Minimally Invasive Surgery: Educating Surgeons Though Proctorships

The benefits of minimally invasive surgery (MIS), surgery done through one or more tiny incisions rather than one large opening, are well-documented at this point for a range of procedures. A recent study published in BMJ found that MIS is associated with fewer surgical site infections, less blood loss and postoperative pain, and shorter hospital stays than standard open surgery. Another study, published last year in the Journal of American Medicine Association (JAMA) found that MIS may result in significantly lower health plan spending than standard surgery. 

Despite these benefits, a report by Johns Hopkins found that some hospitals capable of performing MIS aren’t providing it nearly as often as they could. In many cases, physicians might not have the equipment or training to perform MIS.

As healthcare delivery is moving towards “quality,” it would make sense for safer, easier surgical approaches to be used. Why, then, have many doctors been slow to adopt MIS in practice?

Dr. Michael Tarnoff, a surgeon at Tufts and Covidien PLC’s chief medical officer, is working to fix this practice gap. Covidien is a leader in MIS products, and Dr. Tarnoff states that the company knows the benefits of the less invasive procedures. Despite the shorter hospital stays, more rapid recovery, and lower costs associated with MIS, he notes that less than 30% of the 15-20 million procedures of interest to Covidien’s advanced technologies are performed using the procedures. Dr. Tarnoff spoke with Policy and Medicine last week about his hands-on education plan that he hopes will speed the adoption of MIS.

In describing the inertia in the MIS area, Dr. Tarnoff noted that MIS is not new technology—it’s been around for close to 20 years. However, there are barriers to adoption including an improper education model. 

Dr. Tarnoff used the example of learning to drive. Students can attend driver’s education classes, seek out information online, or even drive bumper cars. However, actually learning behind the wheel with an instructor is essential for students to ever be able to merge onto a highway or parallel park. Dr. Tarnoff sees a parallel to surgical education. He believes close, hands-on proctorships are the best way to allow surgeons to adopt these MIS techniques that are both beneficial to patient well-being and cost efficient.

According to Dr. Tarnoff, companies are allocating their dollars in the wrong place—no one in the industry has embraced a large-scale “proctorship” model. Such a model would both shorten the learning curve and also develop better prepared doctors for actually conducting minimally invasive surgery.

Dr. Tarnoff laid out five aspects that he believes are essential for a successful education plan. With a proper relationship between teacher and trainee, he believes that active instruction can speed the learning curve process immensely.

(1)  Qualify teachers: Not only by looking at their number of surgeries or publications, but how interested they are in teaching, and their ability to engage learners

(2)  Evaluate trainees: Not everyone is capable of doing this procedure, while some are more motivated than others, Dr. Tarnoff notes. Other doctors don’t have the support of the hospital or the capital equipment.   All those factors come into play in deciding which trainees to include in the proctorship program.

(3)  Interaction between teacher and trainee: Allow time to ensure that the relationship will be successful.

(4)  Proctorship: The teacher either goes to the trainee’s site or vice versa. The guided training is successful because it pairs the new trainee, who may have done one or a few procedures with someone who has done 100. This limits the risk and speeds up the learning curve. 

(5)  Data collection to track outcomes of the trainee’s first ten patients. Dr. Tarnoff stressed that the amount of procedures is only one of the metrics. How well the surgery is performed on a consistent basis is key.

Covidien’s Progress

Covidien last year ran a pilot in 6 countries (in the US, Canada, Mexico, UK, Malaysia, and Japan) to bring these proctors and learners together. The surgeons participating in the program first learned the procedure guided by an expert; after several guided procedures the learners went on to do 200 cases alone in 2014.  Many of those who went through the educational activity will now be proctors themselves in 2015. 

Covidian believes so much in this model that several years ago they stopped supporting international attendees’ travel at International and National Surgical Congresses.

The down side is the lack of accreditation. Current rules do not allow credit for surgical CME on specific procedures using a single device and organized by a device manufacturer for the participants to receive credit.  One could argue that this type of education is much more useful for surgical education than lectures or videos of procedures.

With the proper training, Dr. Tarnoff hopes that the vast majority of procedures can be used with minimally invasive procedures. In the end we may see patients living longer, more productive lives as result. 

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