"STRUCTURING A MULTI-YEAR

RESIDENT CURRICULUM"

Carlos Galvani, MD, FACS

 the 10,000-hour rule

ü A much-touted theory suggests that practicing any

skill for 10,000 hours is sufficient to make you an
expert. No innate talent? Not a problem. You just
practice. But is it true?

Malcolm Gladwell's Outliers, "the 10,000-hour rule"

 Deliberate Practice

• The sheer number of hours engaged in practice is

not as important as the quality of deliberate practice
Ericsson, 2013

• There is nothing magical about 10,000 h of

deliberate practice
Ericsson, 2013; Kaufman, 2013
The Apprenticeship Model for Surgical Training

ü A time-honored model

ü High volume of cases

ü Experienced surgeons taught surgical techniques by demonstration

and repetition
The Apprenticeship Model for Surgical Training

ü High-risk and stress environments

ü Lack of practice on a regular basis

ü Lack of rigorous evaluation

ü Training on real patients

Rodriguez-Paz, J. M., et al. 2009

Modified Apprenticeship Model

• Apprenticeship model in combination with

structured assessment and feedback
Modified Apprenticeship Model

¨ Structured training programs in

laparoscopy during residency
¤ Predetermined goals
¤ Parallel to the conventional training
¤ Skills labs
n Dry Lab (simulation)
n Animal training facilities
University of Arizona
Department of Surgery

¨ Program Description:
¤ Simulation lab (ASTEC) 1 hour/week
training in Basic lap surgery
¤ Skills lab: (Wet lab)
n Every 2 months, 4 times/year, 10
residents/lab
n Duration: 1 week
¤ Didactics
¤ No clinical duties during that week
 Is a proficiency-based skills training curriculum needed for the
Fundamentals of Laparoscopic Surgery (FLS) during General Surgery
residency?

• All residents improved as a result of a structured proficiency-

based laparoscopic skills training program
• Junior Residents (PGY2) with one year of clinical training
and enrolled in a structured curricula demonstrated to
have performance levels similar to senior residents (PGY4)

T Rankin, J Samamé, A Gruessner, Carlos A Galvani ACS 2014

Global Assessment

• OSATS: Objective Structured Assessment of

Technical skills
• GOALS: Global Operative Assessment of
Laparoscopic skills
THE IMPACT OF INTENSIVE LAPAROSCOPIC TRAINING COURSE WITH
STRUCTURED ASSESSMENT AND IMMEDIATE FEEDBACK ON RESIDENTS’
OPERATIVE PERFORMANCE IN ANIMAL LAB

¨ 40 residents (20 junior and 20 senior residents)

¨ Residents showed general laparoscopic skill improvement in

incisional hernia repair and Nissen fundoplication (p <0.05)

¨ Procedure specific skills improved in cholecystectomy,

incisional hernia repair and low anterior colectomy (p<0.05)

¨ There was a moderate to strong correlation in scores between

faculty and resident assessments (r>0.6)

¨ Three themes were identified: (1) operative skills assessment,

(2) instruction (3) learners’ factors.
Global skills assessment
Post Training Survey
Adv GI MIS Fellowship Program at Banner -
University Medical Center Tucson

¨ Number of Positions Available: 1

¨ Type of Fellowship: Adv GI MIS
¨ Duration: 1 year
¤ Bariatric Surgery

¤ Foregut Surgery

¤ General Surgery
Robotic Surgery
¤ GI Endoscopy
Robotic Surgery Volume

Case Volume
Total 459
140

120

100

80

60

40

20

0
2009 2010 2011 2012 2013 2014 2015 2016
Robotic Training path

¨ Intuitive Fellows Course

¨ Skills acquisition - DaVinci Sim

¤ Basic skills (expected to self-practice)
¤ Non procedure-specific

¨ Bedside Assistant - 10+ cases

¨ Console Surgeon - 20+ cases (Dual Console)

¤ Procedure breakdown into steps (Proficiency-Based Progression)

¨ Console Surgeon - Program Director at bedside

Robotic Training path

¨ Key elements

¤ Trained OR stuff (surgical tech/circulator/surgical assist)

¤ Case selection

¤ Dedicated surgical assist for the first 3 months

¤ Dual console

¤ Robotic surgery volume

Learning robotics...in the past?

¨ Intensive courses Didactics

¤ Videos
¤ Dry Lab
¤ Wet lab – Grandma
¨ Lack of standardization (different from center to
center, from country to country)
¨ Used as the principal way of training is
inappropriate and dangerous (excessive
confidence??)
ROBOTIC SURGERY TRAINING

ü Is not well defined if training in laparoscopic surgery is

required before training in robotic surgery

ü Unknonwn type of training program and time needed in te

program (quantity vs quality)

ü Number of cases necessary to be considered

competent/proficient

ü Are there minimum training requirements?

Robotic Surgery training...15 years
later
¨ Need to train residents in traditional procedures
(open/lap surgery)

¨ Faculty with limited robotic surgery experience

¤ Need to do more cases, less time to teach, cost,

stress and ethical concerns

¨ No formal faculty training

¨ No formal instruction; trainees responsible for their

own learning

¨ Most training is provided by industry

¨ Lack of structured training curriculum

Objectives of Robotic Training

¨ Shorten the Learning curve

¨ Increase OR self-confidence
¨ Decrease operative times
¨ To train surgeons for different
procedures
¨ Decrease complications
General Surgery Residents’ Perception of Robot-
Assisted Procedures During Surgical Training

¨ Setting
¤ 50% university training programs,
¤ 32% university-affiliated programs
¤ 18% community-based programs.
¨ 63% participated in robotic cases
¤ 18% experience operating the console.
¨ 60% received no prior training before their first robotic
case
¨ 64% reported that formal training in robotic surgery was
important in residency training
¨ 46% indicated that robotic-assisted cases interfered
with resident learning.
Farivar et al. Journal of Surgical Education 2015
General Surgery Residents’ Perception of Robot-
Assisted Procedures During Surgical Training

Farivar et al. Journal of Surgical Education 2015

Our challenges

¨ Not enough resident time in GS service

¨ Lack of defined training path
¨ Not enough faculty doing robotic surgery
¨ Not enough resident interest
¨ Faculty need to do more cases, less time to
teach, cost, stress
¨ Not enough GS block time
Conclusion

¨ Curricula are a crucial step in global standardization of

training and certification of surgeons for robotic surgical
procedures.

¨ The use of virtual-reality simulation and cadaveric or

animal laboratory experience are paramount in learning
any new technology, including robotics.

¨ The experience with laparoscopy has provided us with a

great road map for this.

¨ Where to incorporate non-simulated robotic surgical

training is still a matter of debate