"STRUCTURING A MULTI-YEAR

RESIDENT CURRICULUM"

Carlos Galvani, MD, FACS

 the 10,000-hour rule

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

A time-honored model

High volume of cases

Experienced surgeons taught surgical techniques by demonstration

and repetition
The Apprenticeship Model for Surgical Training

High-risk and stress environments

Lack of practice on a regular basis

Lack of rigorous evaluation

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 Samam, 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

Is not well defined if training in laparoscopic surgery is

required before training in robotic surgery

Unknonwn type of training program and time needed in te

program (quantity vs quality)

Number of cases necessary to be considered

competent/proficient

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