Becoming a good surgeon is not just about graduating from medical school or making it through residency. Carl Snyderman, MD, MBA, Otolaryngology Director of the UPMC Center for Cranial Base Surgery, discussed what it entails in the May 2 Eye & Ear Foundation webinar, “What Makes a Good Surgeon? Advances in Surgical Training.”
Training
The Accreditation Council for Graduate Medical Education (ACGME) lists the following as its core competencies:
- Patient care
- Medical knowledge
- Practice-based learning & improvement
- Interpersonal & communication skills
- Professionalism
- Systems-based practice
When the novice surgeon begins their residency, they are expected to progress through multiple levels of competence, ultimately becoming proficient. Under the Competency Development Model, there are lots of tools used to grade surgeons and monitor how well they are progressing. They might be competent, but not necessarily proficient. Why do people differ so much in their abilities? How can training be improved so that everyone becomes competent?
Following residency or fellowship training, the learning process continues. It can take years to become an expert surgeon. For example, to become an Endoscopic Skull Base Surgeon, there are five levels of proficiency:
Level I: Sinus surgery
Level II:
- Advanced sinus surgery
- Cerebrospinal fluid leaks
- Sella/pituitary (intrasellar)
Level III:
- Sella/Pituitary (extrasellar)
- Optic nerve decompression
- Orbital surgery
- Extradural skull base surgery
Level IV: Intradural skull base surgery
Level V:
- Coronal plane (carotid dissection)
- Vascular surgery
Due to the rapid evolution of surgical techniques, “if you stop learning the day you graduate, you’ll become obsolete in 5-10 years,” Dr. Snyderman said.
Learning Curve for Endoscopic Cholecystectomy
Ways to predict proficiency in a specific procedure include:
- Proficiency in traditional techniques
- Endoscopic experience with other procedures
- Duration of practice
- Number of cases (specific procedure)
Only a number of cases performing a specific procedure are predictive.
Training outside the Operating Theater
Before residents can even enter the operating room, they should undergo training, so they are better prepared. This can be done indirectly and directly.
Indirect:
- Surgical simulation devices
- Anatomical dissections (the gold standard)
Direct: Video review (watching video of surgery and providing feedback)
Laparoscopic (endoscopic abdominal surgery) Training is done with the use of box trainers and virtual reality simulators. Metrics used include:
- Path length of instruments
- Idle time
- Number of movements
- Speed of movements
- Accuracy (clipping)
- Time to complete exercise
- Completion of exercise
Training Systems for Sinus and Skull Base Surgery
Anatomically correct models derived from CT DICOM data are used for training. These include a webcam-based navigation system, realistic OR set up and surgical workflow, and application of real surgical instruments.
Chicken Wing Model for Endoscopic Microsurgery
Using chicken wings from the grocery store is a very inexpensive, easy, and realistic way to train for endoscopic microsurgery. The chicken wings are injected with latex to color the vessels, and then placed in a Styrofoam box for residents to perform endoscopic vascular dissection.
Studies have shown that people get better over time. Even a medical student who starts at a very low level of expertise can quickly gain experience. Further studies have validated this chicken wing model, demonstrating correlation with surgical procedures performed in human cadavers. The quality of dissection improved with training. Untrained students took longer to complete the surgery. This validates that the training in the lab translates into superior performance in the operating room.
“So you want to be a surgeon…”
The American College of Surgeons says this about surgical traits: “Intelligence, professionalism, conscientiousness, creativity, courage, and perseverance on behalf of your patients are the critical factors, and they outweigh the small differences in dexterity.”
According to one Japanese hospital, “unsteady hands need not apply.” Students compete for surgical internships there by folding tiny paper cranes (origami), reassembling dismembered insects, and making sushi using a single grain of rice.
But, Dr. Snyderman said, even if you are good at this task does not mean you will be a good surgeon. In addition to surgical dexterity, the outcome of surgery really depends on other things: knowledge, operating environment, ergonomics, stress and fatigue, and judgment. Technical skills only make up one component.
Minimally Invasive Surgery
Minimally invasive endoscopic techniques have transformed all of the surgical specialties.
- Urological surgery – TURP
- General surgery – cholecystectomy
- Otorhinolaryngology (ENT) – endoscopy sinus surgery
There is a controversy between open surgery vs. endoscopic surgery:
- Access
- Visualization
- Complications
- Morbidity
- Oncological control
The limits/challenges of endoscopy include access, instrumentation, and visual information (2D vs 3D, landmarks: orientation, and visual data). It takes a while to learn how to use this environment, and it is easy to be disoriented.
Skills
Does the modern surgeon require a different skill set? Does it matter whether you grew up doing activities like Lincoln Logs and puzzles, or if you grew up with smartphones and video games? Is there a critical period of development when young to acquire certain skills? Do surgeons today have a different skill set? These questions are being studied.
When it comes to video games and surgical skills, there is a correlation between video game use and laparoscopic skills, but only before training. The overall impact is minimal.
Surgical Aptitude
Studies show that medical students with low innate aptitude cannot reach skills necessary for a competent career in surgery. Training does not compensate for pictorial-skill deficiency. Video gaming and musical instrument playing did not significantly promote an aptitude for microsurgery. The space-relation test, however, has predictive value for a good laparoscopic surgical virtual reality performance.
In a study on surgical cognition with Pittsburgh CREATES and Parkview-Mirro Center, the goals are to:
- Measure variations in care for patients undergoing laparoscopic cholecystectomy
- Establish new metrics for video evaluation of surgical performance
- Correlate measures of neurocognitive function and laboratory skills with surgical performance
- Explore new measures of surgical performance
This project is supported by a grant from the English Bonter Mitchell Foundation through PNC Charitable Trust.
“Can we look at certain tests to see if someone will perform well as a surgeon?” asked Dr. Snyderman. They are planning to develop new training methods based on this information.
Skills of a Surgeon
- Visual-spatial abilities – hand-eye coordination/dexterity
- Visual cognition – pattern recognition, spatial relationships: mental map
- Surgical cognition – problem solving, judgment
No two surgeries are the same. Many involve a lot of problem solving and coming up with new solutions during surgery. The Raven Matrices test is a good overall measure of cognitive abilities.
What predicts surgical performance? Take the mental rotation test, which judges your ability to see things in your mind and manipulate them. Which figure is the same, from a different point of view? Looking at a systematic review of predictors of surgical performance, visual-spatial perception is correlated with surgical performance, including rate of skill acquisition.
A great example is Neal Godse, MD, a current resident in otolaryngology. One of his hobbies is to create his own origami constructions. He designs and builds these complex structures on his own, showing a very high level of visual-spatial ability.
When it comes to creativity, necessary ingredients include knowledge, technical skills, and improvisation (innovation). Dr. Snyderman quoted jazz pianist Charlie Mingus, “You can’t improvise on nothing; you’ve gotta improvise on something.”
Divergent Thinking
When it comes to problem solving, divergent thinking (exploring multiple options) is superior to convergent thinking (considering only one solution). When testing divergent thinking, the following are considered:
- Fluency: large # of responses
- Flexibility: produce ideas that are different from each other
- Originality: rarity of ideas produced
One example is a picture of a clothespin. List everything you can do with a clothespin. What are all the applications of that object?
Assessment of Surgical Performance
Indirect measures of assessing surgical performance:
- Patient satisfaction
- Length of stay
- Readmission
- Mortality
Direct measures:
- Nerve injury
- Completeness of resection
- Postoperative hemorrhage
- Wound infection
- Recurrence
Data analytics at an institutional level, such as the UPMC Dashboard Clinical App, can track individual surgeons and outcomes.
The simplest way to assess surgical performance is by looking at a surgery video, as mentioned earlier. This has become part of residency training. A judgement can be made quickly as to whether the surgeon is exhibiting good technique. The surgeon can be objectively assessed using a variety of different tools.
For example, there are different categories for rating, which include respect for tissue, time and motion, instrument handling, knowledge of instruments, flow of operation, use of assistants, and knowledge of the specific procedure.
There is even a website where cholecystectomy videos can be uploaded, and a machine learning algorithm will analyze the video. The more videos people post, the better it becomes in analyzing.
Total surgical performance, however, is about more than just technical skills. The entire performance should be assessed, throughout the entire surgical experience.
Current Research
Surgical aptitude includes mental flexibility, problem solving, selective attention, processing speed, memory, and pattern recognition.
Can surgical aptitude be predicted using neurocognitive games? A Pitt medical student, Nikita Desai, is presenting a study at the annual meeting of the Association for Surgical Education. The study objectives are to identify students and physicians with a greater aptitude for surgery and determine if there is self-selection of physicians for surgical specialties based on neurocognitive function.
Tests involve a battery of online brain games, Raven’s advanced progressive matrices, and timed completion of a jigsaw puzzle. Surgical skills are tested by using laparoscopic instruments with a virtual reality simulator and doing the chicken wing dissection.
One of the early outcomes showed that the ability to complete a puzzle is highly correlated with the overall measure of cognitive function with Raven’s matrices assessment of visual-spatial ability. Lumosity brain games can enhance specific cognitive function by playing different categories of games.
The Parkview study is working to establish new metrics. Portable neuroimaging technology will allow them to look at what parts of the brain are active during particular tasks.
We have all been in situations where our brain is overloaded, making it difficult to handle a situation or task. An expert surgeon will be much better at performing a task with distractions in the background compared to a novice surgeon who is very focused and not able to handle a lot of information at once. This means a novice may have to recruit more of their brain and work harder to complete a task. Current studies will measure cognitive load to see how it differs between surgeons and see how surgeons perform in a more complex environment.
Visual Perception
Vision is important; it makes up 30% of the brain. But cultural and individual differences should be considered. Some people have color blindness, others have binocular vision or stereo-blindness. Does any of this affect surgical abilities?
Dr. Snyderman is embarking on a new program with Drs. Mayo and Herman – vision scientists in the Department of Ophthalmology – to research visual cognition. They are applying for funding to assess patients as well as surgeons. They will look at perceptual abilities and utilize different kinds of tools to assess surgical performance. Eye tracking devices, measuring the size of pupils, looking at brain activity, and exploring how to augment reality to enhance the surgical experience will all be part of this study.
Teamwork: Dynamic Endoscopy
Dr. Snyderman is interested in how teams work together. Everyone interprets things differently. Surgeons have different priorities and tasks during team surgery. There is a lot to be learned from a highly functioning surgical team. What are they doing in concert? Can this kind of training be improved?
“In regard to surgical training for endoscopic surgery, there is a lot to be learned, a lot to explore, and it is a very exciting area of study,” Dr. Snyderman said.