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Good evening, everyone. And uh welcome to our fourth session in our Robotic Sister Surgery uh training webinar series from the G club. So we are absolutely delighted. This is our fourth session. But today we're looking at the standardization of robotic training. We're really privileged to have some expert speakers joining us here today. Um The plan is get a kind of broad view on how we can try and improve training at the moment, some of the issues that trainees are facing and we've tried to invite key stakeholders who are involved in delivering robotic training and who've been through the training themselves to give their input on, on how we can make things better in the future, what we're looking at in the future as well for robotics. Um So kicking off, uh we've got a, a 10 minute presentation for Mr Justin Collins. Er, he is a precept of CMR, he's also a consultant neurologist from UCL London, and he's going to be talking to us about proficiency um training in robotics. So, over to you. Thank you. Thank you very much Charlotte. Um So let me just get the sound working in this as well. Ok. So, hi. Yes. Um, I'm a urologist at UCL and also associate medical director at CMR Surgical, where I've got an interest really in the training. Um, when we talk about training, standardization and, and metrics, we need to look at what the needs are of surgical training. If you compare a surgery to other high reliability organizations, if you look at the aviation industry, they have not 0.4 deaths per billion RS and 60% of those are pilot error. If we look at cars, 50 deaths per billion Rs and for surgeons, it's 50,000 to 100,000 death hours operation and over 90% is human error. Um And you've probably all heard of James Reese's sort of Swiss cheese model of accident causation. And, and uh he said that really the problems happen when these holes line up and some are due to active failure such as human errors and other things are due to latent conditions such as maybe to me medicine bottles with similar names or, or labels being beside each other when they they're needed in an emergency. But James re also talked about uh defenses to pro er these problems. And the first one was policy writing and training. Then he talked about standardization and simplification, then he talked about automation um and automation process. And then he, he talked about improvements to devices and systems architecture. Um And if we look at the difference this, we can, we all know that the wh O checklist came in in 2008 and, and, uh, really did an amazing job of improving safety but the first pilots, uh, checklist came out in 1920 which was 88 years earlier. And if we look at standardization and simplification, er, the first pilot license came out in 1927 the first validated robotic curriculum came out by the E AU Earis in 2015 for robotic surgery. And coincidentally that was also 88 years later. Um I've been involved in helping writing uh various er er curriculum, standardized curriculum, multiple specialities and, and they've all pretty much followed what we did with the EROS which is baseline evaluation ele, then we go to simulation based training, then modular consult training where the procedure is broken down into phases, transition to full procedure training and final evaluation. And there's different ways that we can improve all these aspects. But really the driving force for all of this is objective metrics and metrics define the simulation based training and also the credentialing. And they're also really important whenever we have remote training with things like tele mentorship. Um so we can take uh metrics of performance and we can put them into things like basic skills training or the fundamentals of robotics. And these are examples of the, the, the basic skills training that we've done with er, versus a CE Mr system. Um If we do have training and we have these metrics. It's good. It's important or a continuum from uh virtual reality to lab to procedure. We don't want people being taught to hold the suture one way and being told to do it a different way. In a different scenario. We can actually now take these um these metrics and put them into 3d hydrogel models. So we can do 10 things like doing anastomosis. We can have uh tensiometer to measure the tension and nerve sparing. And we can, we can measure water tightness for things like uh anastomosis. So the metrics will drive a whole digital suite if you like of training, that is consistent and follows this uh coaching continuum. So we have the versus trainer, there's also a a vus connect. I'll show you a little bit about that. We have hospital dashboards clinical Registry to collect the data afterwards and be on one of the key aspects of robotic is it is no, but I need to translate that information into quality for my patients. So back of excellence. So this is in Spanish, but you can see what the divers is actually showing here with giving you outcome for your own performance. Um So what we've tried to do with uh CMR is really integrate novel technologies that can help collect the data and connect the data points. Um This is something for device training that we've done with the VR headset. So here you can be using your VR headset and you can be learning about things like uh WW what buttons to push in the, in the case of a, a, an alarm warning, uh how to drape the robot. And it's really teaching you orientation more than fine motor skills. So we have er, vs se learning. Uh So that's the knowledge then we have versus training, which is starting to bring in some skills, but it's really orientation knowledge and skills versus trainer. We have versus super practical training, we have dry runs. Uh Then we go with preceptor case, which is the definition of preceptor as someone who can take over in the ur. Um, and then we have telemetric case where at the moment they can't take over but they can give guidance. Um, we've tried to increase accessibility and affordability to training. So we do a lot of these things locally. So we're using mannequins now to teach people how to do port placement. Um And, er, we can, er, once people have got through their early sort of learning curve and, and uh um familiar with the set up and, and the, the, the steps and the phases, the, the tasks and the errors to avoid within each of the procedures, then you might want a preceptor case either in an elective setting or in an emergency setting. So we can, we can plan for both of those and make sure that somebody's available if they need help or guidance during the operation. So all these things I said have been replicated previously in the airline industry. We had first black box in 1953 with automation. We have with robotics, exciting data coming from kinematic data and this is where it's been done by Andrew Hung's group in, in California. But if you look at the, er, the movements on, on the, on the right, you can see that an expert trainer has more small controlled movements, whereas novices tend to have more sort of bigger random movements before they get the instrument to where they need to. And we can give people really good feedback line that with uh didactic training such as a 360 degree up down anastomosis. So, um, we talked a little bit about the telementoring and this is a paper we published, uh, that, that uh shows you how to set up, how to deliver and how to audit the TEP presents services. And I think the most important bit is you really need to agree the plan and the telepresence schedule for the operation. What you don't want to do is for an inexperienced person to be ringing up an expert and saying, I'm really struggling here. Can you help me? And the other person says, yes, I can and they s, they say, but II don't want to do it that way. That's not the way I do it. You t, you, you watch me and tell me what I'm doing wrong because then you have the less experienced person on a discovery curve and the experienced person remote, not really sure what they're gonna do. So, telepresence actually promote, promotes standardization of training by necessity. It's cheaper. It uh it is reproducible. It improves access to expertise and because we can collect a lot of data, it aids machine learning. This is just a video of something else we do with the VR headset. This is actually a procedure I show very much of it. But if any of you have ever visit a center of expert, you can do this with the head. And what's quite nice is you can turn your head because it's a 360 degree recording to your left. See what your niece is doing. Basically move around who you are to learn from the people you want to learn from in that team. Um We're also collecting data from the data registry and this is a funnel plot. So we're collecting this data, it'll show outliers and, and hopefully, this identifies people that are uh performing suboptimally earlier on and correct them. So it's not there to stop them from operating, but it's very much supportive data to enable them to identify the low hanging fruit and identify how they can improve and, and all these technologies are trying to collect and connect data points. So if we start with gold standard performance and metrics, if we have digital training, we have of knowledge, t presence enables a collection of data as does the data registry and we can put all that into A I machine learning. And we need to really have more incentives for surgeons to share data, as we say, 50% of surgeons are below average. But what we're really trying to do with the digital technology is to collapse that normal distribution and move it to the right. And there's actually some very exciting examples of that in the literature. So if we define consensus, we start with the metrics. Uh the way we've initiated that is with train the trainer courses. Uh then we have the telepresence services for development. Then once we can collect that data, we have opportunities to put that into machine learning and A I. Um and this was a paper that was published uh at the end of 2022 it already has 100 and 60 citations. And I think it really shows how rapidly this area is growing, but you can collect data from lots of different sources of which robotic surgery is one, we can interpret it. And then we can start to use this to assist us in exactly the same way as smart cars are making us better drivers. So in conclusion, uh metric based training enables objective assessment of collected data. Um adoptive init from aviation are well recognized, although there remains considerable differences in regulation. And if we think about er digitalization and data collection and benchmark metrics, future development of surgery will likely evolve in similar ways we see, not just in aviation, but as we see in current utilization of smart cars. So that's the end of my talk. Thank you very much. I just thank you very much Mr Collins for your great presentation. Um, some really exciting technology there too which hopefully will come to fruition in our time as trainees, something we're, we're looking forward to. Um if you don't mind. Uh with regards to the questions, I think we'll move it on into our, build it into our round table um session, which we're really excited. We've got some really esteemed and, and prestigious speakers on board. Um And I will, in fact, let them introduce themselves as a, everyone as a collective um group. So if I just start by um walking around the, the screen, if you will, I'm Tanner, I'm the Duke's Club Robotics rep. Um Andrew's the er secretary and then next on screen is Mister Di misic. Oh, sorry, I'm not next on my screen. So I was surprised, taken by surprise. Yeah. Hi, I'm Daniel MSW. I'm a consultant, colorectal surgeon at ST Mark's Hospital. Um And I've been doing robotics for the last 10 years or so. Um And uh I have been uh working as a um proctor for intuitive um for the last six years or so. Thank you. Thank you for joining. Um And next mister Charlie Evans. Uh Hello. Hi. Uh You can see here. I am, thank you. Um I'm a consultant colorectal surgeon in Coventry in the Midlands. I've been doing robotics since 2015 and I've been a proctor for intuitive since 2019. I'm also on the ACP GBI Robotics Committee and Robotic EP training programs. Um Currently for my own since the uh the chairman of the ACP Robotics Committee. So very much involved in sort of hopefully helping trainees robotic planning for the future. Ok. Thank you so much for joining um MS Alice Hartley. Hello. Um My name is Alice Hartley. I'm a consultant urologist in Sunderland and I've only been a consultant just over a year. Um I didn't really have any access to robotics during my training. So, apart from the last three months, but I trained up um post CT, I didn't do a fellowship. I did it on the job. So um I've been, I did my training kind of April to June July last year. So I've been, I'm doing robotics since then. So very new to this. I think that will be really interesting to hear, hear your views as well. Um And lastly, Mr Peter Vaughan Shaw, ah evening, I'm a consultant surgeon in Edinburgh. I've been a consultant for two years and I again, mostly did robotic training post CCT actually in Sunderland Fellowship there. So hopefully we can talk to you about sort of the different pathways to robotic competence between the five of us this evening. Perfect. Um So why don't we kick things off with sort of a, a general question and, and you can take this up as you will or, or I can pick on people. Um There's no responses but um why don't we go with everyone's experience of, of sort of robotic assisted surgical training at present and, and your feelings on what's currently happening. Uh So I think it's important to note that we've got different specialties in the room, but this is a probably a colorectal audience. Um So, the urologists um to an extent are doing better than the colorectal surgeons I think is, is my experience in that I do see robotic trainees coming out of higher surgical urological training, which of course is one year less than general surgical, higher surgical training. Um So, so I think they're slightly further along the oo on in the curve in my experience. Uh But there's still a bit of a, a bum fight between consultants wanting to get on the robot versus trainees wanting to get on the robot versus no one getting on cos there's not staff or there's, there's not money or there's not equitable access. So that's, that's probably my, my opinion. Uh No, for the border, I would say to counter that. Um I, that was the opposite of my experience. So I think it very much depends on where you are um in my region there are three units that have robotic urology and in one of them trainees aren't allowed to access the robot. The other one has a post ct fellows. So they get kind of main dibs. And then the third one is where I am now. Um And you will get trained if you're there as a senior trainee. But unfortunately, I was in there in my last three months. So that's hence my lack of exposure. And I think this is part of the problem, isn't it? It's really variable. And if it's ended, if it, if it's left where you end up being placed, it's, it's a bit of a lottery and it's, it's not equitable. So I think that's maybe something we need to look at across the board. Um, because I think people are getting different exposure depending on, on the luck of where they're, where they're put for their placement. I mean, I would, I would say that first of all, we also have to recognize we've come a long way. Um, you know, when I, when I started, um, 2013 or something, um, you know, I, my training was lasted exactly 20 minutes. Um, and that was the end of it because the Proctor then disappeared to go drink coffee and never came back and, and that was all the training I got and, and that was as a consultant at the time. Um, so things have changed dramatically since then. I think how we're getting trained. But although I recognize, you know what you're saying, that there is um not equitable access according to regions, I think it's not so much a training issue, that's just an access issue, um which is gonna change um Quite soon, I think, you know, the, the, the, the distribution and, and um uh purchase of robotic systems has increased so much over the last even two or three years and I'm sure it's gonna change even more. So the next two years. So I think that's a problem that will adjust quite quickly. Um The question is how we can, you know, support training opportunities for trainees really, because there's still um a lot of, I think the consultant body that probably needs to be trained up, at least in colorectal, maybe not so much in urology. I, I'd very much echo what Danilo says, I started probably about a year later and when I started, there were about 20 hospitals that had robots and in, and in those hospitals, not many even had allowed access to the colorectal surgeons. So it was very much, it was completely dependent on where you were as to what access you've got. Er, there's been a huge explosion in the access to robotics since the pandemic and sort of again, help, fully driven by what happened in Scotland in terms of them, sort of having a national program. There's now beginning a national program in Wales and in the UK, the numbers, most hospitals that didn't have a robot occur trying to getting a robot and if they've got one, they're normally looking for two or even three. So it, so, and it without, because with no access, you can't have the training what it has happened. And in the time we've been there, there has been a structured program for training in robotics created by industry. Like, you know, you know, the talk was from CMR before and we know we both, you know, and I have worked on the intuitive training programs. We've been at meetings where there's, you know, a standardized way of teaching people, which is really good because it's objective, you've got digitalization of it all. So it really, it's really helpful and we just need to transition that into allowing it there to be access to the trainees. And we need to, what we need to work out is whether this is, well, one of the things we need to work out, whether this is sort of industry led, which is basically what's happening at the moment and how we transition that into just being training, you know, part of everyday practice and, and, and, and it will come and it is coming. But, you know, and, and this just for an example of, you know, we, we, we've recently created um some ACP GBI robotic Fellowship posts and we've, we've advertised for, for the centers and what you saw with the centers is, they're all across the country and they're all doing outstanding work, not just with one surgeon, but they're mostly with multi, multi systems, with multi consultants doing it. And if you, once you've got that in a hospital, you start being able to get better access to your trainees to allow them to do it. And, you know, in the time we've been trainers, it's largely been treating, you know, either either teaching consultants or fellows, but it's beginning to evolve and it's beginning to be the standard trainees, but we need to help push this forward. And certainly I've been at a lot of Royal College, some Royal College meetings where there's been a lot of pushback from the people who don't have access, which is understandable and we need to kind of work around that. So, um my, my own personal experiences were about uh 1213 years ago, I went to bordeaux because at that time, I think there was only two or three systems in, in the UK that were used by urologists. So I went off and worked in clinics Augusta, which is a very famous urological clinic. What I didn't appreciate the time was, is primarily a private clinic. So, although I got lots of experience as bedside assistant, I wasn't going to get to do much of full procedure. So I got through the bladder drop and spend time practicing at the weekends on models and things. But um that was also six months that I took out of my training and it was completely unpaid. It was approved by the Royal College of Surgeons, but there was no income. So II basically lived off savings for six months. II don't think it's a necessity for people to travel so much now and I don't think people should be doing training without having some sort of funding. I think that's probably unreasonable in, in today. Um We have six fellows at UCL H and we have fellows that come from all over the world. So we've currently got several from Australia. Um And, and they get really, really good experience and they'll all do independent prostatectomies within six months to a year of their fellowship. So I think we've, we've, there are, there are centers that have got very good training centers. We recently published a paper with uh Josh Burke was the first author of Asset, the Association of Surgeons in Training and they sent out to Delphia and I think it had 100 and 40 responses. Um And over 70% of people that responded in UK and Ireland said they currently have no access to robotics in their training. So I think, you know, we're all lucky to be working in centers that have access to robots. But I think if you look at it generally across the country, it's not as good as we think it is. Um They say there's four A's to adoption and integration of anything and, and you need awareness of the benefits and you need agreement and how to do things like the training and then it comes down to access and affordability. So I think access and affordability are very tightly linked and, and, and something like robotic surgical training, but it's much more accessible and scalable if you can do training regionally and locally or have local training centers rather than expecting people to fly off to Belgium or to France to go to wet labs there. I think what we're also starting to see is transitioning of training away from Cadavers. II was a medical director at or academy for a year and we did a lot of cadaver training. If I'm honest, I'm not a big fan. I think there's uh I think it is um there's a movement against that. Now, we've got much better models with objective outcome data hidden tensometer. We can collect blood loss with 3 g hydrogel models. We can stain tumors to see if you've got positive surgical margin rates. You know what I kind of saw with people doing cadaver training was they, they, they start messing around a little bit and they just sort of, they're just happy to spend time on the technology, on a patient, but they're not actually defining often learning objectives that they're working towards or getting objective feedback. Can I um play a bit of a devil's advocate here and, and maybe take it back a step and say, you know, uh when should we be training uh general surgical or urological trainees? Is it pre CCT? Is it per CCT? Is it post CCT? Does it depend on where you are or your subspecialty? Um If I was a trainee now, I think I'd struggle to know whether or not I needed to learn a lap, anterior section or a robotic anterior section or both. I think I was of the generation where actually you, you sort of learned to do things open and lap, but now it feels like trainees have got to learn to do things maybe in three ways. Uh maybe not for urology, but gen for, for general surgery. So I think that's uh that's something to, to think about. Um because you know, that that is an issue, I mean, they are, they're the same operation and you probably need to learn to do an anterior resection in some way. I mean, I mean, I think if I can uh first pass an answer, not the II, think you're absolutely right, Peter, that you don't want to be wasting expensive training in any sort of setting on people that aren't going to benefit from it. What I would say is if we move towards a sort of benchmark driving license approach where people have device training, then they go on to basic skills training away from patients and then go into procedural training, I think you could envisage a set up where even medical students can take the time and effort to learn skills and knowledge, um, away from patients that would maybe be a competitive advantage to get into these fellowships where there's more limitations. Um, I always find it fascinating, you know, to, um, when I listen to these discussions because these are exactly verb, the same discussions we had 1012 years ago in colorectal surgery when the whole laparoscopic kind of thing exploded suddenly, um, you know, that was the same thing at the very beginning. There were the very few who were doing it, um, in the kind of early ties or, or two thousands and, and then, um, you know, the vast majority, critical worrying that this is something that they might have to do or might not have to do and then suddenly kind of swept over and everybody was doing it. There were the fellowships that came in, there were sparse at the beginning and then they suddenly became more available and eventually kind of all transitioned into normal registrar training. And now it's part of your normal ordinary training that you do laparoscopic surgery. I think exactly the same thing is happening with robotic surgery at the moment. We are just kind of on the peak of that, um, initial wave of kind of where it's getting common, common practice. And I think these developments just take some time. I mean, I'm, I'm, I'm, I have to say I was slightly surprised when um Alice said that she was struggling getting robotic training in urology. I thought every urologist in this country gets robotic training. I thought that was like already part of the kind of normal practice, but I'm surprised to hear that. And so I think there, I'm wondering because it has been much more or longer round for, for the urologist and for, for colorectal surgeons. So you know what went wrong there? And how can we avoid that for colorectal search that this is not happening again? II think what your your point Peter was was a really good one because actually I'm, I'm a research and I don't do prostates. I do kidneys and doing a lap nephrectomy. Um There's actually no real benefit for a, as you know, radical or a simple nephrectomy doing it lap or doing a robotic. It's more fun doing a robotic, it's easier doing it robotic. But actually, if you learn how to do it lap, then it's just, you know, the technology is, is the different bit, but the operation is the same. Um It, it gives you a benefit if you've got a, a patient with a high BMI or a very adherent tumor or that kind of thing. But where robotics comes into its own, for renal surgeries, for the partial nephrectomies for the suturing. Um and for things like pyeloplasties. Um So the majority of nephrectomies can actually be done laparoscopically still. And II always say that and I sometimes get shot down by people. Like why don't you want to do it robotically? Well, I do but I, you know, there's no need to do it in the majority of cases. And actually from a learning perspective, if you train someone up to do it lap, if they can do it lap, they'll be able to do it robotically. So you could um if you don't have access to, to the technology in all the centers, you can still kind of build your training that way. Uh That may not be applicable in so many of the colorectal procedures. I don't, I don't know, but um certainly is the case in urology. II, can II jump in and agree with you, Alice on that front? I think, I think we almost make, we're making this almost too complicated and worrying too much about it. Like the operations of the operation. Like I get there is a difference between open and laparoscopic because it's really hard to do them laparoscopically, the robot is slightly easier once you get going with it doing it robotically and if you can do it laparoscopically, the operation, you basically will be able to do it robotically. Obviously, there are nuances and there are certain things that are like you, we all love talking about with our robotic training and why we want to do it that way and the benefits. But you know, at the moment there isn't access enough access for everyone to be learning it all in all the centers robotically, continue learning it laparoscopically, like continue learning the steps, continue doing it. You will eventually get access to the robot because basically, I mean, I work in the Midlands which is a strong, like the strongest centers. They've, they've looked at this intuitive have done. It's not stupid like the northeast, the northwest and then the Midlands have the highest percentage of robots per hospitals and, but it's all, it's all catching up, everything is catching up. And so you will end up in centers where the robot is available. And I think, you know, for colorectal and it's interesting because obviously you're a renal surgeon. I it's the prostates where they've, there's a robotic curriculum for prostates as far as I was aware and that's where it's all robotic sort of from what I understand. Um, whereas, you know, clearly colorectal for low TME s difficult ones where, you know, you have, you know, obviously there are certain centers where difficult rectal cancers go to. They probably need to be the ones where if you're going later on in your career because you'd be going on later on in your career anyway, to do those, those more advanced bits. But now where we are, we us as probably the biggest center in the South. We do the complex ones, but we also have Warwick and George Elliott nearby and they're now getting, well, certainly Warwick's got a robot and I'm sure they say that they do advanced stuff there as well, which they do. But like, you know, there's transitions depending on which part of your training you are. And if you can learn the generic skills of how to use a robot, you'll be able, hopefully it will be quite an easy transition between laparoscopic and robotic. And I think where I, you know, I sit and I know I'm skewed. I know I've been just doing, sat in a robotic world for like 10 years and this is what I do. So I think everyone should have a robot. But like, I'm also, I'm meeting people who have got nowhere near a robot and they really struggle with it and we need to kind of merge the two and get a middle distance and encourage those people who do the curriculums who write the curriculums who are looking for changes to, to sort of slight, become slightly more flexible and see that. Well, you know, cos like, I know for numb numbers is a big thing for like getting your sign off is like the number of anterior sections you've done and it was open or laparoscopic. It needs to include robotic and it is starting to include robotic. But these are the things that sort of will help trainees keep their training going. And it never, you know, we all all pretty much all on this, learn as consultants, how to be robotic surgeons. Your learning continues from, you know, still, still learning. I'm doing robotic hernias learning that at the moment. So, like, I don't think trainees have to worry too much quite as much as they are potentially about this. But I also agree it must be frustrating and a difficult, you know, time when you think. Oh, lap open and robotic. How do I do it all? We will get you through it and you will get through it. I think that's, I think that's a nice way to sort of look at it that, you know, if you're doing open, you're often operating on your fingertips, especially if you're down in the Pelvis as a urologist. If you're doing lap or robotic, you're operating with what you can see in your vision. Um The steps are mainly the same, what I would say is a slight caution to what some of the other comments our, our sort of experience in the, in the training labs is the most difficult people to train in terms of the time that it takes them to, to, to, to learn, to control the robot is the really, really experienced laparoscopic surgeons. And I think that's because they almost have to unlearn certain skills. You know, a really good laparoscopic surgeon has got good haptic feedback, they feel tissue at the end of their instruments, they can tie knots and you need to, um, as some people quote it, it, it's a sort of a reverse braille phenomenon with the robot, you have to feel with your eyes. So in the same way as you run your finger over letters and you say that's ac that's an a that's at, that's the word cat. You, you experience robotic surgeons will say this tissue feels fibrotic, this tissue feels sticky but they can't feel anything, but they're just reacting to the way that they see the tissue is moving with their instruments and they'll learn to look at the knot and look at the tissues, not tear tissue, not snap knots, but actually experience laparoscopic surgeons off for the robot come in and they're waiting for that haptic feedback to say the knots tied and they start snapping things. So, um but then you could argue, I mean, not being brutal, but our trainees aren't experienced laparoscopic surgeons, trainees. So, you know, maybe that's not a worry. But I do agree with you that the hardest people to train are the experiences ones. It does bring whenever we got Epic at UCL H the Epic people said there's one sentence that sells every Epic system, it closes the deal and that, that this is a governance issue. It's a data governance issue. If you don't have Epic, if you don't have electronic patient records, you, you, you don't know what people are doing and we might get in our, you know, in the next 5 to 10 years, the same with robotic surgery because this is automated data collection. And if that is the tipping point and I'm not saying we need to have this conversation now with the trainees. But then would you say to the trainee that you do need to do laparoscopic in case it breaks down? Or actually you don't need to learn laparoscopic cos it's just gonna delay your learning curve. Well, how many, how many las how many, how many prostate surgeons can do a laparoscopic prostatectomy? Most most of us can do. I mean, I did laparoscopic training before I did robotic. I haven't done a lap prostate in 8, 10 years. But if I've got adhesions, I would still take them down laparoscopically. So I have laparoscopic skills. Um But I think, I think this is an interesting perception because I can remember this conversation with laparoscopic that people said, oh, we're going to teach you how to do laparoscopic nephrectomies. But you still need to do open nephrectomies in case you struggle and need to convert to open. I don't think any trainees being taught an open nephrectomy for the sake of you would have to know how to convert to open. And I was going to say that actually because, you know, having open skills is still needed because ultimately, if you have horrendous bleeding, especially with kidneys, you know, they bleed. If they bleed, you make a hole in the caver, you might need to convert. So you need that skill. And again, I don't know how that is with colorectal. Um, but we would, we would need a renal surgeon to be able to do an open nephrectomy, emergency conversion courses. That isn't necessarily how to do an open nephrectomy, but rather how to control the situation. I think that's probably where that will go. I just wanted to say the same thing because I think, um, that's, that's true. You need open skills but you need to know how to do kind of damage control, open, um, rather than learning a procedure step by step. Um, I certainly have the same problem that I can't do an open TM ei can't do a laparoscopic TME anymore. I'm pretty sure. And that's, you know, that's poor me although I've learned these things in at some point, but I un unlearned them again. Um But so I don't think that's necessarily the case that you have to do this step by step. It's like, you know, translated into general surgery. We don't learn how to do an open cholecystectomy. And then we learn how to do a laparoscopic cholecystectomy. And then we learn how to do a robotic, it's not how it works. We just learn what is the best procedure at this point. And then, um, we can, we, we, we, we need to be equipped with general surgical skills to sort out situations, but not necessarily to do full procedures. Um So what about the, what about the cost of robotic training to er, the trainees if they're not being trained. So, as, as robotic surgeons, do we have a responsibility to sort of limit how many consultant colleagues are getting on the console? Because actually they're taking away nice easy cherry picked cases from our trainees who need to get up to their 2530 high anterior sections. Maybe that's not really within the, uh the title of this talk, but that's, that's one thing that trainees also. And I'm sure happened in, in the sort of open to lap laparoscopic era where uh you know, consultants were training, consultants had to be laparoscopic surgeons. So the trainees were sort of stood in the corner or, or holding the camera and, and how do we actually balance that? I think that's a good point, Peter. So just to, just to jump in. So having spoken to trainees recently in the region, there are talk of some trainees who won't be able to see CT because they can't get their um lap rectums because they're now being used as training cases for consultants who are on their learning curve for robotics. And as Charlie said, you know, we've got, I think we've now got eight robotic centers in the West Midlands which leaves only three or four hospitals without a robot and we've got about 20 ST eight. So I'm not sure how we can counteract that going forward. I appreciate it's not a discussion for today, but obviously PT touched on it. So I thought that's something good and it's not just happening in the, in the West Midlands, but it's happening across the country as well. You don't need a lap rectum to, to ct, you need an resections. Now that, that could be, that can be an open sigmoid or, you know. But, yeah, the, the point I suppose, and there is the, you know, trainees want to learn to do rectal cancer surgery. The reality is we're not all going to be doing rectal cancer surgery in 10 years time as, as I think it is a point that you're making because II see this as well, but I don't think it has necessarily to do with it there on the learning curve. I think what's often because the learning curve to be honest is, you know, or it shouldn't be that long, you know, it shouldn't take a consultant five years to learn how to do a robotic interior section before he or she is able to teach that. Um But I think sometimes this is just happening because they are kind of getting used to it just to do these things and then it seems to be kind of comfortable just to do these procedures and they forget their responsibility to train. And I think that's, that's generally a problem. Um uh II see this as well, you know, with some of my colleagues who kind of transition to robotics and they just got used to it and they just think, well, I better do this myself. Um, but actually it's just like, I think some of it is a bit just out of comfort rather than actually taking their responsibility as a senior surgeon and, and as a teacher. Um, seriously, and I think we need to counteract that. I think you're quite right. Um, but you also, what I, what I, sorry, just jumping in is that, that's easy if the trainee also has the skills to use the robotic console and has done the basic training and the be stuff because obviously if, if you're a trainee and you haven't had the access to use the console, it's not like an open operation where you've kind of already got those basic skills or those basic laparoscopic skills. So what we need to do is give those trainees that basic training level of the robots so that, you know, access to the simulators. So they're ready for that next step because you know, the great talk at the beginning, the actual live operating is quite far down the line. So I think when this is where I feel with my ACP on is our responsibility is to enable trainees to get that bit so that they are, they are ready when they are because I think the exposure will come with the robots being in the theaters but like, you know, like, and that will just keep growing. But we have to have them ready to be able to use that. And at the moment, probably a lot of them, if you're honest, aren't, you know, a lot of consultants will use it as an excuse because they're like, oh, yeah, but he can't, he doesn't know what he's doing with the, you know, like the kids and all the clutches or whatever that stuff. So, you know, there is a bit of a responsibility for trainees because you, you know, most hospitals will have a simulator that you can kind of access outside of hours. But there's also bits that are quite hard, like learning docking and undocking. And unless you're not in those theaters, you know, if you just turned up, it's difficult. So we do have to improve that and we do have to work on access to the, to the baseline bits so that you can then kind of actually do the live operating or bits of the live operating. If, if we can identify the actual needs of training, I think we can be bring in other efficiencies as well. There's, there's basically orientation of understanding a procedure and the steps of it. And then there's the sort of performance skills. And if you can do device training and basic skills are fundamentals of robotic surgery such as different types of dissection, suturing, not tying and, and a 360 degree anastomosis with both your dominant and non dominant hand going away and towards yourself. Those are all the building blocks to take into procedural training. If you were a professional sports person, you'd spend a lot of your time, you know, watching people drive fast around the course and how they take the corners or, or watching how a team attacks or defends. We, we could, we could learn a lot about procedural training as trainees by studying expert performance and understanding why they're doing things in different ways to, to others. And then actually, it's, it's the fundamentals, it's the basic skills. You put those together, you probably need, you know, less than 10 cases that are straightforward to actually be up and running in, in a key in DEX procedure. But II agree with you, Justin and I think, you know, this is al always sounds great but um I always feel that these comparisons are difficult um with that athletes or musicians or pilots because they have one single task, you know, get down that race course or fly that plane from A to B or play that violin, violin. I'm not saying it's not complex the task, but it's one task. Our trainees are in this mud, well, in this kind of muddled waters of kind of service provision training, working, doing stuff. And then, and then procedure training is just like a small part of their time that they actually have. And it's actually, I feel this time is getting smaller and smaller. So, um ii it's quite difficult how to translate this into, into surgical training. I agree with Charlie that has responsibility, not only from the trainers, but only the, also the trainees, you have to take responsibility of your training you can't expect. And I think often that is also done because the way it's set up, you feel like, oh, I'm in training now. So give me training, but it doesn't work like this. You have to, you have to work for that. You have to be proactive about your own training. And you know, like Alice had explained earlier, she had, you know, suddenly, you know, she was seeking out clearly that opportunity to kind of work somewhere where she has a robot. Um But, but I think what, I don't know, I still don't know after thinking about this for many years, how, what, how can we do it structurally that, you know, this ideal world that you described of the athletes and the musicians and the pilots that we can reproduce that really medicine. I haven't come to any conclusion. Um So I think it's, it's instructions for you. So it's your device training. Um The basic skills training is verification that you understand which buttons do what and how to control things. And then I think you need to go into procedures, procedure training with uh guidance on making sure you don't go to. But I don't understand how this is going to work practically in, in, in a surgical training curriculum. What about morning to evening if we can do it in orientation and skills? Um What we've done, what we've attempted to do is to give people more access to skills training with things like VR headsets. So the VR headsets now you can actually do basic skills training. Interestingly, I don't think that's as good for the fine proper receptor skills of controlling sutures and things as doing it on a VR simulation on a console or better still doing it on a dry lab box, but it's good for orientation of the skills of procedural training from sort of being virtually in a room with somebody. Um So I think if we, you know, it's nobody develops knowledge or skills without spending time to do it, it's just about how do you give them access to that? And I don't think it could be flying them to a wet lab. What do the trainees on the call think? I think this is a really good moment to come in just to pick up on your point. Mr Moscovitz about the impact of service and training and how we marry those together. So we've got a question from our chart um asking about um whether we've done enough to sort of recognize the impact that um the loss of uh the perhaps loss of open operating skills is, is having um on our ability to provide an on call service. Um be it through um loss of of procedures to, to robotic cases or the, as you were saying earlier, the the sort of um loss of open and laparoscopic skills as our consultant body becomes more established in their robotic skills. Um And is that something that we need to sort of recognize and, and be, be conscious of? Um I don't know, I mean, is this again, II think, II don't know um how acute this situation is that people feeling that they don't have enough open exposure or whether this is just an issue of, we don't have enough exposure to surgery. Um, I think, I think, I suspect it's the latter. Um, I think people just operate less nowadays in training than they may have done 1015, 20 years ago. Um, and, and that's a sad, sad situation I think, and I think this is what I was trying to get, um, at earlier, you know, I suspect it's not the problem that we don't have a headset in every hospital where we can train or a surgical simulator. I think the problem is we don't have the focus and the time on, um, surgical skill training because there are so many other things that you have to do and that's not just service provision, it's also kind of other stuff that you have to do for training, endless filling in the forms that mean nothing. Um, and, and I think we should, you know, we, we have to think how can we refocus surgical training on what we do as surgeons, which is basically a craft plus um knowledge and decision making. But the craft bit I think gets neglected more and more, which is, which is really sad. So what I would say so that it's not all doom and gloom is that the, the robot actually provides, I think a real opportunity to, to make training, you know, really objective and systematic and, and high fidelity because the amount of data that comes out of a single robotic operation is, is phenomenal and it's, and it's easier than it ever has been to extract that data. So I II was never very good at recording laparoscopic operations uh and watching them back, uh it was a bit of a hassle, you know, but now that, that is, that's really easy, you can get, you can get the metrics of your performance either from a simulation or, or a, a real procedure. You can quite easily sort of download that onto a flash drive and watch it back. So I think the key for trainees is, yes, you're, you're operating time is getting squeezed and squeezed. Um But actually make sure that every second of, of your sort of theater surgical training, you know, counts. Um And, and that's, I think so so that, you know, 50 years ago, you'd do however many 100s of 1000 of operations. But you gotta remember, you probably didn't have a trainer there for most of those. So you'd sort of be learning, learning by mistakes. But now you've got, you've got trainers who will be there, you know, every second of that operation, you've got the opportunity to, to, to extract all of that data. And I think this is where the future will, will become a lot brighter because, you know, there will be ways that, that surgical robotic training becomes, you know, really digitalized and, and next generation. So, you know, I think it's an exciting time and it's maybe that, that you can't quite see that as trainees at the moment. Um But, you know, II think, you know, there, there is, there is, you know, we should be optimistic about things. Sorry. Go on, go on Alice up to you. 00 and Charlie's back as well. Go on, I'm back here. Sorry. So I'm traveling around um London. I would completely agree with what's just been said, it is actually a really exciting time and I do think that you can still see when trainees turn up who've been engaged with the robotic process that they kind of, they get more out of it. And it is a, I mean, and there's no doubt there are sort of frustrations with, you know, consultants taking straightforward cases. But that's it. I mean, I had that when I was doing my laparoscopic training, like it was a nightmare watching these poor consultants struggle with the left anterior section and that's just part of the journey of surgery. But if you engage and there's lots of more opportunities to do this other stuff outside of the, outside of the, the actual theater so that when you're there, you can kind of get the most out of it. And I know that's hard and I know that takes organization which, you know, for a lot of people's a challenge with everything else going on. But you, but it, it, it will get more streamlined and more efficient and we're going to hopefully help improve that for you. Can I ask you everyone's mentioned about um getting as trainees, getting on, getting some training. Can I ask maybe the more experience proctored um proctoring surgeons as a trainee coming to you? What, what would it take to, to let you to let us get on the console? Do you have to hit an X number of assisted cases? Do you have to say I logged X number of simulated hours? Like what, what personally would, would let you make us get on the console for example. So, so we do this at UCL H and um II mean, I think the what you can obviously do is is show willingness if, if you're showing um you know, going and, and working on a dry lab model or, or completing your VR simulation and showing that you're keen to, to develop the skills, if you understand the process from the device, training, basic skills training, procedural training. I mean, I was thinking about what the other comments or what would you do in an ideal world. If we had an ideal NHS, we would allocate an allotted amount of time to training. If, if you, if you have a professional football team, they spend so much time working in fitness and so much time in strategy and planning and then they spend so much time actually playing football or playing in the Seconds team. Um And I think that one of the pushes that we've got unfortunately, on the NHS is increasingly, people say, well, just being on the shop floor is experience on your learning. But actually, we need to define what that curriculum is and allocate the right amount of time for it. And I think that would protect everyone because if we don't do that for the juniors now that might eventually come to the consultants, sort of, you know, and then we're all in the same boat and just nobody's getting through what they want to do, but we've just become a very inefficient workforce. So, can I ask the experienced robotic surgeons here if you would accept like immersion, robotic trainees? So you might be aware for colonoscopy, the state of colonoscopy training is so poor for want of a better word that our trainees now have to go for sort of these immersion weeks in sort of high volume centers. And, and, and, and is that a solution to um inability of access. Sorry Peter. What, what do you mean by that? So, so what did they just turn up for a week to do some operating? I don't know, 22 weeks sort of smash out 10 anterior resections robotically and then go back to their D GH, that's just not gonna happen though. Is it cos you're not gonna get 10 anterior sections in two weeks. But I mean, I would say so what I say to my trainees, I mean, and again, it's lucky because I'm probably more experienced and can, can dig myself up a big hole. But as long as they've shown winning this have come at least once or twice to understand how to dot the robot. But mo more importantly, showing me that they are safe on the console as in, they've done their stimulator time. That's all they need to do because you can stop and you can teach them the steps of the operation as long as they are in control of the instruments. And that's the only thing I'm really asking of them. And that's kind of where it stops and depending on where their ability is, is how much I'll let them do. But if they can't use the console as in their clashing hands, the robotic arms are not safe, then I have to stop them because it's dangerous for the patient and that, but that's it. And, and that doesn't take that long. That's just about a simulator time which can be done outside of your other and it's not hours and hours again. You know, people, you know, the UR talk about 30 to 40 hours before, you know, you go on your first course you don't on, in honesty, you can definitely be safe before that if you're sensible and, and, you know, imply yourself when you're doing those hours, which I know is not, you know, probably not completely politically correct. But if, but if you're in the theater and you're safe, you should be allowed to operate my opinion. And, and the other thing I'd add for the trainees on a pos sorry, on a, on a positive note is, you know, we're probably all much safer car drivers now because of the technology that's in modern cars and people coming into robotics and, and minimally invasive surgery. Now with, with sort of digital surgery approaches are gonna learn faster, they're gonna be safer, they'll probably get better outcomes. So I think that's a real positive that technology is gonna make us all safer and better and maybe quicker as well. Um I mean, in answer to your question, Peter, I'm not sure how that's gonna would work for complex procedures. Uh It might work in straightforward procedures, um such as colonoscopy. I'm not saying that this is always straightforward, but uh it is, you know, a kind of defined task. So it could, could it be to do a straightforward procedure surgically, but to do complex advanced cancer surgery, uh, in multi hour cases, I think, I'm not sure if this is the right model when I take on a trainee, I'm, I'm having every six month, a new fellow. Um, you know, this is, we, we spend some kind of intense time together and, um, I'm spending the first few weeks getting into their brain, um, and then understand how they work and they understand how I work. We kind of kind of find some sort of way of working together and then they kind of really learn and I couldn't do that if I get some random person next week and they would just say you should just do procedures. Now, I just, I wouldn't be able as a trainer, I think, but maybe that's my failing as a trainer, but II would find that very, very difficult. Um, so I agree with, with, you know, what has been said that technology is really there to, to do this, to learn skills that you through simulation. That, that, that must be the aim that you learn the skills through simulation. And then the procedures is something that you learn after that and that, that, that can be done with kind of quality time that you spend with someone experienced. Uh, and that doesn't have to be necessarily just numbers. Um, the numbers at ours have to come from simulation. It's, it's like you, you, you mentioned football earlier it's like what you are saying is basically to learn how to play football, to stick them into football matches that are on in the premier league, you know, on the kind of real football matches they have to play there all the time and then they will be get good, but that's not true. They have to train. So you sent them to training and that's how they learn and don't underestimate for the, for the trainees that are watching, you know, getting into the or and watching other people. The, the great thing with the laparoscopic and robotic surgery is there's usually three or four screens in the room that you can actually see. II spent hours and ors learning open surgery and not seeing anything. And it probably being a huge waste of time for, you know, from a learning curve point of view because if you're not scrubbed in and, and really getting your hands in there, you're not learning something. So you learn an awful lot from looking at expert surgeons, there's lots of different platforms that you can get access to videos of expert surgeons doing things. And I would encourage people to look at those. When you're actually doing your procedural training, you're better to focus on one approach and learn 10 different ways to skin a cat and then it'll just confuse you. So you do have to sort of narrow your focus down whenever you start to do it for yourself to develop the skills. But uh it's always a good thing to get into the, or, and, and it's another sort of tick box to get yourself sooner on the console. If people say that you're, you know, helping with the poor placement. If you're watching the surgeries, if you're doing the, the work on the VR simulation, you'll, you'll get to the top of the queue. So, just to ask, um so we've only got a few more minutes left actually. Um So this, this webinar has, has whizzed by. So thank you so much. It's been really, really interesting, but just some advice for the trainees going forward because at the moment, robotics is very much seen as consultant focus, senior focus. I, I'll approach it when I come to CT and as we've talked about, there's plenty of learning opportunities. It certainly is beneficial for surgical training as well. And it is the future, we can't escape from the fact this is going to be the future, it's going to be the norm. So what would you advise the trainees who are watching? So, Justin, you touched upon early years learning training. So what would you say to trainees out there? When should they start approaching their robotic training? At? What stage in their career would you recommend? How should they go about it? I ah I wouldn't say to anybody to delay getting interested in something like this. If to do it, it's whether they will get the credentialing and signed off. That'll be the limiting sort of factor, but you can start early, you can do the e learning, you can get access to simulation training. Um A lot of the robotic companies will give you access to training instruments. I think there is still a big step up from doing suturing in VR simulation to doing it in a dry lab box. Um You don't need to do it. II don't think on chicken legs or certainly not pigs or cadavers to, to learn basic skills. So make sure you don't do something silly, like bring a chicken leg into an or, and then you end up not being able to use the robot on a Monday because you've covered it in prions and things. But there are lots of different models that you can get and simple models to learn to do suturing and knot tying and get yourself a mentor. Um So speak to people and, and, and ask them if they can give you guidance and they might open up some doors to you and it might be something simple like we'll come and watch you operate uh you know, on this day or this weekend. Um But I think it's, it's good to, to get a mentor and they will give you guidance on, on that journey because it's not a one day course, but it will be, you know, 5 to 10 year part of your career. So I'd say, squeeze every sort of last drop of training out of your, out of your day. So everyone's time is precious. So er if you go into a robotic case and there's an eu a starting off without sort of denigrating proctology, you know, maybe robotics is the focus of, of that particular day. Can you get on the simulator whilst your consultants doing, doing the EU A or doing the brief or, or waiting for the two hour spinal to get put in. Um So, so use the uh use every opportunity to, to get on the simulator and do not allow an opportunity to come to you to say like, do you wanna go on this console and find that you're not actually um warmed up, you're the, you're the substitute. If we wanna continue the analogy, you're the substitute uh on the sidelines warming up just in case the manager says right on you go PBS, it's time for your, your time to shine. So II, remember one, when I was the fellow in Sunderland, I said to the S TA. OK. Do you want to do, do the sort of lateral mobilization? And it was clear within 10 seconds, he'd, he'd done little to no simulation at all. Um And you know, unfortunately, for him, that meant, you know, that was the end of that opportunity and, and obviously, probably for a few weeks thereafter. So, you know, make sure, make sure you're ready uh When your number's called. Thanks Peter. Any other tips and tricks? Alice, anything from your recent recent journey that you'd like to advise? I would, I would echo about just using every opportunity, you know, our robot Sim was in theater on the robot. So obviously getting in there during the day, working day was difficult. So you have to assume that, you know, you're gonna go in, but you've got a quiet patch on you on call, go in. Then it audit mornings, things like that won't be in, use any opportunity that you can to get in there. One of the things I struggled with was actually getting access onto the getting a log in the rep was because I was so dependent on the rep and the rep wouldn't reply to my emails and it was so frustrating. So if you're having difficulty, there will be other people you can speak to. But don't, don't see that as a, a shut door, just, just keep pushing. Um Having a mentor is so important. So I didn't do a fellowship. I trained on the job. I had a proctor come in from intuitive and then one of my colleagues is available. So when I'm doing a case, um he will be in the hospital. Um So if I run into trouble, I know that I've got someone I can call. I think that that gives you a bit of a confidence boost. You know, you, you, you're able to do it independently. But you, you know, there's someone there that if, if there is difficulty, then, then you've got you help because I think when you're first starting out it is pretty scary. And, um, you know, you haven't, you have that transition from being a trainee where you're not, the book doesn't stop with you and then suddenly the book does stop with you, but you don't really know what you're doing, um, or you do, but you don't know how, how to, to get out of complications all the time. So, yeah, mentorship is really important, I think. Thank you. Any other thoughts, Charlie speech. Anything else just for talking about? Um I would definitely look out for courses that are available, like lots of places are now offering courses like the ALS GBI and stuff just because it's really, I know this talking about like having time for training. Sometimes it's, and sometimes they do cost money, but a lot more of them are free. It's just some time away. Get to think and kind of get immersed is a really good thing and a lot of sense to doing that. I mean, and, and institutions, the color robotic has some amazing online learning modules. So all of that stuff outside of your day to day practice is important. And then I'd agree with everything else that everyone said about being prepared trying to get as much console time, you sort of simulated time before you kind of get into the actual or um, but like, ii if you, if you do find people that inspire you, talk to them because they'll want to help you. And there's lots of like, you know, once you have like the intuitive app, they, you know, there's evidence, you can keep records of everything much more easily than you can with the old traditional log books and stuff and I'm sure it's the same with TMR. So, so the more you infuse, the more you will get out of it, which is, you know, I get difficult with a lot of other things going on, but it is the future. It is where you're going to be. And if you look at those who kind of lead with laparoscopic and even lead with robotic, they are the ones who kind of grabbed it by the horns and went for it. I'll stop. Now, we're trying to, uh, I think in answer to your question, you know, when, when should you start? If I was a, an ST five trainee, I would start. Now, if I was an ST three trainee, I would start now. And if I was act one trainee, I would start now because I think now is the time when you have to start thinking about these things as we all kind of recognizing. Now, I see this is the future how surgery is going to be when you, um, whatever trainee grade you are at the moment uh when you are um finishing your training, you will most likely be uh confronted in one way or the other with robotic. Um So I think um as everybody said, you know, take the opportunities, kind of go for it now and the more you're interested, the more you will also push um the people who are in charge of training to do something about this and to kind of change the curriculums accordingly. Brilliant. Thank you so much. I'm going to have to draw the sessions for a close. I'd like to thank everybody who registered and tuned in this evening. Um I will say that our next webinar session is on the 11th of March and it's looking at E GS in robotics. So thank you very much and we hope to see you all then. Thank you. Take care. Bye bye, bye-bye. See. Right.