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Morning, ladies and gentlemen, and to everyone who has joined us online, my name is Angela. I'm your asset innovation Lead. And it is a great honor to be able to host this research and surgical innovation plenary session over the last 10 years, 5 to 10 years, we've seen some in credible technologies be introduced into our surgical track practice and revolutionized patient care. I'm extremely honored to be able to present to you a distinguished panel of speakers who will take us through a journey to show us and allow us to discover some of these technologies that have transformed the way that we practice surgery today. Unfortunately, our first guest speaker, Dr Eric Can't Barker was unable to attend today. So instead allow me to introduce you, Mr Josh back who is an academic general surgery registrar. He is an asset past presidente and he's the Director of Education for the Royal College of Surgeons Innovation Hub and he's also the chair of the Future of Surgery Technology Enhanced Surgical Training report. Please, can we give a warm welcome to Mr Josh back? Thanks Angela. Good morning, everyone. Um Our thoughts and prayers go to Eric and his family and it's, I'm sorry, you can't make it today, but hopefully I'll do his time justice on the stand and complement the amazing speakers you've got in this session. Okay. Um So I think it's difficult to argue with the comment that there's never really been a more difficult time to be a surgical training. So in terms of absolute log, but numbers um things are still really poor since the start the pandemic. Um And during this time, we've had a change of our surgical training curriculums. Um So for the more junior colleagues in the audience, we've switched from more of a numbers game to a competency based progression. But how, how well that's being adopted throughout the regions in line with known regional variances in A R C P outcomes is still yet to be established. But what's really clear is that if we don't get on top of the training problem, we're not really gonna be able to deliver the service required to tackle the backlog which the pandemic generated. And so whenever you mention technology and surgical training, it often divides the room um and creates antibodies amongst both trainees and trainers because lots of people are just struggling to deliver safe and effective care. And I don't think have the head space or the capacity to consider how technology might complement that. But actually, the commission feels that there is huge scope to help with the delivery of care, not only um to patient's but to improve training. So investment in this area is has skyrocketed really over the last 10 to 15 years, particularly UK. But in our regions were really bad at adopting digital transformation. And this is a government report from about 56 years ago after the first transformation attempt. And um it lacks effective governance, adequate investment and clear accountability and it just wasn't quite fit for purpose. Our journey with this from an asset point of view started right at the advent of the pandemic, where we approached by around 70 companies for advice, consultation, help with new and innovative products which I've been sat on the shelf and dusted off as we transition to a virtual living arrangement or indeed have been developed to try and tackle some of the problems which the pandemic had highlighted. So what this did was led us to go back and read the original future surgery report, the top will review which I encourage all of you to read uh and take with us the opinion to the then president's of the four old college is that perhaps training had been overlooked and there's still some work to be done. And this led to the formation of the fastest commission, all elected members of the respective specialty associations that set an asset council. In addition to those invited members from the college training committees to represent the views of training within their specialist and colleges on everything to do. With technology and training. We published this report back in August co badged and done independently from. But in collaboration with most if not all of the key stakeholders, you have an influence in how you are trained in the UK and Republic of Ireland. What became clear right from day one really of the meetings was that there were huge numbers of solutions available. But actually the paradigm of starting with the solution and trying to match it with the problem which the pandemic and China light on was probably the wrong way around. The second thing was that there's huge international variation, not only in Europe, but internationally about how we train surgeons and trying to drag and drop solutions from one country to another, doesn't quite work and it hasn't worked in the UK for a number of companies and then finally with mixed and augmented reality, which you'll hear more about a little bit later, the fidelity in terms of the evidence base isn't quite there yet. Do you have a decision to make at this point? Do we go blue sky? I think it's quite easy to do that in this space or do we produce a report which is evidence based, considered peer reviewed and hopefully useful for doctors at the time who were struggling and are still struggling um to deliver care and train um and also useful for trainers and patient's to approach to health education, England who um at the time our links weren't great with. But since I have been hugely important and asked to analyze two of their big data set. So the first was a surgical solution survey and the second was a risk reporting tool which highlighted only second ophthalmologists that surgical training with the highest risk of having their training affected by the problems with the virus. We put these survey results, there's about 800 of them into two consensus hackathon. So this is some novel methodology combining um Delphi criteria with consensus. And we managed to generate a long list of themes and unmet needs based in order of priority and urgency. And this was done completely open to any, any training or prospective training could attend. The first one and the second one was done with elected representatives from all the key stakeholder groups um including the J C S T health education and, and the Royal colleges we did then was take those. And what we noticed was there was key themes running through them, map to both the trainee pathways, all the hurdles you have to go through um to progress through the UK and Republic of Ireland training systems and also the patient pathway. So each of the pinch points along that care delivery where there's learning opportunities well then match those to the capabilities in practice framework, which as most of you will know is our current currency for progression in the new curriculum's. We went out to invitation to anyone who was interested to submit articles of interest proposals, case studies of cool stuff they see or things that they thought were useful within our working environment. We accepted 120 after peer review where we were a little bit light in submissions in areas which the commission thought were important. We invited 11 key consideration articles were published. 10 out of the 50 case studies that industry had submitted to us for technologies which we thought were there or thereabouts ready for assessment, either locally or nationally and importantly, right from the start, we were committed to ensuring that anything we published any recommendations we came up with met these three themes. So equality and diversity and we just had an incredibly important session. Um And if you weren't here, I encourage you to, to watch it back on the recording sustainability and considering recovery and the surgical workforce because I thought was that if we didn't consider these any recommendations would perhaps be futile. So the core themes that the report highlighted a five fold. Firstly, the biggest unmet need that was constantly repeated was increased exposure to operating. The second was how can technology enhanced training along that entire patient pathway in line with the change of curriculums? How do we assess training competency? Do we do it? Do we do it well? And can we improve it? How can innovation broadly help the surgical workforce which is struggling? And then finally, what needs to happen to embrace technology enhanced surgical training. The report came up with seven key recommendations. We started with 63 but the commission reminded me that perhaps no one would read them and they certainly wouldn't recommend them. Um And a lot of the new on stuff is found in the conclusion sections of the executive summary. So if you're interested, maybe you're starting a phd in this area, maybe you're just interested and want to do some extracurricular stuff. I'd recommend reading those sections if you need anything in the report. So it's already had quite a significant impact. I think an evidence based piece led independently by those affected by the potential changes and decision making from stakeholders is difficult to ignore. Um It's currently being used as the blueprint for the government discovery into surgical technology training. And what it's done is it's allowed us to strengthen our collaboration with some of the key stakeholder group. So we're supporting the H E N R C S Radar Fellowships which will hear about shortly early conversations with the Irish College on their robotic education research. And it's allowed us to develop industry collaborations and to try and assess some of these technologies in a rigorous way which as you'll hear in a moment, we don't think is quite there to hear more about this with two amazing robotic um consultant colleagues in this session. But I'll just touch on robot assisted surgical training. I'm sure the speakers would agree that the evidence base is probably not caught up with the adoption yet. Um And I think that is somewhat of a problem training in particular is industry driven. I know that's frustrated. A lot of our higher surgical trainees. And we've heard that yesterday in some of the pre conference course is an exposure is a key issue. I think it was Professor Hardy. You highlighted this statistic to me that in 2019 from the bows registry highlighted that prostatectomies in 86.86% of cases were completed robotically without a single mention of the word robot in any of our specialty curriculums. Um We thought that was perhaps a problem curriculums last time around to go out six years to change, have it on good authority that the gynecology one uh next year will contain it. And so we are behind. We think this is a table from a paper he published last year which highlighted in higher specialty trainees that 70% had no access to robotic training, not even getting close to observing a robotic procedure. So it's an issue and these issues are well documented in the advent of laproscopy, laproscopic surgery and it feels like we're making similar mistakes. So how can we help? Well, the specialty association industry have procedure specific training curriculums covered. Um But what's not being tapped into is a core robotic surgery curriculum. So how do you get into it? What's the basics. How do you use the device is? Um what simulations available? What are you learning is available? And so we've just published our consensus recommendations with all specialty associations on what that might look like. Um And supporting Charlotte El Sayed, who's the first radar fellow with RCs England and H E who's doing a qualitative piece looking at the granularity of what curriculum will actually say and do. Next thing which I think has got huge potential is this concept of a virtual I SCP. Um It's interesting that are only technology intervention that we have is our portfolio which is entirely funded by trainees pockets. This is a paper for just a couple of years ago which demonstrated that in 900 trainees, 40% were aware of trainees filling out their own work based based assessments with no input from their consultant trainers before sign off. And further third, we're aware of password disclosures. The trainees had their trainers, passwords were signing off their own WBS. And for those of you that are aware of the work based based assessment evidence based on medical education. If you combine it with the statistics, it supports the theory that perhaps they're not worth the paper they're written on what we have at the moment is an opportunity to adopt some of the usps that companies are selling as part of operative video libraries. So if you consider modular trainings and breaking up an operation in two different steps which fits really nicely with robotics. Um And then it is in line with the new curriculum's rather than just doing a W A on a procedure to demonstrate um, proficiency. Perhaps if you could through some of the AI systems, which are available, identify where you're weak spots are throughout an operation, you could have more granular feedback and more efficient training and hopefully reduce your learning curve. We've got a barriers to recording consensus session tomorrow because we're around. This is a sensitive topic, not only for trainers but for trainees. Um And we need your opinion. So if you're interested and keen to be involved, a number of projects, this is what we're doing with bench telecoms group with approximate. Then please do come along to that session tomorrow. So what's the nirvana of a surgical training intervention? Well, ideally you'd introduce the intervention, trainees and trainers would go through it and you'd have an improvement in a patient outcome, but that's really difficult to demonstrate the methodology to assess. That's quite tricky and it would take a long time. So what's the next best thing? So medical education outcomes are really poorly defined. And actually, I think as a surgical group, we're pretty bad at med medical education research and qualitative methodology. What we can influences how we procure these training interventions. So if you have a clinical intervention, you have to prove every pound you spend that there's an improvement in patient quality of life for system based resources, you have to demonstrate that there is a cost benefit to your trust before you buy them off the procurement list. But for education interventions, nothing like that exists. There's no assessment of educational efficiency, there's no sustainability consideration, there's no consideration for E D I and how that gap will be broadened. We think by um an inefficient adoption of these technologies and there's certainly no health economics assessment. So selling to individual trusts and Dean Aries with products that have no evidence base is probably futile and isn't gonna work. So we think a training intervention framework is probably needed to bring together all the key stakeholders who have an influence in this area to help guide those who have power. Um And the decision making authority on those who hold the budgets for training interventions because at the moment, it's really difficult to decide where along the innovation pathway. One of these interventions is, is it blue sky instill in someone's mind and a really early concept or is it at the other end of the spectrum where it's ready for local testing? It's had some rigorous independent assessment and there's a signal that perhaps it might be useful. Again, this doesn't exist currently. So what we did was approach ideal, some of you will be aware of this. Um You have a well thought out structured framework for pragmatic surgical trials. And our hope is that we can adapt the methodology that went through to developing that for educational interventions. And so that can be a pivot point for educational theory, which is some somewhat way, somewhat far away from the pragmatic surgical training environment that we find ourselves in every day to try and improve responsible spending, make things more sustainable and equitable and reduce the reporting outcomes from these uh efficacy studies which have huge heterogeneity at the moment in the literature. Final thoughts and this is more of a broad theme which was highlighted and there's huge amounts of the report and I just want to highlight a few of them for you today. It's been well documented that there's huge complex health care challenges. Um It's very different to those that are predecessors. Um We're faced with over the last even five and 10 years ago, the huge amount of technology that's available is gonna need clinicians with insight and the ability to be able to adopt and assess these things that are coming through the market. It's quite clear and photos have come up from are taking an F three session which was jam packed. They have a new generation of trainees. You want something a little bit different. Um Two years gone by and the way we're delivering our care is also changing with our extended surgical teams becoming more at the forefront of what we do. It feels a little bit like we've been here before. So many of your recognizes Richard Horton paper. On the left hand side, which are similar question as to how we conducted research as a surgical community. On the right is a recent paper from Bristol Methodology Group, which has suggested that innovation is perhaps making the same mistakes that we did with academia. And for those of you that remember this is the Waldport report which really catapulted the way we integrated academia within our training programs. So for the A C S and see else in the audience, this is one of the big reports that was responsible for integrating that within your training. So what we thought is all these new skills, all these new interests could possibly be benefited from an integrated innovation training proposal. This was a paper first authored by Angela um in the bulletin a couple of months ago which highlighted how this might work, what barriers they are to stop this from happening. We pitched it to the H D board meeting last month where there was huge amount of interest, but they've asked us to go away um and get more consensus and opinion from you guys. So if you're keen interested and this is your cup of tea and got another session tomorrow, we'd be delighted to see that. And finally, certainly anecdotally and there's no data on this yet, but the people who are leaving are often very talented and it seems such a shame to lose this ambition. Um This, this blue skies thinking and these new skills that trainee doctors are eager for um to industry, to other countries. So we partnered with the, the English College in December, twisted their arm to run the course at cost. But the first Asset rcs Innovation Skills course, which is sort of like your basic surgical skills for innovation, which we hope to continue this year with the support of B Braun final thought. If we're unable to develop training interventions as part of our training programs in the house, then we're gonna have to start to learn how to interact with companies in a way that efficiently and responsibly assesses the efficacy of the intervention that they're proposing. I think it's a dangerous situation to connect a industry led intervention to training progression. But I think there's a system that we can come up with to rapidly assess these technologies and get them into the hands of trainees to better our training and improve patient care. We need an evidence based assessment framework and guide people in how to implement these novel technologies within our training environments. It's clear that without trainers without training time, these are just shiny objects without any use. Every test that's been done without good trainers who are engaged and keen. The technology doesn't make any difference. We need to appropriately staff workforce without which your lap scopic skill centres, your robotic skills centers will go unmanned and need to make sure we're responsible with our spending a plea to the decision makers who are in the audience will be proactive rather than reactive and not going with trodden ground and make the same mistakes we've done years gone by. And if any of you interested, you're doing work in this space or you want to start a project in this area with asset support, please do get in touch. This has always been a collaborative and open project for anyone that's interested. We'd be delighted to hear from you. Thanks. Thank you very much Josh for brilliant talk. So we have a couple of minutes for questions. Um I think we have to roaming mics for questions from the audience and I would encourage anyone who's listening via medal to ask any questions in the chat. Any questions? I have a question for you. Um So uh the fastest report is brilliant and outlines a lot of um novel and exciting interventions for surgical training. Um Despite that there's, there is a lot of barriers to overcome to actually implement them um in real life. What do you think of, you know, the biggest barriers and how can we overcome that? I think I highlighted it in the first few slides. I think the variation in how Dean Aries are adopting new technologies will increase the inefficiency of their adoption across the nation. Uh The evidence base with some of the stuff that's being brought into is pretty weak. Um And I think that's done because of potentially a lack of methodology to assess educational outcomes, but also the one a need to do something. Um And I think we've, we've started to run before we've been able to walk with a lot of the assessments and how they've been done. Um So I think the framework will help, I think engagement from the key stakeholders in a group um that is independent and as best as possible with terms of reference and without conflict will help for the assessment of whether or not these things are useful. Thank you. Thank you very much. Just it's always extremely insightful to hear just how far we've come in technology and surgical um in surgical training. So we definitely recommend if you haven't read it already to read the future surgery, technology and heart surgical training reports, it's a bit of a mouthful. Um.