Identifying barriers to resident robotic console time in a general surgery residency through a targeted needs assessment

Robotic-assisted general surgery is experiencing exponential growth. Despite our institution’s high volume, residents often graduate with inadequate console experience. Our aim was to identify the educational needs of residents and perceived barriers to residents’ console time from both attendings and residents. Separate surveys were created and distributed to robotic surgery faculty and general surgery residents at our institution. Questions were a variety of modalities and focused on the robotic surgery experience at our institution, including barriers to resident console time from both attending surgeon and resident perspectives. Although residents' interest in robotic surgery exceeded that of open and laparoscopic surgery, confidence in their robotic skills was low compared to the other modalities. The top barriers to participating in robotic cases according to residents included minimal or no previous console time with the attending, lack of simulator time, and being required to perform bedside assistant duties. Faculty reported resident preparedness, prior robotic skill demonstration, simulator time, case complexity, and their own confidence as significant factors influencing resident console time. Using these results, we concluded that the design and implementation of a formal robotic surgery curriculum should incorporate simulation-based opportunities for residents to practice their skills, improve confidence, and increase console experience. In addition, simulation opportunities for faculty should also be considered to allow for improvement and maintenance of robotic surgical skills.


Introduction
Since the first robotic surgical system was implemented at Corewell Health East (formerly Beaumont Health) in 2002, the number and complexity of robotic cases performed have drastically increased.Our 8-hospital healthcare system has 24 da Vinci ® (Intuitive Surgical, Sunnyvale, CA) surgical robots, and Corewell Health East-William Beaumont University Hospital (formerly Beaumont Health-Royal Oak) has recently surpassed the 20,000th robotic case, making it one of fewer than 20 hospitals in the United States to reach this milestone [1].Despite the high volume and breadth of complexity, our general surgery residents have had a subjectively limited and varied experience as robotic console surgeons during training.The purpose of this needs assessment is to assess barriers to robotic console time for general surgery residents from the resident and attending perspectives.
With an eye toward solutions, we employed Kern's sixstep model for curriculum development to guide the development and implementation of this needs assessment [2].For step 1, problem identification and general needs assessment, it was noted by residents that robotic console time varied during their training.For step 2, targeted needs assessment, separate surveys were distributed to general surgery residents and robotic surgery faculty to identify barriers to residents' robotic console time.
We hypothesized that residents' and attending surgeons' perceptions of barriers to robotic console time differ.More specifically, we believed that residents equate less console time due to their faculty still gaining experience with robotic surgery themselves.Conversely, it was hypothesized that attending surgeons are less likely to hand over the role of console surgeon due to their perception that the resident does not have enough experience with the robot, either in the operating room or on a simulator console.

Materials and methods
This study was approved by the Corewell Health Institutional Review Board (#2022-195).

Survey instruments
Two surveys were developed by attending surgeons (NNo, AI, and FI), a medical education specialist (NNg), and a single surgery resident (KH).Surveys were anonymous, voluntary, and web-based.A 14-question survey was distributed to general surgery residency attending faculty who perform robotic surgery at our institution.A 13-question survey was distributed to general surgery residents of all PGY levels.Responses were collected from January to February of 2022.Reminder emails were sent periodically to improve response rate.No response data contained identifiers.The surveys utilized a combination of question modalities.Two versions of the instruments were created-one for attending surgeons and one for residents-to target specific barriers and perspectives for those groups.
The attending survey used binary (yes/no), multiple choice, Likert scale, and free text questions.Questions queried robotic operative volume, years in total practice and robotic practice, frequency of residents performing bedside assistant role in their cases, number of cases residents should bedside prior to being allowed console time, number of cases to achieve a feeling of 'plateauing' in robotic operative skills and teaching residents to operate robotically, importance of resident-modifiable and resident non-modifiable factors when deciding to give residents console time, and importance of verifiable simulator practice in allowing residents console time.
The resident survey used a similar distribution of question modalities to the faculty survey.Questions queried confidence in operative skills (open, laparoscopic, robotic), factors influencing decision not to participate in robotic cases, frequency of "fill-in" bedside assistant coverage for the robotic advanced practice provider (APP) team, interest in different surgical approaches (open, laparoscopic/thoracoscopic, robotic), time spent on a robotic simulator, frequency of participation in robotic cases, anticipated future practice pattern (open, laparoscopic/thoracoscopic, robotic, endovascular), number of cases required to achieve an acceptable comfort level as a bedside assistant, and typical degree of participation in a robotic inguinal hernia repair.
For both the faculty and resident surveys, additional demographic information (age, gender, PGY) were also collected.

Statistical analysis
Statistical analysis was performed using the Qualtrics software and SPSS to calculate mean, median, mode, and standard deviation (where applicable).

Resident survey
Surveys were sent to 37 residents in the 6-year general surgery program at Corewell Health East-William Beaumont University Hospital, including two preliminary undesignated residents and two preliminary urology residents.Preliminary residents designated for interventional radiology, as well as other transitional year or rotating residents, were not included in the resident survey.

Interests in operative modalities
Residents were asked to rate their interest in various operative modalities (open, laparoscopic, and robotic) on a Likert scale of 1-5.The mean levels of interest for open, laparoscopic/thoracoscopic, and robotic surgery were 4.20 ± 0.87, 3.85 ± 0.57, and 4.30 ± 0.64 out of 5, respectively, shown in Fig. 1.

Confidence in operative skills
Residents rated their confidence in the various operative modalities on a Likert scale of 1 to 5. The mean levels of confidence in their open, laparoscopic, and robotic surgical skills were 2.95 ± 1.07, 2.65 ± 0.91, and 2.05 ± 0.86 out of 5, respectively, also shown in Fig. 1.

Robotic case-time spent and degree of participation
When asked the number of times per month they participated as console surgeon, seven (35%) residents reported four or more times, five (25%) residents spent between 1 to 3 times per month, and eight (40%) residents spent less than one time per month.

Barriers to scrubbing robotic cases
Residents were queried about different barriers to participating in robotic cases and were asked to rate the importance of the barrier on a Likert scale of 1 to 4. The respondent was also allowed to pick 'not applicable' to any barrier.According to residents, the top three barriers to scrubbing robotic cases were: 'minimal or no console time with the attending' (2.9 ± 1.09), 'lack of simulator time' (2.7 ± 1.05) and 'being required to perform bedside assistant duties' (2.6 ± 0.73), as shown in Fig. 2.

Robotic simulator time
Residents were given the opportunity to input a free text response detailing the number of hours weekly they would or do spend on a robotic simulator.Nine residents (45%) of residents reported spending no time on the simulator, while the remaining 11 (55%) residents estimated spending less than 2 h per week (average time = 1.73 h; range = 1 to 3 h) practicing on the simulator.

Learning/teaching robotic surgery
Attendings were asked to estimate the number of robotic cases it took them to reach the "plateau" phase on a skill curve for robotically operating on a moderately difficult case.One (10%) attending reported plateauing between 0 and 10 cases, one (10%) between 11 and 20 cases, three (30%) between 41 and 60 cases, and one (10%) between 61 and 100 cases.Two attending (20%) reported that they were not at the plateau phase, and one (10%) did not answer the question.
Similarly, attendings were asked to estimate the number of robotic cases it took them to reach the "plateau" phase for teaching residents how to operate robotically.Four (40%) attending reported plateauing between 11 and 20 cases, one (10%) between 41 and 60 cases, and three (30%) between 61 and 100 cases.One attending (10%) reported that they were not at the plateau phase, and one (10%) did not answer the question.

Factors influencing attendings' decision to give residents console time
Attendings were polled about resident-modifiable and resident non-modifiable factors that influenced their decision to give residents time on the console during robotic cases.For both questions, attendings were asked to rate the importance of each factor's influence on a Likert scale of 1-5.

Access to robotic simulator
Attendings were asked to rate the likelihood of allowing residents more time on the console if they were able to track their simulator time.Specifically, they were queried on if a resident had verifiable increased time on a robotic simulator, how likely would it be that the faculty member would give a resident increased console time on a Likert scale of 1-5.One (10%) faculty member responded 'extremely unlikely', two (20%) responded 'neutral', seven (70%) responded 'likely' or 'extremely likely'.

Discussion
It is undeniable that robotic-assisted surgery will continue to grow in the field of general surgery.With both the increasing number of robotic systems and rapidly increasing volume of robotic-assisted cases being performed in the United States, general surgery residents' interest in gaining proficiency in this operative modality has also increased.In 2003, Patel et al. indicated that 57% of residents were interested in robotic surgery [3].This number increased to 81% in 2015 [4].Our study shows that residents' interest in robotic surgery exceeds both laparoscopic and open surgery.However, confidence in their robotic-assisted skills scored low compared to other operative modalities.One significant barrier to robotic console time reported by residents is insufficient robotic simulation time leading to less comfort in the procedure and operative modality.Approximately half of our residents reported spending no time on the robotic simulator, while the other half reported spending less than 2 h per week on the simulator.We believe that there are several factors contributing to a lack of simulation time.At the time of creation of this TNA, there was no formal robotic curriculum in place at our institution, no dedicated team for creation or implementation of a robotic curriculum, and no standard assessment tools used for evaluation of residents during robotic cases.One of the biggest factors that was both immediately apparent and readily correctable, however, was the lack of a technically reliable simulator device.At the time of conducting this needs assessment, the Mimic dVTrainer (dV-Trainer ® ) (Mimic Technologies, Inc., Seattle, WA) was the only robotic simulator available in our hospital system.The simulator, however, was often non-operational and required frequent maintenance and repair.From March 2018 to November 2020, the Mimic was officially reported broken to our simulation lab leadership 4 times, although no concrete timetables are available.In November 2020, the computer system running the Mimic software became non-operational, and remained so as of the conduction of our needs assessment.As a result of these frequent malfunctions, our residents had limited access to a working simulator to practice their robotic skills.As the lack of simulator time was noted by attending surgeons as one of the most significant factors when determining resident readiness for the console surgeon role, we recommend that institutions would benefit from a working simulator and ensuring that it is a priority in the simulation department budgeting for those wanting to educate residents on robotic techniques.A recent study conducted by Imai et al. found that nearly all faculty and residents agreed that console simulation time should be an integral part of resident robotic skills training [5,6].While other simulator-focused barriers such as completion of a curriculum, recent simulator usage, and simulator scores were all queried in our TNA, our attending surgeons placed more emphasis on the number of simulator hours than the other factors.However, number of hours, curriculum completion, and recent usage were all rated similarly in terms of their impact on resident console time, and we feel that all aspects of a resident's participation in simulator training should be concerned to some degree.We predict that increasing resident robotic simulation time will boost residents' confidence in their own robotic-assisted skills and increase attendings' confidence that residents are able to practice skills outside of the OR.
While resident confidence is a factor in cases, it is ultimately up to the attending surgeon to decide when to hand the console over to the resident.When a new surgical modality is introduced into clinical practice, an attending surgeon's confidence in performing the operation using the new modality is a barrier to resident education.This was first seen with the advent of laparoscopic surgery, where the cholecystectomy, a previously junior-level case became an advanced senior case leading to decreased resident experience that we now take for granted [7,8].Like the advent of laparoscopic surgery, where attendings gradually gained proficiency and expertise to hand cases over, an attending surgeon's confidence in their own robotic skills is likely a barrier to resident console time [9,10].Our study confirmed that attending surgeons' own confidence in their robotic skills was a significant barrier to resident console time, second only to the complexity of the case itself.Thus, in addition to increasing robotic simulation time for residents, we recommend increasing robotic simulation time for attending surgeons.A robust simulation program designed specifically to improve attending surgeons' confidence would flatten the learning curve for faculty, with the added benefit of enhancing residents' educational opportunities [11].
Several of the significant barriers demonstrated in our needs assessment can be addressed with the implementation of a simulation-based robotic surgery curriculum.Although curricula such as the Fundamentals of Robotic Surgery were created in the spirit of standardizing training, individual institutions are still responsible for creating and implementing their own robotic curricula [5,[12][13][14][15][16][17].While multiple aspects of a robotic curriculum such as an industry-sponsored didactic curriculum and graduated levels of responsibility during robotic cases, are important, we believe that the incorporation of simulation-based training opportunities should be a cornerstone of a future robotic curriculum.This desire for a strong simulation component is reflected in the sentiments of residents and attendings polled by Imai, et al. as well as other investigations related to robotic surgery curriculum development [5,15,[18][19][20].
An additional barrier or consideration noted by residents was that they were sometimes required to perform the bedside assistant role in a case instead of getting opportunities on the console.Our institution has a dedicated team of robotic surgery PAs and certified surgical first assistants (CSFAs) to facilitate that role, but due to high surgical volume, scheduling, and other factors, residents are still occasionally required to perform that role themselves.Although we believe that the bedside assistant role is an important one for surgical trainees to understand and perform when needed, it should not take away from the resident's opportunity to operate as console surgeon.While staffing an operating room is a complex and nuanced process, the hospital should prioritize hiring these staff members for surgical resident education.
While we plan to use the barriers identified in our survey to tailor a curriculum to our institution's greatest needs, we believe that our results found in our needs assessment can be generalized to other programs.If our high-volume robotic surgery hospital has difficulty with simulator access, bedside assistant availability, and resident confidence in robotic surgery, it is possible that other programs, especially those with lower volume centers, might also experience these challenges.Addressing these barriers can be partially addressed with the addition of a simulator-based robotic curriculum but also increasing buy-in from the program and hospital to ensure there are adequately trained staff and equipment available.
While there are several relatively minor limitations to be addressed in our study, we feel the most significant limitation was that of sample size.Although we did receive quality responses from those attendings and residents that answered the survey, the total number of responses was a relatively low proportion of the population at our institution.

Conclusion
We used the Kern model to identify the needs of our residents and attendings in the context of our institution's robotic surgery experience.We hypothesized that our TNA would successfully identify one or more barriers to resident console experience from the perspective of both residents and attendings, and several resident modifiable and non-modifiable barriers were demonstrated.These barriers centered principally on (the lack of) simulation experience.Residents' high interest and low confidence in the robotic surgery experience and attending confidence validate the need for the implementation of a formal robotic curriculum.We believe that our experience is not unique and that a formal simulation-based curriculum should be implemented at facilities training surgical residents.

Fig. 3
Fig. 3 Importance of resident modifiable barriers to console time per attending surgeons

Fig. 4
Fig.4 Importance of resident non-modifiable barriers to resident console time per attending surgeons