surgeon’s professional development. Junior residents (postgraduate years [PGYs] 1–3) are just beginning to learn or are still learning critical components of surgical technique while simultaneously being introduced to robotic technology. Simply speaking, the way in which today’s teachers acquired robotic skills cannot be replicated with today’s learners. Today’s learners are faced with more complicated technology that is not just a supplement to core surgical technique: Tool and technique must be integrated. Our respondents acknowledged observing the degree of complexity their learners faced. Many commented that the volume of new information likely creates a state of cognitive overload24 in the operating room, decreasing residents’ acquisition of content required for the mastery of both surgical technique and the robotic tool.
Approaches to managing this challenge centered around using simulation to familiarize learners with the robotic tool in an environment outside of the live operating room. Most of the robotic surgeons we interviewed had trainees participate in dry labs or work with the da Vinci simulator (Intuitive Surgical; Sunnyvale, California) to teach robotic-specific skills such as docking (moving the base of the robot to the operative bedside and then connecting the robotic arms to ports and positioning them), instrument exchange, clutching (using a foot pedal to adjust between robotic components), and moving between robotic arms at the console. As one interview participant said, “The simulation system is very important for resident learning so that the[y] can become familiar with the robot and its capabilities” (Social media surgeon 28). According to the robotic surgeons, familiarizing residents with these components of the tool outside of the operating room appeared to increase trainee confidence during live operations. Some participants commented that trainees could focus on more technical components of the surgery if they were able to dock the robot and exchange the instruments more smoothly.
Given the repeated emphasis on learning the surgical tool separately from surgical technique and the advantages participants observed with simulation and dry labs, the following recommendation emerged: Differentiate learning environments for focused acquisition of surgical techniques and surgical tools.
Theme 2: Variable timing of exposure
The second theme gleaned from the semistructured interviews is the variability in timing of trainee exposure to the robot. We estimated that the educational levels of the populations our participants worked with were distributed as follows: 15% junior residents (PGYs 1–3), 55% senior residents (PGYs 4–5), and 30% fellows.
When we asked the surgeons what they thought the ideal stage of trainee would be, about three-fourths felt strongly that trainees should wait until reaching the senior resident or fellowship level before learning how to operate robotically. This sentiment is exemplified in the following comment: “A certain degree of operative skill is required to understand robotics” (Surgeon 22). These surgeons thought it was essential to thoroughly understand surgical technique and anatomy before integrating the complex technology of robotics. A smaller number of surgeons differed, thinking that specific robotic tool components should be taught at the most junior level because only minimal surgical knowledge or experience is needed to learn how the tool functions. Additionally, these surgeons claimed that basic principles of surgical technique could be taught more effectively using the robot, given the magnification of the surgical field and the ability to freeze the instruments when structures are visualized.
Despite the divergent attitudes about the best time to expose trainees to robotics, all surgeons agreed that trainees should initially use the robot to complete the more basic steps of a procedure. Surgeons commented that basic steps occur in all types of procedures, even technically complex operations. Surgeons consistently emphasized that learners should initially focus on the most basic operative steps of surgical procedures regardless of the overall complexity of the case. One surgeon (Surgeon 24) observed that junior-level cases often have a larger ratio of basic to complex operative steps than more senior-level cases. Therefore, the following recommendation surfaced: Regardless of level of training at initial exposure, provide increased access to cases with basic surgical steps in an effort to smooth the integration process.
Theme 3: Relationship of robotics to laparoscopy
As with the ideal timing of exposure, opinions about the relationship of laparoscopy to robotic surgery were strong and diverse. Respondents were perplexed about why they were asked, “Is robotic surgery more like open surgery or laparoscopic surgery?” as they insisted the answer was obvious. However, participants were divided in their responses, and their opinions correlated with when they thought robotics should be integrated into the resident curriculum. Respondents who claimed that robotic surgery was more similar to laparoscopic surgery than to open surgery thought robotics should be taught after trainees have learned the basics of laparoscopic surgery, as illustrated by this quote: “Laparoscopic skills such as patient positioning and port placement are critical for robotic surgery” (Surgeon 11). These participants believed that comprehending certain features of robotic technology required laparoscopic experience. They cited as examples previous experience with, and an understanding of, concepts such as port placement and triangulation. Moreover, participants emphasized that, similar to laparoscopy, the visual field in robotic surgery is limited and requires ongoing attention to the peripheral limits on-screen to identify possible complications occurring off-screen.
Other respondents, although they agreed that robotic surgery and laparoscopy have overlapping features, felt that the surgical technique using robotic technology was much more similar to open surgery than to laparoscopy. These surgeons pointed out that the hand and wrist movements used in robotic surgery are much more similar to those used in open surgery than to those used in laparoscopy, where there is a fulcrum effect. One surgeon (Surgeon 16) asserted that teaching concepts of open surgery was easier using the robot because the operation can be paused (and the instruments kept in a static position) while the instructor explains elements of anatomy or technique. The surgeons who thought robotic surgery was more similar to open surgery than to laparoscopy thought robotic surgery should be taught in tandem with other types of surgical procedures and did not favor sequential exposure to laparoscopic and robotic technology.
Despite these opposing views, all surgeons agreed that some features of laparoscopic surgery and robotic surgery overlap, leading to the third recommendation: Highlighting overlapping and varying features of laparoscopic and robotic surgery during all minimally invasive surgery cases will improve the learner’s understanding of these features regardless of sequence of exposure.
Theme 4: Dual console
The fourth theme highlights the dual console (a system that enables two consoles to operate the robot; the primary console determines what functions the secondary can use) as a unique teaching tool. The dual console seems to provide a platform that allows seamless role transfer from teacher to learner. The “seamless” component, emphasized by one respondent (Surgeon 6), differs dramatically from laparoscopy because the dual console enables transfer of the controls from one surgeon to the other with minimal tissue manipulation. Unlike the situation in open or laparoscopic surgery, with the dual console, surgeons do not need to physically exchange instruments or change positions around the operative table. Participants also highlighted the teaching assistance enabled by the dual console’s ability to provide graded responsibility: Instructors can decide if they want to relinquish one, two, or three of the robotic arms to the resident. Additionally, the dual console displays the identical three-dimensional image that the attending physician sees, providing excellent visualization of the surgical field and the pertinent anatomy.
Almost all surgeons mentioned that the dual console was a unique teaching tool in the robotic environment. Although all surgeons did not have a dual console at their institutions, all expressed interest in using this technology if it were available. However, a few highlighted some of the limitations of the dual console, including the loss of visualization of off-screen actions, the inability to mirror the actions that trainees should perform, and the difficulties in verbally explaining instructions to trainees. Although the dual console displays the same intracorporeal view to the attending surgeon and to the trainee, the visualization does not capture anything outside of the camera’s magnified view. Off-screen information includes the position and activity of instruments outside the camera’s range, the external components of the robotic equipment, and the operating surgeon’s actions (such as clutching or pressing foot pedals to exchange control of the instruments, introduce electricity, or staple tissues). Additionally, surgeons highlighted the importance of accompanying the graded autonomy innate to the robotic system with dialogue so that they could guide residents’ actions from a separate location (the other console). Surgeons reported that they find teaching challenging when a resident is in control of the robotic instrument because they cannot physically move the instrument to illustrate directionality or precise tissue manipulation. Instead, this operative guidance has to come from the instructor’s verbal description because joint movement of the instrument (as seen in open and laparoscopic surgery) is not possible. As summarized by one respondent, “It’s amazing how purposeful your communication needs to be when there are parallel tasks happening in a room” (Surgeon 16). Unaddressed, these limitations could significantly diminish residents’ skill acquisition, which is why the final recommendation is to use the dual console as a unique teaching tool to provide graded autonomy but to remember that verbal guidance is necessary to appropriately convey technique.
Since the emergence of surgical practice, training the next generation of surgeons has challenged educators. Recent attempts to standardize the resident training process have been confounded by efforts to reduce health care costs and decrease adverse outcomes.25 Emphasis on decreasing hospital lengths of stay and increasing clinical productivity results in faculty surgeons with less time for teaching or mentoring resident surgeons.26
With these evolving challenges, surgical educators must critically assess the effectiveness of educational techniques in the operating room. Efficient and effective training requires continuous evaluation and modernization to parallel the constant transformation of the operative environment (surgical classroom) and the learners within it.27,28 Recent examples of education innovation include the use of online tools such as social media, podcasts, videos, live streaming, and other resources.28–31 The process of introducing robotic technology into surgical training influences residents’ experiences and thus requires investigation.
The results of our study lend further support to ongoing concerns that the rapid growth in robotic technology has created new challenges for surgical educators.25,32 The first and most frequently cited challenge for surgeons integrating residents into robot-assisted cases is the ongoing learning curve of surgical faculty. This challenge has been documented in the literature on robotics25 and laparoscopy33 and is often present with any new technology. However, in our study we discovered themes with challenges that were not described with earlier technology. Additionally, for each of the four themes, we were able to identify an associated recommendation (Table 1) that we developed after considering the varying opinions of participants. These recommendations can benefit all surgical educators.
The first theme underscores the two types of skills residents must learn: surgical and technological. The surgical faculty who participated in our study were introduced to robotic technology after completing their general surgery training. Because of this sequencing, the instruction provided by the technology industry that specifically focused on the robot as a surgical tool was a sufficient addition to the surgeons’ already-established surgical expertise. Our results suggest that exposing trainees to fundamental surgical technique and the specifics of robotic technology in tandem may lead to a cognitive overload and result in decreased skill acquisition overall.34 By providing opportunities for focused acquisition of the robotic tool skills outside the operating room, trainees are prepared to use the operative environment to focus on learning surgical technique. Surgeons in other specialties than our respondents (who were mainly gastrointestinal and endoscopic surgeons), such as thoracic surgery, argue for a similar emphasis on simulation outside the operating room.35 Additionally, the materials created by the robotics industry for instructing fully trained surgeons to successfully and safely use the robotic tool may not be as effective with or applicable to a group of learners who comprehend less about surgical technique.
The second theme, which highlights opinions about the best timing for exposing trainees to robotic technology, reflects the various timings currently used. Some institutions are introducing robotics during the first year of surgical training, while others have a single month of exposure offered in the fourth year of training.15 To combat this variability and attempt to standardize expectations, some fellowships require completion of a robotic course before fellowship training starts. Further exploration is needed to determine the costs and benefits of these courses as robotic surgeries, and resident participation, continue to increase.
Variability of exposure is a challenge that has plagued surgical educators for years. Current techniques for increasing learners’ access to a wide variety of clinical presentations and diverse surgical approaches, and ultimately for standardizing the content of the educational experience, include the use of e-learning, online curricula, and simulation for surgical training.27 These methods attempt to increase the opportunities for hands-on experience and accessibility to information, but they cannot replicate the robotic experience. Thus, educators must consider how to increase access to the robot in the operating room. Greater access may be feasible if surgeons expand the number and type of basic surgical procedures using robotic technology (more basic surgical steps could translate into more learner opportunities). Of course, for every surgical operation, surgeons must consider all risks and benefits, and ultimately the type of surgical approach chosen should reflect what is best for each patient.
The third theme highlights an unexpected finding from this study. Opinions regarding the similarities of robotic surgery to open or laparoscopic surgery were absolute but divided. Because robotic surgery is advertised as the most advanced minimally invasive tool, one can understand the argument that robotics is an extension of laparoscopic surgery. However, recent research suggests that a preexisting understanding of laparoscopic technique may make learning robotic skills more difficult.36 This finding supports the argument that learning how to operate robotically and learning how to operate laparoscopically require different skill sets. By emphasizing overlapping and varying features of laparoscopic and robotic techniques, educators can begin to define these similarities and differences for learners. Using all minimally invasive surgeries as an opportunity to discuss both laparoscopic and robotic technique allows trainees to better understand multiple modalities of minimally invasive surgery. With the technological advances occurring throughout the surgical field, comprehension of multiple modalities appears inevitable.
The final theme highlights the dual console as a unique teaching tool that provides seamless role transfer between two surgeons. However, unlike other modalities of surgical technology, use of the dual console requires verbal instruction. The need for appropriate communication in the operating setting is hardly new, but the challenges of the surgeon being at a distance from other team members is a new feature of the environment created by robotic technology37 that influences the importance of direct and effective communication. Without understanding off-screen components of the operating room, trainees will be unable to independently recreate the same surgical field and adequately employ the appropriate surgical technique.
Despite our findings, we recognize that the study has several limitations. Using interviews allowed for exploration and analysis of robotic surgeons’ perspectives. However, we were limited to interviewing surgeons who were both present at the conference and available to meet with us, and thus our interview data do not include perspectives of current trainees. Additionally, interviewing in the context of a meeting resulted in an inconsistent collection of demographic data. We do not know the age range, surgical specialties, geographic regions, or gender composition of our group of participants. Collecting data at a single event, although nationally attended, could have created an unintentional respondent bias. Additional studies are needed to explore the degree of generalizability of our findings. Finally, the format of our data collection precluded validating our participants’ responses.
This study confirmed that integrating robotic technology into resident training is indeed challenging. Additionally, this study yielded four recommendations that are likely to improve the process of integration and, ultimately, trainees’ ability to provide appropriate and safe patient care regardless of the ever-changing operating environment. Future studies are needed to determine whether these recommendations improve the integration of robotic technology into resident training at academic medical centers.
The authors wish to thank Pamela Derish at the University of California, San Francisco, Department of Surgery for editorial assistance.
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