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TECHNOLOGY ENHANCED SURGICAL TRAINING FUTURE OF SURGERY REPORT OF THE FOS:TEST COMMISSION August 2022 futureofsurgery.rcseng.ac.uk/trainingCONTENTS Foreword by Mr Josh Burke 6 Foreword by Professor Jon Lund 8 Foreword by Miss Esther McLarty 9 Acknowledgements 10 FOS:TEST Commission members 11 Executive summary 14 Key stakeholder commentary on behalf of Health Education England 17 Approach taken by FOS:TEST Commission 19 1. How technology can increase exposure to operating 24 2. How technology can enhance training along the patient pathway 27 3. How technology can support assessment of trainee competence 29 4. How innovation can help the surgical workforce 31 5. What needs to happen to embrace technology enhanced surgical training 33 Key recommendations 37 Contributors 38 Case study: Aesculap Academia’s EinsteinVision 42 Case study: Medtronic’s Touch Surgery 44 Case study: C-SATS learning community 46 Case study: Proximie 48 Case study: Intuitive’s SimNow 50 Case study: One Shot Immersive 52 Case study: Fundamental Surgery 54 Case study: Versius Virtual Reality 56 Case study: 3D LifePrints 58 Case study: Microsoft’s HoloLens 60 Evidence submissions 62 2 |CONTENTSSection A: How technology can increase exposure to operating 63 Simulation and 3D printing 63 A1. Simulation: training to proficiency using simulation 63 A2. Cadaveric, animal and alternative models: are we there yet with fidelity? 63 A3. 3D printing enhanced surgical education 65 Immersive technologies: augmented, virtual and mixed reality 65 A4. Surgical video and image databases 65 A5. Recovery online programme for surgery in London: proposal on behalf of the Confederation of Postgraduate Schools of Surgery 66 A6. Live streaming 66 Accelerating operative competence 67 A7. Key consideration: Shortening surgical learning curves in competence-based progression 67 A8. Video analytics, AI, machine learning and deep learning 68 A9. Training in cardiothoracic transplantation in the UK: actuality and perspectives 69 A10. Use of AR/VR to enhance learning of major trauma situations 69 A11. Virtual basic surgical skills 70 A12. Robotics and minimally invasive surgery 70 A13. Trainee preoperative checklist for the multidisciplinary team 71 A14. Intraoperative decision making, digital mapping, image fusion and navigational surgery 73 Section B: How technology can enhance training along the patient pathway 74 B1. The emerging role of AI in diagnostic imaging 74 B2. AI and preoperative prognostic scoring systems 75 B3. Personalised surgical care using AI in the perioperative setting 77 B4. Genomics for surgical trainees in the 21 century 79 B5. Digital consent 81 B6. Using AI and technology enhancement to optimise surgical consent 81 B7. The future of wearables in surgical training and remote monitoring 81 B8. Key consideration: The ethics, challenges and limitations of big data and machinele82ning Section C: How technology can support assessment of trainee competence 85 C1. Key consideration: The changing pedagogy of surgical training 85 C2. Key consideration: Assessment of competence through performance metrics 85 C3. Key consideration: Ensuring equal access and opportunity 86 C4. High stakes assessment of operative skill using simulation 87 C5. Portfolio, progress tracking and feedback 88 C6. Two-way training logbooks 88 3 |CONTENTSSection D: How innovation can help the surgical workforce 90 D1. Mentorship vs supervision in surgical training 90 D2. Digital options for reducing burnout 90 D3. Workforce solution: the annual career report as a mandatory instrument for workforce planning 91 D4. The RCS England surgical workforce census 93 D5. Workforce planning innovation: exemplar from current issues with neurosurgery workforce planning 93 Section E: What needs to happen to embrace technology enhanced surgical training 95 E1. Key consideration: The need for interdisciplinary collaboration 95 E2. Key consideration: Generating evidence to inform innovation and technology adoption in training 96 E3. Key consideration: The importance of sustainability in the era of digital surgery 97 E4. Digital literacy skills for surgeons in training 98 E5. Key Consideration: Integrated Innovation Training 100 E6. Consensus hackathon 101 E7. Frugal innovation in surgical training: a global surgery viewpoint 103 E8. Surgical research training: learnings from the NIHR Advanced Surgical Technology Incubator 104 E9. Key consideration: Health economic considerations – How training interventions can demonstrate added value 105 E10. Key consideration: Technological considerations in human factors 105 A final word by Mr Richard Kerr 107 References 107 4 |CONTENTSFOREWORDS 5|FOREWORDFOREWORD BY MR JOSH BURKE MR JOSH BURKE Chair, Future of Surgery: Technology Enhanced Surgical Training Commission @_JoshBurke_ We publish the Future of Surgery: Technology Enhanced Surgical Training (FOS:TEST) report at a time when the NHS continues to face significant challenges arising from the COVID-19 pandemic. In surgery, previously unseen figures in elective waiting lists and continued deficits in surgical training logbook numbers are the tip of the iceberg. There has perhaps never been a more crucial time to be proactive in our approach to surgical training and train the workforce for what we will likely need and not for what we are currently lacking. Over the past 50 years, the capability of technology to improve surgical care has been realised. In many healthcare systems, innovation and digitalisation have resulted in a shift in how funders and care providers generate returns. This may explain why some of the most integrated healthcare systems (including the US) have been at the forefront of digital adoption. efforts to develop surgical digital literacy have been In the UK, the 2020 House of Commons Public minimal. The impact of COVID-19 has highlighted Accounts Committee’s review into the NHS digital the barriers and inefficiencies that both trainees and transformation indicated that proposals to transform trainers face in achieving excellence. This has resulted services lacked ‘effective governance, realistic and in educational bodies reaching for digital solutions detailed plans, sufficient investment nationally and to make up for the loss of training opportunities. locally, and clear accountability’. This followed the failed national programme for IT from 2002 to 2011, THE PROBLEM which cost the UK government £10 billion. While surgical trainees and trainers strive to deliver There has perhaps never been care and train, the technological ‘solutions’ market continues to expand. However, there remains no a more crucial time to be proactive coordinated process to assess these technologies. in our approach to surgical training The current tactic of attempting to match potential solutions to problems is flawed. Regional investment and train the workforce for what in technology without proven efficacy is likely to be we will likely need and not for inefficient and costly, and will increase variation in what we are currently lacking. access to training that already exists across the UK and Republic of Ireland. Instead, we must work to identify the unmet needs from the end user (the In more recent times, attention has been afforded to surgical trainee) to produce a streamlined, evidence- technology in healthcare delivery and training through based pathway to test the feasibility and scalability the Topol review and specifically in surgery via the of any technology. We must also support, listen to and invest in the needs of our trainers, without Future of Surgery report. Despite the predicted advances, few have penetrated surgical training and whom any technology is merely a new, shiny object. 6 | FOREWORD ensure that any intervention is scalable for national We must work to identify the implementation. We must also ensure that any unmet needs from the end user technological change is inclusive and sustainable. (the surgical trainee) to produce Considering that the only current technological solution linked to training progression is our self-funded portfolio a streamlined, evidence-based (the Intercollegiate Surgical Curriculum Programme), pathway to test the feasibility adequate evidence of efficacy is vital if these solutions are to be resourced by our educational bodies. and scalability of any technology. At present, there is no replacement for hands-on operating. However, for future surgeons in the UK and The FOS:TEST Commission was borne out of what Republic of Ireland to stay relevant in a global market, is a pivotal point in the digital transformation of our training methods must adapt. The FOS:TEST report surgical training. Academic expertise and collaboration provides a blueprint for how this can be achieved. I would will be required to evaluate the efficacy of any novel training solution. This must be coupled with like to thank the Commission and contributors for all their time, thought and expertise in producing this report. pragmatic assessments of feasibility and cost toFOREWORD BY PROFESSOR JONLUND PROFESSOR JON LUND Chair, Joint Committee on Surgical Training @Schoolofsurg By the time this Future of Surgery: Technology Enhanced Surgical Training report is published, over 1.5 million fewer operations will have involved a trainee than in equivalent periods before the COVID-19 pandemic. Up to 35% of trainees have already had training extended or are at risk of extension because of the impact of COVID-19. This impact is evident across all areas of training (except perhaps management of the unselected take) but is seen most clearly in acquisition of technical skill through exposure to supervised operating. Trainees need to be helped back on to a normal training Technology is often expensive and resource limited, trajectory as quickly as possible to avoid a crisis in supply and that this report recommends above all, namely of Certificate of Completion of Training holders to the that technology enhanced learning should demonstrate workplace, especially as early retirement of consultant educational effectiveness, is welcomed. Technological surgeons shows no sign of slowing. solutions are sometimes made of the ‘Emperor’s new clothes’, and support through evidence, research and cost–benefit analysis is essential before money from Support through evidence, a defined and limited budget for training is spent on the research and cost–benefit analysis latest technological solution. Care should be taken to avoid differential access to technology. Opportunities is essential before money from should be available to all, at no cost to trainees, and should not exist behind paywalls of colleges, specialty a defined and limited budget for training is spent on the latest associations or other providers. Consideration should also be given to the timing of access to technology so technological solution. that we all maintain a sustainable work–life balance and so that there is no differential access to opportunity because of caring or other commitments. Technology enhanced surgical training should form part of the solution to these challenges. It may allow However, it is important not to lose sight of the fact aspects of technical skill to be conserved, and non- that we treat real patients, each one individual and technical skills to be developed away from patients and different, and no simulation (no matter how high fidelity) in multidisciplinary teams. Learning curves (especially will compensate for prolonged, supervised exposure to earlier in training) may be shortened by simulation and the real-world treatment of patients. Resource may be simulated skill rehearsal may also be useful in return best spent on overcoming barriers to access to training to training packages when colleagues have been away opportunities at surgical hubs and on NHS patients in from surgical practice for reasons including research, the independent sector, including expanding the team a career break, parental leave or redeployment. and other backfill solutions to allow release for training opportunity in any of the capabilities in practice, wherever The one large and obvious positive feature of the they occur. Further funding of real time for training (in pandemic has been to normalise the delivery of job plans, on clinic and theatre lists etc) on real patients online learning so that all can have access to the with trainers who are trained in how to deliver effective same learning opportunities regardless of geography and variability in local expertise, with clear savings training and supportive, developmental feedback is in time and environmental impact. It may be that an central to providing a safe and rounded workforce. easy win for investment in technologically enhanced Technology can augment training but will never replace learning is establishment of permanent online learning real experience. This report is a welcome step towards programmes across all surgical specialties as part helping technology to find its evidence-based, costed of a blended training package. niche in all areas of surgical training. 8 | FOREWORDFOREWORD BYMISSESTHER MCLARTY MISS ESTHER MCLARTY Chair, Confederation of Postgraduate Schools of Surgery Developments in technology in surgery and surgical training are not new but the pace and range of change is ever increasing. Surgical technology has historically been adapted by different specialties, at different rates, led by enthusiasts with variable outcomes and longevity of technique. In my own specialty of urology, the use of laparoscopy for complex oncological procedures took off early with prostates, bladders and total or partial nephrectomies translated to a minimally invasive approach. We adopted robotics early, ahead of the other surgical specialties. Surgeons in training and surgical trainers need a systematic template for the evaluation of new technologies to enhance learning and patient care in a safe, evidence- based approach. This needs to be fast and flexible, moving training at the pace of technological innovation. But was there a plan or process? A critical evaluation of utility across the healthcare environment? Were trainees and training needs identified in time for the following generation of surgeons to be ready to adopt new technologies? Surgeons in training and surgical trainers need a systematic template for the evaluation of new technologies to enhance learning and patient care in a safe, evidence-based approach. This needs to be fast and flexible, moving training at the pace of technological innovation This report sets out clearly the unmet needs in surgical training and outlines prospective technology led solutions. It is most welcome, written by the surgeons of the future having learnt lessons from the past. They are digitally literate and ready to lead the way. 9 | FOREWORDACKNOWLEDGEMENTS The Future of Surgery: Technology Enhanced Surgical Training report has been produced voluntarily by the Commission with the support of a production and research bursary from the robotic and digital surgery initiative (RADAR) of The Royal College of Surgeons of England (RCS England). The Commission was born out of the Association of Surgeons in Training (ASiT) Robotics and Digital Surgery Trainees Working Group. It is supported in kind by the Royal College of Surgeons of Edinburgh (RCS Edinburgh), Health Education England, the Confederation of Postgraduate Schools of Surgery, the Joint Committee on Surgical Training and the National Institute for Health and Care Research Advanced Surgical Technology Incubator. Commission members have worked collaboratively but independently with key technology partners from industry to generate case studies pertinent to the unmet training needs identified. No financial support was sought or received from industry. ASiT, RCS England and RCS Edinburgh are registered charities. The Commission would like to thank Sally Williams, Director, inQuisit Ltd, for assisting with the report. Citation: FOS:TEST Commission. Future of Surgery: Technology Enhanced Surgical Training: Report of the FOS:TEST Commission, August 2022. DOI: 10.1308/FOS2.2022. Correspondence to: joshburke@doctors.org.uk 10 | ACKNOWLEDGEMENTS FOS:TEST COMMISSION MEMBERS Mr Oliver Adebayo Mr Abdul Badran Mr Will Bolton President, British Orthopaedic Trainee Representative, Society Past Innovation Lead, Association Trainees Association (BOTA) for Cardiothoracic Surgery in Great of Surgeons in Training (ASiT) Britain and Ireland (SCTS) Mr Josh Burke Ms Charlotte El-Sayed Ms Tamara Gall Chair, FOS:TEST Commission Digital Fellow, Health Education Robotics Representative, England Roux Group 11 |FOS: TEST COMMISSION MEMBERS Mr Manish George Ms Lolade Giwa-Brown Ms Francesca Guest Past President, Association Past President, Association ASiT Representative, of Otolaryngologists in Training of Surgeons in Training (ASiT) Rouleaux Club (AOT) Ms Deena Harji Mr Neil Harvey Ms Natasha Jiwa RCS England Robotic and Digital Chair, BAUS Section Chair, Mammary Fold Surgery Trainees Group of Trainees (BSoT) Ms Natasha Keates Mr Martin King Mr Mark Mikhail Past Vice-President, Association of President, Association of Surgeons Innovation Lead, Plastic Surgery Surgeons in Training (ASiT) in Training (ASiT) Trainees Association (PLASTA) 12 |FOS: TEST COMMISSION MEMBERS Mr Omar Nasher Mr Michael Okocha Mr Anand S Pandit Past Representitive, Trainees in Equality and Diversity Officer, Digital Surgery Representative, Paediatric Surgery (TriPS) Association of Surgeons in Training British Neurosurgical Trainees (ASiT) Association (BNTA) Mr Ricci Plastow Mr Haroon Rehman Ms Catherine Wicks RCS England Robotic and Digital Chair, RCS Edinburgh Trainees Representative, British Association Surgery Trainees Group Committee of Oral and Maxillofacial Surgery Fellows in Training (OMFS FiT) 13 |FOS: TEST COMMISSION MEMBERSEXECUTIVE SUMMARY Healthcare technologies have dramatically improved surgical care over the past half century, 1,2and the need for novel technological solutions is continually increasing; driven by the global disease burden of an ageing and comorbid population and scientific advances. 3,4In parallel, the expense of healthcare technology is also climbing, highlighting the urgency of cost effective and frugal solutions, particularly given the frailty of healthcare systems following the COVID-19 global pandemic. 5,The Future of Surgery Report suggested that developments in robotics, big data, artificial intelligence, genomics, virtual and augmented reality, and imaging would mean that future surgical care is more minimally invasive, 2,7–10 personalised and technology. Furthermore, the Topol Review highlighted the urgent need to up-skill the healthcare workforce to ensure they are digitally literate and ready to realise the full potential of these novel technologies to better care for patients.11 URGENTNEEDTOUP-SKILLTHEHEALTHCAREWORKFORCE SURGICAL INNOVATION HAS TO GAIN MORE TRACTION A COMPREHENSIVE EVALUATION FRAMEWORK IS ESSENTIAL ADVANCESININNOVATIONREQUIREACLINICALCHAMPIONANDDEFINEDNEED COLLABORATION BETWEEN PATIENTS, TRAINEES, TRAINERS, INDUSTRY AND EDUCATIONAL STAKEHOLDERS WILL SUPPORT DEVELOPMENT 14 |EXECUTIVE SUMMARYDespite these seminal reports and technological EVIDENCE SUBMISSIONS advances, few training solutions have achieved widespread adoption in surgical training programmes, The FOS:TEST Commission received more than not only in the use of technologies in practice and 120 evidence submissions from surgeons in training, curriculum delivery but also in the trainee acquirement of innovation proficiencies and digital literacy. These skills consultant surgeons and training leaders. Following peer review, 32 were selected that covered a range are vital if we are to adopt beneficial advances and wo13 of innovations, from how 3D printing or surgical across disciplines to realise the NHS Long Term Plan. video and image databases might enhance surgical The recent pandemic has highlighted shortcomings in education to genomics and wearable technology in our surgical training programmes, and shone a harsh light on inefficiencies and barriers that both trainees surgical training. Our contributors have also highlighted 14–17 a number of important key considerations, including and trainers face in achieving excellence. In order the changing pedagogy of surgical training, the ethics to ensure we continue to develop and retain excellent and challenges of big data and machine learning, surgeons of the future and to deliver the best possible sustainability and health economics. patient care, surgical training in the UK and Republic of Ireland must adapt.18 Submissions highlighted that surgical innovation often fails to gain traction, and that the innovations most likely to succeed are those with a defined need and aclinical Submissions highlighted that champion. The Commission observed that taking surgical innovation often fails technology for surgical training from ideation through to widespread adoption into routine practice is a complex to gain traction, and that the process that is challenged by several barriers, including innovations most likely to succeed the lack of an appropriate and comprehensive evaluation are those with a defined need and framework for this category of innovation. Generating effective evidence will require steer from educational a clinical champion. theorists, clinical educators and the key stakeholders responsible for training the healthcare workforce as well as, crucially, from trainees and trainers. The Commission on the Future of Surgery: Technology Enhanced Surgical Training (FOS:TEST) was formed by the Association of Surgeons in Training and the Robotics and Digital Surgery Group of The Royal College of Surgeons of England. All specialty training committees and the four surgical royal colleges were invited to elect a representative to join the Commission. 15 |EXECUTIVE SUMMARY We must work together to construct a map to navigate THE APPROACH TAKEN BY THE FOS TEST COMMISSION: the innovation ecosystem. The approach taken by the FOS:TEST A golden thread that runs through many of the Commission is set out in the section that follows. The findings and conclusions of the Commission evidence submissions is the need for interdisciplinary address five areas: collaboration, including between patients, trainees, trainers, the extended surgical team, training and 1. How technology can increase exposure curriculum providers, and technology partners. We must work together to construct a map to navigate to operating the innovation ecosystem. It starts with everyone 2. How technology can enhance training along the achieving a contextual understanding of where we patient pathway are today and where we are going in the future. It is clear that there are a number of lessons to be 3. How technology can support assessment learnt from global surgery. The use of frugal surgical of trainee competence technologies and the research surrounding it must be ethical, affordable and sustainable for low and middle 4. How innovation can help the surgical workforce income countries, and that equitable, accessible global 5. What needs to happen to embrace technology surgical training is the overriding goal. enhanced surgical training TECHNOLOGY CASE STUDIES The FOS:TEST Commission worked with technology Another theme that arises from these case studies partners to highlight ten case studies. These showcase is the difficulty often encountered in introducing some of the ways in which surgical innovation is already technological innovations to the NHS and the piecemeal approach to innovation that can result. This again supporting surgical training and has the potential to do so in the future. highlights the need for national frameworks that facilitate technological innovation in surgical training A theme arising from these case studies is that in a coherent and equitable way. technology partners are working hard to support surgeons in training with information and data to inform The Commission makes seven high level benchmarking and progression. However, too often recommendations to support the advancement of this is happening in silos and a lack of read-across technology enhanced surgical training. Each section also has a number of conclusions with greater from one technology to another in terms of metrics will only increase unless standardisation is introduced, granularity on what needs to happen. combined with mapping to curricula relevant to the UK and Republic of Ireland training programmes. 16 | EXECUTIVE SUMMARYKEY STAKEHOLDER COMMENTARY ON BEHALF OF HEALTH EDUCATION ENGLAND Health Education England (HEE) has the responsibility groundwork for the adoption of new technologies but to ensure the quality of education and training for the it was the disruption created by the COVID-19 pandemic health and care workforce. Our objective is to produce that led to the recognition that something needs to the best possible future workforce, and to transform the change and that change needs to happen at pace. current workforce to meet the ever changing health and care needs of patients. HEE recognises the This FOS:TEST report identifies the existing limitations importance of simulation, immersive technology and in surgical training and proposes a number of technology- other innovative technologies as important enablers based solutions that, if implemented, may assist in its in training the current and future workforce. transformation. Many of the proposals are innovative (even to the point of being disruptive) but all need consideration. A collection of illustrative and informative Our objective is to produce the best case studies is included and make terrific reading. possible future workforce, and to HEE is pleased to have been able to support the transform the current workforce to FOS:TEST report and looks forward to utilising the meet the ever changing health and outputs to help inform and develop surgical training for the future. care needs of patients. MR CHRIS MUNSCH This impressive report from the Future of Surgery: Clinical Lead, Technology Enhanced Learning Technology Enhanced Surgical Training (FOS:TEST) Programme, Health Education England Commission comes at a time when the need for technology enhanced education in surgical training has never been more relevant. The Topol report DR PAUL SADLER and the Future of Surgery report both provided the Lead Postgraduate Dean for Surgery, Health Education England 17 | FOREWORDSUMMARY 18 | APPROACH TAKEN BY THE FOS:TEST COMMISSIONAPPROACH TAKEN BY THE FOS: TEST COMMISSION AIMS METHODOLOGY The FOS:TEST Commission was underpinned Phase 1: Data collection by three aims: Two national datasets provided by Health Education 1. To define the current, unmet needs England were used to generate a long list of unmet surgical training needs through qualitative analysis in surgical training; against pre-defined coding frameworks. These findings 2. To assess the current evidence base of were used at two virtual consensus hackathons with the aim of identifying and prioritising unmet needs in technologies that may be beneficial to training and surgical training. The first hackathon was open to all mapped on to both the patient and trainee pathway; surgeons in training across the four nations; the second 3. Make recommendations on the development, was for members of all surgical trainee associations assessment and adoption of novel surgical elected specifically to represent the view from their technologies to surgical trainers, policy makers specialty. Table 1 summarises the findings from these and technology (industry) partners. two consensus hackathons. Table 1: Summary of findings from surgical training consensus hackathons Consensus Hackathon 1 Consensus Hackathon 2 27 February 2020 (1 day) 2 June 2021 (1 day) Stakeholders Virtual consensus hackathon in Virtual consensus hackathon in collaboration with collaboration with HEE’s Technology HEE, CoPSS, the JCST and the specialty trainee Enhanced Learning team and BOTA associations Preliminary HEE’s surgical solutions survey, HEE specialty training risk reporting tool, November 2020 (n=188, foundation to 2020 – March 2021 (n=664, all specialties, core: 37%, dataset consultant grade) ST3–ST5: 31%, ST6–ST8: 32%) Participants Open invitation distributed to all Elected specialty representatives of ASiT and specialty trainees across the four nations with trainee associations with representation from HEE, representation from HEE (n=44) CoPSS and the JCST (n=30) Themes 1. Competence attainment 1. Reduced theatre experience identified 2. Delivering the new curriculum 2. Reduced opportunity for specialist skill development 3. Placement exposure and service 3. Working arrangements delivery 4. Access to formal teaching, training and other 4. Trainer recognition and curriculum requirements beyond direct clinical skills development to aid adoption 5. Learning and working environment and implementation 6. Personal learning challenges 5. Burnout and workforce retention 7. Challenges with exams 6. Career progression 8. Risks to training experience 9. Risks to progression in training 10. Risks to career 11. Risks to HEE training more generally 12. Adjustments made to support trainees to stay on track with their progression 13. Adjustments made to support ongoing training/learning 19 | APPROACH TAKEN BY THE FOS:TEST COMMISSION Unique themes and sub-themes n=38 n=111 identified Top ranked 1. Reduction in operative cases 1. Reduced theatre experience 2. The recruitment process 2. Reduced opportunity for specialist skill development unmet needs 3. Cancellation of courses 3. Risks to progression in training 4. Difficulty in prioritising trainees 4. Adjustments made to support trainees to stay on placement on track with their progression 5. Limited simulation 5. Adjustments made to support ongoing training/learning 6. Working arrangements 7. Risks to training experience (personal) 8. Access to formal teaching, training and other curriculum requirements beyond direct clinical skills 9. Risks to career 10. Learning and working environment 11. Challenges with exams ASiT = Association of Surgeons in Training; BOTA = British Orthopaedic Trainees Association; CoPSS = Confederation of Postgraduate Schools of Surgery; JCST = Joint Committee on Surgical Training; HEE = Health Education England Phase 2: Evidence and case study synthesis capabilities in practice (CiPs) framework. There are The findings of both hackathons were reviewed by the five CiPs common to all specialties 20d four specialty FOS:TEST Commission, which mapped unmet needs specific CiPs, as shown in Table 2. Table 3 shows to both the patient and trainee pathways as well as the how the unmet needs were mapped to the CiPs. Table 2: Capabilities in practice (CiPs) CiPs common to all specialties CiP 1 – Manages an outpatient clinic CiP 2 – Manages the unselected emergency take CiP 3 – Manages ward rounds and the ongoing care of inpatients CiP 4 – Manages an operating list CiP 5 – Manages multidisciplinary working Specialty specific CiPs Plastic surgery: CiP 6* – Safely assimilates new technologies and advancing techniques in the field of plastic surgery into practice Paediatric surgery: CiP 6 – Assesses or manages an infant or child in a neonatal or paediatric intensive care unit environment Cardiothoracic surgery: CiP 6 – Manages patients in the critical care area Cardiothoracic surgery: CiP 7 – Assesses surgical outcomes both at personal and unit level *It is the Commission’s view that CiP 6 for plastic surgery should be applicable to all surgical specialties. 20 | APPROACH TAKEN BY THE FOS:TEST COMMISSIONTable 3: Unmet needs and potential solutions mapped to both patient and trainee pathways and the surgical curriculum capabilities in practice (CiPs) Unmet need Potential solutions CiPs Patient pathway Diagnostics and Training to better Trainee accessible remote 1,6 preoperative care personalise patient care consultation Utilising radiological diagnostics 1,6 Prognostic scoring tools 1,2,6 Artificial intelligence 1,6 Genomics 1 Digital consent 1,2 Surgical intervention Decreased exposure Simulation and 3D printing 2 to operating Augmented, virtual and mixed 2 reality Surgical video and image databases 2 Live streaming 2,4 Parallel operating lists and 2 trainee preoperative checklists Improved intraoperative Digital mapping 2,4 decision making Image fusion 2,4 Navigational surgery 2,4 Accelerating operative Video analytics, artificial 2,4,7 competence intelligence, machine learning and deep learning Performance metrics 2,4,7 Big data 2,7 Lack of exposure Core robotics curriculum 4 to robotic surgery Postoperative care Lack of hospital capacity Wearable technology 2,3,6 (cardiothoracic), and resource 6 (paediatric), 7 (cardiothoracic) Virtual ward rounds 2,3,6 (cardiothoracic), 6 (paediatric) Interdisciplinary collaboration 5,6 (plastic) 21 |APPROACH TAKEN BY THE FOS:TEST COMMISSION Trainee pathway Recruitment and Reliable, fair and cost Workforce census 5 workforce planning effective recruitment process across entire extended surgical team Lack of connection Workforce modelling interventions 5 between recruitment and required consultant workforce Assessment and Barriers to patient Augmented and virtual reality 1 courses involvement Course availability and Sustainable solutions 1-7 cost Virtual platforms 1–7 Portfolio, progress Usability of surgical Virtual logbooks 4 tracking and logbooks feedback Efficacy of workplace- based assessments Difficulty in achieving Trainer logbooks 4 indicative numbers Digital literacy Lack of skills in digital National course delivery 6 (plastic) and innovation literacy and innovation proficiency Hackathons 6 (plastic) Mentorship Lack of mentorship Novel mentorship solutions 1–7 Equality and diversity of the workforce Loss of the surgical firm Wellbeing Burnout Support networks and 5 buddy systems Human factors 5 Through a launch webinar on 27 May 2021, with a series of 11 invited ‘key consideration’ articles the FOS:TEST Commission invited submissions to place the submissions into context. The FOS:TEST categorised by these unmet needs from trainees, Commission also conducted a series of discussion trainers, technology partners and policy makers. A total sessions and interviews with technology partners, which of 120 submissions were received. These were peer were written up into case studies. The types of articles reviewed and the 32 that were accepted underwent and their respective authors are summarised in Table 4. editing by Commission members and were combined 22 | APPROACH TAKEN BY THE FOS:TEST COMMISSIONTable 4: The types of articles accepted by the FOS:TEST Commission Article type Authors Trainee submission Surgeons in training Trainer submission Consultant surgeons Stakeholder submission Training leaders Technology partner case study Industry partner representatives Key consideration article Surgical trainees and trainers Phase 3: Recommendations Following review of the evidence, the FOS:TEST Commission agreed on seven recommendations to enhance surgical training through the wider adoption and dissemination of technology. 23 |APPROACH TAKEN BY THE FOS:TEST COMMISSION 1. HOW TECHNOLOGY CAN INCREASE EXPOSURE TO OPERATING The COVID-19 pandemic has had a direct impact on access by surgeons in training to operative cases. UNMET NEED A recurring theme from submissions to the Commission was that technology can support the recovery now • Decreased exposure to operating needed in surgical training. Operative exposure is the area where surgical trainees • Intraoperative decision making feel least able to develop independently; logbook numbers continue to be low and are affecting trainee • Accelerating operative competence progression.15,2It is increasingly difficult for trainees to develop sufficient trust with trainers owing to increasing • Lack of exposure to robotic surgery workforce pressure, service commitments and rota design. New methods of surgical training are needed • Lack of hospital capacity and resource to counteract the loss of the ‘surgical firm’ and supervisor–apprentice model. POTENTIAL SOLUTIONS The FOS:TEST Commission identified several unmet needs related to gaining sufficient exposure to operating • Simulation and the skills needed to become a competent surgeon, including a need to strengthen intraoperative decision • 3D printing making and accelerate operative competence. The evidence submissions called for action toaccelerate • Augmented, virtual and mixed reality the learning curve for surgeons in training and identified opportunities for technology to assist in achieving this. • Surgical video and image databases • Live streaming POTENTIAL SOLUTIONS • Parallel operating lists Immersive technologies were referred to repeatedly across submissions. These technologies encompass • Trainee preoperative checklists a range of tools that provide users with access to additional or alternative sensory and cognitive • Digital mapping information beyond actual reality and circumstance, including augmented reality (AR), virtual reality (VR) • Image fusion and mixed reality (MR). They are sometimes grouped under the term extended reality, including enclosed • Navigational surgery 3D VR environments, where actual reality is totally replaced by a new VR, through to digital projections • Video analytics, artificial intelligence, that overlay the real world to create ‘augmented/mixed machine learning and deep learning reality’ (AR/MR) experienced as actual reality with additional information. • Performance metrics • Big data • Core robotics curriculum 24 | HOW TECHNOLOGY CAN INCREASE EXPOSURE TO OPERATINGThe applications of these tools across many industry HOW TECHNOLOGY PARTNERS sectors have increased rapidly in recent years, fuelled ARE SUPPORTING OPERATING by increasing computing power, faster connectivity and SKILLS DEVELOPMENT accelerated hardware development. Striking examples of the tools’ rapid adoption is evident in the gaming and entertainment industry as well as creative design Technology partners are innovating specifically to applications in consumer products and fashion. The use of support surgical training while providing clinically focused technologies that have wider applications. these technologies in science and healthcare is beginning For example: to be explored but many examples are principally limited to research contexts. The potential applications in healthcare for these technologies are vast, and both • One product able to support training in surgical the Topol review and the Future of Surgery report techniques is the Aesculap EinsteinVision: B. Braun’s 3D camera system for laparoscopic surgery. highlighted the urgent need to explore their adoption i2,11 health workforce training and improving patient care. • Medtronic’s Touch Surgery offers free access to more than 200 simulations in 17 specialties as well as a surgical video and data platform. Less than 30% of surgical • C-SATS is a learning community designed by trainees are gaining access to the surgeons for surgeons, drawing on both artificial required literacy and skill to deliver intelligence (AI) and machine learning. Clinical robotic surgery in their future insights are provided by AI and digital analytics to a personal dashboard that shows development of consultant practice. 25,26 technical skills over time. • Proximie is a software platform that allows clinicians These technologies have the potential to affect to virtually ‘scrub in’, recording and interacting with several aspects of the patient pathway, especially in any operating theatre or cath lab from anywhere in surgical training, preoperative planning, intraoperative the world. navigation and enhanced patient recovery. Despite this • Intuitive’s SimNow is the simulator for da Vinci potential, widespread adoption is currently limited by surgical systems, which has pioneered minimally the lack of evidence to inform the use of these tools, invasive, robot assisted surgery. including acceptability, feasibility and utility, and clinical effectiveness. • One Shot Immersive offers a mass casualty triage Another important area identified by the Commission is training experience using VR. robotic surgery training. There is increasing adoption of • Fundamental Surgery offers a VR education robotic surgery in clinical practice. In one study, it was platform to support surgical learning in an immersive estimated that around a quarter of NHS trusts in 2019 VR surgical environment. had a robotic platform and use of robotic systems in practice increased threefold over the six-year period • Versius Virtual Reality is a new VR headset and of this study. The British Association of Urological professional education programme for the Versius Surgeons’ national registry results from 2016 to 2019 surgical robotic system from CMR Surgical, offering outlined that over 86% of radical prostatectomies in the surgical teams increased flexibility to practise UK were performed robotically, and yet less than 30% their skills. of surgical trainees are gaining access to the required literacy and skill to deliver robotic surgery in their future • 3D LifePrints uses 3D technologies to provide 25,26 innovative solutions to the medical sector. While the consultant practice. core business is clinical, the technology has useful With the ability to record operations, and the development applications for surgical training. of laparoscopic and robotic technology, there is vast potential in our ability to better understand and measure • Microsoft’s HoloLens enables a surgeon to how we train – if trainees are afforded access to these broadcast a surgical procedure to trainees so they opportunities. In future, if done correctly, it is predicted can gain a detailed view inside the body cavity as well as supporting trainees to connect with other that this may result in competence benchmarks or colleagues working on holograms. ‘credentialing’. This has been a significant topic of debate in recent times, particularly regarding the process of removing competences from training curricula and making them a post-qualification credential, potentially 27 diluting the Certificate of Completion of Training. 25 | HOW TECHNOLOGY CAN INCREASE EXPOSURE TO OPERATINGCONCLUSIONS Other approaches to improving exposure to operating Having considered the evidence, the conclusions of • Live streaming is a useful sustainable aid to remote the FOS:TEST Commission regarding trainee exposure to operating and how technology can enhance this are operative case exposure. as follows. • Dual operating lists with technological adjuncts (eg live streaming, supervisor annotations) could Augmented, virtual and mixed reality be considered training opportunities if it can be demonstrated that they can be delivered safely and • Immersive technologies should form a central element provide training rather than service provision. of recovery and future training by offering scalable learning environments and on-demand training. • Trainee preoperative checklists should be • Immersive technologies should be used as considered as a useful addition to operative training. a technology enhanced adjunct and not regarded Technologies to support intraoperative as a replacement for hands-on training. decision making • Immersive technology proficiency-based training • Further investigation is needed to understand the could be a valuable supplement to traditional effectiveness of video analytics, AI and machine simulation methods for junior surgical trainees. learning in guiding surgeons on recognition Simulation and 3D printing and optimal instrument use, procedural steps, enabling interoperative navigability and detecting • Regional simulation training centres need to be intraoperative errors. The fusion of kinematic and resourced appropriately with sufficient technology, video data and its ability to predict error or instigate equipment, trainers and rostered time for development the trainer to provide guidance or ‘take over’ also in order to minimise barriers to access. requires further investigation. • The 3D printing techniques currently available • There is a need to standardise annotations for both have the potential to affect multiple areas of the video recording and kinematic data, and clinically surgical patient’s pathway, and could have beneficial relevant objective metrics of simulation. application for both patients and surgeons in training. Core robotics curriculum and inclusion in higher • Haptic technologies may enhance the applicability specialty curricula and value of immersive technologies such as VR • There is a need to develop a pan-specialty, by providing tactile (and other) sensory feedback to improve learning. However, further research and pre-procedural core robotic curriculum that takes development is required to optimise its fidelity. trainees up to the point of specialty procedural training. This would mean including robotics Surgical video and image databases in all surgical training curricula. • A multi-specialty video and image database should • Benchmarks for robotics training across all be curated, validated by the UK and Republic of specialties should be developed, both generic Ireland, and mapped to the surgical curricula. and procedure specific. • Any digital solution platform should provide • Robotics companies should collaborate to develop capabilities for trainees in specialties that perform training interventions that include operative and open surgery so as not to limit opportunities to safety metrics to aid in benchmarking surgical minimally invasive-based specialties. trainees. Collaboration should extend to focus on avoiding duplication of frameworks, curricula • Having a standardised, national approach to teaching the main components of both the core and guidance. and higher curricula may be more sustainable and increase equality of access compared with current regional approaches. • Video and image database technology may be adaptable to produce a virtual logbook. However, the feasibility of this needs to be investigated. 26 | HOW TECHNOLOGY CAN INCREASE EXPOSURE TO OPERATING 2. HOW TECHNOLOGY CAN ENHANCE TRAINING ALONG THE PATIENT PATHWAY In order to allow surgical trainees to progress, there must be28 balance between service provision UNMET NEED and training. The best training environments provide educational opportunities in all areas of the rota, allowing trainees to learn while delivering safe and • Training to personalise patient care better effective patient care.9 • Lack of hospital capacity and resource Before, during and after the COVID-19 pandemic there has been a significant lack of hospital capacity, elective POTENTIAL SOLUTIONS beds and a reduction in urgent care provision. There are two key areas where technology can play an important role: • Trainee accessible remote consultation 1. In managing emergency patients in an ambulatory • Utilising radiological diagnostics fashion; • Prognostic scoring tools 2. In enabling postoperative patients to leave hospital earlier than they would otherwise have done. • Artificial intelligence The FOS:TEST Commission identified two key unmet needs: training to better personalise patient care, • Genomics and a lack of hospital capacity and resource. • Digital consent POTENTIAL SOLUTIONS Our general practitioner trainee colleagues have far greater exposure to this challenge and we should perhaps learn from their training environment. Using digital solutions rather than face-to-face care interactions to deliver personalised care will require Most guidance on the use of such systems and setting a new skillset for both trainees and trainers. 30 up a remote consultation service has come from The challenges of communicating remotely by primary care, and training in video consultation skills telephone or video need to be considered since has been adopted in some medical school curricula. 34–38 In surgery, there remains no guidance on how to train establishing rapport, obtaining accurate information, in such circumstances, which, owing to the shift in conveying attention and empathy to the patient, and accurate understanding may be more challenging. secondary care to remote consultation, may result in These challenges are particularly relevant given further lost training opportunities. This is especially that groups who may most require personalised care important given the curriculum capability in practice tend to also require support in accessing and using (CiP) of a trainee’s ability to manage an outpatient 31 clinic. Recognition of the capabilities of this training digital solutions. medium could enhance surgical training through reduced travel and allow trainees to access trainers If these challenges can be overcome and patients are appropriately triaged for remote consultation, there in other regions, particularly where certain tertiary or are perceivable benefits; these are centred around regional services are limited in their deanery for higher increased patient satisfaction, the ability for patients to specialty trainees (eg hepatopancreatobiliary). access out-of-region care, and improved sustainability of patient and clinician travel.2,33 27 | HOW TECHNOLOGY CAN ENHANCE TRAINING ALONG THE PATIENT PATHWAYSince 2006, the ‘virtual ward’ has been tested in • There is a requirement for guidance on effective undergraduate-based teaching to bring the patient’s 39 training using remote consultation for both trainees bedside to the medical student’s lecture theatres. and trainers. In its most simple format, this entails utilising a visual and auditory wearable device to stream a live • In order to realise the potential of technology in the feed. More complex systems allow for mixed reality, patient pathway, both trainees and trainers need to: overlaying40f x-ray images or pre-loaded anatomical • Develop familiarity with the fundamentals and diagrams. This capability was employed for the potential applications of AI and imaging-based delivery of care on a trial basis during the pandemic in some institutions. However, both clinician and patient diagnostics; perceptions of its acceptability remain unevaluated. 41,42 • Become familiar with prognostic modelling There is potential to utilise this technology to aid methods and limitations to inform their training geared towards CiP 3 (manages ward rounds interpretation of the results and aid clinical and ongoing care of inpatients) with remote supervision decision making; of ward rounds or multiple ward rounds if trainees are competent to act with indirect supervision. • Consider digital consent solutions. • Surgical trainees should be made aware of potential Patient wearables and remote monitoring have significant potential to facilitate earlier hospital uses of genomics for their future surgical practice. discharge of postoperative patients. These devices have been tested on surgeons themselves during Lack of hospital capacity and resource procedures and could (if coupled with future surgical • Wearable technology will form an important metrics) prove to be a useful data point in predicting component of digitally driven surgical care and and preventing error or indicating an intervention surgeons in training should understand the potential from a surgical trainer. use of these technologies in the perioperative period. • Patient and trainee/trainer acceptability of CONCLUSIONS wearables in surgery requires further investigation to understand the feasibility of wider dissemination The conclusions of the FOS:TEST Commission of wearable technologies in clinical settings. relating to how technology can enhance training along the patient pathway are as follows. • Virtual ward rounds could improve clinical decision making where they are supervised remotely by Training to personalise patient care better trainers (eg through live streaming) and can be a • There is an urgent need for policy and oversight useful adjunct to undergraduate surgical training. relating to surgical artificial intelligence (AI) development and deployment into clinical practice. 28 | HOW TECHNOLOGY CAN ENHANCE TRAINING ALONG THE PATIENT PATHWAY 3. HOW TECHNOLOGY CAN SUPPORT ASSESSMENT OF TRAINEE COMPETENCE For the surgical trainee, attainment and assessment of knowledge and technical skills is mandated by the UNMET NEED General Medical Council in Good Medical Practice before performing a procedure. The downturn of surgical activity because of the COVID-19 pandemic has • Barriers to patient involvement required flexibility in the relationship between trainee • Course availability and cost and trainer, and agility from healthcare and educational providers. It is said that agile organisations are foremost designed to work in an uncertain environment. 44 • Usability of surgical logbooks The FOS:TEST Commission identified several • Efficacy of workplace-based assessments unmet needs relevant to the assessment of trainee competence, including the usability of • Difficulty in achieving indicative numbers surgical logbooks, the efficacy of workplace-based assessments, and course availability and cost. POTENTIAL SOLUTIONS POTENTIAL SOLUTIONS • Augmented and virtual reality With uncertainty surrounding access and the time • Sustainable solutions available in the operating environment, utilisation of technology offers potential solutions. In order to reduce • Surgical video platforms the time for cognitive skill acquisition and proficiency of surgical skills in the operating environment, access to • Virtual logbooks video and image recordings of the specific procedure or task is beneficial, with some evidence supporting • Trainer logbooks ‘warm-up’ prior to operating.45,4Surgical video platforms fulfil these criteria, with most having the capability to Accelerating the learning curve in a safe, fair and record, store, share and analyse a procedure. equitable manner is fundamental to the rebuild and Time efficiency in setting up and accessing a surgical recovery of surgery. The new curriculum will place video platform will be important for cultural acceptance. less emphasis on granular requirements (eg indicative The introduction and integration of both hardware and numbers and workplace-based assessments), instead software solutions to pre-existing healthcare systems allowing progression of surgeons in training based will see substantial hurdles. Trainees and trainers will on achieving the required outcomes in generic be required to become conversant in cybersecurity professional capabilities and capabilities in practice. and information governance to ensure that information If a virtual logbook can be achieved, there is the potential shared with the patient as part of the informed consent to assess competence remotely. Where operative process is relevant, accurate and meaningful when competence is being assessed, this could be visualised utilising surgical video platforms. There remains retrospectively through video recording, annotation and uncertainty on data storage and whether this should metrics. This may help to address the known issues be on a third party application (with untrodden with surgical workplace-based assessments. 47 medicolegal considerations) or in patient health records (which requires a significant amount of Adopting surgical video and image-based platforms additional data storage capacity). will require careful consideration by all parties, including trainees, trainers and patients. 29 | HOW TECHNOLOGY CAN SUPPORT ASSESSMENT OF TRAINEEE COMPETENCECONCLUSIONS Assessment of competence through performance metrics The conclusions of the FOS:TEST Commission on Performance metrics should meet the following how technology can support assessment of trainee requirements: competence are as follows. • Metrics data must be standardised, verified, open Portfolio, progress tracking and feedback source and collaborative with trainees consenting Further evidence gathering is needed before several to its use. technologies can be used to support trainee progress evaluations, including: • Operative and safety metrics should be transparent and reproducible. • The use of video and image database platforms • Specific metrics are needed that capture as virtual surgical logbooks; longitudinal performance and map to trainees’ operative clinical outcomes. • immersive technology and virtual platforms for workplace-based assessments (eg video • The relationship between surgical training and procedure-based assessment); both short and long-term patient outcomes as well as the potential of technology to improve • Training case recordings – the opinions of trainees, trainers and patients should be this should be investigated. explored before widespread use is made of such recordings. Assessment and courses • The potential role of ‘trainer’ logbooks should be • Virtual solutions may facilitate greater patient involvement in surgical training. Further consideration explored as part of a review of incentivisation of is needed around the requirement of patient trainers and what constitutes ‘excellent training’. volunteers in postgraduate exams. Decision making here should be informed by the opinions of patients, Accelerating the learning curve in trainees and trainers. a safe, fair and equitable manner • Assessment is needed to establish the efficacy of at-home, virtual basic surgical skills courses is fundamental to the rebuild and compared with traditional delivery methods. recovery of surgery. Shortening learning curves in competence-based progression The following are needed to shorten learning curves in competence-based progression effectively and safely: • A recognised, standardised definition of competence in both generic and procedure specific skills; • Standardised parameters of learning curves predicting where along the curve individual surgeons in training may fall at a given time point when progressing through the curriculum (both generalised and procedure specific); • Methods to predict a lack of progress along the learning curve. 30 | HOW TECHNOLOGY CAN SUPPORT ASSESSMENT OF TRAINEE COMPETENCE 4. HOW INNOVATION CAN HELP THE SURGICAL WORKFORCE The NHS workforce is in crisis and the government has launched an inquiry into workforce planning.8 UNMET NEED In surgery, there are no transparent data on current staffing figures and the workforce needed as we move forwards. Early work from Health Education England’s • Lack of mentorship extended surgica19team pilot attempted to answer • Equality and diversity of the workforce these questions. Despite this, there remains no accurate census on staffing resource. At present, there is no ‘minimum’ requirement for safe staffing in surgery. • Loss of the surgical firm How trainee numbers are decided and allocated varies • Burnout from region to region, with no standardised rationale published. Populating rotas is the responsibility of • Reliable, fair and cost effective individual departments in trusts, and there is disparity recruitment process across entire between surgical trainees and locally employed doctors. Recent changes to self-assessment and national extended surgical team selection processes by Health Education England’s 50 • Lack of connection between trainee Medical and Dental Recruitment and Selection group recruitment and required consultant have frustrated trainees and trainers, and where a change to virtual assessment was predicted to workforce improve standardisation and reduce disparity, in some specialties it has had the opposite effect. POTENTIAL SOLUTIONS The FOS:TEST Commission identified several unmet needs, including lack of mentorship, trainee burnout, • Novel mentorship solutions and a disconnect between trainee recruitment and • Support networks and buddy systems the required consultant workforce. One of the most prevalent unmet needs is ensuring the workforce accurately represents our society. The Commission • Human factors recognises the recommendations already published in the Kennedy review on diversity and inclusion for • Workforce census The Royal College of Surgeons of England. We must ensure that the introduction of any novel technology • Workforce modelling interventions increases access equitably. We should empower surgeons in training to make data driven choices in their careers and avoid the existing bottlenecks seen in many specialties. For example, it is unknown how many robotic surgeons we will require in future. However, if we find ourselves needing more than we currently predict and have a generation of trainees with no exposure, this will continue the disconnect between recruitment and the consultant workforce requirement. 31 |HOW INNOVATION CAN HELP THE SURGICAL WORKFORCEPOTENTIAL SOLUTIONS CONCLUSIONS The application of big data and machine learning over The conclusions of the FOS:TEST Commission on how time has the potential to improve workforce planning, technology can support surgical trainees in these areas ensuring that the right numbers of trainees are recruited are as follows. for each specialty. Recruitment and workforce planning There is a growing recognition that surgeons in training are more likely to neglect self-care than equivalent • A census of the extended surgical workforce grades of trainees in other specialties, and that this is required to quantify existing staff resource. 53 is a contributing factor to burnout and subsequent • There is also a need to reach consensus on attrition from surgical practice. Telementoring could minimum safe staffing levels in surgery. Once agreed be used to mitigate the risk of burnout. Machine learning applications utilising pattern recognition of and when combined with the working hours guidance speech, typing and facial movements hold potential (EWTD) and rota pattern requirements (2016 junior doctor contract), this can be used to quantify in alerting to those in greatest need of assessment staffing resource need. for depression. 54,5Cognitive behavioural therapy and mindfulness therapy training is already available on Mentorship smartphone applications, and wearable devices prompt 53–55 • Novel digital mentorship solutions exploring trainee mindfulness pauses. and trainer phenotypes should be developed. Wellbeing • Any technological adoption should demonstrate measurable improvement in the training and working lives of trainees and trainers. 32 | HOW INNOVATION CAN HELP THE SURGICAL WORKFORCE 5. WHAT NEEDS TO HAPPEN TO EMBRACE TECHNOLOGY ENHANCED SURGICAL TRAINING There has been a significant increase in the development and investment in technological and UNMET NEED innovative solutions to challenges in healthcare education. This report describes key technologies that will be important over the next two decades. However, • Lack of skills in digital literacy there remains a deficit in the adequate evaluation of and innovation these educational interventions. The problem is twofold: POTENTIAL SOLUTIONS 1. There is no formal pathway for the assessment of surgical training interventions. 2. There is no comprehensive framework that • National course delivery in innovation defines where along the development pathway and digital literacy an intervention sits. • Hackathons These problems are not limited to surgery but are made more complex because of a perceived lack of cross-pollination between education theory and The FOS:TEST Commission identified an unmet need surgical training. regarding a lack of skills in digital literacy and innovation proficiency. The evidence submissions to the Commission also identified important considerations in Active workforce participation embracing technology enhanced training, including the need for interdisciplinary collaboration, generating is crucial to achieving what is evidence to inform innovation and technology adoption, a cultural transformation. and sustainability and health economic considerations. ‘Digital readiness’ describes the level of readiness of an organisation’s workforce to adopt and transition to the use of digitised work streams (in both service delivery and training) that are enabled by emerging software and technology. As the NHS continues to realign its objectives and improve its infrastructure with technology, the transition must begin at the employee level. The quicker we can adopt these evolving technologies, the smoother the road to digital transformation will be. Active workforce participation is crucial to achieving what is a cultural transformation. 33 | WHAT NEEDS TO HAPPEN TO EMBRACE TECHNOLOGY ENHANCED SURGICAL TRAININGBARRIERS TO TECHNOLOGY ADOPTION The barriers to technology adoption are listed in Table 5. Table 5: Barriers to technology adoption Patient Surgeon Researcher Industry Intervention System Privacy Culture Limited exposure Market pressure Fidelity Elective recovery need Medicolegal Job plan capacity Innovation Financial Standardisation implication Change pressure motivator Compatibility Regulation Consent management Research and Inter- with UK and Systemic bias Healthcare Incentives for development organisational Republic of Lack of equitable pressure training funding collaboration Ireland systems access Lack of and training Digital patient/ Compensation evaluation programmes clinician for formal relationship training roles framework Digital readiness and literacy POTENTIAL SOLUTIONS • Reducing errors and early warning of operative error through recording annotations, artificial Action is needed on several fronts if the potential intelligence (AI), big data, and surgeon and patient of technology to enhance surgical training is to be wearable devices; realised, including: • Streamlining the patient pathway, reducing workforce burden and creating more ‘space’ for training. • Demonstrating the evidence base underpinning technologies; ASSESSMENT PATHWAY • The development of a rapid assessment pathway AND FRAMEWORK for new technologies with the potential to enhance training; A proposed solution for the absence of a formal pathway • Inclusion of innovation proficiencies and digital for the assessment of surgical training interventions is literacy in medical school and foundation training; to establish a working group with representation from all key stakeholders across the four nations (Figure 1). • Ensuring that equality, diversity and inclusion, sustainability, and the wellbeing of both trainees The working group should be funded appropriately, and trainers are at the core of any advancements; and should allow for adequate representation from trainees and trainers with the specific role of aiding the • Earlier exposure to operations at undergraduate evaluation and development of technological surgical and foundation level though immersive technologies; training interventions. • Quicker skill acquisition (reduce learning curve) in line with the new UK and Republic of Ireland competence- based curricula through enhanced simulation; 34 | WHAT NEEDS TO HAPPEN TO EMBRACE TECHNOLOGY ENHANCED SURGICAL TRAINING Scalability Evidence Base Unmet Training Cost Needs Sustainability Effectiveness Adoption of Technological Training Possible Solutions Resource Readiness Feasibility Interventions • Joint Committee on Surgical Training • Royal College of Physicians and Surgeons • Association of Surgeons in Training (ASiT) of Glasgow • National Institute for Healtht Research • Royal College of Surgeons in Ireland • Northern Ireland Medical & Dental Training Agencies • The Confederation of Postgraduate Schools of Surgery • NHS Health Education England • The Royal College of Surgeons of England • NHS Education for Scotland • The Royal College of Surgeons of Edinburgh • Health Education and Improvement Wales Figure 1: Proposed pathway for assessment of surgical training interventions with representation from all key stakeholders at every stage in the process In order to address the absence of a comprehensive The intended outcome of these proposed solutions framework and development pathway for technologies, would be to provide researchers, educationalists, a package of work is required in collaboration with key trainers, policy makers and industry with context stakeholders and educationalists to identify methodological specific guidance on the development and evaluation considerations, study designs, outcome measurements of training interventions to improve appropriate and and implementation considerations that are specific to timely adoption of educationally effective interventions. educational interventions. This information can then be used to co-develop a structured framework to guide the scientific evaluation of technologies or innovations that aim to improve training in surgery (Figure 2). Phase 0 Phase 1 Phase 2 Phase 3 Phase 4 Initial usability Unmet need National pilot + Investigation identified – + cost Early measurement of effect on effectiveness feasibility mapped to assessment study of training patient outcome curriculum of intervention outcomes measures Figure 2: The different phases of evaluating innovations to improve training in surgery 35 | WHAT NEEDS TO HAPPEN TO EMBRACE TECHNOLOGY ENHANCED SURGICAL TRAININGCONCLUSIONS Surgical research training • An accessible system of research mentorship should The conclusions of the FOS:TEST Commission be piloted, optimised and implemented for surgical on what needs to happen to support technology adoption in training are as follows: and non-surgical theatre team members at all stages of their careers. Equity, diversity and inclusion • Increased interfacing between industrial research • There should be equity of access to technology and development, the NHS and higher education institutions is needed to support surgical technology enhanced surgical training. Any technological adoption, including reciprocal placements and joint intervention that benefits trainees and aids progression should be trialled in more than one project funding. region, and if effective, it should be made available in all deaneries. Defining a pathway and framework for assessment and adoption of surgical training interventions • Inclusivity should be used as a measure of success • An assessment framework is needed that defines in implementing novel training technologies. where along the development pathway an intervention sits. • Healthcare funders will need to consider additional investment in education and communication to • There is a requirement for a central group with encourage a shift in mindset among the surgical workforce towards digital technologies. presence from all key stakeholders to streamline the assessment of surgical training interventions Ethical considerations associated with big data developed locally or through industry collaborators. and machine learning • When considering a technological intervention, both tangible and intangible costs and benefits • Patients should be involved in the design and must be considered. implementation of AI software for healthcare, ensuring that their needs and preferences are Human factors reflected in the co-design process. • Surgeons in training should understand the • Changes to human factors should be considered ethical issues of, challenges in and limitations when introducing technology into any training environment, recognising that the intervention is to AI in healthcare so as to best equip them novel and that it may be perceived and utilised for the inevitable adoption of such technologies. differently among members of the surgical workforce. • Bias in AI tools needs to be further understood Digital literacy and innovation proficiency to avoid discrimination against under-represented patient groups. • A standardised national course on digital literacy Interdisciplinary collaboration should be made available to all trainees and trainers. • Opportunities for interdisciplinary collaboration • The use of hackathons or consensus hackathons should continue to identify unmet between surgeons, the extended surgical team, needs in surgical training. engineers, scientists and industry representatives should be fostered in surgical training programmes and academic surgical initiatives. • Generating effective evidence will require input from educational theorists, clinical educators and the key stakeholders responsible for training the healthcare workforce. 36 | WHAT NEEDS TO HAPPEN TO EMBRACE TECHNOLOGY ENHANCED SURGICAL TRAININGKEY RECOMMENDATIONS effectiveness should be considered for integration into surgical training. These should 1 augment and not replace hands-on training. Technology enhanced training solutions need to be sufficiently resourced and made 2 and trainers from all specialties across the UK and Republic of Ireland.ical trainees Trainees and trainers require training in the use of technologies (including digital literacy and proficiency, the fundamentals and potential applications of artificial 3 and digital consent) to ensure that they can take advantage of the potential to enhance future care delivery for patients. stakeholders to ensure that any future assessment of competence, benchmarking andning 4 training metrics are standardised and mapped to curricula. Collaboration should seek to avoid duplication of frameworks, curricula and guidance. A clear educational outcomes framework for the assessment and adoption 5 trainers and technology providers. is needed for the benefit of patients, trainees, gathering of evidence. Promising or early developments that should be prioritisedn and include: the feasibility of video and image database technology to produce a virtual 6 trainers; the views of patients, trainees and trainers on the use of training casend recordings; the use of immersive technology and virtual platforms in workplace-based assessments; and the need for a core, pre-procedural robotics curriculum. The ethical considerations of any technology with the potential to enhance surgical training must be explored to ensure that patients are safeguarded and are not 7 disadvantaged by its use. 37 |KEY RECOMMENDATIONSCONTRIBUTORS The FOS:TEST Commission would like to thank the following individuals and organisations for providing submissions and/or participating in interviews. • Ms Charlotte El-Sayed Robotics and Digital Surgery SURGEONS IN TRAINING Fellow, Health Education England and • Mr Oliver Adebayo Orthopaedic Registrar, The Royal College of Surgeons of England President – British Orthopaedic Trainees @charlotte_e_25 Association, Royal National Orthopaedic Hospital • Mr William Foster MB/PhD Student and @orthooliveruk National Operations Director at MedTech Foundation MedTech Foundation @Will_Foster_ • Miss Joanna Aldoori General Surgery Registrar, Leeds Teaching Hospitals NHS Trust • Miss Tamara Gall HPB Surgical Fellow, Imperial College Healthcare NHS Trust @gall_tamara • Mr William Allum Consultant Upper GI Surgeon, The Royal Marsden • Mr Manish George Otolaryngology Registrar, • Mr Noel Aruparayil Honorary Research North London Imperial College Healthcare NHS Trust Fellow, Global Health Research Group, Surgical Technologies, The University of Leeds • Ms Francesca Guest ASiT Representative, @Noel25Dec Rouleaux Club @FrancescaGuest • Mr Abdul Badran Chair Trainee Committee, • Miss Makinah Haq Medical Student, King’s College London @Makinah_Haq Society of Cardiothoracic Surgery • Mr John Hardie Trauma and Orthopaedic • Miss Jasmine Winter Beatty General Surgery Registrar, Queen Alexandra Hospital, Portsmouth Registrar and Sustainability Champion, Royal @HardieSurgery College of Surgeons of Edinburgh, Imperial College London, London, United Kingdom @jasminewbc • Mr Matthew Harris General Surgery ST2, Northwestern Deanery @Mattharrisdr • Dr Sanchita Bhatia Academic Foundation Doctor, University Hospital of Wales, Cardiff, UK • Mr Neil Harvey Outgoing President, BAUS Section @bhatia_sanchita of Trainees (BSOT) @Neil_J_Harvey • Mr William Bolton NIHR Academic Clincial Fellow • Miss Antonia Hoyle Speciality Registrar, Trauma in Neurosurgery, Leeds Teaching Hospitals NHS Trust and Orthopaedic Surgery Northwestern Deanery @willboltontiger • Mr Arif Hanafi Bin Jalal Medical Student, UCL • Ms Lolade Giwa-Brown ASiT Past President, Medical School, University College London, London, Association of Surgeons in Training @LolaASiT United Kingdom @ArifJalal99 • Mr Josh Burke Chair, Commisison on The Future • Doctor Gnanaraj Jesudian Past President, of Surgery: Technology Enhanced Surgical Training Association of Rural Surgeons of India @_JoshBurke_ @jgnanaraj • Dr Harry J Carr Foundation Year 2 Doctor • Ms Natasha Jiwa Chair, Mammary Fold South Tees Research, Innovation and Education @natash@_jiwa (STRIVE) Centre @Harry_J_Carr • Mr Neeraj Kalra Neurosurgery Registrar, • Miss Yeonwoo Chae Medical Student, University Yorkshire Deanery @neerajnkalra of Bristol • Mr Karan Kapur Core Surgical Trainee, • Mr Joshua Clements General Surgery Registrar West Midlands Surgical Deanery @kazkapur and Clinical Research Fellow, Ulster Hospital, Belfast, Northern Ireland @_joshuaclements 38 | CONTRIBUTORS• Mr Michal Kawka 6 Year Medical Student, Imperial • Miss Eleanor Walker Research Registrar, College London @KawkaMichal Royal Devon and Exeter Foundation Trust • Mr Fawz Kazzazi Core Surgical Trainee/PhD Law @EllieWa82900651 Student, Mason Institute, University of Edinburgh • Mr Jack Wellington Medical Student, Cardiff Law School @fawznk University, School of Medicine • Ms Natasha Keates ENT Registrar, University • Ms Catherine Wicks Specialty Registrar in Hospital Plymouth NHS Foundation Trust Oral and Maxillofacial Surgery BAOMS Fellows @TashKeatesENT in Training @wicks_catherine • Mr Oliver Kennion Neurosurgery Trainee, SURGICAL TRAINERS Royal Victoria Infirmary, Newcastle Upon Tyne @KennionOliver • Professor Martin Birchall Chair, NIHR Surgical • Mr Martin King General Surgery Registrar, Technology Incubator University College London Causeway Hospital, Northern Ireland @voice_prof @kingmartinj • Professor Peter Brennan Consultant Maxillofacial • Dr Angela Lam Foundation Year 2 Doctor, Surgeon, Honorary Professor of Surgery Portsmouth Cambridge University Hospitals NHS Foundation Hospitals University Trust @brennansurgeon Trust @Angee00123 • Miss Deena Harji Consultant Robotic Colorectal • Dr Gedeon Lemma Clinical Entrepreneur Fellow, Surgeon, Manchester University NHS Trust NHS Clinical Entrepreneur Scheme @glemma7 @DeenaHarji • Miss Jun Wei Lim SpR Trauma and Orthopaedic • Miss Ekpemi Irune Consultant Laryngology, Aberdeen Royal Infirmary @JunWLim Head and Neck Surgeon, Cambridge University Hospitals Foundation NHS Trust @entmimi • Mr Patrick Longman Surgeon in Training, FOS:TEST Contributor @B55Mr • Mr Gnananandan Janakan Colorectal and Major • Mr Mark Mikhail Plastic and Reconstructive Trauma Consultant, Royal Sussex County Hospital @janakan7 Surgery Registrar, PLASTA @mark_mikhail • Professor David Jayne Chair, Bowel Cancer UK • Mr Walid Mohammed Cardiothoracic Registrar, @dgjayneLeeds National Trainee Committee for Cardiothoracic Surgery @drwalidosama • Mr Frank D McDermott Consultant Colorectal Surgeon, Royal Devon and Exeter Foundation Trust • Mr Omar Nasher Paediatric Surgery Registrar, Yorkshire Deanery @OmarNasher1 @Mcfark • Miss Victoria Ngai Medical Student, University • Professor Paul McMenamin Emeritus Professor Monash University, Melbourne, Australia College London @VicNgai • Mr Chris Munsch Clinical Lead, Technology • Mr Michael Okocha Equality and Diversity Enhanced Learning, Health Education England Officer, Association of Surgeons in Training @TheTraumaSurg • Mr Steve Payne BAUS Workforce Lead • Mr Anand Pandit Academic Neurosurgical Registrar, • Mr Mark Peter, Consultant General Surgeon, Victor Horsley Department of Neurosurgery, Calderdale and Huddersfield NHS Trust National Hospital for Neurology and Neurosurgery • Mr Ricci Plastow Consultant Orthopaedic @anandpandit00 Surgeon, The Royal College of Surgeons • Miss Victoria Pegna ST8 Colorectal Registrar, of England RADAR Group University Hospital Sussex @victoriapegna • Miss Hassiba Smail Consultant Cardiothoracic • Mr Haroon Rehman Trauma and Orthopaedics Transplant Surgeon, Royal Brompton and Harefield Fellow, Wrightington Hospital @rehmanorthopod NHS Foundation Trust • Mr Conor Toale General Surgery Registrar and • Ms Celia Theodoreli-Riga Consultant Vascular Regional Representative, Association of Surgeons Surgeon, Imperial College London in Training @ToaleConor 39 |CONTRIBUTORS• Mr Andrew Robson Consultant Transplant, • Dr Nadine Hachach-Haram CEO, Proximie Sarcoma and General Surgeon Leeds Teaching Hospitals NHS Trust • Mr Sam Miller Senior Product Marketing Manager, B. Braun Medical INTERDISCIPLINARY THOUGHT • Ms Fiona Morrison Global Head of Professional LEADERS Education, CMR Surgical • Dr Peter Culmer Associate Professor, • Mr Andrew Wilson Senior Marketing University of Leeds @peteculmer Communications Manager, CMR Surgical • Dr Gedeon Lemma Clinical Entrepreneur Fellow • Mr Enda Mulvany Commercial Director, EMEA, Medtronic • Ms Jacque Mallender Economist, Economics • Mr Henry Pinchbeck CEO, 3D LifePrints By Design Ltd • Mrs Aynsley Pix Business Development Manager, • Mr Richard Price Learning Technology Advisor, Aesculap Academia Health Education England • Mr Chris Scattergood Co-Founder, FundamentalVR TRAINEE REPRESENTATIVE The FOS:TEST Commission would also like to thank ORGANISATIONS the following individuals for their guidance and support: • Professor Neil Mortensen President, • Association of Surgeons in Training (ASiT) The Royal College of Surgeons of England • Association of Otolaryngologists in Training (AOT) • Professor Mike Griffin President, • British Neurosurgical Trainees Association (BNTA) The Royal College of Surgeons of Edinburgh • British Orthopaedic Trainees Association (BOTA) • Professor Jon Lund Chair, Joint Committee on Surgical Training • Dukes’ Club • Miss Esther McLarty Chair, Confederation • Herrick Society of Postgraduate Schools of Surgery • Mammary Fold • Mr Richard Kerr Director, RADAR, The Royal College of Surgeons of England • National Trainee Committee for Cardiothoracic Surgery (NTCCTS) • Mr Simon Bach Co-Director, RADAR, • Oral and Maxillofacial Surgery Fellows in Training The Royal College of Surgeons of England (OMFS FiT) • Professor Naeem Soomro Co-Director, RADAR, • Plastic Surgery Trainees Association (PLASTA) The Royal College of Surgeons of England • Rouleaux Club • Professor Peter Beard RADAR, The Royal College of Surgeons of England • Roux Group • Dr Paul Sadler Lead Postgraduate Dean for • The Moynihan Academy Surgery, Health Education England • Trainees in Paediatric Surgery (TriPS) • Mr Ralph Tomlinson Director of Research and Quality Improvement, The Royal College TECHNOLOGY CONTRIBUTORS of Surgeons of England • Ms Kim Lewry Head of Publishing, • Dr Myriam Curet Chief Medical Officer, Intuitive The Royal College of Surgeons of England • Dr James Gough Chief Executive Officer, • Ms Jessica Sheridan-Sneyd Head of Marketing, One Shot Immersive The Royal College of Surgeons of England • Mr Ben Griffiths Director of Digital Healthcare UK • Ms Tara Nikovskis Copy Editor and Proof Reader and Ireland, Johnson & Johnson • Ms Lucy Davies, Executive Director, The Royal College of Surgeons of England 40 | CONTRIBUTORSCASE STUDIES 41 | CASE STUDIESCASE STUDY: AESCULAP ACADEMIA’S EINSTEINVISION B. Braun’s mission is to share expertise. For surgeons One product able to support training in surgical in training, this is achieved via its two core brands: B. techniques is the Aesculap EinsteinVision, B. Braun’s Braun Medical is a healthcare solutions company and 3D camera system for laparoscopic surgery. a subsidiary of the B. Braun Group while Aesculap Academia is a medical education and training provider Key features that offers training courses to a range of clinical and non-clinical staff in more than 40 countries. Examples • It involves the surgeon wearing 3D glasses and a dedicated screen provides an immersive view of the latter include training in basic knot tying and of anatomical shapes inside the body. suturing, and a podcast series – Medicine on Air – in collaboration with The Royal College of Surgeons of • Surgeons in training can watch the main screen or England (RCS England). Aesculap Academia (UK) has view from an additional monitor. Recorded footage been accredited by RCS England for its surgery related can be played back on the camera stack, either via educational provision. a 3D screen or a mobile phone. • Its training application extends to nursing and other theatre staff. ‘We believe it is important not to think only about the people who ‘From a trainee perspective, it does two things. It accelerates understanding of the anatomy on a operate today but the people who will be operating tomorrow.’ screen and it enables trainees to perform more difficult procedures during the operation’, says Miller. ‘This Sam Miller, Senior Product Marketing Manager, includes learning the motor skills necessary B. Braun Medical for intracorporeal suturing’. Equality and access Sam Miller, senior product marketing manager at B. This technology can be employed in any operating Braun Medical, and Aynsley Pix, business development environment that uses a camera stack for rigid manager at Aesculap Academia, explained how their endoscopy. The 3D image can be converted to a 2D approach differs from other medical companies. image if needed. There is potential for surgeons in ‘There’s an ever increasing role in industry, particularly training to watch footage of laparoscopic surgery after for education of trainees’, says Miller. The company the event via the hospital’s secure picture archiving positions itself as enhancing training offered by other providers and works closely with the Association of and communication system. Sustainability Surgeons in Training. It will loan its equipment to other training providers if needed to make training more Aesculap Academia is preparing to launch the fourth accessible and share knowledge with a wider audience. ‘We want to talk about technique, sustainability and generation of 3D technology in late 2022. Users can ergonomics, and how things can enhance training, upgrade their existing camera stack, minimising the not just sell our product’, says Pix. disposal of equipment. The company has recycling passports for any instruments that require disposal. Camera stacks that have come to the end of their operating life can be repurposed for training. 42 | CASE STUDIESEffectiveness Critical success factors Aesculap EinsteinVision is credited with supporting The company emphasises the role for industry to design learning by significantly reducing the learning curve of technologies with the education of trainees in mind. traditional cameras, aiding anatomical understanding, As Miller points out: ‘EinsteinVision is a tool to be used and as a tool for teaching and training. Such 3D in the operating theatre but as its use has increased, technology also offers other potential benefits, namely: the relevance of 3D technology in training has become greater. This is a product where sometimes we forget • Helping to improve efficiency and productivity the impact of it – and then you see an image and (reducing procedure times, increasing patient think wow!’ throughput and reducing surgeon fatigue); • Improving surgical outcomes by aiding surgical precision, enhancing dissection techniques and simplifying advanced skills; • Reducing the likelihood of conversion from minimally invasive to open surgery. 43 | CASE STUDIESCASE STUDY: MEDTRONIC’S TOUCH SURGERY Touch Surgery is a collaboration between Digital Surgery and Medtronic (now one company since ‘The benefits aren’t only for February 2020). There are two distinct Touch Surgery trainees. It empowers all consultants offerings: an academically validated and accredited with access to review their own mobile training app that offers free access to more cases against their own peers,and than 200 simulations in 17 specialties; and Touch Surgery Enterprise, a surgical video and data platform. through sharing knowledge, gain Enda Mulvany, commercial director at Medtronic, provided an overview of Touch Surgery Enterprise. incremental improvements.’ Enda Mulvany, Commercial Director EMEA, Key features Medtronic • Described as the first ever smart surgical digital video recorder, the DS1 computer has built-in artificial intelligence (AI) and takes video from Equality and access a laparoscopic stack or robotic feed. The technology can be accessed by mobile phone, • AI automatically anonymises surgical frames in real tablet or laptop. These devices have bespoke interfaces time to ensure any identifying information relating to support accessibility. to the patient or the theatre team is excluded. Sustainability • Surgical video and intraoperative notes are uploaded to a secure cloud-based platform. Surgeons in Cloud storage avoids the high power consumption training can segment the video into key steps, associated with using servers, and offers benefits in annotate them and share with their trainer. Medtronic terms of security and storage costs. The DS1 computer is developing the technology to annotate videos and is approximately twice the size of an Apple TV and does segment steps automatically. not consume much power. Software updates will be released periodically and can be downloaded remotely. • Most demand from surgical trainees is reported to be with respect to colorectal, cardiothoracic and upper gastrointestinal surgery. • Analytics facilitate benchmarking of surgical process and performance as individuals or teams. Trainees can look at examples to help them learn and improve. • The trainer can ask questions of the trainee via an assessment portal. • Every user has control over how they share their videos, with unlimited storage. Users can also upload procedures previously recorded on DVD and AI will still redact all out-of-body footage. 44 | CASE STUDIESEffectiveness sometimes be regarded as a third party (instead of a partner). There is great opportunity for hospital sites In 2019, Touch Surgery Enterprise was deployed at Royal Cornwall Hospital. It was reported to have had that are new to cloud or AI powered technologies to take a partnership approach. ‘It’s one of the reasons impact in terms of promoting patient safety and educating why data security and privacy are so central to what the next generation of surgeons. One surgeon noted that we do’, says Mulvany. the tool had made the time between cases an ‘invaluable window for teaching, learning and reflection’. These hurdles need to be overcome to realise the potential on offer. ‘We’re moving along the road from Critical success factors software as a service to software as a medical device’, ‘Change is never easy but we see a large cohort of says Mulvany, who envisages this technology will in future assist during surgery. For example, by providing surgeons requesting and embracing access to digital alerts where AI identifies the critical structures during technologies’, says Mulvany. He emphasised that the procedures. Automatic analysis of an operation has challenge lies not in convincing surgeons of the value of this technology but in securing timely administrative the opportunity to better support patient outcomes, agreements so digital transformation happens sooner drive efficiencies and reduce waste. The world of a fully digitally connected operating theatre is on the horizon. rather than later. Medical technology providers can 45 | CASE STUDIESCASE STUDY: C-SATS LEARNING COMMUNITY Part of the Johnson & Johnson group of companies, and GOALS (global operative assessment of C-SATS is a learning community designed by surgeons laparoscopic skills) – validated assessment for surgeons. It has elements of machine learning and tools for grading overall technical proficiency artificial intelligence, and the interplay of these is used in robotic surgery. to improve outcomes and drive improvements in surgical skills, according to Ben Griffiths, director of digital • Sentiment analysis of feedback from trainers healthcare at Johnson & Johnson. C-SATS is planning is distilled to help trainees focus on areas most needing attention. to launch in the UK in 2022. • Surgical trainees can discuss procedures with peers Key features and receive feedback from expert surgeons from a • Video capture of surgery using a C-CAP recording global faculty. A UK specific faculty is being developed. device that takes video from a laparoscopic stack • The community function allows trainees to or robotic feed and pulls the video into a cloud-based comment on cases and seek advice or feedback C-SATS video library private to the surgeon. from a community of surgeons. • AI automatically segments the steps of the procedure so key aspects can be reviewed • Surgeons in training can use the academy function without having to watch the whole operation. to watch videos before performing a procedure for the first time. ‘They can see how the best in the • Clinical insights are provided by AI and digital world perform a particular procedure or discreet analytics to a personal dashboard that shows technical skill’, says Griffiths. development of technical skills over time. Each step of a procedure is scored out of 5 using GEARS • The academy and community functions are (global evaluative assessment of robotic skills) open access (and free). The machine learning and AI functions require a monthly subscription. 46 |CASE STUDIES Effectiveness ‘The surgical insights and ability of Griffiths reports that feedback from trainees in the US the system to automatically skip to who have used C-SATS has been very positive. In a the most interesting part of a case cross-sectional analysis, surgeons in the top quartile allows trainees to really maximise of GEARS scores performed better than other groups their learning.’ of surgeons, including in terms of having a lower risk of blood loss, lower rates of conversion to open surgery Ben Griffiths, Director of Digital Healthcare and reduced patient length of stay. UK and Ireland, Johnson & Johnson Critical success factors ‘We know that when introducing technology into a Equality and access hospital without the appropriate change management process for staff, it is never going to achieve its full Surgeons in training can choose to display their identity or remain anonymous. This creates the ability potential. That’s why with any of our digital offerings, to remove any potential bias (such as sex or ethnicity) we also deploy a skilled change management team to from feedback given to trainees. support a seamless integration, and ensure everyone knows their role in utilising and getting the most out of Sustainability the technology, and the reason why it is in the room’, says Griffiths. A cloud-based platform means software updates can happen remotely. The only hardware (C-CAP) looks His vision is to make this software available to every ® operating theatre in the UK. He reports that interest from like an iPad and Johnson & Johnson is committed to recycling any outdated capital equipment. surgeons is high: ‘I haven’t spoken to a surgeon who isn’t excited about the potential of using technology to improve surgical proficiency.’ Future aspirations include extending the technology beyond minimally invasive to include open surgery. Meeting the unmet needs of surgeons through technology is at the heart of C-SATS. 47 | CASE STUDIESCASE STUDY: PROXIMIE Proximie is a software platform that allows clinicians Equality and access to virtually ‘scrub in’, record and interact with any operating theatre or cath lab from anywhere in the ‘Democratising access to safe surgery is a key purpose’, world. Dr Nadine Hachach-Haram, a consultant plastic says Hachach-Haram. This ambition extends to providing surgeon and chief executive officer of Proximie, founded access to the best surgical expertise for training. the company with the aim of extending the reach of a ‘Training becomes more accessible as you can access surgeon’s expertise, and combining artificial intelligence, opportunities to learn irrespective of your location.’ Proximie is currently used in more than 350 hospitals, augmented reality and machine learning to create the in over 50 countries. ‘The platform provides access to effect of a borderless operating theatre. surgery globally; this means surgery is no longer siloed Key features or reserved for anyone’, says Hachach-Haram. • Using augmented reality annotation as well as real-time video and audio communication, the user ‘We have created the beginnings can virtually scrub in to operating theatres. of a borderless operating room, • The platform allows multiple people in remote where every operation in every locations to virtually interact in a live procedure as they would if they were in the same theatre. hospital can be recorded, analysed and predicted for future use.’ • Augmented reality hand annotation allows users to physically show each other where to make an Nadine Hachach-Haram, Chief Executive Officer, incision, in real time, or use physical gestures to Proximie illustrate a technique. • Users gain an immersive 360° view of the clinical setting via four low latency, high definition cameras. The low latency is designed to align with the ability of the human eye to register movement. • Proximie is seeking to move from ‘see one, do one, teach one’ to ‘prepare, perform and perfect’, with a digitised continuum cycle of learning. Recording procedures enables trainees to review their own performance, either alone or with a trainer. Every procedure can be reviewed ahead of time from a library of existing cases. • Proximie is phone, tablet and desktop compatible. 48 | CASE STUDIESSustainability Critical success factors Proximie is aligned to the UN Sustainable As a software-only platform, Proximie can be used in Development Goals. The company claims to have an array of surgical landscapes (from battlefields to saved over a million miles of travel in a single quarter, specialist hospitals) utilising existing operating theatre thereby demonstrating its environmental impact. hardware. The company works with partners to deliver solutions tailored to their particular needs. Effectiveness Hachach-Haram’s vision is to use real-time insights Proximie has been used to facilitate remote access to clinical expertise across the world – from connecting and data to improve patient care. She says: ‘We’re really moving towards a more predictive and pre-emptive surgeons in the US to clinical teams in Peru and El model of healthcare, and technologies like Proximie are Salvador for cleft lip and palate repair procedures, to going to play an important role in that behavioural shift.’ supporting care provided to frontline soldiers from the UK. Proximie is positioned to harness the powers of new During the COVID-19 pandemic, Proximie was used technologies, from 5G to space tech. Hachach-Haram in 20% of NHS hospitals to limit physical numbers says: ‘The ingredients for better connected healthcare systems are right in front of us.’ in operating theatres without compromising clinical expertise. A US study published in the Journal of Urology in 2020 found that Proximie performed as well as on-site, face-to-face visits by proctors to monitor surgeons in theatre and provide support. 49 |CASE STUDIES 49 | CASE STUDIESCASE STUDY: INTUITIVE’S SIMNOW SimNow is the simulator for da Vinci surgical systems Equality and access from Intuitive Surgical, the pioneer of minimally invasive, robot assisted surgery. It is designed to be a safe and SimNow is a global simulation product available in all countries where Intuitive operates. The price varies efficient way for users to gain hands-on technical skills across regions. Most SimNow simulators are purchased preparation and learning. It does this by building on the Intuitive systems and programmes, using the da Vinci at the time of obtaining a da Vinci surgical system but surgeon console. This console allows surgeons to have they can be added to an existing da Vinci programme total control of wristed instruments on each of four arms at any time, to drive surgical skills and efficiency as and to see the surgical field in 3D high definition. programmes grow in specialty and types of procedures. ‘Surgeons lack access to a simple, scalable and The surgeon console adjusts in multiple ways to objective way to learn and practise the myriad of da ensure a good fit for the surgeon’s height and reach. This makes it suitable for a range of surgeons. Vinci skills at their own pace’, says Dr Myriam Curet, chief medical officer at Intuitive. SimNow addresses Sustainability this as well as enabling hospitals to assess the technical robot assisted surgery skills of their surgeons. SimNow allows repeated practice of certain skills without having to use multiple tissue or synthetic Key features models requiring manufacturing and disposal. It is • SimNow uses virtual reality and video in a 3D high developed, produced and serviced by a diverse definition interactive platform that replicates the group of Intuitive employees. da Vinci surgical experience for training purposes. • Users have access to technical skills exercises, from basic to advanced training and practical modules. • There is an ever growing library of skills exercises and virtual reality surgical procedures. • A networked SimNow system automatically updates simulation software, and enables remote tracking and management of users’ simulation performance from any PC or smart device. 50 | CASE STUDIES Critical success factors ‘SimNow allows surgical technical training to become more Sites where SimNow is in high use are reported to have taken several measures to successfully embed personalised and efficient without the technology. The first of these has been to place additional human intervention’ the SimNow simulator and da Vinci surgeon console in a high traffic area that is accessible to all surgeons. Myriam Curet, Chief Medical Officer, Second, hospitals need to set expectations that all Intuitive Surgicale surgeons (regardless of experience) must demonstrate that they are maintaining technical robot assisted surgery skills. Third, there should be a credentialing Effectiveness programme that incentivises compliance across surgeons. Challenges to successful integration include Intuitive reports that there have been more than 300 surgeons finding time to stay on the simulator for peer reviewed publications on the impact of da Vinci preparation and practice. simulation. SimNow is the third generation of the da Vinci skills simulator. Utilisation of SimNow is expected to increase as new surgeons acquire technical skills for da Vinci systems and with expansion of applications for SimNow for surgeons who have completed training. Curet says: ‘We believe SimNow utilisation will continue to increase, both as new surgeons acquire technical skills for da Vinci systems but also as we expand the applications for SimNow for [fully trained] surgeons.’ 51 | CASE STUDIESCASE STUDY: ONE SHOT IMMERSIVE One Shot Immersive founder and chief executive officer Key features Dr James Gough is on a mission to deliver a virtual reality (VR) experience that empowers people to save lives. • A mass casualty triage training experience using A former military and aid doctor, his own experience of VR and involving ten patients in quick succession. a multifracture and burns injury in Afghanistan crystallised • The application is pre-loaded into a headset, the value of life saving skills during a catastrophe. avoiding the need for Wi-Fi , with the downside that Gough left emergency medicine training in 2015 and updates to the headsets must be done manually. applied what he had learnt medically to the VR space. The ambition is to be able to access the training In 2018, VR medical training scenarios created by One experience via an Android™ phone app, allowing Shot Immersive were pressure tested in Idlib, Syria. the phone to be slotted into any headset. In 2020, 60 Yemeni healthcare staff benefited from VR • The user receives a text message that describes mass casualty triage training. Foolproof, an experience the context (such as an explosion) and asks the design company, became involved at this point. In 2021, user to triage patients according to the World Health working with the World Health Organization, 20 headsets were sent to conflict zones in Afghanistan and Somalia. Organization triage categories. ‘For surgeons who haven’t seen enough, they can see it and feel it. ‘My big vision is that we train the shopkeepers of Kabul It can create a sense of jeopardy’, says Gough. to provide a first response in trauma’, says Gough. The One Shot ethos is that if its technology can • Gough highlights the potential for application in work in some of the most hostile environments, Advanced Trauma Life Support and Care of the it can work anywhere. Critically Ill Surgical Patient . It is also being used to prepare surgeons to deal with polytrauma at a paediatric trauma day at Imperial College Healthcare NHS Trust. 52 | CASE STUDIESEquality and access ‘Virtual reality lends itself to clinical One Shot is considering sex and ethnicity decision making under pressure.’ representation in the VR experiences. In terms of access, the experience can be refined to accommodate James Gough, Chief Executive Officer, the needs of visually or hearing impaired trainees, One Shot Immersive or to use a different language. For instance, Gough explained that audio is a key factor in creating the VR experience and dubs could be used to provide visually Critical success factors impaired users with more guidance. For hearing Gough envisages that this technology will work impaired users, more special effects and infographics best when embedded in training like a mini-clinical can be deployed. evaluation exercise to test competences. NHS trusts Sustainability interested in immersive VR will need to decide which application would best fit their circumstances. If they Gough’s aim is to make this technology ubiquitous prefer it built into headsets, they would need to commit and enable access worldwide, whatever the budget. to hardware. The key, says Gough, is clarity of what This aim is supported by allowing any headset to be you are trying to achieve. He adds: ‘VR is good for the used, from a Google Cardboard headset (costing expensive, difficult and ethically challenging.’ less than £10) to a high end device. One Shot is also committed to green cloud use of technology and is The application of this technology in the UK would working to identify the emissions created by its VR be of benefit to surgeons worldwide. Gough says: in collaboration with Infinite Lambda. ‘If we build this in a place that is the gold standard of surgical care, we can create the gold standard Effectiveness immersive training experience.’ Foolproof gathered feedback from those using One Shot VR in Yemen; it was well received in terms of usability and the immersive experience. Foolproof also led an expert review to hone the VR experience. Foolproof and One Shot Immersive were announced winners of the BIMA10 2021 awards for digital enterprise, for their work in Yemen using VR to train doctors for mass casualty events. 53 | CASE STUDIESCASESTUDY:FUNDAMENTALSURGERY FundamentalVR offers a virtual reality (VR) education Equality and access platform to support surgical learning in an immersive VR surgical environment. Fundamental Surgery is the only The technology can be enabled for a range of trainees. VR education platform accredited by The Royal College For example, audible and visual support can be selected of Surgeons of England and the American Academy of for those needing this. Orthopaedic Surgeons. ‘Anything we build or deliver needs to meet the standards of the Royal College of Sustainability Surgeons and they assess the company annually’, Each purchased licence allows for one installation on a says Chris Scattergood, company co-founder. single computer or laptop but with any number of users. This technology could be purchased by a simulation Key features centre in a hospital and with just one licence, a range • A multimodal software platform that can be used on of surgeons could use it; an orthopaedic trainee could be followed by a surgeon training in ophthalmology or haptic units, 3D systems, headsets and robot arms cardiothoracic surgery, for example. The hardware is already on the market. off the shelf and the most expensive component costs • @HomeVR uses standalone headsets to allow approximately £2,500. The software application is held surgeons to walk through a procedure from wherever in the cloud, supporting updates and upgrades without they are. the power consumption of server systems. • HapticVR is the company’s patented haptic system designed to deliver the full sense of force-feedback ‘We believe that every surgeon touch with immersive VR. It is said to support skills development by enabling full rehearsal of medical should have the opportunity and surgical procedures. Users experience the to rehearse, practise and test same sights, sounds and physical sensations of the themselves in a safe, controllable human anatomy. Surgeons can collaborate in a virtual operating theatre, including handing instruments to space that is as close to real life one another. as possible and is within an arm’s • The application provides real-time feedback to reach of their workplace.’ users, who can repeat specific steps to gain a better understanding. Chris Scattergood, Co-founder, FundamentalVR • The trainer can stand looking over the trainee’s shoulder to watch the trainee perform a procedure, Effectiveness or watch from the trainer’s home or other setting. Surgeons completing a training procedure can • A dashboard summarises the trainee’s answers to gain continuing professional development points. multiple choice questions asked during the procedure. At St George’s University Hospitals NHS Foundation National specialty guidance could be incorporated, as Trust, the Fundamental Surgery platform is reported to have been mandated as part of the orthopaedic needed. Trainees can compare their data with others training programme. across the UK. • The anatomy application has the option of turning off the layers of skin to focus on the anatomy underneath. 54 | CASE STUDIESCritical success factors FundamentalVR is working with industry, He also argues for procurement arrangements that pharmaceutical companies and other organisations are proportionate to software subscriptions of £6,000 to design new simulations. The NHS will benefit and without technology providers having to perform downstream from these developments; however, demonstrations multiple times in the same hospital. Scattergood would like to see the NHS and Scattergood adds: ‘Ideally, Health Education England Health Education England move to the forefront of would define the curriculum and commission a company commissioning technologies to meet training needs. to develop the right suite of VR solutions to fit the needs of training.’ 55 | CASE STUDIESCASESTUDY:VERSIUSVIRTUALREALITY ‘The virtual environment is so Key features realistic that even if you’re sat • Simulating a lifelike and immersive experience, at home, you feel like you are Versius Virtual Reality mimics the real-life environment of the operating theatre. Users are guided through in the operating room.’ learning objectives by a virtual assistant to support them at every step. Fiona Morrison, Global Head of Professional Education, CMR Surgical • Versius Virtual Reality has been developed to give the wider surgical team the opportunity to practise and develop their skills when setting up Versius in theatre. Versius Virtual Reality is a new virtual reality (VR) headset and professional education programme for the • The Versius Virtual Reality headset is wireless, Versius surgical robotic system from CMR Surgical. does not require connecting to a PC, and is packaged in a small box for portability and convenience. Versius is the first soft tissue surgical robotic system to It can therefore be used outside the operating theatre, offer VR training as part of its training pathway. The VR platform aims to give surgical teams increased flexibility in any location, including from home. to practise their skills, according to CMR’s global head of professional education, Fiona Morrison. • CMR Surgical has produced Versius Virtual Reality in partnership with FundamentalVR, a leading VR education company. The platform will continue to be developed in partnership with surgical teams. • Versius Virtual Reality utilises VR technology from HTC Vive .™ 56 | CASE STUDIESEquality and access Effectiveness The Versius Virtual Reality headset has been developed ‘Our professional education programmes are always to make training with Versius even more accessible focused on optimising the use of Versius for surgical than before. As part of its commitment to proficiency- teams’, says Morrison. ‘It is exciting to add a VR element based training, CMR Surgical already offers clinical to our already comprehensive and well respected online resources (the Versius Trainer simulator) as courses. Now, surgeons, trainees, nurses and the entire well as residential and hospital support. According to surgical team will be able to develop their skills with Morrison, the VR headset is an additional offering that Versius, when and where it’s convenient for them.’ was developed owing to the requirements of the wider surgical team. The portability of the VR headset means Critical success factors that the entire team, including surgical registrars and One factor that was crucial to the development and nurses, will be able to practise with Versius at a time to success of Versius Virtual Reality was to develop and suit them, without having to spend time in the operating theatre. The VR headsets can be utilised in any work or pilot the platform alongside surgical teams so that it home environment. would truly enhance clinical skills with Versius. Morrison says that they have had incredible feedback Sustainability from surgeons and nurses all around the world. What has impressed surgical teams the most is how lifelike the The Versius Virtual Reality headsets are shareable operating theatre is when clinical teams put on the and reusable. If new members of the surgical team require training, the headsets can be assigned to them. VR headset. The platform environment will be updated in conjunction with surgical teams so headsets will not need to be Developed in conjunction with FundamentalVR, Versius Virtual Reality is being piloted in spring 2022 with global regularly replaced. Although offered as an added-value roll-out in the summer. professional education tool to complement existing training, it is anticipated that access to the VR headsets will reduce demand for travel to external professional education owing to the remote nature of training. 57 | CASE STUDIESCASE STUDY: 3D LIFEPRINTS 3D LifePrints is a medical 3D printing company that Sustainability uses 3D technologies to provide innovative solutions to the medical sector. The company supplies patient At its core, 3D printing is a reasonably sustainable specific medical devices including anatomical models, technology as only devices that are required are surgical guides and bespoke titanium implants (under its manufactured. Additionally, by moving manufacturing to the point of care, all the logistical costs and impact ISO 13485 certification). The core business is clinical. are avoided. However, the technology has useful applications for surgical training, according to Henry Pinchbeck, The surgeons with whom Pinchbeck and colleagues co-founder of 3D LifePrints and chief executive officer. work tend to keep the models, compiling a library of Key features cases that they can use for training. The concept is that rather than using a standard model to demonstrate a • Working with surgeons, engineers at 3D LifePrints procedure, the surgeon can simulate on the model of take computed tomography and magnetic resonance the patient’s anatomy, effectively recreating the case for imaging data to design and manufacture patient the students. If clinicians wish to dispose of the models, specific devices. the plastic can be recycled. ‘But reusing is so much better than recycling’, says Pinchbeck. • The company’s unique selling point is that it sets up facilities at the point of care in a host hospital where its engineers can work directly with clinicians. ‘The will to innovate is strong in • Surgeons use these devices to plan surgery, surgery; the problems come down guide a surgical procedure or implant into to funding, access to technology the patient. The following surgical specialties are currently covered: cardiothoracic, general, and time.’ oral and maxillofacial, otolaryngology, plastic, trauma and orthopaedic, urology and vascular. Henry Pinchbeck, Chief Executive Officer, 3D LifePrints • There are complex regulations that apply to the 3D printing of medical devices for clinical use. These regulations do not apply for simulations Effectiveness and the training environment, which offers scope One of the areas of highest impact for patient specific to use the technology for training. devices is oncology. Pinchbeck reports that surgeons at the Royal National Orthopaedic Hospital consider • Once a device has been designed and created, it can the use of guides and models from 3D LifePrints to be be reprinted for use as a training tool (the main cost essential for the removal of tumours while excising a already having been incurred in the design phase). Reprinting models provides trainers with the exact margin of surrounding tissue with accuracy. patient anatomy with which to bring a case to life – from a heart to a kidney, complete with kidney stone. Equality and access One of the greatest assets of medical 3D printing, according to Pinchbeck, is the ability to provide bespoke devices, meaning it is no longer necessary for devices to be designed to a standard size or shape. As the technology advances, this will allow universal access to medical devices notwithstanding the patient’s (or clinician’s) physiology and preferences. 58 | CASE STUDIESCritical success factors ‘We sell to 50 different NHS hospitals and the approach 3D LifePrints currently has hubs at Wrightington Hospital, to procurement is different in every single trust’, says Alder Hey Children’s Hospital, Leeds General Infirmary Pinchbeck. He is frequently asked by surgeons for and the Nuffield Orthopaedic Centre. Design engineers patient specific models to use both for clinical decision in hubs are linked together by a digital 3D platform, making and for surgical training but says that the system Embedmed. Pinchbeck’s aspiration is for patient specific struggles to pay for them. Pinchbeck believes that the devices to be made readily available to all clinicians. best way to deploy this technology in the NHS is from He also believes that the reuse of anatomical models for point of care hubs embedded in host hospitals, with training is an effective and cost efficient way to make best engineers on hand to design bespoke medical products. use of these resources. 59 | CASE STUDIESCASE STUDY: MICROSOFT’S HOLOLENS Health Education England (HEE) has purchased a large • HoloLens can enable trainees to participate in virtual number of mixed reality holographic devices including ward rounds. Instead of straining to see what is Microsoft’s HoloLens to loan to NHS trusts to support happening, trainees can see what the trainer sees, training recovery following the COVID-19 pandemic. and ask questions of the patient and the clinician Richard Price, learning technology advisor at HEE, wearing the device. The patient’s vital signs are explained the potential of HoloLens to support medical displayed on an admin screen. Trainees can walk training, including for surgery. Price stresses that HEE around the bed and the patient. is vendor neutral and independent of any technology suppliers. HoloLens was the first to market and therefore • A surgeon wearing the HoloLens device can broadcast a surgical procedure to trainees, one of the first that HEE decided to test. enabling them to see what the surgeon is doing and gain a detailed view inside the body cavity. ‘We’re testing the water. If we • Trainees can connect with other colleagues working on holograms. can demonstrate return for the investment, we can apply for • A library of holographic patients can be used money to centrally fund more.’ for group teaching sessions. Equality and access Richard Price, Learning Technology Advisor, Health Education England This technology offers clinical experiences for trainees who cannot physically attend a clinical placement. Key features Its application to trainees affected by the COVID-19 pandemic is clear. Price also highlights the value for any • The user wears a head mounted display with a visor trainee seeking more clinical experiences, including those that overlays the eyes, containing a holographic returning to clinical practice after a period of absence display and an array of cameras and multiple sensors (such as parental leave). that pick up the surrounding room. Holographic processing then creates holograms by taking a 2D Sustainability video and turning it into a 3D object, overlaying the real environment. HEE leases the equipment and loans it without charge to NHS trusts for a set period before passing it on to • When looking through the visor, a holographic the next trust. At the end of three years, HEE may decide to buy the kit or replace it with something different. patient can be placed on an empty chair in the The HoloLens devices can be recycled or repurposed. physical room, or in a holographic trolley or hospital bed with surrounding machines. HEE has covered the cost of the hardware, software and insurance; all users need to do is power up the device. ‘We’re calling it the “just add fuel” model’, says Price. By centrally leasing and distributing technologies that support training, HEE can cover places that do not have the resource to invest directly in these technologies. While the current focus is on medical trainees, Price is mindful of the need to broaden access to paramedics, nurses and allied healthcare professionals. 60 | CASE STUDIESEffectiveness Critical success factors HEE has commissioned Maudsley Learning to conduct Price emphasises that data generated from one an evaluation of HoloLens and its impact on specialty technology or application need to be compatible across training. ‘We need to get beyond the anecdotal to the breadth of technologies. ‘Siloed data that do not get quantitative feedback’, says Price. This includes bear any relation to the rest of the trainee portfolio understanding the return on HEE’s investment to date won’t be useful’, he says. ‘There are several hundred and whether (and how much) more funding might providers; if they all have their own data standard, be warranted. there’s no chance of getting it in a format we can work with. Data need to be captured in a format that enables educators to work with trainees in a more holistic way.’ 61 | CASE STUDIESEVIDENCE SUBMISSIONS THE EVIDENCE HAS BEEN DIVIDED INTO THE FOLLOWING SECTIONS: SECTION A: How technology can increase exposure to operating SECTION B: How technology can enhance training along the patient pathway SECTION C: How technology can support assessment of trainee competence SECTION D: How innovation can help the surgical workforce SECTION E: What needs to happen to embrace technology enhanced surgical training 62 |EVIDENCE SUBMISSIONS SECTION A HOW TECHNOLOGY CANINCREASEEXPOSURE TO OPERATING SIMULATION AND 3D PRINTING Substantial evidence has accrued regarding the use of virtual reality (VR) models to train to proficiency. In an early randomised controlled trial, surgical trainees A1. SIMULATION: TRAINING TO undergoing VR-based simulation training before live PROFICIENCY USING SIMULATION operating performed significantl56better than those undergoing ‘traditional’ training. In Seymour et al’s Conor Toale study, VR training (with the MIST-VR system) led to ‘live’ gallbladder dissection that was 29% faster and residents The sophistication of simulation models coupled with were five times less likely to injure the gallbladder or competence education allows for the development 62 of training-to-proficiency curricula with learning and burn non-target tissue. Operative errors were six times assessment taking place outside the operating theatre. 56 less likely to occur in the operating theatre with residents Proficiency-based progression (PBP) is a method of trained using VR. learning and assessment where the required level of Ahlberg et al again demonstrated that PBP training trainee competence is pre-defined, conventionally based using VR translated to fewer errors in live operating57 on the mean performance of ‘experts’ performing the while Van Sickle et al showed that training to same procedure. Performance is measured using proficiency using the MIST-VR system led to improved defined metrics constituting acceptable performance. 58 63 performance in laparoscopic suturing. Palter and Trainees then practise with continuous feedback until Grantcharov used both VR and cadaveric models to these benchmarks are met. A recent systematic review train residents to proficiency benchmarks in laparoscopic and meta-analysis of 12 clinical trials by Mazzoneet al right hemicolectomy, recording superior subsequent demonstrated that PBP training reduced the number of performance in live operating compared with residents performance errors by 60% (p<0.001) and procedural 64 time by 15% (p=0.003) as well as increasing the number undergoing standard training. 59 of steps performed by 47% (p<0.001). Simulation practice with proficiency benchmarks can be used by surgeons to ‘warm up’ before a live operation. Several studies have demonstrated the value of Moldovanu et al recorded improved ‘respect for tissues’ training to proficiency using dry lab simulation models. scores in surgeons undertaking such warm-up exercises Pedowitz et al described the use of the Fundamentals compared with controls. 46Lendvay et al used a VR of Arthroscopic Surgery Training Program knot tying robotic simulator as a warm-up tool for surgeons prior bench model. The knots of orthopaedic trainees using to live operating and recorded improved economy of the model and knot tester for immediate feedback were motions compared with controls. 65,6If coupled with almost four times as likely to ‘pass’ pre-defined metrics. validated proficiency metrics, this could represent a Angelo et al used a high fidelity bench model simulator powerful tool for improving and maintaining surgical coupled with PBP benchmarks to significantly improve performance. In an era of increasing pressures on performance compared with standard training; 56% fewer errors were made by the group undergoing trainee operative time and ongoing implementation of 61 competence-based curricula, simulation represents a PBP training. way in which learning curves can be shortened, trainee competence assured and skill standards maintained without relying on case volume or subjective trainer evaluations as proxy competence measures. 63 | SECTION A: HOW TECHNOLOGY CAN INCREASE EXPOSURE TO OPERATINGA2. CADAVERIC, ANIMAL AND ALTERNATIVE MODELS: ARE WE THERE YET WITH FIDELITY? Paul McMenamin and Mark Mikhail Teaching of human anatomy in undergraduate medicine and postgraduate training has undergone significant change over the past few decades, especially in respect of the technologies available to augment or replace traditional cadaver-based dissection instruction. Figure 4: A model of one internal carotid artery (from carotid canal to division in anterior and Anatomy teaching in medical or healthcare professional middle cerebral arteries) training programmes has for several decades had access to a range of other options for classroom-based instruction, including plastinated specimens and digital resources/software programmes. Nevertheless, very With improvements in 3D surface scanning and 3D printing technology, the 3DID team has managed to recent technological advances have seen the advent of new resources in the form of 3D printed replicas of achieve photographic-quality accurate replicas that more human anatomy. closely resemble traditional prosections (Figure 5). In addition, we have recently also created a 3D printed Our group at the Monash University 3D Innovation pathology specimen for teaching (Figure 6). The future Design (3DID) lab in Australia developed a range of 3D of a haptically identical and anatomically accurate replica printed replicas of normal human anatomy dissections based on high quality radiographic data and/or of human cadaver specimens for surgical and medical training is already upon us. surface scanning data of real 3D cadaveric material. Combinations of these methods has allowed us to accurately capture critical 3D anatomical information (Figure 3). These can then also be delivered in virtual and augmented reality delivery platforms. Figure 5: Partly false coloured 3D print of posterior abdominal wall Figure 3: 3D printed hand (left) based on the cadaver specimen on the right With regard to the need for recapturing dissectible, hepatically realistic models for training surgeons and proceduralists (eg anaesthesiologists), the challenges are in the realm of the material types suitable for 3D printers. In addition, there are very few multimaterial printers on the market, they are expensive and the soft materials may struggle to replicate the haptic property characteristics of fresh human tissues. These limitations may never be completely eliminated and the future is likely to be solved by hybrid anatomical replicas that are a synthesis of 3D printed moulded Figure 6: 3D printed pathological specimen and cast components (Figure 4). 64 | SECTION A: HOW TECHNOLOGY CAN INCREASE EXPOSURE TO OPERATINGA3. 3D PRINTING ENHANCED SURGICAL EDUCATION Harry J Carr 3D printing was pioneered in the 1980s to validate computer aided design models through rapid production of real-world prototypes. Fused deposition modelling is the most common type. It extrudes a selected material in a semi-liquid state on to a platform in a pre-determined pattern. The three dimensions arise via application of further layers until the full structure is complete. While 3D printing has been Figure 8: Combined use of the da Vinci surgical used in industry for decades, it is only recently robot with a 3D printed splenic artery aneurysm. 69 Copyright permission granted by Springer Nature (mostly in th67past 3–5 years) that it has blossomed in medicine. Much of this can be explained by the combined effect of Moore’s law on 3D printing and radiological technologies, making high quality medical Realistically, the benefits of 3D printing enhanced 3D printing quicker, cheaper and easier. The clinical surgical training are close. However, they have not possibilities of 3D printing are certainly enticing for yet been fully realised owing to limitations of high NHS trusts and have been lucrative for outsourced cost commercial software and unintuitive open commercial printing companies, so why should we access options, low fidelity of simulated tissues and invest in 3D printing for surgical education? complex prints requiring frequent troubleshooting. High quality examples in the literature demonstrate Beyond polymeric 3D printing, bioprinters may help us make ultra-realistic models that allow us to hone the well established benefits such as low cost, rapid the finer nuances of our operative skills and test out manufacture with patient specific models. 3D printing new operating technologies such as robotics, remote can not only enhance basic anatomy learning but it can also be especially applicable to difficult concepts such operating and artificial intelligence before working as fetal anatomy (Figure 7). For basic surgical skills directly with patients. development, 3D printing can be combined with other technologies to create low cost suturing trainers (and with increasing fidelity of more complex models IMMERSIVE TECHNOLOGIES that can simulate full operations) (Figure 8).69 AUGMENTED, VIRTUALAND MIXED REALITY A4. SURGICAL VIDEO AND IMAGE DATABASES Martin King The relationship between trainee and trainer or educational provider is important to the development of various domains in pre-defined curricula. The downturn of surgical activity as a result of the COVID-19 Figure 7: Production of a multimaterial 3D printed fetus for enhanced understanding of pandemic has required flexibility in this relationship, 68 and the application of agility from healthcare and developmental anatomy. educational providers. It is said that agile organisations are foremost designed to work in an uncertain Used with permission of John Wiley & Sons environment. Individual trainees, representative (© 2018 American Association of Anatomists), from: Young JC et al. Three-dimensional printing organisations and educational providers have had to of archived human fetal material for teaching manage uncertainty over the past few years. purposes. Anat Sci Educ 2019; 12: 90–96; For the surgical trainee, attainment and assessment permission conveyed through Copyright Clearance of knowledge is mandated by the General Medical Center, Inc Council in Good Medical Practice before performing 65 | SECTION A: HOW TECHNOLOGY CAN INCREASE EXPOSURE TO OPERATINGa procedure. With uncertainty surrounding access surgical teams in London, archived online and offline and the time available in the operating environment, through secure servers, accessible through a Health utilisation of technology to bridge this deficit has Education England login that can be extended to become crucial. In order to reduce the time for cognitive the wider multiprofessional team. This resource can skill acquisition and proficiency of surgical skills in then be further enhanced through virtual reality (VR) the operating environment, access to video and and artificial intelligence software to allow remote image recor45ngs of the specific procedure or task is digital anatomy teaching, case-based discussions, beneficial. Surgical video platforms fulfil these criteria, perioperative planning, multidisciplinary team working with most having the capability to record, store, share and patient risk assessment discussions, which are and analyse a procedure. all essential parts of the surgical curricula. It can be adjusted to attract continuing professional development Efficiency of time in setting up and accessing a platform points and can be trained to individual learner needs. will be important for cultural acceptance. The introduction and integration of both hardware and software solutions There is also potential to apply technology enhanced to pre-existing healthcare systems could mean initial learning solutions for remote assessment of learning delays. Trainees and trainers will be required to become integrated with e-logbooks and Intercollegiate Surgical au fait with the language of cybersecurity and information Curriculum Programme portfolios through laparoscopic/ governance to ensure that the information given to endoscopic/endovascular video recordings and dry patients for their consent to participate is relevant, labs, and this has already been piloted in some accurate and meaningful. specialties (gastrointestinal, cardiothoracic, vascular). We have identified practical skills, human factors, and Accelerating the learning curve in a safe, fair and centralised online webinar and video library resources equitable manner is of paramount importance in the rebuild and recovery of surgery. Adoption of as key priorities during recovery. Specific learning outcomes and/or competence acquisition that this surgical video and image-based platforms will require proposal will result in include: careful consideration of the trainee, the trainer, the organisation and (most importantly) the patient • Acquirement of capabilities in practice for that can only be addressed in a collaborative, well perioperative care, indications for treatment, structured feasibility study. anatomy, instruments, operative steps, surgical techniques and technical considerations, A5. RECOVERY ONLINE PROGRAMME interactions with the multiprofessional team and alternatives to treatment FOR SURGERY IN LONDON: PROPOSAL ON BEHALF OF THE • Technical skills gain assessed though VR platforms and a trained, UK based core assessment faculty CONFEDERATION OF POSTGRADUATE SCHOOLS OF SURGERY – This will provide feedback based on validated quantitative (technology enhanced learning) and qualitative (faculty) metrics. (Skills gain will vary Celia Riga depending on specialty but will be directly linked to The COVID-19 pandemic has had a direct impact the new curriculum requirements.) on access to operative cases across all surgical disciplines. Deficiencies in exposure (especially for • Integration of multiple choice questions with progress reports generated for trainees and trainers benign disease and elective pathologies) is evidenced through Joint Committee on Surgical Training data • VR assessment, which will provide data on where and trainee logbooks. 14,15,Several online resources individual trainee performance stands compared currently exist, and are popular in Europe and the with peers. US. 70–7UK trainees often report using video libraries but these tend to be linked to US training requirements. A6. LIVE STREAMING A UK-based, validated, multispecialty resource with direct links to the UK curriculum is lacking. This represents a unique educational leadership Karan Kapur opportunity for the London team in Health Education ‘Come and look over my shoulder’ is a phrase known England to produce and endorse a valuable and to every surgeon. Active discussion and feedback over sustainable education resource to fill a much needed the operating table is the bread and butter of the early gap in the e-learning landscape for UK surgical training. surgical trathee’s educational life. Drawing on lessons An operative video library will act as the backbone from the 14 Dalai Lama, who said ‘Transforming these of this proposal. Trainees will be able to search and obstacles into opportunities is a challenge to our human ingenuity’, we can explore the role of smart wearable view index procedures performed by experienced 66 | SECTION A: HOW TECHNOLOGY CAN INCREASE EXPOSURE TO OPERATINGdevices and virtual education in addressing the training platform and its value being recognised in the curriculum gap. Using Google Glass™, surgeons can provide by statutory education bodies is key to adapting surgical live feedback to trainees via augmented reality, 74 education in the current climate within a nationalised teach a wi73,74udience by recording/livestreaming an 75,76 model of training. operation and use Glass™ as a consultation tool. Another approach, demonstrated by Rods&Cones, utilises purpose built platforms called visOR and ACCELERATING OPERATIVE 77 COMPETENCE mirrOR. Although they have similar applications, both are designed as computing devices to be worn as spectacles with built-in displays projecting information A7.KEYCONSIDERATION:SHORTENING into the field of view. However, their architecture sets ™ ™ SURGICAL LEARNING CURVES IN them apart. Google Glass is built on the open Android COMPETENCE-BASED PROGRESSION platform, an application-based ecosystem that gives surgeons the freedom to collaborate with a developer community that is free at source. Rods&Cones provides Jun Lim and Haroon Rehman a packaged solution, which is ready to implement and The surgical learning curve has been defined does not rely on end user development. as ‘the time taken and/or number of procedures Understandably, these approaches will affect product an average surgeon needs to be able to perform availability, lead time for implementation, affordability, a procedure independently with a reasonable outcome’. 82The adaptation of new technology in technological support presence, research, collaboration surgery is often associated with a learning curve and and most importantly, data security.78,79Usability is dependent on software, hardware, battery life and the concept of a learning curve is best understood comfort. There is currently little available peer reviewed in minimally invasive and robot assisted surgery. 83,84 data on the use of Rods&Cones products. Virtual reality Surgical simulation to reduce a trainee’s learning curve remains of interest but requires further development was recognised in the early 1990s and deemed a with haptic feedback and definition, a likely candidate 80 safe environment for trainees to practise techniques for development in the post-COVID environment. repeatedly without compromising patient safety. 85 Repeated simulation delivered over a sustained period Virtual surgical skills training, an Association of can lead to better retention of knowledge and skills, Surgeons in Training hackathon concept developed by a group of junior surgical trainees, aims to address reducing the learning curve and decreasing the risk of adverse operative events. 86–8For example, Bartlett et al learning needs by engaging trainer and trainee to observed a significant improvement in time taken, construct virtual content using the tools above or even a simple camera. The surgeon can host a live efficiency of movement and number of collisions classroom through a virtual whiteboard system and with soft tissue after three sessions of simulated arthroscopies of a healthy virtual hip joint by record it for review. This is reinforced through relevant medical students with no previous experience of hip postoperative online assessment, allowing trainees to 89 use their time in theatre better. This proposed solution arthroscopy. This study demonstrated that the virtual addresses the need for more personal assessment, reality environment generated by the simulator had sufficient visuohaptic consistency to enable individuals reduces trainer burnout and keeps implementation to develop basic arthroscopic skills. costs low for a centralised model of training. It has been said that ‘surgery remains a skills-oriented For a novice surgeon, there is an intraoperative profession requiring expanded knowledge acquisition learning curve as well as an increased level of stress associated with new technology. The use of robotic to be effectively complemented with technical skill assistance reduces the learning curve for both development’. The main goal for these virtual 84 instruments is to reduce footfall in theatre while standardised simulated tasks and actual operations. overcoming training access pressures. Although there Despite minimal robotic training, robotic technology 79,81 has allowed novice laparoscopic surgeons to complete is a clear demonstrated positive impact on education, various laparoscopic training drills faster than expert feasibly incorporating wearable devices in a centrally 90 governed training programme is complex. This system laparoscopic surgeons. Robotic arm assisted technology in total hip arthroplasty is an additional gives individual localities less autonomy to implement technological tool that is increasingly used in the such tools and make them part of the curriculum. Most studies assessing the use of wearables are small operating theatre to mitigate the learning curve by 83 scale and/or based in training programmes with greater providing real-time haptic feedback intraoperatively. There is significant discrepancy in the methods used to localised autonomy. Empowering surgical educators and measure learning curves and a lack of standardisation learners alike to take advantage of an effective virtual 67 | SECTION A: HOW TECHNOLOGY CAN INCREASE EXPOSURE TO OPERATING 91 101 in defining competence in the literature. This has scale categories with a mean accuracy of 77%. made comparison of learning curves between studies Such applications of ML can have direct application of the same procedure difficult. There are two types of in surgical training and automation of competence variables that are commonly used to measure learning assessment in future. curves: patient outcomes and surgical process. Deep learning models that recognise surgical anatomy The learning curve can also vary considerably depending on the nature of the procedure, manual have also been developed. Safe and unsafe dissection dexterity of the individual surgeon, case mix and patient zones during cholecystectomy were identified with an factors.82,8Being able to measure the surgical learning accuracy of 0.94 and 0.95. 102The Institute of Image- guided Surgery of Strasbourg in France has used curve can have potential benefits for patient safety and surgical education. Consequently, standardisation intraoperative augmented reality feedback during of methods used to measure learning curve and cholecystectomies, highlighting the cystic duct and cystic competence are warranted. artery, enabling decision support. We hope that the future will allow a real-time dynamic overlay of anatomy during A8. VIDEO ANALYTICS, AI, MACHINE the majority of minimally invasive procedures. LEARNING AND DEEP LEARNING These combined ML applications will help to reduce the surgical learning curve and decrease the time needed to reach proficiency in training. Surgical videos can be Michal Kawka and Tamara Gall automatically analysed in real time, with ML providing Artificial intelligence (AI) can be defined as the ability information about the next surgical step, suggested of a computer to demonstrate behaviour and perform instruments to be used and cues about time devoted tasks commonly associated with the human brain. 92 to each stage as well as safe and unsafe areas for Machine learning (ML) is an application of AI, where the dissection. What is more, recording of operations can developed algorithms use statistics to find patterns, and be graded retrospectively based on video recording, have the ability to automatically learn and improve their providing performance metrics and helping to identify accuracy. Both AI and ML have become omnipresent areas for future improvement. in medicine in the 21 century and yet their penetration As with all research, AI outputs are limited by the into the world of surgery has not been widespread scientific question that is proposed. In addition, the despite the great potential of these technologies to revolutionise the operating theatre and surgical training. accuracy of algorithms is based on datasets, which are likely to have systematic biases in clinical data One main area where ML can contribute to surgical collection, particularly if surgeons are unwilling to training is video analytics as surgical videos constitute submit recorded videos of difficult or problematic cases, 94 a rich dataset. The applications of ML to intraoperative ultimately affecting AI predictions. While big data may video analysis began with surgical phase recognition. enable AI to recognise patterns missed by humans, it is Most operations can be divided into distinct steps or unable to provide clinical interpretation of the analyses phases and as such, after annotation by an expert, or provide appropriate clinical context. Furthermore, algorithms can learn to detect these stages. Surgical concern over the accountability of103tomation may slow phase recognition studies have been conducted its development and clinical use. for laparoscopic cholecystectomy, laparoscopic sigmoidectomy, sleeve gastrectomy and endoscopic Such granular, trainee level data are currently not widely available but platforms such as Medtronic’s myotomy, all showing the ability of the ML to correctly Touch Surgery and Johnson & Johnson’s C-SATS identify surgical phase with an accuracy of >90%. 95–98 offering personalised video libraries and surgical Another application of ML to video analysis is surgical analytics already exist. If we can utilise these datasets instrument recognition. The choice of the surgical tool and harness the capability of big data 104to predict error, can provide contextual cues to the surgical phase this could accelerate training and improve patient safety 99 and surgical task being performed. Instrument (Figure 9). Their widespread adoption has not occurred recognition thus allows for instrument tracking, leading yet but undoubtedly will occur in the future given that to automated gesture and potential error identification. as more research is conducted in this area, a shift will It has been shown that ML driven instrument tracking occur towards personalised, automated performance using neural networks can be achieved with 83% analysis. Collaboration between surgeons, computer accuracy. 100Similarly, deep learning has been used to scientists and engineers is crucial to facilitate adoption, analyse suturing videos and was also able to stratify drive AI literacy among clinicians and promote their participants into three skill levels (novice, intermediate active involvement in this field. Only then can the and expert), estimating their scores on the objective benefits of AI and ML be translated into better surgical structured assessment of technical skills global rating training and ultimately, improved patient safety. 68 | SECTION A: HOW TECHNOLOGY CAN INCREASE EXPOSURE TO OPERATING EXPERT NOVICE Z Z Y Y X X Left hand instrument tracking Right hand instrument tracking Figure 9: Example of laparoscopic instrument tracking comparing a novice and an expert surgeon A9. TRAINING IN CARDIOTHORACIC for transplantation training in adult cardiac and TRANSPLANTATION IN THE UK: general thoracic surgery. The learning is ad hoc, and is dependent on patients treated and the will of the ACTUALITY AND PERSPECTIVES implanting surgeons to supervise parts of a larger, more complex operation. The training environment must be Hassiba Smail and Abdul Badran improved and shortened to facilitate uptake from a Cardiothoracic transplantation as a subspecialty wider pool of candidates and to improve accessibility. is divided into three fields: organ retrieval, organ In collaboration with The Royal College of Surgeons of implantation and mechanical circulatory support covering England, NHS Blood and Transplant provides an annual two different organs (the lungs and heart). A difficulty cadaveric masterclass on heart and lung retrieval. in teaching trainees how to perform thoracic organ However, modern tools in simulation and training in retrieval is that it differs markedly from other technically procedures are essential in facilitating progress on the challenging cardiothoracic operative procedures. The first step towards an excellent transplant recipient outcome is learning curve. This could be achieved by centralising resources into a transplantation academy with a an optimised donor organ. Teaching these skills requires dedicated structure of progression and multicentre strong non-technical skills in sustaining an atmosphere mentorship integrating the pre-Certificate of Completion of communication and flexibility, taking responsibility of Training (CCT) curriculum under specialty advisory for donor organs and being clear on the rationale for committee guidance. This would be supplemented with the order of procedures as well as teaching donor cuff logic and diplomacy while working with multiple surgical a post-CCT programme devised with the Society for Cardiothoracic Surgery in Great Britain and Ireland, teams. The complexities of patients requiring heart and NHS Blood and Transplant, and The Royal College of lung transplantation are also increasing. This sometimes Surgeons of England comprising scheduled mandatory mandates dual consultant operating with subsequent training with theoretical courses and practical elements direct impact on training experience. including simulation, virtual reality, augmented reality, Cardiothoracic surgeons in training do not all and wet lab cadaveric and animal work. These changes rotate through cardiothoracic transplantation must be adopted to make cardiothoracic transplantation in the UK; indeed, not all centres accommodate training more accessible, shorter and more effective. trainees. Currently, there is no existing structure 69 | SECTION A: HOW TECHNOLOGY CAN INCREASE EXPOSURE TO OPERATING More than 150 students took part in several standalone A10. USE OF AR/VR TO ENHANCE LEARNING OF MAJOR TRAUMA sessions in which feedback was gained. There was a strong agreement between participants that the virtual platform was SITUATIONS high quality, was easily accessible, provided good learner– tutor interaction with real-time feedback and ultimately, Gnananandan Janakan was something that they felt provided good value and that There are only 33 major trauma centres across the they would like to attend again and see integrated into the undergraduate surgical curriculum. Most participants felt UK and this translates to limited training opportunities. that they had improved their skills enough to feel confident Virtual reality (VR) involves a fully immersive, often assisting in theatre. Common themes surrounding perceived pre-recorded or computer generated environment. Augmented reality (AR) allows for a blended limitations were issues with variable internet connection experience, where the real world has an overlay with quality causing intermittent disruption, and the inability for one-to-one coaching and feedback. Virtual surgical other information. The hardware consists of a headset skills sessions could be a useful adjunct that is low cost, or a smartphone with a head mounted display and hand controllers. Google Cardboard is the simplest convenient, and a readily accessible means to enhance the and cheapest head mount (£10–£20) but there are also quality of undergraduate surgical skills teaching both in the ™ UK and overseas. high end headsets and controllers such as HTC Vive (£500–£1,000). Viewing using a laptop or smartphone is possible but lacks the immersive element. A12. ROBOTICS AND MINIMALLY INVASIVE SURGERY A key benefit of the technology is that reproduceable scenarios can be viewed simultaneously by multiple Michal Kawka and Tamara Gall people, which can allow for structured assessments. Quantitative improvement in operative skills acquisition Many ascribe the first application of robotics using AR/VR is established but to date, there is no in surgery to Kwoh et al, who in the late 1980s research on non-technical surgical skills using AR/VR. 105 AR/VR is evolving with early adopters in other medical described using a robotic system to assist in brain biopsies.109Since then, robots have reached specialties including surgery although more evidence is widespread adoption across multiple surgical needed to inform widespread effective adoption. 106,107 specialties. The appeal of robotic surgery over its open counterpart stems from the benefits shared A11. VIRTUAL BASIC SURGICAL SKILLS with other minimally invasive surgery techniques, which have long been established to shorten the postoperative hospital stay, lower blood loss, Harry J Carr and lead to additional dexterity of movement provided In recent years, technology enhanced learning such by endowristed instruments as well as tremor as virtual reality and simulation have proved to be an elimination; these advantages have pushed robotic effective adjunct for higher surgical trainees.0However, surgery to the forefront of surgical research at this level, virtual reality and simulation is typically usedand innovation. 110 to complement previously learnt skills, as opposed to Robotic surgery can be divided into three categories: establishing the very basic skills such as tool familiarity, tissue handling and suturing, which have traditionally active, semi-active and master–slave systems. With always been done in person. In addition, the platform future advancements in artificial intelligence, active may be prohibitively expensive and/or requires a steep and semi-active systems might become the primary modalities of robotic surgery but currently, the master– technological learning curve. slave systems are the most used clinically despite At present, there is no evidence in the literature that basic lacking pre-programmed autonomous elements and surgical skills can be taught at home via distance learning. relying on the surgeon’s movements. Among these, As such, we aimed to explore whether a live, online the da Vinci robot, produced by Intuitive Surgical, platform could be a beneficial supplement. has dominated the market, having been employed in urology, otolaryngology, gynaecological surgery Virtual surgical skills sessions lasted two hours, and and general surgery among others. 11However, novel covered the practicalities of going to theatre for the first systems have emerged, including the Versius robot time, scrubbing in, common tools and basic knot tying manufactured by CMR Surgical (first used in the NHS techniques as well as simple interrupted and continuous ™ sutures required for closing simple wounds. Students in 2020), with other systems such as Medtronic’s Hugo and Johnson & Johnson’s Ottava being developed. were able to participate in the practical aspects by using everyday household items such as mugs, shoelaces and ironing boards. 70 | SECTION A: HOW TECHNOLOGY CAN INCREASE EXPOSURE TO OPERATINGThe rise in the popularity of robotic surgery will inevitably A13. TRAINEE PREOPERATIVE affect surgical training. Surgical robots offer advantages CHECKLIST FOR THE in terms of training. It has been shown that the acquisition MULTI-DISCIPLINARY TEAM of surgical skills in a simulation setting takes less time with a robotic than with a laparoscopic platform.112 Joanna Aldoori, Mark Peters and Andrew Robson Achieving technical proficiency has also been shown to take less time with robotic systems across an array The operating theatre is a crucial learning environment not only for the surgical trainee but also for other of surgical procedures, including hepatectomies, colectomies and nephrectomies. 113–11The faster learners including anaesthetists, nurses, operation acquisition of skills via robotic training is partly facilitatedepartment practitioners and increasingly, members by high fidelity simulations available on the robotic of the extended surgical team including surgical first assistants and physician associates. Availability of consoles. Surgical trainees can access these simulations training in the operative department may be disparate in their own time to develop basic skills (suturing, instrument handling) and procedure specific skills, and between different specialties. In recent years, the to simulate whole surgical procedures step by step. 116 surgical team has grown to include several extended roles to address gaps and service shortages, as The number of robotic consoles will undoubtedly outlined in the surgical care team guidance framework increase across the UK in the next 5–10 years, as will published by The Royal College of Surgeons of access to simulation training. We expect UK-wide fully England 118and more recently, in Health Education equipped robotic training centres to be developed. England’s extended surgical team pilot. 19 In the future, trainees could arrange for self-directed It is good practice for trainers to discuss with trainees simulation training before real-life operations, likely reducing the theatre time needed to develop proficiency, what they are expecting to gain from the list, what decreasing surgical errors. With the advancements in experience they have, what skills they are hoping to machine learning driven surgical video analytics, such gain and which procedure or aspect of the procedure they are hoping to perform. 119However, there is limited simulated surgery performed on a robotic console could discussion between disciplines of the extended team. be graded to establish proficiency of surgical trainees in a safe setting, allowing for both more efficient surgical The fact that there are multiple learners in the operating training and improved patient safety. 101,1This should department creates a risk that surgical trainees are less well served than other learners. This reinforces the enable more patients to have access to the benefits of need to develop a tool that will ensure equity and help minimally invasive surgery as early robotic experience may ultimately accelerate skills acquisition for a future improve training across the board. generation of surgical trainees. 71 | SECTION A: HOW TECHNOLOGY CAN INCREASE EXPOSURE TO OPERATINGA checklist tool completed at the start of the list during in the operating theatre during the session to the whole the theatre brief may improve training opportunities theatre team and an agreed strategy for training could be (Figure 10). It would identify the learners/trainees decided together. This may create a dialogue and shared (including surgical and anaesthetic trainees, operating understanding of the need for training among all parties. department practitioners, nursing and medical students) Trainee Checklist Date: AM PM Scrub lead: Consultant anaesthetist: Consultant surgeon: Anaesthetic Surgical ODP/Scrub Other learners Who are the trainees/ CT1 CT1 New scrub nurse learners? ST4 First case Laparoscopic CT1 – Intubation CT1 – Port placement Observes and cholecystectomy ST4 – Calot’s helps with setup dissection of lap stack Second case Open right CT1 – Insertion of CT1 – Opens and Scrubs under hemicolectomy arterial line closes the abdomen supervision Consultant – ST4 – Mobilises Performs anaesthetic colon or performs and intubates patient anastomosis Third case Umbilical hernia CT1 – General ST4 – Performs Goes through tray repair with sutures anaesthetic with CT1 Consultant with scrub nurse unscrubbed but in while performing theatre the count Figure 10: Example of a checklist to improve training opportunities The checklist for training could be used as follows: • Explain in brief terms each procedure or part of the procedure the trainee is going to perform. • Prior to the list, think about what procedure or aspect of the procedure the trainee is able • Any differences in opinion should be discussed to perform. Have a discussion with the trainee away from the theatre team and in a constructive to identify their learning goals. This can be done way between the most senior members of the team informally while waiting for the theatre brief, while (consultant surgeon, anaesthetist, scrub lead). walking down the corridor or in the coffee room. • Identify all learners in the operating theatre during that session to the whole theatre team. This includes all surgical and anaesthetic trainees, operating department practitioners and nursing students in addition to medical students. 72 | SECTION A: HOW TECHNOLOGY CAN INCREASE EXPOSURE TO OPERATINGA14. INTRAOPERATIVE DECISION MAKING, DIGITAL MAPPING, IMAGE Digital mapping: FUSION AND NAVIGATIONAL SURGERY The process by which a dataset is c121iled Manish George, Anand S Pandit and Fawz Kazzazi and formatted into a virtual image. Image fusion: ‘Computer vision’ type algorithms have the potential to be applied in real time for intraoperative assistance. The fusion of computed tomography and A recent small study demonstrated differentiation magnetic resonance imaging is a software between thyroid, parathyroid and recurrent laryngeal dependent processing technique that enables nerves, within 1.4 seconds of processing, using a one to integrate and analyse preoperative machine learning algorithm interpreting intraoperative images for planning. 122 hyperspectral photography. 120The algorithm was able to identify parathyroid tissue with sensitivity of 65% and Navigational surgery: specificity of 94%. While larger studies are warranted to Technology that allows surgeons to precisely develop more sensitive and extensively validated tools, track instrument positions and then project the soon we may see a revolution in intraoperative surgical vision, aiding in both surgical outcomes and training. instrument position on to preoperative imaging data. This sophisticated technology is often compared with GPS tracking, which allows travellers to see their position on a map.123 73 | SECTION A: HOW TECHNOLOGY CAN INCREASE EXPOSURE TO OPERATING SECTION B HOW TECHNOLOGY CAN ENHANCE TRAINING ALONG THE PATIENT PATHWAY pathophysiology and thus predict pathological B1. THE EMERGING ROLE OF 131 132 133 AI IN DIAGNOSTIC IMAGING features, treatment response and prognosis. This has been embraced in oncology and related surgical specialties to assist diagnosis and risk stratification of Sachita Bhatia, Makinah Haq, Anand Pandit cancer. In non-small cell lung cancer, radiomic research and Manish George has been able to accurately predict distant metastasis, disease recurrence, histological subtype, mutations, Overview of AI-based diagnostic imaging 134,135 gene expression profile and mortality. Artificial intelligence (AI) tools can be broadly classified by purpose for prognosis, diagnosis, treatment, clinical Deep learning workflow and expertise. 124In imaging, there is broad application of these tools, spanning from pattern In recent years, deep learning-based algorithms in the form of convolutional neural networks have been recognition to AI software that provides real-time developed as successful image interpretation tools. guidance for clinicians performing diagnostic imaging These are distinct from traditional machine learning (eg cardiac ultrasonography). 125A meta-analysis models and are a sub-field of machine learning. They are conducted in 2020 identified nearly 9,000 published studies for deep learning tools used in identification characterised by their intricate pattern recognition ability of pathology with medical imaging. 126One study in the in the absence of human input to identify and design feature extractors. Deep learning algorithms have the US has suggested that a radiologist needs to interpret potential to demonstrate powerful diagnostic accuracy. 126 an image every few seconds to meet workload demand However, in some specialties, the current evidence in their unit.7 for AI use is uncertain, with larger studies unable It is predicted that AI will reduce the increasing demand to reproduce the efficacy demonstrated in small on human radiologists and provide a diagnostic group studies, and there has yet to be widespread accuracy that is non-inferior to humans. 128AI driven implementation of these tools. 136 tools can help with efficient detection, characterisation Non-radiological images and monitoring of radiologically diagnosable diseases. Notable examples of these tools include identifying lung Much like radiological data, similar processes have cancer through thoracic computed tomography 129and been applied to other modalities. Digitised whole slide a greater diagnostic accuracy for lesions identified on magnetic resonance imaging of the brain. 130 pathological images have been interpre137 via neural networks in the diagnosis of cancer. Ultimately, pathology-based image interpretation may rapidly Radiomics speed up diagnosis and these tools may augment the process by identifying ‘high risk’ specimens for Radiomics refers to the computer-based extraction earlier formal review. In less standardised imaging, of large numbers of data points from medical radiological images and is now one of the leading photography has been a successful medium for deep areas of medical AI research. Multidimensional neural network-based diagnostic interpretation. In a images contain vast amounts of data, far more than widely cited study from 2017, clinical images (including is detectable or interpretable by humans; these so those taken from mobile phones) were accurately classified into common and serious skin lesions. 138 called ‘image biomarkers’ may correlate with underlying 74 | SECTION B: HOW TECHNOLOGY CAN ENHANCE TRAINING ALONG THE PATIENT PATHWAYImplications of AI related diagnostics on surgical training Surgical trainees should develop familiarity with AI-based imaging and diagnostics. With the hyperbole associated with medical AI, appreciating t the fundamentals of this field will help with effectively R ) Model 1 (better) e i Model 2 (worse) evaluating these tools and aid translation into clinical i i Random classifier practice. As digital healthcare advances, these o n systems are likely to be implemented in the outpatient, e ( Perfect classifier r preoperative or emergency settings to streamline T patient care. Furthermore, a solid knowledge foundation also allows trainees to recognise areas of opportunity and contribute to research in this rapidly growing field. Fa(1 - specificity) B2. AI AND PREOPERATIVE PROGNOSTIC SCORING SYSTEMS Figure 11: Interpreting the receiver operating Anand S Pandit, Manish George, Sanchita Bhatia characteristic curve. The curves on the graph and Makinah Haq indicate data points of the true positive rate versus the false positive rate at various decision thresholds. What is preoperative prognostic risk stratification? Curves that are closer to the y-axis indicate a better result whereas curves closer to the random classifier Modern surgery is a quest for precision: maximising line indicate that the model is no better than chance. patient postoperative outcomes and quality of life while understanding and minimising the risk of complications 139 and harm. With the advent of large scale patient clinical outcomes data, a range of tools are now available Prognostic scoring in the pre-AI era that aim to stratify the risks of surgery, predict mortality and morbidity, and assist in clinical decision making. Although there are numerous surgical risk stratification models, their use in clinical practice varies. The ASA Risk stratification involves the creation of a prognostic (American Society of Anesthesiologists) grade is widely model, which (based on readily available patient variables) can predict a particular clinical outcome. 140 used to help predict mortality and morbidity outcomes following surgery by considering the patient’s current physical status as well as other medical conditions. 141 Quality measures for risk prediction The POSSUM (Physiological and Operative Severity Two concepts underpin quality measures for risk Score for the enUmeration of Mortality and morbidity) prediction: discrimination and calibration. Discrimination (143) and the SORT (Surgical Outcome Risk Tool) is a predictive model’s ability to distinguish between 142 score are two other commonly used prognostic tools outcomes (eg low or high risk) and it is measured by that use a logistic regression model. Although these the area under the receiver operating characteristic performed well in internal validation datasets, they had (ROC) curve. The ROC curve is generated by plotting poor calibration, indicating a risk of overfitting and poor a model’s true positive rate (TPR) against its false performance in external validation studies. positive rate (FPR) at various thresholds. TPR is defined as the proportion of outcomes that are correctly The ACS NSQIP (American College of Surgeons predicted as ‘positive’ whereas FPR is the proportion of National Surgical Quality Improvement Program) outcomes that are predicted as positive when they are universal surgical risk calculator was 393eloped using in fact negative. If a predictive model correctly predicts data from 1.4 million patients across US hospitals all patient outcomes, the ROC curve will be near the with the aim of addressing model underperformance. 143 Here, a generalised linear mixed model was used to upper left corner of the graph (Figure 11). predict risk of mortality and complications from a wide range of surgical procedures. 75 | SECTION B: HOW TECHNOLOGY CAN ENHANCE TRAINING ALONG THE PATIENT PATHWAY relationship describes a ‘true’ effect that is unlikely Generalised linear model (GLM): to be caused by noise. Machine learning, in contrast, focuses on prediction by employing general purpose A model that predicts outcome as a weighted learning algorithms to discover patterns in often rich and ‘unwieldy’ data. This is important as these methods sum of the input variables in a linear relationship but can have an arbitrary, non- have significant potential to aid and augment surgical Gaussian distribution. decision making but applied incorrectly or interpreted insufficiently, they can result in overestimation of their Generalised linear mixed model (GLMM): true value. An extension to the GLM, allowing for a hierarchy or more than one level of relationship Inference: between predictors and response variables. ‘The clouds contain water vapour, which is associated with production of raindrops.’ AI-based prognostic scoring in surgery Machine learning methods are especially useful for identifying subtle and complex patterns in large datasets that are frequently imperceptible in human exploratory analyses or unsuitable for modelling using traditional statistical analysis.,14Machine learning has the advantage of leveraging large scale data from multiple sources and it can ‘learn’ which features are associated with a particular outcome, without the need for human intervention. When multiple algorithms work together (ensemble machine learning), they can Prediction: ‘There’s an increased change it’s going be used to calculate predictions at accuracy levels to rain.’ previously thought to be unattainable. Figure 12: The difference between inference and prediction Development dataset: Also known as a training set, this is a sample of data used to train the model. The validation Examples of AI-based prognostic scoring dataset is a sample of data used to provide an unbiased evaluation of a model fit on the Outlined in Table 6 are three recent uses of artificial intelligence and machine learning methods for training dataset and is typically used to help prognostic modelling. MySurgeryRisk 146is an example tune the model. The test set is kept separate from model fitting from the outset and is used to of an electronic health record (EHR) integrated system assess model performance. that utilises machine learning for real-time preoperative risk prediction for adult patients undergoing inpatient operative procedures. It first integrates source data and optimises features for learning before calculating the A major distinction between statistics and machine risk of postoperative complications using a generalised learning is that where statistics seek to draw population additive model. Pythia,147which also uses EHR data, inferences from a sample, machine learning seeks compares three machine learning models (penalised logistic regression, random forest and extreme gradient to find generalisable predictions from data patterns. Inference involves developing a mathematical model boosted decision trees) for the prediction of risk of of the data generation process to better understand complications. The penalised regression model was or test a hypothesis about how the system behaves. both the highest performing and the most clinically interpretable. The third example is a predictor of Prediction, on the other hand, seeks to forecast postoperative liver dysfunction after aortic arch surgery unobserved outcomes or future behaviour (Figure 12). 148 A statistical model can be used to compute a using a naive Bayes model. quantitative measure of confidence that a discovered 76 | SECTION B: HOW TECHNOLOGY CAN ENHANCE TRAINING ALONG THE PATIENT PATHWAY MySurgeryRisk 146 Pythia 147 PLD predictor 148 Model Generalised additive model Penalised logistic Naive Bayes regression, random forest, gradient boosted trees Data EHR: 285 features EHR: 194 features from EHR data from 672 from demographic, demographics, smoking patients from a single socioeconomic, status, medications, institution in Beijing administrative, clinical, comorbidities, procedure pharmacy and laboratory information and proxies for data surgical complexity Discrimination Complications: 0.82–0.94 Complications: 0.780– PLD: 0.77 Mortality: 0.77–0.83 at 0.924 different postoperative timepoints Validation 5-fold cross-validation 5-fold cross validation 70/30 train/test split EHR = electronic health record; PLD = postoperative liver dysfunction Table 6: Examples of recent artificial intelligence-based prognostic models Limitations of statistical and AI-based methods Implications of prognostic modelling for surgical training Confounders: A feature that influences both the dependent variable and independent variable, causing Surgical trainees should become familiar with novel a spurious association. For example, a machine prognostic modelling methods as well as their benefits learning algorithm was more likely to classify a skin and limitations. Understanding how to use prognostic lesion as malignant if an image contained a ruler models and grading systems appropriately will be since the presence of a ruler was correlated with an greatly aided by the ability to critically appraise the increased likelihood of a cancerous lesion. 149 underlying studies based on choice of statistical model, data, discrimination and validation. As digital healthcare Overfitting and generalisability: Overfitting is a advances, many of these systems are likely to be modelling error in statistics that occurs when a function is too closely aligned to a limited set of data points implemented at the point of care to assist in appropriate patient triage. and is therefore not applicable to other datasets. Generalisability is the extent to which the findings of a study can be applicable to other settings and B3. PERSONALISED SURGICAL can be improved by having multiple sets of data from CARE USING AI IN THE different sites and avoidance of overfitting the data. PERIOPERATIVE SETTING Black box phenomenon: A program that allows Oliver Kennion, Jack Wellington, Yeonwoo Chae, visualisation of the input and output but gives no view of the processes and workings in between. 150This can Anand Pandit and Manish George make the results of the model difficult to replicate Preoperative and perioperative care starts as soon as and interpret. the need for surgical intervention is a possibility, and this is delivered through a multidisciplinary team of surgeons, Sample bias: Over-representation of certain subgroups anaesthetists and other allied healthcare professionals to in historical data means that the applicability and validity of the algorithm can shift when trying to generalise the the end of t151critical recovery period that follows surgery model. This can lead to erroneous conclusions being (Figure 13). The primary goal of pre and perioperative care is to improve postoperative outcomes. This is made about subgroups. Maintaining representative accomplished primarily through two means: certifying diversity in the dataset is important to overcome this bias. that surgical intervention is necessary and determining whether the patient is best prepared to withstand the physiological stress associated with surgery. 152 77 | SECTION B: HOW TECHNOLOGY CAN ENHANCE TRAINING ALONG THE PATIENT PATHWAY Surgical work-up • Consent Emergency pathway • Imaging • Diagnostic test Medical work-up • Comorbidity MDT decision Identification of management • Suitability Operation Recovery and need for surgery • Fitness for surgery • Procedure • Surgery rehabilitation • Medication • Date of surgery • Anaesthetic management Allied specialties • Smoking cessation • Diet and fitness • Specialist input Figure 13: The perioperative elective and emergency surgical care patient pathway. Each arrow indicates an opportunity for artificial intelligence facilitation. How AI can contribute towards a personalised Improving preoperative fitness surgical care pathway: stratifying surgical risk and AI guided health recommendation systems can be facilitating patient triage employed to disseminate personalised patient plans Artificial intelligence (AI) can help to optimise decision and provide advice in real time. Diet and exercise making across the entire perioperative surgical spectrum, regimens, 160smoking cessation 161or alcohol excess personalising care for individuals or specific patient treatment pathways as well as chronic disease groups. AI algorithms can stratify and prioritise patients optimisation strategies 162using data collected from for urgent or emergency intervention at the point of wearable sensors and mobile apps can help improve diagnosis. It has been demonstrated that accurate, rapid preoperative fitness. The findings suggest a promising detection and grading of surgical conditions such as acute future for optimising patients through personalised appendicitis,153peripheral vascular disease 154and bowel micro-interventions and real-time feedback to the 155 156 obstruction can aid decision making and triage. anaesthetist and surgeon. Models used to predict preoperative anaesthetic risk 163can be employed to Use in clinical practice identify the likelihood of morbidity and mortality. There has been an increase in efforts to translate this MyHealthKeeper is an electronic lifestyle factors into everyday practice and assess the health economics prescription programme that adopts multimodal data of this technological solution. A recent consortium led from a mobile app and wearable sensors to provide by the National Institute for Health and Care Excellence 164 patients with individualised health guidance. reviewed seven AI algorithms designed to report The information retrieved from the app then integrates computed tomography of the head and identify patients with electronic health records and is converted to who would require emergency surgery; some evidence 157 graphical data for clinicians. In the preoperative setting, was found that overall, they may be cost effective. it would enable patients to monitor their progress and Deep learning methods are currently being used to adjust their preparation before their operation as well detect high risk patients on surgical waiting lists who as allowing the surgeon and anaesthetist to monitor the would benefit from expedited surgery. For example, progress made by the patient and assess the patient’s a convolutional neural network has been used to classify preoperative physiological state. clinically acquired lumbosacral magnetic resonance 158 imaging (SpineNet), which could aid in the identification of patients with spinal stenosis and neural element compression who require more immediate treatment. 159 78 | SECTION B: HOW TECHNOLOGY CAN ENHANCE TRAINING ALONG THE PATIENT PATHWAYEnhancing postoperative recovery Understanding modes of genetic inheritance is highlighted almost universally in core training and the Postoperative recovery represents the final stage ten higher specialty training syllabi. Many surgical of the perioperative pathway. Identifying those conditions arise owing to either somatic (occurring patients who are appropriate for high dependency care, enhanced recovery after surgery or specific following conception in any cell except the gametes) or germline mutations (occurring within the gametes rehabilitation is an area in which AI could prove useful. and therefore heritable), and recognition of differences For example, in one study of patients who underwent in the patterns of inheritance is required to provide hip replacement surgery, postoperative timed walking patients with appropriate genetic counselling, screening, tests were used in a machine learning analysis to treatment and surveillance. predict the risk of falls165d direct subgroups for more intensive physiotherapy. Genomics is important for the diagnosis of rare heritable diseases and is revolutionising cancer care. Impact on surgical training In England, the routine genetic testing of solid tumours Future surgical training will most likely be geared using next generation sequencing, 500-gene panels towards promoting an individualised approach to surgical and whole genome sequencing for paediatric tumours, sarcomas and haematological malignancies 169means management and AI-based tools are well suited to assist that understanding key concepts such as ‘CpG sites’ with this. While much emphasis has been placed on the use of AI in the diagnosis and treatment of surgical and ‘chromosomal instability’ will become essential for conditions, such algorithms are also expected to help surgeons delivering multidisciplinary care (for example, guide patient care in the perioperative setting. There will in the case of Lynch syndrome, which is caused by a germline mutation in mismatch repair genes). However, likely be a focus on patient consent, collaborating with somatic mutations (commonly in BRAF V600E or allied specialties for comorbidity optimisation, and integrating wearable and interactive devices. methylation of MLH1) can produce tumours with a similar phenotype that are not inherited. Differentiating the two In order to adopt this technology with an appropriate is a key diagnostic step, and has a substantial impact on the care of patients and their family members. 170,171 evidence base, it is likely that a curriculum addition and a cultural transformation will be required. As surgeons in training are frequently the first point of contact in Circulating tumour DNA is another exciting preparing a patient for surgery, surgical trainees must development, with studies in patients with lung and other cancers demonstrating utility in screening, be aware of the benefits that this technology affords. diagnosis, surveillance and genomic profiling of The trainee surgeon must comprehend and decipher cancers while reducing the need for repeated invasive the information provided by this technology, and must 172,173 assess its significance in the context of the patient’s investigations. Further examples include the use of perioperative care. decisional tools that integrate genomic data to stratify risk and treatment options for patients (eg Oncotype DX [Genomic Health] in patients with breast cancer). 174 B4. GENOMICS FOR SURGICAL TRAINEES IN THE 21 ST CENTURY Outside cancer diagnostics, genome-wide association studies are also influencing our understanding of common conditions such as adhesive capsulitis (‘frozen shoulder’). Eleanor Walker and Frank D McDermott One study has shown a causal relationship between With the rapid advancement of genomics and further type 1 diabetes175d adhesive capsulitis using Mendelian developments in personalised patient care, ‘omics’ randomisation, providing evidence for a previously is becoming increasingly important for trainees in all noted correlation. Additionally, genomics is used in surgical specialties. In addition to genomics, multiple the tracking of infectious pathogens to detect hospital outbreaks and inform infection control protocols.176 new ‘omic’ disciplines have been established such as epigenomics, microbiomics and pharmacogenomics. Pharmacogenomics describes how an individual’s Since the completion of the 100,000 Genomes Project genome affects that individual’s response to in 2019, genomic medicine in England has been medications. Dihydropyrimidine dehydrogenase metabolises 5-fluorouracil, and gene variants can restru166red around seven regional genomic laboratory hubs. A move towards the delivery of standardised reduce its function, which can be tested to reduce genomic testing and services is also being developed in the risk of severe and potentially life threatening the devolved nations in collaboration with NHS England, complications prior to the initiation of chemotherapy. 177 Immunotherapies are increasingly used in cancer Genomics Partnership Wales, the National Genetics Laboratory Management Committee in Scotland, the management and act via immune modulation enabling Northern Ireland Genomic Medicine Centre and the the host’s own immune system to target neoplastic Republic of Ireland’s Department of Health. 166–168 cells.17One expanding area of research is the 79 | SECTION B: HOW TECHNOLOGY CAN ENHANCE TRAINING ALONG THE PATIENT PATHWAYtargetting of neoantigens. These are proteins that This summary highlights some of the exciting ways are not found elsewhere in human tissue; they can in which genomic medicine is having an impact on the form and be expressed by tumours through non- management of surgical patients as well as rapidly synonymous mutations or gene fusions. 179Neoantigens expanding areas of research. Surgeons are integral are recognised and targetted by T cell mediated to the delivery of 21 century genomic medicine as therapies, and research is ongoing to look at their clinicians caring for patients with complex and diverse utility in a variety of malignancies such as breast and pathology. We need to understand these concepts colorectal.180,1This is a rapidly expanding field that will to be able to counsel patients appropriately and deliver affect the care of patients across all surgical specialties. the best quality, evidence-based care. 80 | SECTION B: HOW TECHNOLOGY CAN ENHANCE TRAINING ALONG THE PATIENT PATHWAY While no standardised national consent form exists B5. DIGITAL CONSENT for the use of patient multimedia data for education, Joshua Clements research or training purposes, often hospital trusts do have a supplementary consent form for these instances. Over 300 million surgical procedures take place Openness, honesty and transparency in the consent 4 globally each year. Obtaining valid informed consent process is vital to ensuring patients remain central to all from patients is an essential skill for surgeons in training conversations about their treatment and use of their data. and a prerequisite to treatment. Ethical, legal and professional standards exist in the UK, which since the 182 B6. USING AI AND TECHNOLOGY Montgomery ruling in 2015 seek to ensure that ‘what ENHANCEMENT TO OPTIMISE matters most to the individual patient’ is central to the shared decision making process. SURGICAL CONSENT No standardised measure of informed consent exists Oliver Kennion, Jack Wellington, Yeonwoo Chae, in clinical practice. The predominant outcome measure Anand Pandit and Manish George studied to date has been knowledge, which lacks validated measurement tools. Large scale reviews Clinicians remain under increasing time pressure of interventions designed to improve the consent during preoperative appointments to provide relevant process have demonstrated heterogeneity in study information about the surgical procedure and obtain design as well as chosen measurement outcomes. 183,184 informed consent. Communication spread over time in Defining how best to measure the shared decision digestible chunks, aided by artificial intelligence (AI), making process is a National Institute for Health and may improve a patient’s understanding of the procedure’s Care Excellence research priority. 185A core outcome set nature and risks. Patients can be fully educated and for informed consent for therapy has been defined. 186 satisfied with the surgical process and expected outcomes by using easily digestible and customisable Advancing digital technologies and innovations has resources such as information leaflets and videos, seen the advent of digital consent platforms as well messaging services and retention checking tests. as a range of multimedia modalities trialled to improve the informed consent process. 18Paper-based consent AI and machine learning could improve communication forms remain commonplace. However, reported by utilising natural language processing and allowing for real-time translation. Prior to consulting with the illegibility, lack of written information and written errors have meant that there is an increasing uptake of digital surgeon, an AI chatbot is being developed to answer platforms with the aim of negating these issues. 188 questions and ensure the patient fully understands the Digital platforms offer convenient access to information, procedure. Concentric and consentapatient and utilise time for assimilation and decision making, remote readily available patient information in addition to the completion of consent and the ability to maintain patient’s level of accessibility and literacy in 189,190o dialogue outside clinical encounters. Although digital deliver information in a more personalised way. consent may standardise and individualise elements AI could help automate the distribution of this of the informed consent process, this modality has no information to patients, allowing surgeons to focus on establishing rapport during the consultation, tailoring proven superiority to date. to each individual patient’s needs and expectations. The use of patient multimedia data (images, photographs and videos) for educational purposes offers valuable learning opportunities to doctors of all B7. THE FUTURE OF WEARABLES levels. Nevertheless, it is essential that the nature of IN SURGICAL TRAINING AND how this data is captured, stored and used is discussed REMOTE MONITORING with patients as part of giving informed consent. This serves to protect patient confidentiality and Patrick Longman ensures patient data protection. Multimedia data may be used for academic publication, in presentations or A trainee surgeon is performing a procedure as an educational resource for surgeons and surgical and wearing smart glasses that take physical trainees. Although in their infancy, video trainee measurements. The trainee’s pupils dilate, their heart logbooks have been proposed by the Association and respiration rate increases, suggesting the trainee of Surgeons in Training as a further adjunct to training is under stress and may make a mistake. An alert is sent to the supervisor. The trainee and supervisor and assessment of performance to progression. Such logbooks also present a new consideration agree the current difficult stage will be completed by for consent. the supervisor with demonstration of the techniques 81 | SECTION B: HOW TECHNOLOGY CAN ENHANCE TRAINING ALONG THE PATIENT PATHWAYinvolved. The trainee then resumes with no mistakes There is a lack of large scale randomised controlled made. The recording forms part of the patient’s medical trials of these devices in surgical practice. However, record and the surgeon’s logbook, and it may also be the large scale studies that exist have demonstrated used as educational material. the ability to detect clinically relevant events. Apple In the outpatient department, a cardiothoracic demonstrated that the electrocardiography function of its smartwatch was able to detect atrial fibrillation surgeon is seeing a patient who has undergone reliably.9This raises the issue of who is responsible a valve replacement and has been discharged early when something of significance is detected. Will with a smartwatch to record vital patient observations. medical professionals be required to monitor the results The recent records of the patient’s weight, heart rate, of all these observations continually? Or does the heart rhythm, ambulatory blood pressure, daily activity responsibility lie with the manufacturers? Until such rate and temperature are reviewed by the surgeon. issues are addressed, widespread use is likely to be Together, the patient and surgeon agree on the next some way off. stages of the patient’s recovery plan, which are sent to the smartwatch. B8. KEY CONSIDERATION: These scenarios are a glimpse of the future promised THE ETHICS, CHALLENGES by ‘wearables’, compact devices with computation, AND LIMITATIONS OF BIG DATA sensors and an internet connection. Worn as an implant or accessory, the technology has been popularised as AND MACHINE LEARNING 81 part of the ‘quantified self’ movement. Fawz Kazzazi, Manish George and Anand S Pandit This technology is already incorporated into medical practice in several fields. For example, home monitoring Data access and data processing devices are used to manage hypertension and portable electrocardiography monitors are provided for The digitalisation of medicine has ensured that almost all patient interactions and details are recorded suspected paroxysmal arrhythmias. Both of these have electronically, which has generated valuable and been available for many years. accessible datasets. With advancements in technology In surgery, there is some research into the use of and a move towards ‘big data’ solutions for clinical these potentially useful devices. One study examined problems, there is significant interest in utilising these datasets for research, novel technologies and the use of smartwatches in prehabilitation for191tients profit. While the value of machine learning algorithms undergoing major abdominal cancer surgery. The use of these devices enabled patients to have an improved lies in their ability to manage large volume complex six-minute walk test pre-surgery. heterogenous datasets, their successful development is dependent on data that are clean, often annotated, Linton et al studied whether home observation readings appropriately specific or broad and sizeable enough. from a wearable device would assist clinicians’ decision This volume of data can be both difficult to obtain and making with patients discharged following paediatric time onerous to pre-process. surgery. 19The data aided decisions as to whether patients needed to attend the emergency department The interest in the transformative effect of artificial intelligence (AI) on healthcare is reflected in 20,000 as well as increased confidence in these decisions. publications in the past 10 years with millions of A similar study also found that data from wearables 197 can help to distinguish recovery trajectories in paediatric pounds of government funding. Nevertheless, there patients after appendicectomy. 193 remains an unresolved discussion on who should have access to data in the NHS. Data held by the NHS One feasibility study examined the use of smart glasses were estimated by Ernst & Young to be worth £9.6 during urological surgery, and found this technology to billion a year, including an estimated £4.6 billion of be safe and useful by the surgeons. 194Capogna et al benefit to patients through personalised care and data used smart glasses to examine differing visual focus initiatives.8The medical records of NHS England’s between experts and novices during lumbar puncture. 195 61 million users were set to be gathered in a new They found significant differences, which may provide centralised database as part of the General Practice the basis for future training tools. Data for Planning and Research programme, 199until over 1.3 million patients opted out of their data being shared in this scheme. 200 82 | SECTION B: HOW TECHNOLOGY CAN ENHANCE TRAINING ALONG THE PATIENT PATHWAYPrivacy uninterpretable by healthcare professionals. This has consequences for trust, decision making, The NHS Constitution explains that patients have the patient communication, consent and liability. right to privacy and confidentiality, the right to expect the NHS to keep patient confidential information safe Despite this dilemma, owing to the potential to and secure, and the r201t to be informed about how their revolutionise patient care, some argue that the ‘black information is used. There are many forms of data box’ should be overlooked in favour of adopting this that can be shared, including personally identifiable, technology if beneficial for patients. Those who support de-personalised (‘pseudonymised’, ‘key-coded’, this notion highlight that clinicians frequently work 202 ‘de-identified’), pooled and anonymised data. on intuition and are often unable to precisely explain As such, health data is stated to exist on a ‘spectrum their reasoning or the evidence base for some clinical of identifiability’ dependent on the ability to match decisions they make. However, there is some concern. health information to personal information. 202De- An AI trained on historical notes concluded, seemingly personalised/de-identified data is ‘information that has incorrectly, that asthmatic patient206ere less likely all Personally Identifiable Information, including direct to die if admitted with pneumonia. Being clinically and indirect identifiers removed or obscured, such inconsistent with the known pathophysiology of both that the remaining information does not reasonably diseases, later analysis would show that the early identify an individual. This includes, but is not limited to, presentation of medically experienced patients with name, date of birth, demographic information, location chronic respiratory disease led to earlier targetted information and school identity.’203 therapy. This situation has prompted a plea for interpretable systems that use explainable AI, including New technologies are being developed that allow data to ‘counterfactual explanations’ to help users understand be anonymised by de-personalising the information without where the most meaningful values arise. 207 losing key data points. This is known as synthetic data and it is created using machine learning generative models. 204 Fragility It produces entirely new datasets as a proxy from the Machine learning algorithms and deep neural networks collected data, which are then tested and validated. are prone to ‘fragility’. Owing to the complex nature of Explainability these networks, they can extract subtle features from input data. Some of these patterns are imperceptible Machine learning algorithms (and specifically deep to humans and may confer a superhuman level of neural networks) are often labelled as ‘black box’ detection or diagnosis; many others may be irrelevant models. 205Through the tuning of countless parameters but given salience because of the idiosyncrasies of the (especially in deep learning), some machine learning training dataset. Subsequently, small and seemingly algorithms become unfathomably complex and innocuous changes to the image or data can confuse thus the ‘reasoning’ for recommendations becomes the algorithm into misclassification. 83 | SECTION B: HOW TECHNOLOGY CAN ENHANCE TRAINING ALONG THE PATIENT PATHWAYOne method to help overcome this fragility is Bias adversarial training, where a second algorithm will test and train the original with examples designed to fool it, Biases in algorithms remain an area of concern thereby engineering a more robust model to safeguard in real-world AI application. Different types of boas against mistakes. 208This method is imperfect and may are summarised below. strengthen algorithms in some areas while weakening it Algorithmic bias:209This refers to the applicability in others. Ultimately, however, the vast and deep human of an algorithm being dependent on the quality and experience of the world enables us to see images as a series of concepts in context and not be distracted by applicability of the dataset alongside the knowledge of abstract or irrelevant minutiae, which is not something the designer. Historical datasets may contain decision making that is no longer acceptable or applicable to narrow AI can achieve easily. wider and diverse populations. Universalisability Reward hacking: 210Some automated systems may find When algorithms are trained on one data acquisition methods to ‘game’ outcomes by achieving short-term source (eg a specific ultrasonography machine model), outcomes that may be detrimental to quality of life or they learn based on that specific set of individualised long-term goals. Examples include automatically dosing medication so that it is given immediately prior to serum parameters and signals. As a result, they may not be level measurements; this would lead to encouraging well suited to interpret data from an alternative source (eg different scanners or different recording devices). blood results even though patient therapy in practice In mixed data sources, machine learning can be may be poor. more difficult. Nevertheless, in large enough studies, Automation bias: 211This is a reliance by healthcare researchers predict an algorithm may see beyond professions on the results of the automated evidence this noise and develop into a more general model despite evidence to the contrary. with sufficient accuracy irrespective of the instrument used. Conversely, it is recognised that the use of data Insensitivity to impact: Doctors tend to err on the side with widely varying acquisition parameters may cause of caution with severe diagnoses, leading to a high signal alterations that are not attributable to biology. false positive rate but also a high sensitivity (ie few This can reduce the efficacy of the model and limit the false negatives). If machine learning systems focus on algorithm’s generalisability. accuracy alone, they may not be optimised for care of Patient and public involvement the holistic patient, especially in cancer diagnostics, where high negative predictive value and sensitivity Professor Eric Topol was commissioned by the are paramount. Department of Health and Social Care to carry out a People from minority ethnic backgrounds are usually review of the education and training changes that may under-represented in large research studies in the be needed to maximise the opportunities of technology, AI and genomics in the NHS. His report was published developed world and outside of AI, this contributes to poorer risk stratification, diagnostics and management. in February 2019 and set out some of the pot11tial of AI Skin cancer detection algorithms prove significantly (and robotics) technologies in healthcare. The Topol poorer at identifying malignancies in darker skin and review recommended that patients should be involved from the beginning in the design and implementation are likely a product of the data 211rce containing of AI software for healthcare, ensuring that their needs predominantly light skin images. Whatever the reasons, developing and employing algorithms that have and preferences are reflected in the co-design process. lower rates of efficacy for minority ethnic or any other groups raises serious ethical questions. These flaws still While a thorough understanding of any new technology is not a prerequisite for use, patient confidence in the undermine accuracy and faith in complex AI systems. system is a necessity. Involvement of the public at early and late stages of development will not only help with trust but will also ensure their patient specific needs are met. Tied in with public trust is the notion of AI as supportive tools rather than replacing the clinician. In this sense, algorithms should be narrow enough to leave the primary responsibility of care delivery with a human clinician – in the immediate future at least. 84 | SECTION B: HOW TECHNOLOGY CAN ENHANCE TRAINING ALONG THE PATIENT PATHWAY SECTION C HOW TECHNOLOGY CAN SUPPORT ASSESSMENT OF TRAINEE COMPETENCE C1. KEY CONSIDERATION: there is no definitive evidence to suggest that short-term THE CHANGING PEDAGOGY outcomes are any worse if the patient is operated on by a trainee who is appropriately supervised. 119,219 OF SURGICAL TRAINING Perhaps the more important question to answer is what effect mistakes in workforce planning and a failure to Matthew Harris train will have on long-term patient outcomes. Historically, surgical training was delivered through an In the past two decades, there have been significant apprentice model with sustained periods of supervised exposure in the discipline. 212Our current pedagogy advances in the development of new technology in surgery. Advances in robotics, augmented/virtual reality remains reliant on skills development over time wh213 and 3D printing have the potential to serve as powerful training under supervision by a senior surgeon. adjuncts in the development of future consultant The majority of skills-based training still takes place surgeons. 220,2As the fidelity and medium of simulation operating on patients. In recent times, there has been develops, this will likely translate to improved skill a shift towards a curriculum-based programme, with 222,223 greater emphasis on non-technical skills, focusing acquisition in the operating theatre. Open access to high quality simulation may help to reduce the on progression through objective assessment and cognitive load that is experienced when training during constructive feedback. This has been developed live operating. This would allow trainees to allocate through the consideration and integration of adult a greater proportion of their attentional capacity to learning theory.214The pedagogy is changing from advancing their operative skills when in theatre, thereby a teacher centred to a learner centred approach, 224 moving away from didactic teaching, rote learning getting the most out of each case. and practice, and putting the trainee at the centre Given the perceived reduction in consistent trainee– of the learning process. This has been proved to supervisor contact, in order for surgical trainees to improve trainee and supervisor satisfaction, motivation progress, we must be prepared to adopt new methods and overall experience. There is also greater emphasis of training that are more efficient if we are to maintain on collaborative peer-to-peer learning between Certificate of Completion of Training standards.225The new trainees at different stages of training.15 competence-based progression specialty curricula may 226 The full implementation of the European Working Time provide the ideal opportunity to integrate novel methods. Directive for doctors in 2009 has resulted in surgi22l C2. KEY CONSIDERATION: trainees working fewer contracted hours per week. Changes to the junior doctor contract in 2016 have made ASSESSMENT OF COMPETENCE surgical rota population across grades difficult, particularly THROUGH PERFORMANCE METRICS in the formation of teams with our consultant workforce.216 It is argued that this combination has resulted in the loss Charlotte El-Sayed and Chris Munsch of the ‘surgical firm’ with reduced consistent supervisor contact, beneficial learning opportunities, team-working Robot assisted surgery (RAS) has previously been viewed and morale. 217,218 as an evolution of laparoscopic surgery but the skills required for the novice surgeon are for console control There is little in the way of evidence to demonstrate and manoeuvres currently without haptic feedback, as the effect of trainee operating on both short and long- opposed to those required for laparoscopic surgery. term outcomes for patients in recent times. The notion of prolonged operating time in procedures involving Laparoscopic surgery requires acclimatisation with 2D surgery operating with instruments that have a limited surgeons in training is perhaps a misconception and range of movement albeit with haptic feedback. 227 85 | SECTION C: HOW TECHNOLOGY CAN SUPPORT ASSESSMENT OF TRAINEE COMPETENCEAt present, there are various training modalities available In terms of assessing trainee performance in theatre, for RAS including industry lead and subspecialty designed proctoring from credentialed trainers237can take several programmes. Industry lead programmes, which are forms. Dual console allows the mentor to take over the common among RAS trainees, include a modular procedure immediately in the event of any difficulties training programme consisting of online training modules, encountered by the surgeon in training. Aside from trainee virtual reality (VR) simulation, dry lab training and finally, access, the main limitation remains a lack of competence 228 238 live operating proctoring. Subspecialty designed benchmarking. Telementoring is a novel option using programmes have adopted a similar model. technology to provide expert advice without the mentor being physically present.227 Performance metrics used to assess competence in RAS training are varied as there is not yet a defined Lovegrove et al developed a safety assessment tool to standardised training programme or competence assess the technical skills of surgeons performing robot standards. Evidence has demonstrated surgical assisted prostatectomy. 239The system scored from 1 to 5, performance directly affects clinical outcomes and with scores above 4 defining competence. complication rates.229Effective assessment is therefore In summary, various performance metrics exist for RAS essential for training safe RAS surgeons. training and the various components of RAS training. Tools available to assess performance include surgical However, to define competence standards, standardised evaluative tools such as OSATS (objective structured performance measures as part of an evidence-based assessment of technical skills), 230GOALS (global curriculum are required. The key will be our ability to 231 operative assessment of laparoscopic skills) and connect surgical metrics to clinical outcomes and patient GEARS (global evaluative assessment of robotic reported outcomes. skills).32However, these qualitative assessment methods are subjective as they are based on direct C3. KEY CONSIDERATION: ENSURING observation by surgeons. 229 EQUAL ACCESS AND OPPORTUNITY VR simulation is commonly regarded as the first and most essential step in robotic surgical training. The advantages Ekpemi Irune of VR systems include the assessment of measurement of progress. There are several VR simulators available The adoption and implementation of technology in for robotic training such as the RoSS robotic surgical surgical training is a welcome initiative that is intended to equip today’s doctors with the skills needed to simulator (Simulated Surgical Systems), the SEP robot keep up with the rapidly changing pace of healthcare (SimSurgery) and the da Vinci skills simulator (Intuitive Surgical).227These simulators have all been evaluated to delivery. Nevertheless, current surgical training already have validity in terms of face, content and construct.233–235 disadvantages individuals such as those from the lower socioeconomic classes, ethnic minorities, women and less 240–245 Simulators also have the ability to create procedure than full-time practitioners. This flaw in the training specific components that allow the trainee to register process comes down to a single issue: access (or more procedure specific movements using educationally importantly, the lack thereof). based procedural videos. The movement of the The problem of access can be addressed first by dispelling trainee can be tracked and assessed using the built-in software. VR simulation can also improve performance the myth that excelling in surgical training is based on the console. 227Finally, VR training also has a role solely on meritocracy. Indeed, achievement is fuelled by opportunity, which lends itself predominantly to the in maintenance of acquired robotic skills. Lendvay et al reported that warm-up practice sessions on the privileged. From medical school selection to higher surgical simulator improved task performance and reduced training, the drivers for progress can be distilled into errors in the dry lab for both simple and complicated access to opportunity unencumbered by discrimination, 65 mentorship and sponsorship in the workplace. A lack of skills, such as suturing. access to these three elements invariably compromises Dry and wet lab simulation also offers benefits: it is cost the ability to thrive and succeed. Examples of the effects of effective, and it can reliably simulate basic tasks such disparity in these areas are made manifest in the Kennedy as cutting, lifting objects and suturing.7Nevertheless, review on diversity and inclusion for The Royal College of 52 simulation labs are often assessed using objective Surgeons of England. Furthermore, the drop-out rates of assessment tools. Siddiqui et al developed the validated women at core surgical training stage 246coupled with the R-OSATS (robotic objective structured assessment of limitations to career development experienced by specialty 236 247 technical skills). This tool demonstrated construct and associate specialist doctors (SAS) and less than validity and designed benchmark scores. full-time trainees45also speak to the inequities of access in training. 86 | SECTION C: HOW TECHNOLOGY CAN SUPPORT ASSESSMENT OF TRAINEE COMPETENCEBridging the divide Operative competence assessment In order to leverage the full potential of the workforce In 2007, the Intercollegiate Surgical Curriculum using this initiative, access to the use of technology Programme introduced competence-based training in training must be democratised. This is achieved by and assessment. Summative decisions regarding acknowledging that there is an ‘access’ problem and trainee progression are made at the annual review focused efforts must be made to mitigate its effect by of competence progression and are informed by considering the needs of all. These could include: multifaceted assessment of operative skill, evaluated through performance in procedure-based assessments • Strategies that explicitly make space for women and (PBAs), educational supervisor assessments and people from ethnic minorities; evidence of operative experience as recorded through • Expert help and advice on the development of ideas an electronic logbook. Several studies have highlighted and projects driven by technology that is available at the challenges of such an approach. Workplace-based assessments such as PBAs are used opportunistically a national level; by surgeons in training, perhaps in an effort to avoid negative feedback. 47,249–2They are also perceived as • Widely available funding resources to acquire 249,250,252 hardware and software across all institutions; being prone to inter-assessor variance. The validity evidence for minimum operative experience • mentorship provided by a diverse array of individuals targets is lacking; studies suggest that recommended who themselves may exhibit atypical traits; targets across a number of index procedures are set • Leadership opportunities targetted to locally too low to ensure 253–255nce in the majority of general employed/SAS and less than full-time doctors surgery trainees. Simulation-based assessments could represent a more reliable method of operative in the technological space; competence assessment in future. • Development of a network that fosters genuine The role of simulation in high stakes assessment feedback, open competition and transparent exchange of information along with a medium of operative skill for participants to register concerns. Aljamal et al described the implementation of a simulation-based objective assessment in a US Of paramount importance is the education of trainers residency programme, mapped to entrustable and supervisors on the ethos of inclusivity that should professional activity assessments of operative skill.256 underpin this initiative as they often occupy the role of gatekeeper. In addition, organisations that implement This assessment was able to measure improvement this model should act as benchmarks for others to in performance over time, and differentiate between performance in more junior (postgraduate year 2) and follow suit. The metric of inclusivity must be considered more senior (postgraduate year 5) trainees. Binkley et as a measure of the success of implementing novel al used simulator measured metrics (number of hand training technologies. This will be contingent on ensuring the timely equity of access in the workplace movements and instrument path length) to record performance in simulated laparoscopic cholecystectomy by a diverse group of individuals who reflect the mixed performance. 257However, no correlation was observed patient group our health service attends. The result will between these measures and trainer Accreditation undoubtedly be a more effective workforce, providing better and safer patient care. Council for Graduate Medical Education milestone evaluations of competence. In the UK, Sarker et al used PBA to assess both real-world and simulated trainee C4. HIGH STAKES ASSESSMENT performance in laparoscopic cholecystectomy. 258 OF OPERATIVE SKILL The PBA tool demonstrated strong inter-rater reliability USING SIMULATION in the simulated setting, and was able to differentiate between junior and senior trainees. Conor Toale The vascular surgery exam for the European Board of Surgery Qualification uses simulation-based The traditional Halstedian model of surgical education is being replaced with competence-based approaches, assessments to inform decisions on trainee certification. orientated around certifying graduate outcome In published validity evidence, examiners performed 248 better than exam candidates in these assessments. 259 abilities. This requires the implementation of reliable No correlation was observed between simulated and objective summative assessment methods, performance scores and either oral exam scores including methods of assessing operative skill. While well established in the field of surgical education or logbook accredited scores, suggesting a role for and training, simulation is not yet as widely used in simulation-based assessments in differentiating between candidates based on operative skill. the assessment of operative competence. 87 | SECTION C: HOW TECHNOLOGY CAN SUPPORT ASSESSMENT OF TRAINEE COMPETENCEMore recently, simulation-based assessments have In recognition of the huge impact of COVID-19 on been implemented into the American Board of Colon surgical training and the increased emphasis on service and Rectal Surgery certification exam; all individuals provision, a more effective and engaging training system who failed the simulation-based exam passed the oral is necessary to ensure that trainees receive adequate exam, again suggesting that current end-of-training and regular training to become competent and safe exams are failing to identify trainees with technical practitioners. This is opposed to an ad hoc opportunistic 260 deficiencies. training model, which lacks consistency and continuity. The development of high fidelity models and validated C6. TWO-WAY TRAINING LOGBOOKS scoring tools will allow for the further implementation of reliable high stakes assessment of operative competence in future. Walid Mohammed and Omar Nasher The aim of this initiative is to incentivise surgical trainers C5. PORTFOLIO, PROGRESS TRACKING to engage with trainees towards achieving their training AND FEEDBACK requirements in line with the 2021 surgical curricula. Although training is ultimately the responsibility of the Omar Nasher and Walid Mohammed surgeons in training, assigned educational supervisors and clinical supervisors have a duty to engage regularly Impact of COVID-19 on surgical training with their trainees in setting objectives and facilitating their achievement. The Joint Committee on Surgical Training November 2020 paper on maximising training opportunities We acknowledge that owing to the exceptional provides an overview of the key areas of surgical circumstances of the COVID-19 pandemic and ongoing training that have been adversely affected by the work pressures, this may be very difficult to achieve on pandemic. 261It provides a detailed action plan to a regular basis. Implementing recommendations should optimise training opportunities, and engage key always be guided by individual training requirements, and stakeholders on a local, regional and national scale. setting realistic and achievable targets in line with national The action plan makes several suggestions to clinical curricula should be encouraged. However, a proactive supervisors to help surgical trainees get the maximum approach from trainers would help to identify the various training out of their theatre, clinic and ward round obstacles to training and would enable them to work exposure. It recommends engaging with the newly together with trainees to address these hurdles. This is introduced multiple consultant report and trainee essential to improve the current training landscape and self-assessment tools on the Intercollegiate Surgical mitigate future issues with surgical training. Curriculum Programme, and providing tailored feedback on specific training needs identified by both trainers Proposal outline and trainees. • Setting reasonable assigned educational supervisor The new surgical curricula for August 2021 and clinical supervisor targets in an appropriate time period (eg monthly) in terms of workplace-based The new curriculum places less emphasis on granular assessments and supervised index procedures requirements (eg indicative numbers and workplace-based (as per the relevant 2021 specialty curricula): assessments [WBAs]), instead allowing progression of These targets should broadly consider variations surgeons in training based on achieving the required in case volume, patient presentation and overall outcomes in generic professional capabilities (GPCs) workload by hospital setting (eg district general and capabilities in practice (CiPs). The new assessment hospital vs tertiary referral centres or major system consists of mandatory WBAs for index procedures trauma centres). (eg direct observation of procedural skills, procedure- based assessments) and critical conditions (eg clinical • Monitoring how well these targets are met at a local evaluation exercises, case-based discussions), and regional level by the relevant educational bodies multisource feedback, relevant exams, multiple consultant (training programme directors, heads of schools of surgery, Royal College of Surgeons of England tutors reports and assigned educational supervisor reports and the respective deaneries): These targets should in addition to optional supporting WBAs and self- assessments of GPCs and CiPs. Surgeons in training act as an indicator of the overall quality of training will still be required to support their portfolio with WBAs in the region rather than as deterrents to trainer to demonstrate their CiPs and GPCs although there will engagement or as an additional workload. Good trainers exist in any unit and targets are already be less emphasis on defining a set number of WBAs being met by surgical trainees in many regions. to complete every rotation or year and a more global approach to training competences at different phases. The purpose of introducing target numbers for trainers is to add a more objective measure of accountability to their role and identifyxceptional 88 | SECTION C: HOW TECHNOLOGY CAN SUPPORT ASSESSMENT OF TRAINEE COMPETENCE supervisors with a good track record in training. • The four statutory education bodies Previous training engagements by trainers should • The four surgical royal colleges also be considered in individual target monitoring and excellence in training should be promoted • Chairs and invited individuals from the JCST as a culture in all departments. and specialty advisory committees • Motivating trainers to achieve the target numbers through departmental recognition and identifying • A communications campaign to support this ways to improve engagement in trainers who are initiative at a regional and national level: This can utilise social media platforms (akin to the CST consistently unable to meet minimum targets: #NoTrainingTodayNoSurgeonsTomorrow Twitter Supervisors are generally recruited on a voluntary campaign) to promote awareness among both basis and most job plans would account for time in those roles in the allotted programmed activities among trainers and trainees of the JCST’s 262 (PAs). The initiative should encourage supervisors recommendations on maximising training, the 2021 surgical curricula and the targets to utilise existing PAs for their roles to cater for introduced as a result of this initiative. individual training needs and could allow external funding from educational bodies invested in training The key aim of this initiative is to motivate trainers to (eg Health Education England, the Joint Committee better engage with their supervisor roles and allow on Surgical Training [JCST] or royal colleges) in the an objective assessment of the quality of training. form of grants for research and educational purposes External obstacles to training will always exist (as awarded to outstanding trainers. To allow taking starkly demonstrated by the impact of the COVID-19 on more trainees or even to pursue degrees in pandemic), and work pressures, theatre time limitations medical education. and service delivery priorities are all factors that can • Relating these targets to any future changes to negatively affect an individual’s training. However, it is essential that internal factors such as lack of supervisor surgical curricula or training pathways at a national engagement at an individual or unit level are promptly level as outlined in the Future of Surgery report 2 identified and addressed as these could have an • The targets should be discussed and agreed unequitable impact on trainee progression. by the key stakeholders in surgical training: Supervisor recruitment should consider funding or PA • National trainee associations (the Association allocation in line with their training profiles and feedback of Surgeons in Training and the specialty from previous trainees to promote transparency and equity in training. Formal feedback from trainers as well trainee associations) as trainees and future analyses of Intercollegiate Surgical Curriculum Programme and electronic eLogbook data would help to identify pitfalls in implementation and guide appropriate changes to the initiative. 89 | SECTION C: HOW TECHNOLOGY CAN SUPPORT ASSESSMENT OF TRAINEE COMPETENCE SECTION D HOW INNOVATION CAN HELP THE SURGICAL WORKFORCE D1. MENTORSHIP VS SUPERVISION However, as advocated by the National Association of Clinical Tutors, a mentor should ideally occupy IN SURGICAL TRAINING a pastoral role separate from the formal educational supervisor role. 263Given the formal role of both Antonia Hoyle the educational and clinical supervisor in providing The concept of mentorship has been neatly distilled assessments of competence in specialty surgical by educational theorists as ‘using one’s wisdom (the training,266can either truly provide the degree of detachment and openness necessary for mentorship product of reflection on experien263 to help another in its most authentic form? person build their own wisdom’. In addition to the tradition of the surgical apprenticeship model, there is Moving forwards, surgical training needs to recognise an evolving body of literature to guide evidence-based practice for mentorship in surgical training. Mentorship the vital role that mentorship can play in developing is a dynamic process that is invaluable to surgeons as surgeons with the skills, insight, wisdom and resilience necessary for 21 scentury surgical practice. Strategies for they progress through their training and their career. encouraging and developing mentorships, discreet from In surgery, mentors have been described as ‘a senior existing training supervision roles, need to be explored, member of a field who guides a trainee in personal, implemented and supported to ensure equity, inclusivity professional, and educational matters’. 264Common to most definitions of mentorship is the concept of a learning and a continued development in professional standards. relationship that comprises a variety of functions including D2. DIGITAL OPTIONS FOR skills development, career support and personal growth. Through these mechanisms, mentorship plays a vital role REDUCING BURNOUT in improving patient care, organisational development and surgeon wellbeing. Neil Harvey At present, a significant proportion of mentorship occurs Burnout is endemic in trainees and trainers in the UK with informally as surgeons encounter likeminded individuals through the course of their careers with whom they feel 33% feeling burnt out to a high or very high degree in t267 2021 General Medical Council national training survey. comfortable engaging in shared reflection, and open Burnout is defined as ‘a psychosocial syndrome [involving] partnership between mentor and mentee. This informal feelings of emotional exhaustion, depersonalization system, however, can lead to problems with equity of and diminished personal accomplishment at work […] access to mentorship, and a lack of recognition and generally considered a response by a subject to chronic resourcing for this vital aspect of surgical training. work-related str268 in an attempt to adapt or protect In response, efforts have been made to formally oneself from it’. Over the years, surgical trainees have implement mentorship into surgical training. consistently been seen to be at higher risk of burnout than the all-trainee cohort (in 2021, 16% vs 15% respectively Nevertheless, there is considerable blurring of the lines at high risk of burnout).67,269 between mentorship and training in these efforts, which calls into question whether surgical training has yet fully Technologies being developed to tackle burnout, grasped the true concept of mentorship. Among surgical depression and anxiety (noting that although related, trainees surveyed in 2015, fewer than half reported 270 having a surgical mentor while for those who did, the these have no conclusive causal relationship) are myriad, and will draw on threads from all sections role of supervisor and mentor were frequently combined, of this document (as, similarly, do those designed to either by accident or by design. 265 improve physical health). The biggest driving factor 90 | SECTION D: HOW INNOVATION CAN HELP THE SURGICAL WORKFORCEbehind burnout is the inability for an individual trainee for a multiplicity of reasons. Factors for each of these to continually meet the demands of the service, with have been well researched 277–27and yet the workforce contributing factors including inadequate staffing crisis persists. increasing the workload, inappropriate appointment The crisis seems to have a basis in imprecise intelligence leaving trainees ‘out of their depth’ and lack of structured about what activity (and which subspecialist services) are support, including mentors and social aspects of training programmes. 271 being provided where. This makes proactive workforce planning difficult at a national, regional and local level. The application of big data and machine learning over Better information about the precise nature of phase 3 time will improve workforce planning, ensuring that the trainees’ career intentions and consultants’ contracted 280 right numbers of trainees are recruited year on year for NHS activity would make it easier to ‘job craft’ careers, each specialty, even as assessment of predictors of at both junior and senior levels, to prevent a mismatch in attainment guides trainees to the specialty they are best service provision. This could also help to reduce ambient equipped to deliver. Also critical is the normalisation of stresses, encourage a longer productive working life, 272 less than full-time training and working (and time out of achieve a better work–life balance and counter early training), with working hours restrictions being the single withdrawal from the workforce. most significant intervention in preventing burnout. 273 There is also a growing recognition that surgical trainees Making an online annual career report (ACR) a mandatory instrument in local appraisal would help are more likely to neglect self-care than equivalent trainees, and that this is as a contributing factor to in proactive identification of the trainees required, their burnout 53and subsequent attrition from surgical practice. specialism and subspecialist areas of practice. This The known protective effect of mentoring against burnout could help minimise inappropriately trained appointees, 271,274 unrealistic expectations and job dissatisfaction as is likely to be realised through telementoring. Self- care and meditation workshops have also been shown consultant careers progress. It could also facilitate to reduces aspects of burnout syndrome, 273and may be higher quality appraisal and more appropriate job integrated into curricula going forwards. crafting to extend the NHS working life of consultants; ultimately, more senior consultants would be available Regarding mental health, globally, we can expect to support trainees transitioning into consultant practice. to see machine learning driven applications utilising speech, typing and facial movement pattern recognition A preliminary study carried out by the British Association to flag those (most) in need of assessment for of Urological Surgeons and Bournemouth University depression, 54,5in terms of identifying trainees at risk has identified many of the dynamics of consultant urologists’ careers.281A pilot of a mandatory ACR across before they themselves are aware that they are. Already, applications deliver cognitive behavioural therapy and UK urologists would help in strategic planning for how mindfulness therapy training on our smartphones as the global urological need could be provided and the well as enabling instant access to self-assessment tools subspecialist workforce required (where and when) 275 in addition to informing the training requirements and and self-referral for depression and anxiety, even as wearable devices prompt mindfulness pauses. destinations of senior trainees. A successful pilot could then be presented for wider dissemination across UK Ethical concerns will of course arise and in due course, surgery (or the whole of medicine) by the Department of we may end up debating exactly how far employers Health or the General Medical Council. should be allowed to go in monitoring us for the sake Data (Table 7) could be collected in a pilot on the of our own wellbeing. Currently, however, there are ® significant improvements to be made in how we support SurveyMonkey platform utilising non-repetitive logic the wellbeing of surgeons in training. driven drop-down menus. The information could be collated by the individual and downloaded as evidence for annual appraisal. SurveyMonkey ®will allow for D3. WORKFORCE SOLUTION: database interrogation nationally and resultant data can THE ANNUAL CAREER REPORT be disseminated to a functional level. Bespoke software AS A MANDATORY INSTRUMENT may be required if applied to a wider audience. FOR WORKFORCE PLANNING Steve Payne 276 Shortage in the medical workforce is a fact of life. The aetiology is multifactorial but principally revolves around a mismatch between trainee numbers and vacant consultant posts, early NHS withdrawal of trainees relocating internationally and earlier retirement 91 | SECTION D: HOW INNOVATION CAN HELP THE SURGICAL WORKFORCETable 7: Data categories and data type captured by an annual career report Category Data point Demographics GMC number* Age* Role* Race* Sex* – – – – – Practice Country* Region* Hospital* Single hospital* x2 Hospitals* x3 Hospitals* – – – – – Contract Full/part time* PAs DCC SPAs EPAs Intentions Stay the same Will increase Will decrease – – – – – – – Job/training planSubspecialism % core % subspecialist – – – – – – – SPAs Theatre Day-case Outpatient cliniMDT Other (specify) – – – – – Teaching/training Management Research External Other (specify) – – – – – On-call shifts Number of sites Rota Rota type Cover – – – – – – Plans Type of practice*Subspecialism* Expected CCT Intention to takeIntention for date* grace period* post-CCT fellow- ship* Retirement age Change role Leave medicine Other (specify) – Succession plan Mentor plan – – – CCT = Certificate of Completion of Training; DCC = direct clinical care; EPAs = extra programmed activities; GMC = General Medical Council; MDT = multidisciplinary team; PAs = programmed activities; SPAs = supporting professional activities *Relevant to trainees Finally, the ACR presents an opportunity enabling will not be an appropriate job at the end of training. trainees to sculpt their phase 3 training goals and Should data on protected characteristics also be consultants to shape their careers. The ACR could included in the ACR, this would enable identification inform the reality of a trainee’s desire to practiseof groups not achieving their intended career objectives a consultant in a given region or pursue a required so that appropriate positive action to redress that subspecialty interest while reducing the risk that timbalance could be considered. 92 |SECTION D: HOW INNOVATION CAN HELP THE SURGICAL WORKFORCED4. THE RCS ENGLAND SURGICAL For these reasons, in order to accurately determine the numbers required in the workforce in different WORKFORCE CENSUS areas of practice, there needs to be careful recording William Allum of data of the current number of trained surgeons and those in training on an annual basis. There are some The aim of workforce planning is to deliver a sustainable data available on training numbers held by the Joint Committee on Surgical Training and from the GMC’s workforce that is able to provide safe services for both patients and the NHS. Although this aim seems simple, national training survey. In addition, the details of it is an extremely complicated process owing to the numbers of surgeons is recorded by some surgical influence of several important variables. specialty associations. First, there is the composition of the workforce. The Royal College of Surgeons of England is therefore The NHS People Plan has proposed that the spectrum developing an initiative to produce a regular census of the workforce to determine the actual numbers in post. of the workforce should consist of medically trained This process will require considerable investment of time and non-medically qualified staff, trained staff and those in training.82In surgery, the workforce comprises and resource as it will need to be completed annually consultant surgeons, non-consultant career grade and validated to make it worthwhile. Furthermore, such surgeons, surgical trainees and members of the information will need to take into account other sources of workforce numbers such as those available from the extended surgical team. statutory education bodies, the GMC and the surgical Second, there are the requirements of the service to specialty associations. meet the demands for surgical care. These demands can be computed from the number of surgical D5. WORKFORCE PLANNING procedures performed in all surgical specialties each year with an annual increment to reflect variation. INNOVATION: EXEMPLAR FROM However, this is simplistic as there are variations in the CURRENT ISSUES WITH number of surgical procedures undertaken, and this total NEUROSURGERY figure can be both inaccurate and misleading. WORKFORCE PLANNING Third, data are available from a variety of sources such as the General Medical Council’s (GMC’s) specialist Neeraj Kalra and Will Bolton register, which records the number of trained surgeons according to their specialty of interest. These data can The 2020 UK Neurosurgery Workforce Report published by the Society of British Neurological Surgeons be grouped by age, sex and ethnicity as well as by the highlights an urgent unmet need in neurosurgery: country in which the individual works. considerably more neurosurgery trainees have reached In theory, there should be a straightforward calculation the stage of Certificate of Completion of Training (CC283 to estimate the numbers of consultants leaving than there are substantive consultant jobs available. (either through retirement or for other reasons) and The result is that post-CCT colleagues often have no then to estimate the number of trainees who need to other choice but to move nomadically from fellowship to fellowship. This current trend is set to worsen before complete their training to succeed into consultant posts. it improves. Compounding this issue, a range of new Unfortunately, this calculation is confounded because of variable data about consultant surgeon activity and resource requirements (including capable surgeons because of variation in the timing of when surgical in training) will be necessary to address the surgical trainees complete their training. Depending on the backlog exacerbated by the COVID-19 pandemic. specialty, surgical training lasts from six to eight years This challenge leads to workforce disenchantment but there are clear data showing that approximately because trainees have sacrificed and worked hard to 50% of surgical trainees do not complete training in that complete their training, and rightly want to progress into timescale and training is often extended for a variety of reasons. There is also an increasing preference to train their consultant careers. A contributing factor leading to less than full time and consequently, it is very difficult this issue is the lack of operating capacity expansion in the system and historical poor workforce planning. to accurately predict the number of trainees completing training in a specialty each year. Addressing this unmet need is complex and will require a spectrum of innovation, including process and system This is complicated further as these calculations are innovation. Learning from other surgical specialties based on replacement posts and there is no allowance for new posts. Moreover, the GMC data record details that have gone through similar challenges in the past of those in non-consultant career grades whose is paramount. Fostering effective consensus with the extended surgical team to ensure that middle grade rota contribution to surgical services is very significant. staffing and registrar training opportunities are prioritised 93 | SECTION D: HOW INNOVATION CAN HELP THE SURGICAL WORKFORCEis an important first step as a reduction in entry may also contribute to consultant expansion because to training numbers is felt nationally. these future consultants will have additional interests and responsibilities to add to their job plan alongside Increasing training opportunities and career pathway surgical practice. Finally, exploring new indications for innovation reduces the speed at which trainees achieve neurosurgery in emerging fields with early strategic their CCT. These include established academic training working around workforce for all sub-specialty areas options such as undertraining integrated academic training and PhD/MD degrees but new ideas are to align with disease burdens will be critical in the long term. This may be particularly relevant to high volume being explored such as innovation/digital fellowships surgical catch-up priority disease areas such and time in industry or other sectors. The creation of as degenerative spine disease integrated, flexible portfolio career training options 94 | SECTION D: HOW INNOVATION CAN HELP THE SURGICAL WORKFORCE SECTION E WHAT NEEDS TO HAPPEN TO EMBRACE TECHNOLOGY ENHANCED SURGICAL TRAINING E1. KEY CONSIDERATION: More broadly, innovation through interdisciplinary collaboration requires dedicated research support from THE NEED FOR INTERDISCIPLINARY healthcare organisations to embed it in normal working COLLABORATION 287 practice. A prime example is the National Institute for Health and Care Research (NIHR) Surgical MedTech Peter Culmer and David Jayne Cooperative, which brings together surgeons, academics in the physical sciences and patient stakeholders, Surgery has a long history of interdisciplinary supported by key professional bodies. This allows a collaboration with engineers and allied professions, foundation to conduct activities that catalyse innovation, which have been instrumental in helping shape the such as running innovation workshops to identify key development of innovative practice and improved outcomes. 284For example, integral to the introduction unmet clinical needs and pump priming research of laparoscopic surgery was the development of new to explore potential solutions. Partnership with the instrumentation and camera systems to access the Association of Surgeons of Great Britain and Ireland helped achieve participation across surgical disciplines, abdominal cavity, leading to ongoing collaboration provided professional recognition for those involved and (and innovation) in the advancement of new surgical ensured a broad audience for outputs. robotic systems. 285 The Lancet Commission on Global Surgery recently However, interdisciplinary collaboration in and of itself is not a guarantee for success. Examples abound of found that over five billion people (typically in low ‘the next big surgical innovation’ that subsequently fail resource settings) have no access to safe and to gain traction because they represent a new affordable surgical care.4 Technology innovation has a crucial role in helping to address these inequalities technology looking for a clinical need. While achieving and drive improved access to surgery in low resource success in innovation is notoriously difficult (reports settings.288Frugal innovation, an approach using the suggest that only 1 in 100 innovations make it into principle of ‘doing more with less’,289has helped many clinical practice), it is well documented that the innovations most likely to succeed are those with projects successfully innovate in this resource scarce a defined need and a clinical champion. 286 context. Strikingly, the outcomes can often be translated to high resource settings, a process known as ‘reverse Clearly, there is a need to foster and formalise innovation’, bringing the potential for improvements in both equipment and working processes. 290 interdisciplinary working to ensure that innovation in surgery is driven by clinical need. This is particularly Our own experience of innovation for global surgery pertinent during training, providing a foundation in involved the development of a new surgical device to the ‘language’ of interdisciplinary collaboration. It is no coincidence that academic and medical training support gas insufflation-less laparoscopic surgery in low organisations around the world are developing resource settings. The project was initiated by the Leeds opportunities to formally train in interdisciplinary medical NIHR Global Health Research Group bringing together an international team of UK-based engineers, designers innovation. Stanford’s ‘Biodesign Innovation’ course, and surgeons with surgeons and industry partners in ‘Surgineering’ at Johns Hopkins, new Medical Cobotics India. Interdisciplinary collaboration between this team Centre at the Indian Institute of Technology in Delhi and the Hamlyn Centre at Imperial College London all focus was integral to the innovation process, enabling us on effective communication and collaboration across to successfully move from understanding the specific disciplines to address a common clinical challenge. clinical needs through to commercial production and evaluation of a new system. 291 95 | SECTION E: WHAT NEEDS TO HAPPEN TO EMBRACE TECHNOLOGY ENHANCED SURGICAL TRAININGSurgery is inextricably linked to technology innovation those that have a pharmacological or medical device achieved through interdisciplinary collaboration. mechanism of action. For example, a technology The term ‘Surgery 4.0’ has been used to describe enhanced training technology will need to have (among the increased use of robotic and digital technologies other things) preliminary testing as it develops, basic to improve efficiency and outcomes in surgical user safety testing and usability/acceptability/feasibility processes. 292These themes are echoed in the Topol investigations, progressing to educational effectiveness review , which highlights the need for digital education and cost effectiveness analyses, and ending with across disciplines and th11ability to communicate adoption and dissemination programmes involving in a common language. There is therefore a clear business case development and curriculum integration mandate to formally embed technology innovation and across specialties and regions. interdisciplinary collaboration in the surgical training pathway, empowering individuals to become actively The most relevant study designs to address the broad involved in the evolution of surgery. area of enquiry at each stage may be different from designs used in evaluating purely clinical interventions. E2. KEY CONSIDERATION: However, the rigor of study delivery and quality of the data should not be compromised given that GENERATING EVIDENCE TO INFORM fundamentally, ‘better’ training will result in improved INNOVATION AND TECHNOLOGY patient outcomes because training is designed to produce safe and effective surgical care providers. ADOPTION IN TRAINING Furthermore, policymakers and trainers have a duty Will Bolton to make the most of relatively limited budgets and resources for training, and evidence is needed to Innovation can be defined as the act of doing something inform choices concerning which portfolio of technology new that creates value. Whenever novelty is introduced, enhanced training solutions should be adopted for risk and uncertainty are also introduced. A core objective surgical trainees. of surgical innovators is to balance the urgent need to get innovations that benefit surgeons swiftly and completely Generating effective evidence will require steer from adopted against the risk of doing harm. It is essential to educational theorists, clinical educators and the key remember that simply not innovating would be illogical, stakeholders responsible for training the healthcare workforce. Crucially, trainees themselves should be unethical and bad for training. Consequently, any involved at every stage, and this could be compared evaluation of training innovation should not unreasonably increase costs or delay adoption of beneficial with patient and public involvement and engagement interventions because harm is also done by reducing initiatives seen in clinical research. Every technology access to new training solutions and patient treatments, enhanced training project proposal, grant application and dissemination strategy should have meaningful and suppressing the innovation process. trainee involvement. A clear meta-observation from Innovating technology for surgical training and taking this report is that surgical trainees want to be involved it from ideation through to widespread adoption into in improving their training through technology and routine practice is a complex process that is challenged innovation, and through involving trainees, innovators by several barriers including the lack of an appropriate have an increased chance of achieving the elusive and comprehensive evaluation framework for this widespread adoption required to make an impact. category of innovation. Surgical device development Providing trainees with training in research and is constrained by a number of barriers including a lack innovation skills to contribute to the generation of this of surgeons as co-inventors, challenges in progressing evidence will result in significant added value to the to first-in-human studies and the complexity of surgical technology development–evaluation–adoption cycle, trials.86Together, these barriers result in low innovation and this should be available to all specialties and translation rates and mean that few innovations are regions on a regular basis. ultimately widely adopted. This is compounded by an increasing dependency on and use of advanced Although all widely adopted, safe, cost and technologies by the surgical workforce. For trainees, educationally effective interventions must have been many feel disenchanted and powerless to effect change evaluated along the pipeline, generating evidence in this way does not guarantee successful adoption. and implement innovation to benefit their training and There have been plenty of highly evidence-based their patients’ care. interventions that never made it to market or that This report focuses mainly on technology enhanced only achieved fractured adoption when they did so. training solutions and training pathway innovations. The odds of success can be increased by following From a scientific viewpoint, the study designs (and a few fundamental principles that must be considered relevant outcomes) required to build the evidence throughout the entire evaluation process. First, there base for these interventions are subtly different from is interdisciplinary collaboration. Through fostering 96 | SECTION E: WHAT NEEDS TO HAPPEN TO EMBRACE TECHNOLOGY ENHANCED SURGICAL TRAININGproductive working practices between surgeons, and its linear economy, with technological innovation industry and academics, solutions will be generated and becoming increasingly more central to patient care. In evaluated in a more coordinated way, considering the accordance, surgical training has evolved dramatically needs of trainees, trainers, technologists and business to keep up with technological developments but also in at the same time. response to the well known shifts in training opportunities and more recently, owing to COVID-19 restrictions. Second, innovators should avoid the trap of having a ‘solution’ and looking for ‘the problem’. Always ensure the This means relying ever more on digital solutions including cycle is rooted firmly in a real, high priority, unmet need virtual training programme director meetings, the annual for surgeons in training. In this way, technologies will be review of competence progression and collegiate exams 298,299 pulled along the solution pathway from need to solution, as well as preparation courses. Remote proctoring, rather than pushed chaotically down unfruitful paths. live surgical streaming and virtual conferences have also become more widespread in recent times. These Finally, evidence generators must explore novel new digital tools are essential to modern training, and research methodologies that directly map and causally link training outcomes with patient outcomes simulation (in al300ts forms) has been recognised as an invaluable asset. As these tools continue to develop for technology enhanced training solutions. One of the further, however, we have a duty to ensure sustainability challenges here lies in technology classification and is recognised as a core consideration and is included in associated regulatory frameworks as interventions that directly affect patient care are regulated differently all research assessing their efficacy. from those that do not. However, scientifically We acknowledge that the normalisation of distant understanding the relationship between training and learning and virtual events offers a fantastic opportunity patient care is essential to improve the development to reduce our carbon footprint. Conversely, we must and adoption of the best technologies for training. remember that although ephemeral, digital data Trainees desire technologies that provide educational management requires vast amounts of energy while effectiveness and patients need trainees who have hardware and mechanical devices also have a very been educated effectively. tangible carbon footprint. Each email or newsletter, every webinar or video stream, and all cloud storage The Future of Surgery report highlighted the key technologies that will have an impact for patients in consumes a significant amount of energy when scaled 2 up across the global surgical population. Similarly, in the the coming decades. The trainees of today will be the operating theatre, intelligent devices, extended reality consultants using these technologies in those coming systems, software and associated data will of course decades, and this report strikingly demonstrates increase an operation’s environmental impact, as has how technology can improve surgical training if already been demonstrated for minimally invasive and evaluated and implemented via appropriate processes. robotic approaches. 301 Fundamentally, properly evidenced technology enhanced training will deliver the future of surgery Though imperative not to compromise training delivery that surgeons and patients deserve. or surgical quality, it will become crucial to make sustainable choices. As is occurring in every field, it will E3. KEY CONSIDERATION: be necessary when evaluating surgical practices as well as training tools to consider the environmental impact THEIMPORTANCEOFSUSTAINABILITY of each intervention. Unethical manufacturing and IN THE ERA OF DIGITAL SURGERY material sourcing commonly utilised in the production of digital instruments (as well as our traditional analogue Jasmine Winter Beatty and Victoria Pegna equipment) should also considered and addressed. If healthcare was a country, it would take fifth place What is certain is that the climate crisis and its effects in the world league table for carbon emissions. 293 on human health are inextricable, with the World Health The NHS alone has a carb294footprint that is almost Organization having declared it the ‘single biggest health equal to that of Jordan and accounts for 4% of the threat facing humanity’.302The climate emergency will whole of the UK’s carbon emissions. 295Surgery is one inevitably affect every trainee: sustainability is already of the highest contributors to this footprint, with a study being incorporated into the surgical syllabus, and it will in 2011 finding that operating theatres are three to six become an integral part of clinical governance, clinical times more energy intense than any other hospital effectiveness and clinical practice. area.296An average operation in the UK is estimated to have a carbon footprint of 173kgCO e, more than Including sustainability in surgical innovation and driving from London to Glasgow. 297 2 surgical training is the only choice. As surgeons, we need to adapt our practice – as well as our training – As we face the climate emergency, we are fully invested now. We all hold a responsibility to solve the climate in the exponentially evolving era of digital surgery crisis to protect our global patient population. 97 | SECTION E: WHAT NEEDS TO HAPPEN TO EMBRACE TECHNOLOGY ENHANCED SURGICAL TRAININGE4. DIGITAL LITERACY SKILLS for surgically related problems. Finally, surgeons who FOR SURGEONS IN TRAINING are trained in digital technology are likely to be more comfortable in handling large scale datasets and utilising statistical techniques, which can be readily Arif Jalal, Victoria Ngai, Anand Pandit applied for audit and research. and Manish George Health Education England defines digital literacy as Other professional disciplines have recognised the importance of digital skills education. Both the Institute the ‘capabilities that fit someone for living, learning,303 of Chartered Accountants in England and Wales, and working, participating and thriving in a digital society’. the Association of Chartered Certified Accountants have The term is commonly used to refer to general information technology skills and computer proficiency. produced their own e-learning mo304es related to AI However, as digital technology and the use of big data, and financial decision making. Although not entirely comparable, surgeons would benefit from similar artificial intelligence (AI) and machine learning become context specific training in these areas. more common, a basic understanding of these latter concepts will now be required. Critical appraisal The need for digital literacy Surgeons may be able to conduct studies involving AI As surgical departments in the NHS continue their and machine learning or they may consult the literature to evaluateAI-based tools that have the potential to integrate digital transformation through the integration of large into clinical practice. In either case, it is necessary to be scale patient information and application of AI- able to perform critical appraisal effectively. based tools, it is imperative that surgeons and key stakeholders can appraise new technologies and their Research reporting guidelines, such as those provided application. The need for digital literacy is fourfold. by the EQUATOR (Enhancing the QUAlity and Transparency Of health Research) Network, facilitate First, surgeons need to be able to critically evaluate the planning, writing and critique of research. 305 and commission digital tools as they become available in order to implement them in clinical practice. Second, Extensions to the EQUATOR guidelines have been surgeons need to be able to explain technologically released specifically for studies of AI-based algorithms and interventions. For example, guidelines dedicated assisted procedures and the underpinning surgical to clinical trial protocols (SPIRIT-AI) and clinical trial evidence to patients as well as to lay members of the public. Third, academically minded surgeons who reports (CONSORT-AI) for 306,307ntions involving AI wish to pursue research in this area need to be able were published in 2020, and consensus processes are still underway to produce AI related extensions for converse effectively with engineers and data scientists guidelines concerning other study types (Table 8). 308–311 in order to develop new electronic and robotic solutions Table 8: AI extensions to research reporting guidelines based on study type Study type Example Guidelines Diagnostic and prognostic prediction What is the probability that this TRIPOD-AI (reporting) 308 308 models model can predict the development PROBAST-AI (risk of bias) of breast cancer for an individual patient? Diagnostic test accuracy studies What is the accuracy of this model or STARD-AI (reporting) 309 algorithm in diagnosing breast cancer QUADAS-AI (quality assessment) 310 on MRI? 311 Early clinical evaluation of decision How will this AI system assist DECIDE-AI (reporting) support systems radiologists in diagnosing breast cancer on MRI in a small scale clinical evaluation? Large scale clinical trials evaluating What is the comparative SPIRIT-AI (protocol) 306 AI interventions effectiveness of this AI system in CONSORT-AI (reporting) 307 diagnosing breast cancer using MRI compared with a control? AI = artificial intelligence; MRI = magnetic resonance imaging 98 | SECTION E: WHAT NEEDS TO HAPPEN TO EMBRACE TECHNOLOGY ENHANCED SURGICAL TRAININGOther reference materials containing recommendations algorithms in medicine (MI-CLAIM), which does not 313 that are not specific to particular study types have also specify a study type. Table 9 provides several common been released and are summarised in a review article considerations in the conduct and reporting of clinical published in 2021. 312One example is a ‘minimum AI research based on these guidelines and checklists. information’ checklist for the general reporting of AI Table 9: Considerations in the conduct, reporting and appraisal of clinical artificial intelligence (AI) research Clinical • Researchers should describe the intended use of an AI tool as well as its intended users. context This involves clarifying where it would fit in clinical contexts or pathways and how model outputs would be used to guide clinical decisions. • Current gold standards and methods for achieving the same goal should be identified to justify the AI use case. • Requirements for software, hardware or expertise should be outlined as these can vary in different settings. Model • Researchers should specify the type of model in question as well as the version, especially since AI models may change after undergoing further training. • Suitable metrics should be chosen to evaluate the performance of a model. Separate metrics may be needed to assess technical performance and to demonstrate clinical utility. • AI models can produce an output without users understanding how the result was reached so methods (eg saliency maps) exist to examine models in an attempt to explain the process leading to an output. • Researchers should report and investigate any performance errors as these can pose a clinical risk and may not be as predictable as human errors. • Researchers can direct readers to the code used for the AI model in question so that attempts can be made to validate the model in other contexts. Data • Researchers should report how the input data were acquired or selected as well as how they were cleaned or transformed. Methods of handling poor quality or unavailable data should be described. Knowing the origins of the input data can help readers understand what kinds of data collection and staffing may be needed to train the model. • Training data and testing data should be independent to prevent data leakage, which is when the model is inadvertently given the ‘answers’ that it is supposed to predict. • Demographic and clinical characteristics of the cases that make up the data should be reported, and should represent the intended population where a model would be deployed. Practitioners can also use this information to consider the generalisability of results to their own patients. Digital literacy training A recent review of postgraduate specialty curricula At an undergraduate level, intercalated degrees in noted that health informatics competence domains were robotics, medical imaging and health informatics entirely lacking from core surgical training curricula. represent one example of how digital literacy training can A survey of students and staff in the US found positive be implemented into training. Postgraduate teaching of attitudes towards the use of AI in medicine and in data science is also available in the forms of PG Cert or teaching; however, the majority in both groups had MSc level courses. Nevertheless, for such knowledge primarily learnt about AI from the media rather than in to be accessible to all surgeons rather than only those formal education. 315The aim of digital literacy training with pre-existing interests or career aspirations, there is would be to teach surgeons and medical students how a need for training targeted at a wider group of surgeons to safely and confidently use common AI and machine who only need to grasp key concepts. On a national learning digital tools related to patient care. level, Health Education England is in the process of carrying out a learning needs analysis to develop the first national capability framework for AI and digital medicine tools, the results of which will have an impact on the direction of education in the field. 99 | SECTION E: WHAT NEEDS TO HAPPEN TO EMBRACE TECHNOLOGY ENHANCED SURGICAL TRAININGFurther reading and relevant online accessible courses Table 10 lists some of the available resources relating to digital literacy. Table 10: Resources relating to digital literacy skills for surgeons in training Resource Authors Source Link AI for Healthcare: Brass et al University of Manchester, www.futurelearn.com/ Equipping the Workforce FutureLearn courses/artificial- for Digital Transformation intelligence-in-healthcare (course) Artificial Intelligence in Hashimoto et al McGraw Hill www.mheducation.co.uk/ Surgery: Understanding artificial-intelligence-in- the Role of AI in Surgical surgery-understanding- Practice (book) the-role-of-ai-in-surgical- practice-9781260452730- emea Machine Learning (course) Ng et al Stanford University, www.coursera.org/learn/ Coursera machine-learning AI in Healthcare Shah et al Stanford University, www.coursera.org/ Specialization (course) Coursera specializations/ai- healthcare CS50: Introduction to Malan et al Harvard University, edX online-learning.harvard. Computer Science (course) edu/course/cs50- introduction-computer- science E5. KEY CONSIDERATION: Integrated innovation training is not about gaining INTEGRATED INNOVATION TRAINING in-depth knowledge in artificial intelligence, ‘omics’ or robotics. It is about illuminating barriers to healthcare innovation, finding sustainable solutions and baking Gedeon Lemma, Angela Lam, Will Bolton and Josh Burke interdisciplinary networking into the health profession. At the undergraduate level, we are already seeing Today, clinicians are looking for ways to use technology medical students explore innovation first hand. 317 The MedTech Foundation 321offers an 8–12-week to transform healthcare and professional bodies ar318,319 asking for ways to innovate in an age of innovation. structured innovation programme that aims to introduce However, we have yet to see proposals or a the principles of medical device development through coordinated strategy to achieve this. A recent report interactive workshops and specialised mentoring emphasised that the various programmes dedicated to sessions with experts. Students from medical, business and STEM subjects work in teams to develop tangible technology and healthcare innovation form a complex patchwork with little evidence of intentional design.20 solutions to real clinical problems, and pitch them to For this reason, addressing the implementation gap has a panel of judges. Currently, this programme remains become more than a conversation about ‘innovation’. an extracurricular activity but we want to see this type of experiential learning and further education on how It is now a question about being safe clinicians who novel technologies will affect 21tcentury healthcare can meet the needs of future patients. As such, in order to develop the innovative capacity of our workforce, featured across all medical curricula as outlined in we propose a training scheme to teach clinicians the the Topol review. 11 leadership and entrepreneurial skills to participate in an uncertain and fast evolving healthcare industry. 100 | SECTION E: WHAT NEEDS TO HAPPEN TO EMBRACE TECHNOLOGY ENHANCED SURGICAL TRAININGFor postgraduate training, clinicians should be given initiatives. Furthermore, surgeons in training should be time to gain real-world experience, expand their digital encouraged to mould their own career, supported by capabilities and become opinion leaders who can extended time to complete a PhD or MBA degree, gain evaluate the translation of healthcare technologies so further industry leadership experience or (for the brave) that only the best reach our patients. Opportunities found a startup. As such, the National Institute for Health in non-clinical placements should be supported with and Care Research pathway provides a natural platform deanery links to innovation hubs, NHS organisations and to develop this further given its regular exit and entry approved startups, where clinicians can take on discrete points, support networks and established links to funding projects, akin to consulting and knowledge exchange organisations (Figure 14). 322 INTEGRATEDINNOVATIONTRAINING CT1/ CT2/ Undergraduate F1 and F2 ST1 ST2 ST3 ST4 ST5 ST6 CCT MedTech NIHR NIHR ACF NIHR ACL Clinical director Foundation, specialised (9 months) (2 years) of innovation, medical school foundation C-suite, industry (4 months) expert OOPE Support: NIHR Academy PhD, MBA, leadership, Funding: External application support industry, startup, CEP (3 years) ACF = academic clinical fellow; ACL = academic clinical lecturer; CCT = Certificate of Completion of Training; CEP = Clinical Entrepreneur Programme; NIHR = National Institute for Health and Care Research; OOPE = out of programme for clinical experience; UG = undergraduate Figure 14: Integrated innovation training pathway In order to validate training, the EU EntreComp provides E6. CONSENSUS HACKATHON an internationally recognised competence framework for entrepreneurship. 323It is designed to build autonomy William Foster and Angela Lam in generating ideas and opportunities, managing resources and becoming a leader who can turn ideas Healthcare is in constant need of rapid and flexible into action. Most of the 15 competences are synergistic innovation to respond to unforeseen unmet needs. with traditional medical training; we just lack recognised Effective innovative solutions require interdisciplinary opportunities to experiment with them alongside input from clinicians, programmers, engineers, various stakeholders. scientists and businesspeople, who spend most of their time in siloed departments with little cross-pollination In summary, it is challenging to know exactly what of ideas. Hackathons, built around an iterative process integrated innovation training will look like as healthcare where interdisciplinary teams generate solutions is complex and constantly evolving. We therefore rapidly,32are now widely used in healthcare to bridge ask that national bodies, students and trainees join this gap. us in constructing a map to navigate our innovation ecosystem. It starts with everyone achieving a Consensus hackathons have been developed recently contextual understanding of where we are today by the MedTech Foundation 321for the purpose of and where we are going in the future. addressing surgical training needs. These hackathons additionally incorporate the Delphi technique 325 (a consensus methodology), and thereby permit simultaneous identification of high priority unmet needs 101 | SECTION E: WHAT NEEDS TO HAPPEN TO EMBRACE TECHNOLOGY ENHANCED SURGICAL TRAINING VIRTUALCONSENSUSHACKATHON Unmet needs ranked Teams meet Guided breakouts Hackathon introduced Teams innovate in real time to identify potential solutions. Mentors present in each room to guide PARTICIPANT FLOW ON THE DAY Mainstage presentations A mixture of case studies, skills lectures and whole group discussions break Most feasible projects up the day and provide taken forward educational value Elevator pitches Concept notes drafted Figure 15: Participant flow on the day of a virtual consensus hackathon (by real-time participant voting) and development of multiple potential solutions. Aggregated and The MedTech Foundation: anonymised group answers from previous steps are available at each subsequent step, allowing The MedTech Foundation is a national participants to reconsider and revise their prior engagement initiative for university students contributions. Further rounds of summarising and and early career professionals. It aims to gathering responses are deployed until an appropriate support healthcare technology innovation consensus is achieved (Figure 15). by connecting medical, engineering, science, product design, business and The hackathon format of bringing participants together industry specialties together. Each year, the under one roof has further benefits. Not only does collaborative delivers an educational innovation it enable the integration of guided innovative skills workshops but it also facilitates live cross-talk between programme in each of its regional spokes, and organises several research and industry those generating initial ideas and key stakeholders internships. Funding from the National Institute (such as funders) who could help see these ideas through to implementation. Indeed, MedTech for Health Research in 2017 facilitated national expansion and the creation of 11 spokes, Foundation consensus hackathons have seen based in universities. the fruitful development of tangible solutions eligible for funded feasibility studies. 102 | SECTION E: WHAT NEEDS TO HAPPEN TO EMBRACE TECHNOLOGY ENHANCED SURGICAL TRAININGE7. FRUGAL INNOVATION IN Frugal innovation must consider not only the technology SURGICAL TRAINING: A GLOBAL but also the team utilising it. Many rural surgeons have unmet training needs, in part due to training only SURGERY VIEWPOINT being available in distant rural centres, courses and Noel Aruparayil, Will Bolton and Jesudian Gnanaraj training schemes often being expensive and highly competitive, and the lack of staff to cover their absence. Other contributing factors include the lack of funding in Adversity has often provided fertile soil in which weak health systems, infrastructure, hierarchy, and the innovation can thrive. The complexities and challenges absence of structured surgical training and accreditation of global surgery create an exciting landscape for 331 innovation on many levels, ultimately seeking the best programmes for rural surgeons. Training programmes surgical care for patients. While surgeons have always need to recognise the cultural context and empower trainees, resulting in high quality, in-country opportunities been innovating and aiming to progress their craft, frugal facilitating trainee retention, and skill development innovation (or ‘jugaad’ innovation)32relates specifically to innovation in low or limited resource settings. This relevant to the setting and population need. form of creative problem solving has gained particular As an example, our interdisciplinary team developed attention over the last decade, and continues to present an effective structured training programme in GILLS an exciting arena for work at the nexus of surgical skill using objective assessment tools and proctorship advancement, academic surgery, surgical education, for rural surgeons in India,332 policy development, health justice and even the with the aim of providing a surgical intervention that could improve advancement of environmentally friendly surgery. surgical outcomes, and reduce hospital stay and complications for their rural population. During the The gas insufflation-less laparoscopic surgery (GILLS) COVID-19 pandemic, telementoring and proctorship technique is one example of introducing minimal access surgery in rural settings.288,32The procedure via online platforms were successfully implemented can be performed using spinal anaesthesia when to train rural surgeons in GILLS and endourology procedures. 333Virtual reality technology using low access to carbon dioxide gas or general anaesthetic cost headsets made surgical training accessible to a is limited. Studies demonstrated favourable outcomes 288,334 for selective general surgical and gynaecological global audience. Rural hospital teams employed procedures. 328,3As a reverse innovation in high the low cost laptop cystoscope to remove and insert double J stents with remote supervision and guidance income countries, gasless surgery has been a greener during the procedure. 33Formal assessment for surgical alternative by reducing the carbon footprint in surgery.330 techniques could be evaluated and assessed using Frugal innovation may also be a key factor in online platforms, and monitored by means of an online addressing the considerable inequities in surgical registry. A collaborative approach (surgeons, engineers and industry partners in India and the UK) led to the care that remain across the globe. Progression with newer technologies has been rapid in many high developmen291f a newer version of the abdominal wall 335 income countries, supporting improvements in surgical lift device and a low cost laparoscopic simulator. outcomes. Many low and middle income countries are still lagging decades behind regarding the Furthermore, university accreditation of the GILLS course resulted in a growing interest among rural and implementation of newer technologies, particularly urban surgeons, supporting the innovation diffusion in rural settings and for more isolated communities. process. Frugal technology should be an integral part Although technology alone is not the answer to unmet of surgical training with a view to advancing global surgical need, the process of frugal innovation is surgical care. Collaborative partnerships, funding and evidence-based approaches are required for evaluation, beneficial because it champions and promotes effective care with what and who is available, not focusing merely implementation and scale-up, with a focus on process on lack. It values the people in the healthcare system, innovations. 33The use of frugal surgical technologies their specific skills and their adaptability to meet localisedand the research surrounding it must be ethical, affordable and sustainable for low and middle income needs. Such multidisciplinary teamwork is vital to navigating the enhanced complexities of the innovation countries. We must continue to advocate for equitable, diffusion process at all levels from policy to practice to accessible global surgical training and care that is patients in resource limited and/or rural settings. responsive to the evolving needs of the population it serves and the resources available. 103 | SECTION E: WHAT NEEDS TO HAPPEN TO EMBRACE TECHNOLOGY ENHANCED SURGICAL TRAININGE8. SURGICAL RESEARCH TRAINING: Skilled human resource is the most important part of technology development and implementation. LEARNINGS FROM THE NIHR The National Institute for Health and Care Research ADVANCED SURGICAL Advanced Surgical Technology Incubator focuses on TECHNOLOGY INCUBATOR identifying barriers to progression for those theatre team members (including surgeons) who wish to make Martin Birchall, David Jayne and Josh Burke research a major part of both their careers and their lifelong contribution to patient care. Incubator subgroups Advances in surgical technology have accelerated in recent years, with additional impetus from the have identified barriers to research progression at various stages of career and across disciplines (Table 11). demands of responding to the COVID-19 pandemic. For surgeons specifically, there is a need for improved Changes include increasing use and range of surgical support for those who undertake research part or full robots, mixed/augmented/virtual reality and advanced time, including more consideration of their importance, imaging. These all offer improved surgical patient needs and challenges (including financial) by training outcomes. However, their development and successful implementation is critically dependant on input from committees, employing trusts and higher education institutions. There needs to be improved access to trained surgeon-researchers as well as from research- effective mentorship and advice for surgeons in training active non-medical staff (theatre nurses, operating and new academic consultants alike. There should also department practitioners, surgical care practitioners be improved interfaces with industrial research and and others). Research training is essential to the development of a future-ready and future-shaping development, which will become increasingly important in truly effective technology change. surgical and theatre team workforce for the NHS. Table 11: Stages of progression in research career for theatre team members It is recognised that many committed surgical technology researchers will move in and out of the formal (NIHR IAT) and informal research career pathways as denoted by the wavy line. There is a serious lack of role models and mechanisms for progression beyond master’s/doctorate levels for nursing staff and ODPs/SCPs. The NIHR Advanced Surgical Technology Incubator has identified barriers to progress at all these stages and is exploring solutions. Basic Early career Pre- Doctoral Post- Early research doctoral doctoral independence training NIHR IAT 3–6 years Intercalated Academic ACF Fellowship ACL Senior lecturer medical MSc F1/F2 school Medical 3–6 years Basic F1/F2 CST/ST Fellowship CST/ST Consultant ad hoc medical research (research- school skills active) Theatre 2–3 years Basic Diploma Master’s Fellowship Lecturer Senior lecturer nurse degree + research courses skills ODP/ 2 years None Basic Master’s Fellowship Lecturer Senior lecturer SCP diploma, research 3 years skills degree ACF = academic clinical fellow; ACL = academic clinical lecturer; CST = core surgical trainee; F1/F2 = foundation doctor year 1/2; NIHR IAT = National Institute for Health and Care Research integrated academic training; ODP = operating department practitioner; SCP = surgical care practitioner (including first assistants); ST = specialty trainee 104 | SECTION E: WHAT NEEDS TO HAPPEN TO EMBRACE TECHNOLOGY ENHANCED SURGICAL TRAINING sheet’, and use this to create a compelling narrative E9. KEY CONSIDERATION: HEALTH 343 ECONOMIC CONSIDERATIONS – of value to support investment decisions. Finally, it is important not to confuse economic value with budget HOW TRAINING INTERVENTIONS impact; economic value is all about demonstrating CAN DEMONSTRATE ADDED VALUE the value of something whereas budget impact is focused on whether the investment is affordable. Not all Jacque Mallender economic benefit can be monetised in budgetary terms. Sadly, in a budget constrained system, not everything Where does value come from in healthcare? In recent of value can be afforded. years, health systems around the world have started to focus on the value of population health and on delivering ‘value-based care’.337Population health as E10. KEY CONSIDERATION: measured by longer, healthier life expectancy adds TECHNOLOGICAL CONSIDERATIONS economic value through extending formal and informal IN HUMAN FACTORS employment and social participation, and by increasing lifetime human capital and associated consumption. 338 John Hardie and Peter A Brennan Value-based care adds personal value (goals aligned outcomes), technical efficiency, allocative value Error is an inevitable aspect of being human. (reduced inequalities) and societal value (through social Most surgical errors can be attributed to human factors participation and connectedness). 339In this context, (HF). Training all team members in HF principles is part recent initiatives from the World Health Organization of the Health Ed344tion England 2021 national patient have emphasised the huge value of the health and care safety syllabus. workforce, and that investment in the workforce should be seen as developing an asset, not as a cost. 340 Technology enhanced surgery has the potential to reduce HF related patient harm through good system How do new training interventions add value? design, simulation training and incident analysis. Estimates suggest that an investment of £530,816 is However, unanticipated adverse incidents may occur required by trainees and the health system to train a when humans interact with new technology. single NHS consultant. 341To the extent that training interventions are financed by the trainee, return on Improving performance and reducing patient harm investment will need to come from increased salary and begins at the design stage. The term HF is often used interchangeably with ergonomics – the science of how other tangible and intangible employment compensation. If a training intervention is financed by the health system, we interact with systems and with each other. Any the investment value will be determined by how much new technology should reduce the likelihood of error the intervention contributes towards meeting additional by reducing ambiguity and preventing high risk action or inaction occurring. Complex procedures enhanced demand and delivering the goals of value-based care with automated anatomical navigation or augmented required by those paying for services. reality may reduce the surgeon’s cognitive workload, Where training interventions are targetted on supply aid with decision making, and allow capacity for higher shortages, value can be measured through the increase thinking and adverse event management. Any actions in capacity, reducing stress for existing staff. Technical risking harm may be mitigated with real-time visual or efficiency values include reductions in vacancies and audio alert systems. Technology cannot eliminate error sickness absences, improved retention and reduced in theatre. Systems correctly activated to prevent harm staff turnover, and reduced reliance on locum or may be overridden by clinicians if external influences agency staff. Where training interventions enable new such as time pressure 345or distraction and loss of treatments or care pathways, longer-term technical situational awareness are allowed to dominate. 346 value could result from operational efficiency such as shorter lengths of hospital stay or increased ambulatory The introduction of novel technology enhanced surgery care. Ultimately, training interventions should deliver is an opportunity to embed HF principles, such as threat improved clinical outcomes and safety. All of these and error management, in training and practice from the outset. High fidelity surgical simulation will allow can be measured and valued. Even HM Treasury has surgeons to learn how to get an operation right and referenced £70,000 as the average value of a quality adjusted life year.42 more importantly, practise procedures to safely handle when things go wrong. These skills have traditionally In practice, however, many costs and benefits are difficult been developed by surgeon experience over many to measure and value. Intangible effects such as improved years, usually as a result of personal incidents resulting 347 staff satisfaction, patient experience and culture at work in patient harm. all need to be considered. Many economists now present intangible and tangible costs and benefits as a ‘balance 105 | SECTION E: WHAT NEEDS TO HAPPEN TO EMBRACE TECHNOLOGY ENHANCED SURGICAL TRAININGData collection, machine learning and video analysis Automation of processes may reduce the capability will help in-depth investigation of how HF contribute to to carry out a task manually. Airlines encourage pilots adverse events. The power of national databases such to ‘keep current’ with manual flying skills, rather than as the National Joint Registry in identifying patterns of relying on autopilot.350If complications occur in robot patient harm is already recognised. Data from robot or artificial intelligence assisted surgery, surgeons assisted procedures or decision making have the potential may need to revert to manual skills in a highly to identify hidden patterns of error contributing to patient demanding situation, requiring they ‘keep current’ with harm and aid incident analysis of individual events. 348 competences that may otherwise have been little used. Human interaction with healthcare technology has Several fatal air crashes have highlighted that simulator consequences for mortality and morbidity. Some of these training is not infallible; startle reactions and real-life lessons have already been hard won by high reliability sensations cannot be reproduced effectively. Similarly, organisations such as aviation, rail and oil production.349 in surgery, simulator training may need to be blended with other forms of learning to make it ‘more real’. 106 | SECTION E: WHAT NEEDS TO HAPPEN TO EMBRACE TECHNOLOGY ENHANCED SURGICAL TRAININGA FINAL WORD MR RICHARD KERR Chair, Future of Surgery Commission There is huge anticipation and much has been written about the impact that advances in digital technology will have on all our lives. Such changes will potentially revolutionise communication, transport, commerce, finance and of course healthcare. We have a shared vision of improving outcomes for all patients with early diagnosis and personalised care, using the rapidly evolving developments in all aspects of medical care, especially that of surgery. The major areas of expected and anticipated change in surgery have been defined in the Future of Surgery report. This described the potential value of advances in minimally invasive surgery (in particular, robot assisted surgery), the benefit of data acquisition and analysis, the use of genomics, the possible roles for immersive technology including simulation and other areas of The Commissioners have taken very wide opinion development. The importance of education and training and produced a document written by those involved in was emphasised, as it was in the Topol report. and undertaking surgical training. It is aimed at those who are involved in the delivery of training as well as However, this Future of Surgery: Technology Enhanced those who will undertake training but it is also aimed at Surgical Training (FOS:TEST) report provides that patients, whose care we are dedicated to improve. crucial and vital critical analysis of how training to deliver these changes may be undertaken, and perhaps more The FOS:TEST report aspires to be a blueprint for the importantly, a detailed review of the way our surgeons future of surgical training. I think it has achieved this in and surgical teams of the future could be trained, and a very well researched, carefully planned and eloquent how this can be improved using all the advances publication that will not only act as said blueprint but in technology. also as a springboard for all aspects of surgical training. 107 | A FINAL WORDREFERENCES 1. Debakey M. The future of surgery. Ann Surg 1963; 158: 778–784. 2. Royal College of Surgeons England. 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