Latest / Show Me The Evidence / Dr Ruben DeGroote, From Proficiency to Wisdom in Surgical Training

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Dr Ruben DeGroote, From Proficiency to Wisdom in Surgical Training · Show Me The Evidence

0:07
My guest today is Dr. Ruben De Groote.
0:10
Ruben and I met in 2019 when we were
0:13
developing and validating the metrics for the robot assisted radical
0:17
prostatectomy. Ruben is a consultant
0:19
urologist at Azorg in Aalst in Belgium
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and his practice primarily consists
0:25
of robotic surgical procedures mostly
0:28
oncological. He is the CEO of 4Health
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and it's very successful digital platform,
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learning platform, SurgeQuest.
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Ruben recently completed his PhD on the
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development and evaluation of a proficiency based progression robotic
0:44
surgical training program for three
0:46
surgical disciplines and proficiency
0:48
based progression and training will
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form an important part of our conversation
0:53
today. You're very welcome Ruben to show me the evidence.
0:59
Ruben, what are the fundamental
1:01
limitations of current surgical education models that
1:05
make a new approach to teaching and learning
1:07
operative skills not just desirable but necessary?
1:11
What's your views on that?
1:13
It's not an easy question to answer, but then
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again it is because the problem is very, very
1:23
clear.
1:24
Surgical education as it was in the past
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and as it was until very, very recently is not
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the same anymore as it is now and as it will be in the near future.
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The problem is that the way how surgical
1:40
residents were trained in the past is not possible anymore
1:45
to get to the same stage and to the same level
1:49
of expertise by the end of residency training.
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So before about 100 years ago surgical
1:55
residents started training using the Holsted model, the
1:59
apprenticeship model, the see 1-do 1, Teach 1
2:02
model as they say and everything stands or falls
2:07
by exposure.
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So in the ideal way surgical residents they
2:13
are being trained using surgical exposure.
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So this is if you were in a good training
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centre this was actually applied step wise.
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So you first got exposure by observing cases
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in the OR then you might go a little bit closer.
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You actually be sterile at the operating
2:33
table to see the procedure a little bit better.
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Again, better exposure.
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Then probably when you get a little more
2:40
experienced and if you make some steps on the ladder you
2:44
can increase your exposure by doing
2:46
some basic steps of the procedure.
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And so you evolve step wise gradually in
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your surgical exposure where at the end of your
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training you were supposed to be able to do
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independently complex steps of surgical procedures
3:01
and basically also full surgical procedures independently.
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Now over the last 15-20 years the circumstances
3:12
of surgical training have changed significantly.
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There are different external factors which
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make that surgical exposure in the OR has
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diminished significantly.
3:25
The residents nowadays they have to attend
3:27
way more bureaucracy and this is not a long
3:30
time.
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When I was a surgical resident and this is
3:33
not that long ago I was able to actually do
3:36
all my bureaucracy before 10 o'clock in the
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morning and then I went to the OR to get the
3:41
exposure in the OR that I wanted to have.
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Nowadays surgical residents even if they
3:47
are very ambitious and they do their best they
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have to spend at least half a day at the OR to
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actually deal with all the bureaucracy before
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they can get into the OR.
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So that's problem number one.
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Problem number two is that there is a restriction on working hours.
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So surgical departments are actually being
4:08
punished legally if they allow the residents
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to work more than 60 hours a week on average.
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So this makes that they get again less exposure
4:19
in the OR and so that they are actually getting
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less trained according to the training model.
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And so this is a vicious circle where
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they are in because they get less exposure.
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So by the end of their training because we
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are still in a time based curriculum where
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they actually get five or six years of
4:38
surgical training and then they have to be finished.
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By the end of their five or six years
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they are deemed to be independently.
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But because of the lack of exposure which
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is still the cornerstone of surgical training
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we know based on good publications that
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almost one out of three surgical residents are not
4:55
independently ready anymore to do surgical practice.
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And this is of course a hazard for patient safety.
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Now luckily most of the surgical residents
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are quite smart and they realise that they
5:08
are not ready.
5:09
So what they do, they don't go into
5:12
independent practice but they go into different hospitals
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to do fellowships to actually get to the level
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that they want to have before doing independent
5:21
practice.
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And so these fellowships, and I did a
5:24
fellowship myself, it was actually to super specialise
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myself into surgical robotics because I was
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already able to independently do a surgical
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procedure at that time.
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They are now being transformed into sort
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of an extension of surgical residency to get
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independent in their practice.
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So this again leads to less exposure
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of the residents who are still there.
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So this is a vicious circle and this is really
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really going fast that the exposure has diminished
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significantly and so the cornerstone of the
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time-based curriculum, this exposure is vanishing
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very fastly.
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So there is probably no space anymore.
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It's not justifiable anymore to actually
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go with this way of surgical training in the
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future.
6:12
Can I ask you a naive question?
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Where did all this bureaucracy come from?
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Well I mean I don't know.
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I do know.
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I have been a resident myself and I have seen it changing.
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This is a change in medicine in general.
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It's not only in surgical medicine.
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This is a phenomenon where people
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don't want to take responsibility anymore.
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Before when I was a resident, nurses were
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allowed to accept verbal orders to give medications
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for instance.
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Nowadays, they are not allowed to do that
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anymore because they don't want to take the
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risk.
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They don't want to take the
6:53
responsibility anymore and it's not their fault.
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They are not to blame.
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But it's actually the hospital management
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who forced them to not do this because if
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they do, they are getting punished.
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The consequence is that for the most simple
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task, even prescribing paracetamol for instance,
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there needs to be a written order.
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So this extremely increases the bureaucratic
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burden for everyone, not only for the residents
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but also for the nurses.
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This is good until a certain extent because
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of course before there was no written orders
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whatsoever.
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So you need to have some standardisation.
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But nowadays, you are living in a time that
7:38
the smallest thing you do needs to be written
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down and this is actually backlashing extremely.
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So what you're saying is more process driven
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practices imposed on surgical trainees which
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is actually impeding on their time and you
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describe it as exposure to the operating room
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and what's required and so on.
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Are these problems the same or worse for robotic surgical training?
8:06
Well, I think that robotic surgical training
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is quite special because it has pros and cons.
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Robotic surgery is a challenge for surgical training.
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Why?
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Because you have to combine two different aspects.
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You have to combine quite challenging procedures.
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This can be procedures of any kind.
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But most of the procedures that you do
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robotically, they actually have several steps.
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They have different possible errors which can occur.
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So they are quite complex and challenging procedures.
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So these procedures by themselves are not that easy to learn.
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But then again, you also have the
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technological part which needs to be combined.
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So you have to master the technology, of
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course, before you can actually apply the added value
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of this technology for the sake of your procedure.
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So this is a challenge on its own.
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I think, however, that robotic surgery is
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a really good thing to apply new training
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and methodologies on because where it differs
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from open surgery or pure laparoscopy, for instance,
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is that robotic surgery, you have a
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computer in between of your eyes and the patient.
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So this allows to store your video
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files, to store all your surgical data.
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And this allows you to actually go back
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into your surgical procedure, to review it,
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to give formative feedback to your
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residents and to also measure some kinematics
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which can make a difference and which can
9:28
actually objectify your surgical procedure.
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So I think that robotics is a really, really good tool to measure
9:35
surgical quality in order to improve it.
9:39
Oh, I agree with you about robotics.
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But is observing somebody using the robot
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and doing the procedure, is that sufficient?
9:47
Because I mean, what you were saying previously was that it was in
9:52
surgical training, it was exposure.
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And to be quite frank with you, I'm not
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convinced that exposure on its own is sufficient.
9:59
I think you're going to need some sort
10:01
of structured and metricised training.
10:05
And there was a structure in the Halstedian approach.
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I mean, but he or his colleagues imposed the structure.
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And for robotics, you know, you absolutely,
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I think you absolutely need that structure.
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Would you agree or?
10:22
Yes, absolutely.
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I think this is the case for every technology, whether it's robotics
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or where you implant cardiac pacemaker device, for instance,
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every technology stands or falls with the use of it.
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Still, we are living at a time where the added value of robotics is
10:37
being disputed because some people
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actually don't use it as it should be used.
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So, of course, exposure is not enough.
10:45
It's how you do it.
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In the time when Halsted at John Hopkins actually developed the
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training methodology of the see 1-do 1, teach one,
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he was like the chef of a very famous restaurant.
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Let's say there were a few hospitals very well known for surgical
11:03
training where everyone wanted to go.
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It's like you had a very few very well
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known restaurants with very good chefs.
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And actually they made the laws.
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They made their own recipes and they made it happen.
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They took care of their residents and
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they made a good training curriculum.
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But it was not universal.
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There was no universal cooking recipe,
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which was applicable for every single centre.
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And so I think that you're coming now in an era where we need much
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more standardisation of surgical training.
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You cannot only rely on being in a very good
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surgical training centre to get proper surgical training.
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There needs to be benchmarking on
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surgical quality, on surgical training.
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Not every one, not every single centre where they perform surgery
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should be allowed to probably do surgical training unless they have
12:01
proven to reach certain benchmarks of quality of surgical training.
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So this is trained trainer, of course.
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But also the methodology which should be used in those training
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centres should be universal and should be driven by science and by
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scientific evidence rather than only to rely on the expertise and the
12:19
experience of the trainer who is
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actually present in that training center.
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So the apprenticeship model has served certainly surgery and
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procedure based medicine for more than a century now.
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So I'm getting the impression that you think that it's more than
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simply the problems that the
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training, surgical training is facing to.
12:41
It's more than simply a reduction in work hours.
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It's more probably than a problem simply of exposure.
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So do you think there are more systematic issues that need to be
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addressed in not just surgery, but in procedure
12:57
based medicine in terms of a training paradigm?
13:01
Yeah, yeah, absolutely.
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So exposure is one thing.
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But during my residency and during my fellowship, I was lucky enough
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to see different people, different ways of surgery.
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And this, of course, can be an added value because there are
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different ways to skin a cat and you can get
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to the same surgical outcome in different ways.
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So learning different ways how to do a
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surgical procedure is definitely an added value.
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But what I also have seen, and this is a downside of not having
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standardised surgical training curricula, is
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that different people train in different ways.
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And this can be extreme.
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If you're unlucky and if you're with a trainer who actually is not
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interested in giving surgical training, you
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won't get any surgical training whatsoever.
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And this can be purely determined by the fact that this person
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doesn't like you, for instance, or he doesn't like a certain, he
14:00
doesn't like the fact that, for instance, female surgeons are getting
14:02
into surgical training more and more.
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This is something that we see that female surgeons often complain
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about the fact that they get less
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training just because they are females.
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And so you're extremely, you're very much
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depending on the goodwill of your surgical trainer.
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What I've seen during my fellowship and we were six, we were sorry,
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you were six fellows and there were nine
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different consultants doing all radical prostatectomy.
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And one week you get trained by one consultant, the other week you
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get trained by another consultant.
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And by the end of your week, when you actually appreciated certain
14:36
ways of how to do that part of the procedure, you went to the other
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consultant and he said, like, what are you doing?
14:40
You're doing completely wrong.
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You should do it like this.
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So this is crazy for me.
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I mean, there are different ways, but it's not
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that one way is wrong and the other way is only right.
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So there is a complete lack of standardisation.
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And this was not in a very small hospital.
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This was in the biggest UK cancer centre where I did my fellowship.
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So the lack of standardisation is a real problem still nowadays.
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And it's only increasing, in my opinion.
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For me, what is also one of the biggest issues is that nowadays
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surgical safety more and more is being compromised.
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People are not ready anymore at the end of their training to
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independently operate on patients and patients are not only being
15:25
used as training models, according to the
15:27
apprenticeship model in the beginning of training.
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But they're actually, and this is more dangerous, they are being used
15:32
as still training models of consultants who are not ready anymore
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because they didn't get trained well.
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And so the patient is the victim because they will get worse outcomes
15:45
because of the lack of training of this person.
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And so I think this is something that needs to be addressed legally.
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There needs to be benchmarking of surgical quality, not only at the
15:58
end of surgical training, but also during surgical training, at the
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beginning of surgical training, who to allow, who has enough talent.
16:08
This can be measured to be allowed to get into surgical training.
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So benchmarking, I think it's everything.
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And this actually defines how I would see it
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because we are still now in a time-based curriculum.
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Everyone does five or six years of surgical
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training, depending on the specialty where they're in.
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And at the end, they actually get a thumbs up or a thumbs down,
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mostly as a thumbs up, whether they're good enough to start or not.
16:33
Very, very subjective.
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But we know that most of the people are not ready anymore.
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And so you need to move away from a time-based curriculum to a more
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competency-based curriculum where some people probably will not even
16:46
meet four or five years to get
16:49
completely proficient at certain procedures.
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Then again, some people will need more, will need seven or eight
16:57
years to get to the same level of proficiency.
17:01
And that's okay.
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Not everyone can be as talented as the others, but at least you will
17:06
have safe surgeons when they start.
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Yeah, I totally agree with you, Robin.
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At Yale, when we did the VR to OR
17:14
study, there was one of the surgical residents.
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She took the longest to demonstrate the proficiency benchmark.
17:21
And that was fine because it was on a simulation.
17:24
But when she got to the proficiency benchmark,
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she performed the best in the operating room.
17:29
And I think trainees and residents need that space, not just to learn
17:35
the task, but also to hone their skills
17:37
so that they can perform consistently.
17:40
But I suppose this is an unfair question.
17:43
Who should be doing that?
17:45
Who should be policing those standards?
17:48
Who should be imposing those standards?
17:51
Because industry worries about this as well.
17:53
Industry sees individuals, surgeons,
17:55
cardiologists, radiologists using their devices.
17:58
And they know they're not ready, but
18:00
they can't say to them, you can't do that.
18:02
And they would like to push it back to your academic training centres
18:08
or places like Orsi to say, okay,
18:10
you tell us when this person is ready.
18:13
Everybody's looking around for somebody
18:15
else to impose or police those standards.
18:19
I mean, the European Robotic and Urological Society, I think they're
18:22
one of the leading professional or scientific societies in the world.
18:26
And they seem to have grasped that nettle with their fellowships.
18:31
And I suppose the question is, who do you think should be setting
18:35
those standards, policing those standards and
18:39
advising the residents you're not ready to go?
18:42
Well, I think there are different instances.
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So you have setting the standards
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needs to be done by scientific research.
18:51
This cannot just be the opinion of one or a group of people.
18:55
This should be based on scientific research.
18:57
I think PBP is the is a very, very good example of how you set the
19:03
bar, you know, how you set the benchmark.
19:05
This is not something that which is just, you know, opinionated or
19:09
split out of the air is actually the result of a rigorous scientific
19:13
process to get to a very exact description of a surgical procedure
19:17
with the very exact definition of steps, errors, which actually
19:22
represent the ideal way of how to do a certain surgical procedure.
19:24
So I think that it's scientific work done by scientific institutions,
19:30
scientific societies, which needs to set the benchmark.
19:35
I don't think that the scientific societies
19:38
should be in charge to make these benchmarks mandatory.
19:42
I think that this should be a work for the authorities.
19:46
If you see I'm a medical doctor, I
19:48
am allowed for prescribing medication.
19:51
I was allowed to do this after seven years of medical studies.
19:56
I got a diploma and since I got the diploma, I got also the, you
20:00
know, the the fact that I could prescribe medication.
20:04
I think that there should be a sort of a parallel.
20:06
You have credentialing for medicine.
20:09
You you want to go to more credentialing on a lower level micro
20:15
credentialing for certain technologies, certain surgical procedures.
20:19
It's not because you're a urologist that all of a sudden and you get
20:23
a diploma to do that, that all of a
20:25
sudden you're also a good robotic surgeon.
20:27
This is just, you know, this is this is maybe not implemented in your
20:32
surgical training and you should be able to prove that that you can
20:35
that you can use this technology for for the benefit of the patient.
20:38
So I think that the authorities did the and this
20:43
this this of course is government universities.
20:46
I think that should be able to control who can do what and this
20:52
should be driven by scientific research by the scientific societies.
20:55
Yeah, industry.
20:56
I think industry just to conclude, I don't I don't think that
21:00
industry should have a large role in that.
21:03
Let me give you an example.
21:06
Industry has a conflict of interest.
21:09
Industry is driven by sales.
21:12
They want to sell systems.
21:15
If you have a good industrial partner, they will be willing to that
21:20
their systems are being used properly.
21:23
Then again, most of those commercial institutions, these companies,
21:29
they don't really care as long as they have sold their system.
21:32
I'll give you an example.
21:33
I'm asked from time to time to do proctoring.
21:39
And this can be and most of the times is
21:41
proctoring for people who are extremely novice.
21:45
Now, for me, I really, really don't like to do that because you come
21:48
into a new or an or which you don't know there is a person who is
21:54
assumed to do the whole procedure under your supervision.
21:58
And you are actually not allowed or very limited to take over.
22:03
So this goes completely against proficiency based progression
22:08
training, benchmarking, measuring quality.
22:11
And this is endorsed by industry and maintained by industry because
22:16
you're getting paid to do that as a proctor by industry.
22:20
And I think I really don't like to do that proctoring, that kind of
22:23
proctoring when I train my own
22:25
fellows, according to the PBP principles.
22:28
And they will never be allowed to do a nurse pair, for instance, when
22:31
they are not able to do properly a bladder neck dissection or to do
22:36
less complex parts of the radical prostatectomy.
22:39
But as a proctor pay by the companies, you're being forced to
22:45
actually guide someone very difficultly through the bladder drop.
22:49
And in the same procedure, you have to guide this person through the
22:52
nurse pair, which is far more complex.
22:55
So this goes completely against
22:57
principles of benchmarking and quality assured training.
23:01
Yeah, I mean, I mean, frequently devices fail in the marketplace and
23:06
it's really nothing to do with the device.
23:09
It's that the individuals that are using the
23:10
device are not prepared or not ready to use the device.
23:14
And I would have thought industry would
23:15
have caught on to that quite some time ago.
23:18
Can I just digress slightly?
23:20
OK, you've done a fair bit of work on publish or on teaching
23:24
multidisciplinary surgical trainees.
23:28
And the data that you've published seems to offer a compelling reason
23:33
for reimagining surgical training.
23:36
So why is this shift in approach now an imperative for health care
23:41
education more broadly and not just simply for surgery?
23:46
Yeah, so we did a publication where we did a random mass control
23:51
trial where we compared two training methodologies.
23:53
We had the apprenticeship model according compared
23:56
to the proficiency based progression methodology.
23:59
And it was very briefly summarised.
24:02
It was clear that the PBP methodology group, they outperformed the
24:07
traditional trained group, the apprenticeship model significantly.
24:10
So 67 percent of PBP trainees were proficient by the end of the day
24:16
versus 17 percent of the apprenticeship model trainees.
24:20
Now, we deliberately did this RCT as a multi-specialty trial.
24:25
So we included urologists, general surgeons and gynaecologists.
24:29
And this was driven by the fact that there is a very strong opinion
24:34
by certain people in surgical
24:37
medicine that some surgical specialties are
24:40
less skilled than others and actually have way more complications.
24:46
So I am not saying that certain surgical specialties are more skilled
24:50
than others because I think this is definitely the case.
24:54
But the question is why?
24:57
Sometimes it's said like it's because you're that sort of surgical
25:00
specialty and you're born with less skills.
25:04
So what we shown in the in the Propisa
25:07
trial, this RCT, is that this was not the case.
25:11
So the three specialties when they did their first physical urethral
25:17
anosymaosis, the baseline assessment of that very specific task, they
25:22
all performed equally well or badly.
25:25
So they were all not very good.
25:28
By the end of surgical training, they
25:30
all performed as well as each other.
25:32
The three surgical specialties.
25:34
The only difference was that all the surgical trainees, all
25:39
specialties in the PBP group outperformed the apprenticeship model
25:43
trainees in every different and every single specialty.
25:47
So the conclusion there is and these were all robotic naive trainees.
25:51
There were first or second year.
25:52
The conclusion is that it was not their surgical specialty, which was
25:56
predicting their surgical skill set at the end of training.
25:59
It was actually the methodology itself.
26:01
And so what we very often lack in training of surgical specialties is
26:08
that people are being trained only within that surgical specialties.
26:13
And so, of course, there are some habits of surgical medicine is
26:18
actually is built on habits and habits which
26:21
are actually being maintained over generations.
26:25
The way how you close an abdomen, for instance, can be different if
26:28
you're a gynecologist or if you're a general surgeon.
26:31
And this is, you know, this is being maintained because there is very
26:34
little crossover between specialties during surgical training.
26:37
Probably it's differences in surgical training methodologies and
26:41
surgical training between different specialties,
26:43
which determine the difference in skills at the end.
26:45
I was lucky enough during my first year of urology training.
26:49
I did a lot of cardiovascular surgery, a lot of
26:52
thoracic surgery, a lot of intensive care unit work.
26:59
And I really, really benefit from it
27:01
because cardiovascular surgery has learned me.
27:05
Not skills per se.
27:07
I don't have to do vascular anosyma or
27:09
very, very little, of course, as urologist.
27:11
But what I learned is the appreciation for standardisation, need for
27:16
systematics, need for teamwork, which is so very significant,
27:21
important in cardiovascular surgery, for instance.
27:24
And these are principles which I still use being a urologist.
27:28
And this is something which I very often don't see with colleagues
27:31
because they haven't been trained in these specialties.
27:35
So I think that it's a plea to try to build in crossovers in surgical
27:42
training curricula to learn from different specialties and to
27:47
actually get less differences in surgical skills between specialties.
27:52
Yeah, I mean, my interpretation of that published study was that it
27:58
was the systematic, scientific, quantifiable, evidence-based approach
28:04
that actually led to the PBP group, the gynecologist, the general
28:08
surgery and the urologist, to them performing better.
28:12
So it really goes back to more than just exposure.
28:15
I think it's a systematic approach to training.
28:18
So if you want to be that
28:19
systematic, you probably need to quantify it.
28:22
So to what extent is it possible to reliably
28:25
quantify interoperative surgical performance?
28:28
And what do you think are the key methodological and practical
28:32
challenges involved, particularly in developing validated metrics?
28:38
Yeah, so I'll give you an example to start with.
28:42
So I was asked to be part of a study to assess the surgical skills of
28:48
more than 100 senior surgical trainees on a vascular
28:53
anastomosis on the kidney transplant model.
28:56
And so I was very enthusiastic
28:59
and the first five or 10 or 15 videos,
29:03
each day took about 10, 15 minutes.
29:05
I watched them completely.
29:07
And so I was asked to use
29:09
the Likert scale based scoring tool, the GEERS score.
29:15
It's an abbreviation for the Global
29:17
Evaluated Assessment of Robotic Skills.
29:20
And so I was asked to use these Likert scales
29:23
based tool to assess the surgical performance.
29:26
And so the first couple of videos, I watched
29:28
them completely because I wanted to see the skills.
29:31
Now, very quickly, I noticed that my scoring of a certain procedure
29:36
really depended on the procedure which I saw before,
29:39
because I was continuously comparing people with each other.
29:42
And so probably the first video that I scored, if I gave a three out
29:46
of five on a certain skill set, that might not have been the same as
29:51
a three out of five as I had given after 10 videos.
29:55
So this means that there is a very, very subjective way of scoring
30:00
certain domains of surgical skills.
30:03
So that's one of the problems.
30:05
And so this GEERS tool still represents the most used way of scoring
30:13
robotic surgical skills in surgical medicine.
30:17
And so the subjectiveness, that's one.
30:21
Now, I'm speaking about
30:22
subjectiveness, just comparing videos to each other.
30:25
Now, subjectiveness can go to an extent way further.
30:31
The subjective feeling of a trainer towards a
30:34
trainee when he is not blinded makes a big difference.
30:38
When a trainer doesn't like the trainee for different reasons, he
30:42
will probably score less good than
30:46
someone that he likes or she likes.
30:48
And this cannot be controlled.
30:51
There is no way to say you scored this
30:53
person lower because you don't like him.
30:56
He can just claim I scored it
30:58
because I think this is the proper score.
31:01
So subjectiveness, that's a real problem of these Likert scores.
31:08
Then, of course, that's limitation number one.
31:09
Limitation number two is that you have a
31:13
big issue of inter-reader disagreements.
31:16
What is three out of five on a certain domain for me?
31:21
It is not a three out of five on that very same domain for the very
31:25
same procedure for another person.
31:27
We know that if you want to have a diagnostic tool to be valid to
31:32
assess surgical quality, according to the standard of psychology, you
31:35
need to have an inter-reader agreement between two independent
31:37
reviewers of 80 percent or higher.
31:40
We know that the GEERS scores lower.
31:42
In our study, we only had 30 percent of agreement
31:45
between two readers of the same surgical procedure.
31:48
So actually, by default, this makes this tool not
31:51
valid anymore to be used to assess surgical quality.
31:55
So inter-reader agreements, that's a second limitation.
31:59
And then third, it's an advantage, but
32:02
in my opinion, mainly a disadvantage.
32:04
This is very, very generic.
32:06
This GEERS score, for instance, can be used, can be applied for any
32:09
given surgical robotic procedure, whether it's basic, whether it's
32:12
complex, whether it's very advanced.
32:14
It's very, very generic.
32:15
And so if I go back to the example, which I gave at the beginning of
32:21
this explanation, I had to do 100.
32:25
The first 10-15, I watched them completely.
32:29
The last 80, I watched maybe two minutes of every video because that
32:33
for me was enough to actually make an assessment and make a score.
32:36
And there was no way how the people who were responsible for the
32:40
study could correct me and say, like, did you watch the whole video?
32:44
I said, yeah, maybe I've done it.
32:47
So there is no.
32:48
So this is very unfair, in my opinion, to the ones who are actually
32:53
doing the performance because it's your own personal opinion.
32:58
And this is evidence based medicine, which actually you make it more
33:03
important than scientific research and scientific evidence, which is
33:07
the core basis of evidence based medicine.
33:11
So I have significant problems with these Likert scale based tools.
33:15
So and I definitely think I definitely think that there is a way
33:18
forward using metrics because metrics are procedure specific.
33:24
You mean binary metrics?
33:26
Binary metrics are procedural specific.
33:29
So you can only use a certain metrics for a certain procedure.
33:33
These are not applicable for other procedures.
33:36
And this, of course, makes it less generic, makes it, of course, also
33:39
more laborious because you are forced to
33:42
watch the whole surgical procedure in order to
33:44
make an assessment.
33:47
But this is binary.
33:48
You can only score what you see.
33:49
This is zero or one, a step of here, according to a certain
33:54
definition and an error was done or wasn't
33:56
done according to a very specific definition.
33:59
So there is no way to cheat.
34:01
And this is not your opinion.
34:03
You're just following the metrics.
34:06
And these metrics are not made by you, by your personal opinion.
34:09
This was the result of a scientific, of
34:13
scientific research, of evidence based medicine.
34:16
And so you're just applying the results of
34:19
evidence based medicine to that surgical procedure.
34:21
So actually metrics and PBP rules out the personal opinion of a
34:27
certain assessor, a certain surgical
34:29
trainer, of the performance of a surgical trainee.
34:35
And so this makes it fair and very transparent because you know
34:40
exactly what they did and you know, be more important, you know
34:43
exactly what that actually did wrong.
34:46
And so if you go back into the metrics after a procedure, you can go
34:50
to the surgical trainees and you can say
34:51
like here, here, and here you made an error.
34:54
So here you have to pay attention
34:56
next time in order to avoid that error.
34:59
And so like this, they will improve very, very fast and they will
35:04
improve their outcome very, very significantly.
35:06
So what you're saying is the binary
35:07
metrics are not just for assessment.
35:10
They're actually for giving the
35:11
trainee feedback on their performance.
35:14
And I'm assuming that the advice is pretty explicit.
35:19
It's not like a Likert skill.
35:23
So until very recently, in the hospital where I work in in Aalst in
35:27
Belgium, we have a lot of fellows there.
35:29
And so every Thursday, by the end of the day, after the robotic
35:35
procedures, we come together as a group.
35:38
And every time one or two fellows are being asked to show a part of
35:44
the procedure which actually did themselves.
35:46
And so we have a very big screen.
35:48
We make it a split screen.
35:49
So you have the surgical procedure on one side of the screen and you
35:52
have a dedicated, validated operative metrics of radical
35:55
prostatectomy on the other side of the screen.
35:57
I'm just there as a facilitator.
36:00
I am just there to translate these metrics to those procedures.
36:05
And so we go over these procedures and I say like this step,
36:08
according to the metrics you performed well or you didn't perform it.
36:12
You did it or you didn't or you didn't do it.
36:14
And here, here and here, you actually made an error.
36:18
And so this is, of course, extremely valuable for these trainees
36:21
because they get formative feedback.
36:22
You're not lashing, you're not bashing on them.
36:24
You're just pointing it out.
36:27
So this is not my subjective feeling.
36:29
It's just me translating metrics to a certain procedure.
36:33
But also for people who are sitting around the table, they hear this
36:36
formative feedback and they learn from it.
36:38
And this is way more valuable than me just saying this is good or
36:43
this is not good because you don't know why it's not good.
36:46
You know, you have to say, you have to point out the errors.
36:52
So for me, this is the clinical translation of how PBP should be done
36:56
in procedural based medicine in the operating
36:59
theatre because you are not as important as you think.
37:03
Eminence based medicine is ruled by people who have a God complex.
37:10
They think that their way of doing
37:12
a procedure every time is the best.
37:17
But PBP rules it out.
37:21
People actually, we know this based again on big studies.
37:26
We know that people who are deemed by
37:29
scientific societies and not at least by themselves.
37:33
As being expert surgeons, high volume surgeons, very, very good.
37:37
They actually, when you score them based on metrics and we know that
37:42
this is associated with their outcomes,
37:44
they score sometimes extremely poorly.
37:47
And so there is no way to hide anymore.
37:49
You're just being assessed fairly and you cannot blame the one who is
37:54
scoring you because it's not this
37:57
person's fault that you're scoring badly.
37:59
It's just your own performance.
38:01
And with Likert scale tools, you can blame the person who actually
38:04
used the tool because it's his opinion against yours.
38:08
So do you think is proficiency based progression a better way to
38:12
train surgical and procedural skills?
38:15
Yes, absolutely.
38:16
So there is no doubt.
38:18
And again, this is not my opinion.
38:20
We just have to go according to the
38:22
principles of evidence based medicine.
38:24
When a methodology shows that you have when you apply it and you then
38:29
compare it to the traditional training to the apprenticeship model
38:31
that you have on average 60% reduction of
38:34
intraoperative, objectively assessed performance errors.
38:38
That you just have to accept as a
38:41
scientific society that this methodology is better.
38:44
And this is not only errors.
38:46
This is also being translated into better outcomes.
38:49
We know based on studies that if you do a certain surgical procedures
38:54
with lower amount of surgical
38:56
errors, that your outcome will be better.
38:58
And this is not dependent by the surgeon because we also know that
39:02
it's not because you're deemed to be a good
39:03
surgeon that your outcome always will be good.
39:06
If you make, if you have a bad day, if you have been drinking too
39:08
much the day before, and if you make a lot of errors during that
39:12
procedure, your outcome will be bad.
39:14
But if you, if you push the limit, and if you try to do your best,
39:18
and if you avoid errors, then your outcome will be good.
39:22
So, and this is, I think this is something which is really shocking
39:26
because people still surgical medicine goes with the big names.
39:31
People are actually thought to be good surgeons, whether they have
39:36
slept a lot, whether they didn't sleep well the night before.
39:42
It is all about surgical quality.
39:46
And of course, big names, most probably have good performance and
39:52
make low errors, but this is not automatically like this.
39:57
Sometimes you can be a big name for other reasons.
40:01
And so PBP rules it out.
40:04
It's transparent and it's fair.
40:06
Yeah.
40:07
And so at what point in your career, your
40:11
young career, did you come to this conclusion?
40:13
And was it, was learning PBP and the whole
40:16
metricised approach mean did that impact on you at all?
40:20
Because I remember the first time I met you, we were working on the
40:25
scoring of the metrics for the radical prostatectomy,
40:28
robotic prostatectomy with nerve spurring.
40:31
And now you have very clear views.
40:34
You seem to have thought them through.
40:36
So when did you come to this
40:37
conclusion, you know, and why I'm curious?
40:42
Yeah.
40:43
So just as for my background, before I knew you and the principles of
40:48
PBP training, I was trained in a good way.
40:52
I had a good mentor, a very expert surgeon
40:54
who operated in a very, very systematic way.
40:58
I learned a lot.
40:59
I had a huge amount of exposure.
41:02
So I think according to the apprenticeship model,
41:04
I probably had one of the best trainings possible.
41:06
Just to give you an idea of where I was
41:10
at the moment that I learned to know PBP.
41:13
I was actually very, very happy with the way I was trained so far.
41:17
Then I learned to know the principles of PBP.
41:20
And in the beginning for me, this was
41:22
a little bit theoretical principles.
41:24
I got the story, but I was still a little bit searching on how to
41:31
clinically apply these principles.
41:33
And there are two distinct moments during my
41:38
surgical career so far that I noticed PBP works.
41:43
It's not only a theoretical principle.
41:47
The first time was when I was involved in the construct validity study
41:52
of the radical prostectomy metrics, where I had to watch a lot of
41:57
surgical videos, videos of novices, but also videos of very experts.
42:02
And I had to apply these metrics to
42:03
these videos in order to score them.
42:06
So by doing that, I really learned these metrics by heart.
42:10
I exactly knew the procedure divided up into different phases,
42:14
different steps and all the different areas at the different steps.
42:17
And so since then, for me, there is no way back anymore.
42:22
I cannot imagine doing or teaching a procedure not according to these
42:26
principles, because there is no alternative.
42:30
The metrics are the only very, very good, validated procedural
42:34
specific cooking recipe for this specific procedure.
42:39
Before it was only the non-written personal opinion of certain people
42:45
who actually learned you how to do a procedure.
42:48
And now all of a sudden I have this gold in my hand, this validated
42:53
piece of work, which actually explained
42:56
the ideal way of how to do this procedure.
42:59
So then I realised this is something
43:03
which is a hold on for me as a surgeon.
43:05
I can always go back to that and I
43:07
can actually measure my own performance.
43:09
I can actually see how I improve.
43:12
I can actually see which kind of
43:14
errors I made and how I can avoid them.
43:16
So there is no way back anymore once
43:18
you go into the PBP way of training.
43:22
And then the second moment was not applied to myself, but I always
43:27
had the feeling that if I would apply these metrics to someone else,
43:31
would they also catch the message?
43:34
And this was during the Provisa trial,
43:36
the RCT that we have done in Orsi Academy.
43:40
The very first minutes that we trained people in the PBP group,
43:45
according to those specific metrics, I knew it works.
43:50
Because if you give me two videos, one video of someone who is PBP
43:55
trained according to metrics and one video who is not PBP trained
43:59
according to the apprenticeship model, within 30 seconds blinded, I
44:02
can tell you which one is the video.
44:05
Because PBP trained surgical trainees, they think when they operate
44:11
because they think in order how to avoid errors.
44:16
So they move very smoothly, thoughtfully, slowly, you would say.
44:25
But every move they do is efficient and
44:27
every move they do is there to avoid errors.
44:32
And so they look slow, but they are fast because they make no
44:36
unnecessary steps and they make far less errors.
44:41
And they do all the steps as they
44:43
would do in the apprenticeship model.
44:44
In the apprenticeship model, they make errors.
44:47
And the thing is that they don't know they make these errors because
44:50
nobody pointed them out and they repeatedly
44:54
make these errors again and again and again.
44:57
And they will improve slowly, steadily, and they will in the end also
45:04
avoid errors because they get just more fluent in the procedure.
45:08
But if no one points out the errors, you
45:11
will not avoid them automatically immediately.
45:14
And so for me, this was very clear that if you apply this PBP
45:17
metrics, you will get your trainee to a surgical level so much faster
45:24
than if you would only use your personal opinion.
45:27
Yeah. So is PBP only for residents or do you think it might be for
45:31
the consultants or attendings as well?
45:34
No, absolutely. This can be applied for everyone.
45:36
This can be applied, of course, for surgical residents.
45:38
This can be applied in the beginning of the
45:40
surgical learning curve for very basic steps.
45:44
This can be for very complex steps.
45:45
This can be for advanced surgical procedures, for
45:49
novice consultants, even for experienced consultants.
45:51
So then this can be for nurses.
45:55
This can be for everyone.
45:55
So yeah.
45:57
Yeah. So do you think it's only for technical skills or do you think
46:00
it's for other aspects of learning?
46:03
No, I mean, PBP is all about standardisation
46:06
and making things systematic and efficient.
46:10
I think there is a very good paper written by Dorothy Breen.
46:14
And this was also on RCT.
46:17
It was actually the comparison of using PBP methodology versus the
46:23
standard way of doing it on handover of
46:27
patient communication using the ISBAR system.
46:29
And this is done standardly on ICU.
46:33
It was shown that if you apply PBP, if you apply metrics to handover
46:38
communication, to handover information on patients,
46:40
that you just do this way more efficiently, that you don't handover
46:44
information twice, that you don't
46:45
handover wrong or unuseful information.
46:49
You just are better in your
46:50
handover and it just makes sense, you know.
46:53
Yeah. Yeah.
46:54
I mean, the basis of proficiency based progression is that you start
46:58
with somebody that genuinely knows how to do the job and you work out
47:02
what is it they do, what is it they don't do.
47:05
And you don't start with just one person.
47:06
You start with three experts.
47:08
You take it to a group of their peers.
47:12
And so what you end up with is what you said.
47:15
You have a standardised recipe for what you do and what you don't do.
47:20
And it's my experience as well that I totally agree with you that it
47:24
drives the learning curve and accelerates it enormously.
47:29
Because there's no ambiguity.
47:31
I mean, we started off, we talked a few
47:34
minutes ago about the way that you get exposure.
47:37
This is not just exposure, it's instruction.
47:41
And I think that in part drives the whole process.
47:46
So what changes would you like to see
47:48
introduced into procedure based medicine training?
47:51
Because I mean, I know you're heavily involved
47:53
in training, not just training, but proctoring.
47:56
So what changes would you like to see?
47:59
So if we as a surgical community, which we just continue the way we
48:03
are doing it now and neglecting actually all the changing
48:08
circumstances, as we have discussed, bureaucratic circumstances,
48:13
legal circumstances, financial circumstances.
48:15
Working hours, then we just would be stupid because we are actually
48:18
driving a whole generation of surgical trainees into independent
48:23
surgical practice not being ready.
48:25
And we expose patients to surgical hazards.
48:29
It's actually allowing a group of pilots who are in training to fly
48:33
jumbo jets without actually having to show
48:36
them that they are proficient at a simulator.
48:38
So I think that it's time to change.
48:40
And this again, this is not only my opinion.
48:44
Already years ago, there was a proposal made by the Institute of
48:49
Medicine in the United States who are responsible for surgical
48:52
training that the time has come to move away from the time based
48:57
surgical training towards competency based surgical training.
49:01
We're benchmarking and measuring surgical quality based on
49:04
quantitative metrics based analysis is the cornerstone.
49:10
And so allow me to say that I'm still so, so frustrated when I see
49:16
that institutions like universities still very strongly hold on to
49:22
institutionalised way of surgical training.
49:25
It hasn't changed when we say that things are changing.
49:30
Allow me to say at very limited amount of places, more than 90
49:36
percent of the surgical training centres still do
49:38
training the same way as they did 100 years ago.
49:42
And as long as there is no directive from a government where you make
49:47
it mandatory, if there would be, for
49:49
instance, European guidelines endorsed by.
49:53
The European Association of Urology, for instance, which almost make
49:57
it mandatory to train according to certain
50:00
principles, then you will change something.
50:02
But if you just allow if you just allow people to chose the way they
50:06
want to do it, they will just continue the way they do it.
50:10
And what we need, in my opinion, is strong leaders, leaders who
50:15
actually are open, who are unbiased, who are open for the.
50:20
The results of scientifically endorsed papers who show that certain
50:25
methodologies just outperform other
50:27
methodologies and are strong enough.
50:29
To to force our people to apply them and and you need people who are
50:35
willing to do that and you need people who
50:38
are willing to avoid making compromises there.
50:41
Yeah, I totally agree with you.
50:43
I was in Melbourne a couple of years ago and somebody asked me, OK,
50:47
Tony, you've all this evidence about the effectiveness of proficiency
50:51
based progression and simulation training.
50:54
Why has it not been more widely adopted?
50:58
And the words were out of my mouth before I realised.
51:01
And what I said was a failure of leadership.
51:04
And I so I totally agree with you.
51:07
But I mean, this is a methodology has
51:09
been around for a quarter of a century now.
51:11
And why why why was was was Holsted able to to impose a certain way
51:18
of surgical training to a whole surgical community?
51:21
See 1-do 1, teach 1 was invented by him
51:23
and was a standard of care for more than 100 years.
51:26
This guy was a very strong leader.
51:28
He has a very big name.
51:30
He made a lot of revolutions in surgical medicine.
51:33
And so he was actually able with his name and with his power to to to
51:37
change something in surgical training.
51:39
But now circumstances have forced the
51:42
community to move away from that part of paradigm.
51:45
And we need to go into someone else.
51:46
And I think there is a clear answer which one to choose.
51:49
Yeah, I mean, one of the things that's always concerned me is
51:53
proficiency based progression is a paradigm that's got clear steps of
51:59
the development of the metrics, the validation of
52:01
the metrics and then the training of the metrics.
52:04
The one thing that has never been achieved.
52:07
I mean, after somebody gets trained to the proficiency in the
52:11
clinical situation, there's then the development of wisdom.
52:14
And I certainly have never been able to achieve or
52:20
get to the point where I could go about training.
52:22
There was a push for the PBP.
52:25
We're training them to do a standardised
52:26
approach on a fairly straightforward case.
52:30
The surgical community, the other
52:32
procedure based systems, they need more complex.
52:34
You've got to build.
52:35
If any ideas about how one would go about helping clinicians acquire
52:41
the wisdom within the PBP paradigm.
52:45
So just to explain maybe for the people who are listening or watching
52:49
is that so you have different steps up on the learning curve.
52:53
So when you do your learning curve, you can get to proficiency.
52:58
This can be done according to the standard apprenticeship model or
53:02
this can do this can be done according to the PBP methodology.
53:05
It will take you longer if you do it
53:07
according to the apprenticeship model.
53:08
But you will get you can get to a
53:10
certain level, which is called proficiency.
53:12
Proficiency for me means that someone is able
53:16
to perform a standard procedure in a safe way.
53:20
Will he be expert at that procedure?
53:23
No, not yet, because the next step in training, meaning going from
53:29
proficiency to a higher level of
53:31
surgical expertise, that's going to wisdom.
53:35
And for me, what is wisdom?
53:36
That's quite far up the learning curve still, because once you're
53:41
proficient, once you're safe at a
53:43
certain procedure, you will need to have.
53:47
I think, first of all, volume, like a pilot needs to show that every
53:53
year he has a certain amount of flight
53:55
hours, minimum amount of flight hours.
53:57
So you need volume because volume is only one indicator for quality.
54:02
It's not the only, as a lot of people say.
54:05
So you need the volume to continue improve your skills.
54:10
And what also defines so I think that
54:14
expertise by experience is one part of wisdom.
54:19
But another part of wisdom, in my opinion, is the ability to deal in
54:24
a safe way with unexpected or very
54:28
complex situations during certain procedures.
54:32
I, again, I will give the example.
54:34
I was proctoring a guy.
54:37
He is not proficient yet at a radical
54:40
prostheticity, but he is the only surgeon in the hospital.
54:43
And so he told me that he will need
54:45
about 10, 20 cases to independently start.
54:48
I told him, you're crazy.
54:51
Because if you are, you're, you're maybe able to safely perform a
54:56
standard prostheticity, but the day will come that you will have
54:59
extremely difficult prostheticity.
55:02
With a heavy bleeding or extremely challenging tissues.
55:06
And then you will not be able to deal with that procedure and you
55:09
will have to stop the procedure and hopefully you will be able to do
55:12
that before you have done something wrong.
55:14
Because this demands wisdom.
55:17
And so wisdom you can achieve by having someone in your back.
55:22
I was able to achieve wisdom because I had extremely experienced
55:27
surgeons and working in the same department.
55:29
Why?
55:30
And like this, I could actually grow quite fast from proficiency
55:34
towards wisdom and tackling extremely challenging procedures in a
55:38
safe way, because I knew at a certain point when I
55:41
got into problem, I have someone who can help me.
55:44
So this gives you a safe feeling.
55:46
And then last but not least, I think it's extremely important if you
55:49
want to grow towards wisdom to have good examples.
55:52
So we founded SearchQuest.
55:55
It's a digital learning platform.
55:57
And this is a clear overview of experts, global experts, showing not
56:05
only standard procedures, but also very, very
56:08
challenging procedures or very challenging types of
56:13
certain procedures.
56:15
And so by knowing how to tackle or by seeing how to tackle extremely
56:20
difficult types of procedures, you will also know how to do this.
56:26
I'll finish with an example.
56:29
About four years ago, I had to do a
56:33
standard reticulonephrectomy on the right side.
56:36
This was a dialysis patient, had a big tumour on
56:39
the right kidney and he had a low quality CT scan.
56:42
It was a PET scan.
56:44
For me, basically, this was enough
56:46
to actually just do the nephrectomy.
56:48
But I get into the abdomen and I notice
56:51
that the renal vein is very much dilated.
56:54
And so I do an ultrasound and I see
56:56
that this patient has an IVC thrombus.
57:00
So a thrombus going into the inferior vena cava, which of course
57:05
makes that you make a transition from a
57:08
very, from a procedure which is very low
57:11
complex, low complex, just a reticulonephrectomy towards a highly
57:15
complex procedure where you have to completely dissect the IVC, have
57:19
to clamp them, have to do an IVC thrombectomy.
57:23
I was able to do that because I attended a lot of conferences before
57:30
and I see some Chinese surgeons during eras
57:34
years ago how to do these kind of procedures.
57:37
And I remembered it and I said, like, okay, I will prepare myself.
57:41
I will have a cardiovascular surgeon having standby.
57:44
And I finished the case very smoothly.
57:47
And that actually driven me to make these
57:51
examples available for the whole surgical community.
57:54
So in Surgicals, you will find database of more than 300 high level
57:59
surgical videos, which you can use at the moment itself when you get
58:03
into problems to tackle certain complications.
58:06
And I think that defines wisdom that you're
58:08
that you're feeling safe at any given point.
58:12
And that, you know, I run into a complication.
58:14
I will be able to manage it.
58:16
And this also gives you wings when you do surgical training because
58:20
you can give access to the robotic console to your fellows very
58:25
easily because, you know, if they make a
58:27
mistake, you will be able to repair it.
58:30
And this this this is wisdom, in my opinion.
58:32
Yeah. Yeah. But I think the surgquest platform that you lead, I
58:37
think that's the best example that I've encountered so far that helps
58:43
when somebody trains to proficiency, they've got the foundations and
58:47
they've got the basic building blocks.
58:49
But they then need the exposure and a lot of the exposure, they're
58:52
not going to get in their own hospital or maybe
58:55
sometimes, you know, not that often in their career.
58:59
But they need to see it.
59:00
And if they're they're trained to proficiency and they know what the
59:04
indicators are of good and bad performance, if they're exposed to
59:08
good surgeons doing more complex cases, I
59:11
think that's how you help them acquire wisdom.
59:14
So, I mean, I think what you're doing is very powerful.
59:16
And it's certainly what I had envisaged.
59:20
I mean, not not the Surgquest platform, but certainly some facility
59:23
like that that would help the surgical community acquire that
59:29
information that underpins and builds wisdom.
59:35
Thank you Ruben
59:37
Thank you, Tony.
59:39
So, thank you, Ruben, for coming on to the
59:43
Show Me the Evidence podcast. I'm sure it's
59:46
appreciated by our viewers the experience
59:49
that you've imparted here today and your
59:51
views on a more scientific and
59:54
evident-based approach to surgical training.