December 13, 2019

After almost 20 years, there is still no standardized training curriculum or unified credentialing policy for robotically assisted surgery.

By Katja Ridderbusch

ATLANTA — Robotic heart surgery never becomes routine for Dr. Douglas Murphy. Every time he enters the operating room and sits down at the steering console, he says, his senses are revved up and on high alert. His mind, focused.

Murphy is thechief of cardiothoracic surgery at Emory St. Joseph's Hospital. He started out as a transplant surgeon in the 1980s and later became a pioneer in robotically assisted heart surgery. He's done more than 3,000 operations with the robot, mostly mitral valve repairs and replacements -- more than any other cardiac surgeon in the world.

"In many ways doing robotic surgery is more stressful than open surgery," says Murphy.

As some hail it as the next frontier in medicine, robotic surgery has become a highly scrutinized endeavor. The minimally invasive technology reduces trauma, bleeding and downtime for patients, and helps surgeon operate with a higher degree of precision. Common robotic procedures include prostate removals, hysterectomies, hernia repairs and mitral valve surgeries.

But troubling reports have surfaced about the safety of the DaVinci surgical robot, which dominates the market.

Last February, theFDA issued a safety warning against the use of robotic devices in mastectomies. In the past 10 years, more than 2,000 patients have been injured or killed by malfunctioning or mishandled robots, according toan NBC News investigation.

In some cases, patients' blood vessels got nicked. Organs were burned or perforated in others, and broken instrument parts fell into operating sites.

Many of these problems come down to poor training, says Murphy. That's especially true for mid-career surgeons who have done conventional surgery all their lives. Some participate in an introductory course offered by DaVinci's manufacturer, Silicon Valley-based Intuitive Surgical, and then start operating soon after that, Murphy says.

"Robotics is the Wild West of surgical training," he continues.

Standardized training and unified credentialing for robotic surgery are non-existent in the U.S. The American Board of Surgery (ABS), which certifies general surgeons, "has not considered robotic surgery to be a core requirement for surgical training," says Dr. Jo Buyske, ABS president, in a written statement. The same applies to other surgical specialties.

Robotic credentialing is done separately by each hospital, Buyske adds. As a result, standards vary widely throughout the country.

That's surprising, given the technology has been around for almost 20 years. But the robo-assistants are still not the norm, especially in rural hospitals, says Dr. Richard Satava of the American College of Surgeons, an educational association of surgeons.

"The boards can't require surgeons to get credentialed in robotics if the technology isn't available in half of the country's hospitals," he says.

But demand for the technology is growing fast in U.S. hospitals, where nearly 3,000 DaVinci robots are currently deployed. The 800-pound giant sells for about $2 million.

Intuitive offers multi-layered, multi-phase training courses but is not legally authorized to credential surgeons.  “While we are only allowed by law to provide training on our technology, Intuitive has gone the distance to provide ongoing platforms so that surgeons and their teams can benefit from peer-to-training and mentoring,” a company spokesperson said in a written statement.

As the demand grows, so does the call for a more-formalized training for both trainees and established surgeons.

Individual hospitals set the criteria for surgeons to get robotic privileges. All hospitals in the Emory Healthcare system, for example, requires completion of a course facilitated by Intuitive; training on a simulator; and proof that the surgeons have prior experience with other minimally invasive techniques, like laparoscopic surgery.

Surgeons new to robotics are monitored by an experienced colleague before they can operate on their own. Medical centers at Stanford University, NYU Langone, University of Michigan and others have similarly strict credentialing criteria.

Douglas Murphy, who mostly trains mid-career cardiac surgeons and surgical teams at Emory St. Joseph's and other hospitals in the U.S., Europe and Japan, says robotic training requires time, patience and humility. Some of his trainees struggle with the setup because instead of standing at the operating table the surgeon sits at a console about 10-feet away, with a zoomed-in, magnified 3D vision of the operating site, but a limited view of the overall room.

"You're highly dependent on your assistant at the patient's bedside," says Murphy. "You've got to be able to work in a team, you have to forget about hierarchies, and arrogance is a no-go."

Going forward, residency and fellowship programs will drive substantial change in robotic surgery training. Programs have been consolidating rapidly across the country, saysDr. Ankit Patel, a general and gastrointestinal surgeon at Emory Healthcare, who helped build comprehensive robotic training guidelines for the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES).

"Robotics is the future of surgery," he says. "That's why we're working toward a unified, standardized training platform."

Patel's robotic curriculum is modeled after SAGES' endoscopic and laparoscopic training that is required for board-certification in the various surgical disciplines.

Patel trains general surgery residents and fellows mainly at Emory University Hospital, where robotics is a fast-growing elective program.

Residents take an Intuitive course and work on simulators, playing games to help them gain dexterity, precision and speed. They then move to surgical simulations, where they practice procedures like suturing, knot tying or making incisions. Simulator training can take between 30 and 100 hours, depending on the resident's proficiency. Residents also practice operating on cadavers.

Once they advance to the actual operating room, they assist at the patient's bedside for 20 or 30 cases before moving to the surgical console to observe and later, perform certain steps of the surgery. "Typically, residents don't do an entire case by themselves," says Patel, "simply to make sure the surgeries do not get elongated." 

Most surgical residents and fellows have had several years of robotic training under their belt when they apply for robotic privileges at a hospital, says Patel.

Dr. Vivian Wang is going to be one of them. She finished her general surgery residency at Emory University Hospital in June and is working on a one-year fellowship in minimally invasive surgery at Ohio State University, with a focus on robotics. She says she participated in 80 robotic cases while at Emory and operated in about 50. "I am ready," she says.

Wang plans to specialize in bariatric, or weight-loss surgery. She found her robotics training to be thorough but says that it has come a long way from when she began her residency in 2014.

Back then, she says, the training pathway wasn't as formalized as it is today. She admits to resorting at times to "shadow learning," a termed coined by Matt Beane, a professor of Technology Management at the University of California, Santa Barbara. 

Beane wrote a 2018 article about the dire state of robotic training for residents in the U.S. He says some residents felt they were not getting sufficient robotics training and often slipped into a set of "counter-normative and often, highly inappropriate" training methods.

Trainees would, for example, practice on surgical simulators in the middle of the night, binge-watch YouTube videos about robotic cases and try to shadow veteran surgeons, often as early as in medical school, at the expense of generalist medical training.

Beane acknowledges that training has improved since he completed his study but says scientific advances may make it unnecessary to completely revamp the robotic training environment. In the future, non-invasive technologies like nanobots could act as autonomous surgical robots inside the human body, he says, making traditional and minimally invasive surgery obsolete.

"Maybe," says Murphy. "All I know is, I've got patients coming in tomorrow who need help." Sometimes he has to open them up, he says. "But if I can fix their hearts with the help of the robot and without splitting their sternum, I have created more value for the patients." And that's a good enough reason to train for, he says, "in the most structured way possible."


Katja Ridderbusch is an Atlanta-based multimedia journalist. Her work has appeared in Kaiser Health News and aired on several NPR affiliates. She also reports for news outlets in Germany.

Copyright: U.S. News & World Report / Katja Ridderbusch