Zambian Medical Students’ Attitude Towards Robotic Surgery: A Cross- Sectional Survey

doi:10.21203/rs.3.rs-3555299/v1

Download PDF

Research Article

Zambian Medical Students’ Attitude Towards Robotic Surgery: A Cross- Sectional Survey

https://doi.org/10.21203/rs.3.rs-3555299/v1

This work is licensed under a CC BY 4.0 License

You are reading this latest preprint version

Robotic surgery, evolving over half a century, has become a standard in various surgical fields, offering benefits like smaller incisions and improved patient outcomes. Integrating it into medical education is vital to prepare future healthcare professionals. Yet, Zambian medical students' knowledge and attitudes regarding robotic surgery remain largely unexplored. This study aims to bridge this gap, providing insights for healthcare and education.

Methods: A cross-sectional study was conducted using a questionnaire between June and July 2021. The study included medical students from various academic years, both genders, and different institutions. Data was collected through a web-based questionnaire and analyzed using descriptive statistics and statistical tests. Participants were categorized into groups based on their exposure to robotic surgery.

Results: A total of 768 out of 1,113 respondents provided complete responses, resulting in a 69% response rate. Notably, 47.20% of participants had no prior exposure to robotic surgery, while 45.40% expressed a desire to learn more about it. When assessing students' attitudes towards robotic surgery, 38.80% accepted it personally, 51.82% believed patients in Zambia would accept it, and 61.85% agreed that using robots would improve surgical outcomes. However, 62.24% agreed that robotic surgery could make surgeons weaker and less professional.

Conclusion: This study sheds light on Zambian medical students' attitudes and knowledge about robotic surgery, underlining the need for tailored educational strategies to address misconceptions and concerns. This prepares the next generation of healthcare professionals in Zambia to embrace advanced surgical techniques and optimize robotic surgery for improved patient outcomes.

Medical Education

Robotic

Surgery

Zambia

The concept of robotic surgery in medical practice has a history dating back over half a century (1). However, its widespread adoption and utilization began in the 1980s following formal approval of the ROBODOC system by the U.S. Food and Drug Administration (FDA) (2). Since then, robotic surgery has witnessed remarkable progress and evolved into the standard of care across various surgical disciplines. The past decade has seen a remarkable surge in the number of robotic-assisted procedures, with the count escalating from 80,000 in 2007 to over 1 million in 2018 (3)

Robotic surgery is characterized by unique features such as haptic feedback, precise movement scaling, tremor filtering, 3D high-definition vision, and camera integration, which endow surgeons with unparalleled control, comfort, and capabilities during procedures. This, in turn, leads to improved patient outcomes (4). Extensive research corroborates the advantages of robotic surgery, including smaller incisions, significantly reduced blood loss, lower transfusion rates, shorter hospital stays, and enhanced postoperative recovery compared to traditional open surgery (5)

The integration of robotic surgery into medical education has gained prominence, as it is considered pivotal for preparing future healthcare professionals to adapt to and utilize advanced surgical techniques. In this context, the inclusion of robotic surgery in undergraduate medical education (UME) programs has become imperative (6). Sheetz underlined the significance of introducing robotic surgery into UME curricula, emphasizing the need to equip the next generation of healthcare professionals with the skills required to employ these advanced surgical techniques (7). An Indian study stressed the unmet demand for robotic surgical training and the urgency to develop standardized curricula for robotic surgery training (8).

Furthermore, as technology continues to advance, robotic surgical simulation has emerged as a potent training tool. It can be leveraged by novice surgeons to acquire fundamental surgical skills and by experienced surgeons to practice complex procedures. Additionally, the potential of robotic surgery to reduce the prevalence of surgical site infections holds promise for the future of healthcare (9).

The global integration of robotic surgery into medical practice varies, influenced by multifaceted factors such as economic, infrastructural, and cultural dimensions. Therefore, it is of paramount importance to explore the knowledge and attitudes of medical students regarding robotic surgery in specific regions to optimize educational and healthcare strategies. Against this backdrop, this study stands as the first endeavor to investigate the attitudes and perceptions of Zambian medical students concerning robotic surgery. By evaluating the knowledge and attitudes of Zambian medical students, this research aims to offer valuable insights into how future healthcare professionals in Zambia perceive robotic surgery and how best to prepare them for the evolving landscape of surgical practice.

This cross-sectional study was conducted using a questionnaire from June to July 2021. The study was approved by the Ethics Review Board (ERB) of the Tropical Disease Research Center (TDRC) Ndola. The study participants consisted of medical students in Zambia. Inclusion criteria encompassed students of any gender and nationality who were enrolled in various academic years, including interns, and attended either private or governmental colleges. Exclusion criteria included students with incomplete data or those holding a previous certificate in computer science. Data collection was carried out using a web-based Google Form questionnaire in the English language. The questionnaire was adapted from previous research and was modified to align with the objectives of the study. It included sections for sociodemographic information, knowledge related to robotic surgery (4 questions), and attitudes towards robotic surgery (6 questions). The questionnaire was distributed to undergraduate medical students from different universities in Zambia via social media platforms. The minimal required sample size was calculated using a significance level (alpha) of 5%, a power (beta) of 20%, and degrees of freedom (df) set at 5. The study aimed to obtain a sample of 227 participants.

Informed consent for voluntary participation was obtained from all study participants. The purpose and objectives of the study were clearly outlined in the initial section of the questionnaire. To ensure confidentiality and anonymity, appropriate measures were put in place.

Data Analysis

Collected data were processed and entered into Statistical Package for Social Sciences (SPSS) version 22. To provide a comprehensive overview of the data, we employed descriptive statistics. In essence, this involved expressing quantitative variables in terms of their median values and interquartile ranges (IQR), while qualitative variables were conveyed through frequencies and percentages.

Additionally, study participants were categorized into two distinct groups based on their prior exposure to robotic surgery. We conducted rigorous statistical comparisons between these groups. For categorical variables, we utilized the Chi-squared test, and for continuous variables that exhibited abnormal distribution, non-parametric tests were employed. A stringent threshold for statistical significance was set, with results considered significant if the two-sided p-value was less than 0.05.

A total of 1,113 respondents participated in this study, 768 of whom provided complete responses as shown in Table 1 below. This corresponds to a response rate of 69%. The key findings from table 1, reveal that the study participants were predominantly male (59.50%) and concentrated in the 15-25 age group (86.30%). The majority were of Zambian nationality (94.50%), with the highest representation from Copperbelt University (52%). Participants were primarily in their second and third years of study, with varying academic performance levels. Most participants considered themselves computer literate (89.60%), while there was a strong interest in non-surgical fields (64.90%). A significant portion of participants had no prior exposure to robotic surgery (47.20%), whereas 7.40% had some exposure, and 45.40% expressed a desire to learn more about robotic surgery.

In Table 2 below, the key findings regarding medical students' attitudes towards robotic surgery are as follows: A significant portion of students personally accepted robotic surgery (38.80%), while 56.12% did not accept it, and 5.08% were uncertain. Regarding the perception of patient acceptance in Zambia, 51.82% believed that patients would accept robotic surgery, 42.58% were unsure, and 5.60% thought they wouldn't. Concerning the impact on surgical outcomes, 61.85% of students agreed or strongly agreed that using robots would improve outcomes, while 7.29% strongly disagreed and 7.42% disagreed. However, the belief that robots could make surgeons weaker and less professional was prevalent, with 62.24% agreeing, 24.61% somewhat agreeing, and only 13.15% disagreeing. Lastly, regarding Zambia's investment in robotic surgeries, 62.24% agreed or strongly agreed, while 24.48% disagreed or strongly disagreed, and 13.28% were uncertain.

Table 3 highlights key findings regarding medical students' knowledge about robotic surgery: Most students acquired their background information on robotic surgery from the internet (80.70%), with a smaller percentage gaining knowledge from personal experience (1.70%), relatives (10.50%), and other sources (3.50%). When asked to define robotic surgery, 45.60% of students correctly understood that robots perform surgery under the supervision of surgeons, while 31.60% believed surgeons perform surgery using robots in the operating room. In terms of the characteristics of robotic surgery compared to conventional open surgery, the majority (70.20%) correctly identified it as offering more safety and effectiveness, while 19.30% believed it had more serious side effects. Finally, 29.80% recognized minimally invasive surgery as the major advance aided by surgical robots, while 14.00% thought it was remote surgery, and 3.50% selected simple surgery.

In the analysis of students' attitudes towards robotic surgery, several key findings emerged as shown in Table 4 below. Gender did not significantly influence acceptance, with 58.7% of males and 60.6% of females being accepting. Age showed a notable difference, with 90.5% of those aged 15-25 accepting, compared to 84.9% of those aged 26-35 and 2% of those above 36. Nationality also played a role, as 95.6% of Zambian students accepted, compared to 93.6% of non-Zambian students. Year of study was a significant factor, with acceptance rates varying from 29.2% (second-year) to 31.2% (third-year). In terms of academic performance, students with GPAs below 3.5 showed 25.2% acceptance, while those with GPAs above 4.5 showed 26.4% acceptance. Computer literacy was significant, with 2.8% of those unsure, 3.3% of those not computer literate, and 90% of those who were computer literate accepting robotic surgery. Future field of interest and previous awareness about robotic surgery were also associated with acceptance, with surgical interests at 35.3% and non-surgical at 34.8% accepting, while 47.4% of students with no previous awareness accepted compared to 43.6% of those who were aware but wanted to know more, and 7.8% of those with no prior awareness did not accept. These results were statistically significant with p-values below 0.05, suggesting a meaningful impact on students' acceptance of robotic surgery.

Our study reveals that although only a quarter of Zambian medical students have prior exposure to robotic surgery, many of them exhibit a positive attitude and high expectations regarding this technological advancement. Nevertheless, there are concerns among students, particularly regarding patients' acceptance and the perceived risk of job displacement and diminishing professionalism due to the integration of robots into surgical practice.

A noteworthy observation is that even among students with prior background in robotic surgery, knowledge gaps persist, especially concerning the major advances facilitated by surgical robots. This knowledge deficit may be attributed to the limited presence of comprehensive surgical curricula in their medical schools, with the internet serving as their primary source of information. Additionally, the cultural context in Zambia may be contributing to their skepticism regarding the widespread acceptance of robotic surgery by patients. Nonetheless, a significant portion of students express optimism about achieving improved surgical outcomes and show support for Zambia's investment and expansion in the field of robotic surgery.

Our findings align with a systematic review of the literature, which underscores that the acceptance of robots by healthcare workers is influenced by factors such as perceived needs, prior exposure, age, education, personal views, and cultural background (10). Concerns similar to those expressed by our medical students have also been raised by other healthcare professionals who fear that the introduction of robots in the surgical field could disrupt their profession (11).

It is crucial to investigate whether students with more concerns about robotic surgery would be inclined to avoid pursuing surgical specialties, as their reservations could significantly influence their career choices. According to the expectancy-value theory, an individual's attitude toward an object is a function of their beliefs and evaluations concerning that object (7). In the context of medical students' attitudes toward robotic surgery, this theory suggests that their perception of robotic technology's value and their beliefs about its impact on the field are intertwined.

In our study, younger students with high GPAs who considered themselves technologically savvy displayed better knowledge of robotic surgery. This is consistent with the expectation that younger individuals are more open to emerging technologies. A survey among physicians and therapists also reported similar findings. The educational environment during surgical rotations, simulation training, and traditional curricula can significantly impact undergraduate students' career decisions (12). Unfortunately, some studies have identified deficiencies in structured robotic training curricula and found that robotic operating rooms do not always offer motivating learning environments for medical students (13).

It is imperative that Zambian medical students have access to curricular and extracurricular opportunities that encompass the clinical, technical, and ethical aspects of robotic technology in medical practice. These educational components should focus on providing students with essential knowledge and concepts related to robots without delving too deeply into technical details. Students should also be trained to recognize when it is appropriate to recommend robotic surgery for specific patients. A multidisciplinary, integrated approach to learning could be instrumental in achieving this goal.

Surgical training programs should also consider incorporating robotic training, as research has demonstrated the improved performance of individuals who undergo training in robotic surgery skills. Furthermore, assessing innate aptitude for psychomotor and manual manipulative skills, perhaps through exercises on virtual simulators, could complement the selection process for surgical trainees.

While our study provides valuable insights into the knowledge and attitudes of Zambian medical students and interns regarding robotic surgery, it is essential to acknowledge its limitations. Generalization of our findings is constrained by the absence of randomization and the heterogeneity of medical students from various colleges and sectors in Zambia. Furthermore, differences in training curricula and the availability of robotic surgery across Middle Eastern countries may limit the applicability of our results to other nations. Despite these limitations, our study highlights the urgent need to address the absence of standardized curricula for training medical students and interns in robotic surgery, ensuring that they are adequately prepared for their future careers in a healthcare landscape increasingly shaped by technological advancements.

Robotic surgery offers a solution to many of the limitations associated with conventional surgical approaches, providing benefits such as enhanced safety and effectiveness. However, concerns regarding its introduction in Zambia, including potential risks to professional integrity and patient safety, should be addressed through comprehensive education and training programs. The availability of learning opportunities that cover the clinical, technical, and ethical aspects of robotic surgery will empower medical students and interns to make well-informed decisions and prepare them for the evolving landscape of healthcare.

This study sheds light on the attitudes and knowledge of Zambian medical students toward robotic surgery. Despite limited exposure to robotic surgery, students exhibit a positive attitude and high expectations for its role in the healthcare landscape. Nonetheless, concerns persist, primarily related to patients' acceptance and apprehensions about the impact of robotics on their profession.

These findings emphasize the urgent need for standardized curricula and educational opportunities in robotic surgery for medical students. Bridging the knowledge gap and addressing concerns will enable aspiring healthcare professionals in Zambia to make informed career choices and contribute to the integration of robotic technology into surgical practice. As technology continues to shape the future of healthcare, preparing the next generation of healthcare providers is paramount.

Authors contribution
CH, EM, MZ and NEM conceived and designed this study. EM and CH drafted the manuscript. NEM analyzed the data and revised the manuscript. All authors approved the final version.

Ethics approval and consent to participate
Ethics approval for this study was obtained from the Tropical Disease Research Center, Ndola, Zambia. All methods were carried out in accordance with relevant guidelines and regulations. Informed consent was obtained from all subjects and/or their legal guardian(s).

Consent for publication
Not Applicable

Competing interests
The authors declare that they have no conflict of interest.

Funding
The authors declare that there was no funding for this study

Availability of data and materials
The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Acknowledgments

Not applicable

George EI, Brand TC, LaPorta A, Marescaux J, Satava RM. Origins of Robotic Surgery: From Skepticism to Standard of Care. JSLS. 2018 Oct 1;22(4).
Lane T. A short history of robotic surgery. Ann R Coll Surg Engl. 2018;100:5–7.
Patel S, Rovers MM, Sedelaar MJP, Zusterzeel PLM, Verhagen AFTM, Rosman C, et al. How can robot-assisted surgery provide value for money? BMJ Surgery, Interventions, &amp; Health Technologies [Internet]. 2021 Feb 1;3(1):e000042. Available from: http://sit.bmj.com/content/3/1/e000042.abstract
Chen IHA, Ghazi A, Sridhar A, Stoyanov D, Slack M, Kelly JD, et al. Evolving robotic surgery training and improving patient safety, with the integration of novel technologies. Vol. 39, World Journal of Urology. Springer Science and Business Media Deutschland GmbH; 2021. p. 2883–93.
Perez RE, Schwaitzberg SD. Robotic surgery: finding value in 2019 and beyond. Vol. 4, Annals of Laparoscopic and Endoscopic Surgery. AME Publishing Company; 2019.
Al-Fouzan R, Al-Ajlan S, Marwan Y, Al-Saleh M. Factors affecting future specialty choice among medical students in Kuwait. Med Educ Online. 2012;17:1–7.
Sheetz KH, Claflin J, Dimick JB. Trends in the Adoption of Robotic Surgery for Common Surgical Procedures. JAMA Netw Open. 2020;3(1).
Gupta A, Chennatt J, Singla T, Rajput D, Bindal V. Training and credentialing in Robotic Surgery in India: Current perspectives. Vol. 18, Journal of Minimal Access Surgery. Wolters Kluwer Medknow Publications; 2022. p. 497–504.
Mehta A, Cheng Ng J, Andrew Awuah W, Huang H, Kalmanovich J, Agrawal A, et al. Embracing robotic surgery in low- and middle-income countries: Potential benefits, challenges, and scope in the future. Vol. 84, Annals of Medicine and Surgery. Elsevier Ltd; 2022.
Huang R, Li H, Suomi R, Li C, Peltoniemi T. Intelligent Physical Robots in Health Care: Systematic Literature Review. Vol. 25, Journal of Medical Internet Research. JMIR Publications Inc.; 2023.
Heinig MJ, Follett JR, Ishii KD, Kavanagh-Prochaska K, Cohen R, Panchula J. Barriers to compliance with infant-feeding recommendations among low-income women. J Hum Lact. 2006 Feb;22(1):27–38.
Ravi K, Anyamele UA, Korch M, Badwi N, Daoud HA, Shah SSNH. Undergraduate Surgical Education: a Global Perspective. Indian Journal of Surgery. 2022 Apr 1;84:153–61.
Greenberg AL, Syed SM, Alseidi A, O’Sullivan PS, Chern H. Robotic training for medical students: feasibility of a pilot simulation curriculum. J Robot Surg. 2023 Jun 1;17(3):1029–38.

Table 1. Characteristic data of the participating medical students.

		Count	Frequency
Gender	Males	457	59.50%
	Females	311	40.50%
Age	15-25	663	86.30%
	26-35	81	10.50%
	>36	24	3.20%
Nationality	Zambian	726	94.50%
	Non-Zambian	42	5.50%
Institution	Copperbelt University	399	52%
	University of Zambia	207	27%
	Mulungushi University	54	7%
	Apex University	43	6%
	Eden University	37	4.30%
	University of Lusaka	28	3.70%
Year of Study	Second year	234	30.50%
	Third year	311	40.50%
	Fourth year	56	7.20%
	Fifth year	143	18.60%
	Sixth year	12	1.60%
	Intern	12	1.60%
Previous Academic Year's GPA	<3.5	197	25.70%
	3.5-3.9	313	40.70%
	4-4.5	137	17.80%
	>4.5	121	15.80%
Are you Computer Literate	I don't know	23	3%
	No	57	7.40%
	Yes	688	89.60%
Future field of interest	Surgical	269	35.10%
	Non-surgical	499	64.90%
Previous awareness about robotic surgery	No	362	47.20%
	Yes	57	7.40%
	No but I want to know	349	45.40%

Table 2. Medical students’ attitude towards robotic surgery

		Count	Frequency
Do you personally accept robotic surgery?	Do not know	39	5.08%
	Do not know	39
	No	431	56.12%
	Yes	298	38.80%
Do you think the patients in Zambia will accept robotic surgery	Do not know	43	5.60%
	Do not know	43
	No	327	42.58%
	No	327
	Yes	398	51.82%
Do you think using robots will improve surgical outcomes?	Strongly disagree	56	7.29%
	Disagree	57	7.42%
	Do not know	180	23.44%
	Agree	347	45.18%
	Strongly agree	128	16.67%

Do you think using robots could make surgeons weak and reluctant with less professionalism and experience?	No	101	13.15%
	No	101
	Somewhat	189	24.61%
	Yes	478	62.24%
Do you think that Zambia should invest and expand the Robotic Surgeries	Strongly disagree	67	8.72%
	Disagree	121	15.76%
	Do not know	102	13.28%
	Agree	293	38.15%
	Strongly agree	185	24.09%

Table 3. Medical students’ knowledge about robotic surgery

		Count	Frequency
Source of background in robotic surgery	Internet	46	80.70%
	Internet	46	80.70%
	Medical curriculum	2	3.50%
	Personal experience	1	1.70%
	Relatives	6	10.50%
	Workshop	0	0.00%
	Others	2	3.50%
What is robotic surgery?	Do not know	3	5.30%
	Do not know	3	5.30%
	Robots perform surgery in the operating room.	10	17.50%
	Robots perform surgery under supervision of the surgeons in the operating room.	26	45.60%
	Surgeons perform surgery using robots in the operating room.	18	31.60%
In comparison to conventional open surgery, what are the characteristics of robotic surgery?	Do not know	1	1.70%
	Do not know	1	1.70%
	Larger incisions and more local side effects	5	8.70%



	More safety and effectiveness of surgeries	40	70.20%
	More serious side effects	11	19.30%
Which of the following is the major advance aided by surgical robots?	Do not know	30	52.60%
	Do not know	30	52.60%
	Minimally invasive surgery	17	29.80%


	Remote surgery	8	14.00%
	Simple surgery	2	3.50%

Table 4: Comparison of Students' Acceptance of Robotic Surgery with and without Background in Robotic Surgery, Analyzing Various Demographic and Academic Factors

Variable	With Robotic Surgery (%)	Without Robotic Surgery (%)	p-value
Gender
Males Females	58.7	60.6	0.127
Males Females	41.3	39.4	0.127
Age
15 - 25 years 26 - 35 years > 36 years	90.5	84.9	0.052
	7.9	13.1
	1.6	2
Nationality
Zambia Non-Zambian	95.6	93.6	0.071
Zambia Non-Zambian	4.4	6.4	0.071
Year of Study
Second Third Fourth Fifth Sixth Intern	29.2	31.2	<0.001
	40.6	40.5
	6	8.3
	19	18.4
	2.2	1.6
	3	0.9
Previous Academic Year's GPA
<3.5 3.5 - 3.9 4 - 4.5 >4.5	25.2	26.4	0.125
	39.6	40.4
	17.3	18.4
	17.9	14.8
Computer literacy
I don't know No Yes	2.8	3.3	<0.001
	6.2	9.3
	90	87.4
Future Field of Interest
Surgical Non-surgical	35.3	34.8	0.159
Surgical Non-surgical	64.5	65.2	0.159
Previous Awareness about Robotic Surgery
No Yes No but I want to know	47.4	43.6	<0.001
	7.8	6.6
	44.8	49.8

No competing interests reported.

Download PDF

Editorial decision: Revision requested
21 Mar, 2024
Reviews received at journal
20 Mar, 2024
Reviews received at journal
19 Mar, 2024
Reviewers agreed at journal
12 Mar, 2024
Reviewers agreed at journal
11 Mar, 2024
Reviewers invited by journal
11 Mar, 2024
Editor assigned by journal
08 Mar, 2024
Editor invited by journal
04 Nov, 2023
Submission checks completed at journal
04 Nov, 2023
First submitted to journal
04 Nov, 2023

You are reading this latest preprint version

Zambian Medical Students’ Attitude Towards Robotic Surgery: A Cross- Sectional Survey

Status:

Version 1

Abstract

Background

Methods

Results

Discussion

Conclusion

Declarations

References

Tables

Additional Declarations

Status:

Version 1