Curriculum matrix development for a hepato-pancreato-biliary robotic surgery fellowship

The robotic platform in hepato-pancreato-biliary (HPB) disease is starting to gain popularity owing to the advantages it technically can offer over conventional and open techniques. Robotic surgery overcomes laparoscopic limitations through optical magnification, 3-D depth perception, augmented instrument articulation, and greater precision with suture targeting.1 These benefits have brought robotic surgery to the forefront as an attractive and, more importantly, inclusive opportunity for a minimally invasive approach to complex and benign HPB disease. With studies correlating technical performance and surgeon volume with postoperative outcomes, the importance of effective training is paramount.2^,3 Unfortunately, even new graduates are lacking comfort and skill in the robotic arena owing to considerable disparities across education and technical experience of robotic exposure during training. While there have been improvements over the last decade in regards to resident participation in robotic cases, formal curricula remain variable and lacking.4^,5 And, unfortunately, these curricula often limit participation to mainly observation, resulting in inexperienced graduates without the appropriate skill set to operate safely while unaccompanied.6 As a consequence, skill development in this area among attending surgeons depends on the needs of the professional community and surgical societies. As such, a role for robotic fellowships has emerged for comprehensive and formalized training. With no current evidence-based approaches for constructing a curriculum for an HPB robotic surgery fellowship, we describe here our technique in creating a structured curriculum at the Carolinas Medical Center, Atrium Health.

Our HPB robotic surgery fellowship is a 12-month commitment that lies between a postgraduate education level and continuing professional development. As such, the curriculum is customized to meet individual needs and is designed to ensure fellows achieve a minimum level of competence, professionalism and patient safety7 (Table 1). Thus, there are 2 proposed pathways: pure clinical, and clinical and research.

The pathway model addresses content overload and allows each to concentrate on modules or competencies that may be more important in future practice. The essential technical competencies are incorporated into 8 core modules that are required for both pathways. The modules are based on the adult learning theory that emphasizes problem-based learning and active trainee participation.8 Over the last several decades, medical education has shifted from teaching to learning owing to this theory; however, it is not only learning theories that influence a curriculum design, especially on a postgraduate level.9 The trainee should also be able to identify and solve clinical problems in the real world with minimal to no supervision. Consequently, the medical curriculum at a postgraduate level should be problem-based and integrate knowledge, skills, and attitudes. In a word, it should be made for practice.10 Thus, each of these proposed modules follow the principles of adult learning theory and are problem-based.

The curriculum begins with 4 core modules that follow a spiral model (Table 2).3 Module 1 involves an introduction to robotics, discussing technology and equipment to allow for efficient use and appropriate troubleshooting. A robotic skill simulator is used to familiarize the trainees, and Module 2 follows with dry laboratory simulation to practise set-up basics to suturing anastomoses. The simulations are recorded to assess learning curves and areas for improvement. The next 3 modules focus on completion of simple index procedures, such as cholecystectomies, or core parts of larger complex cases while simultaneously advancing work in the dry laboratory (Figure 1). As competence increases, more complex procedures, such as pancreaticoduodenectomies and major hepatectomies, are taught in the subsequent core modules. After completion of the core modules, an additional 4 elective modules are required. Vertical integration (between basic and clinical science) is achieved within each module and, depending on caseload, bedside modules (3, 5 and 7) and console modules (4, 6, 8, 9 and 10) may run in parallel.11

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Fig. 1

Index robotic hepato-pancreato-biliary (HPB) surgical procedures performed at Carolinas Medical Center. CCY = cholecystectomy; LN = lymph node.

This curriculum focuses primarily on incorporation and importance of the cornerstone of intended learning outcomes (ILO), which is competence in performing hepatic, pancreatic and biliary operations. However, other important objectives, such as problem solving, researching, socialization and professionalism, are also incorporated and are considered equally important. These inform fellows of what they should achieve, guide teachers to what they should teach, and clarify assessment processes. All modules are structured to align each ILO with an appropriate teaching/learning activity and a meaningful assessment process.

As our intention is to produce highly specialized HPB surgeons who practise in a tertiary level hospital, teaching and learning activities include substantial operative exposure and in-house and outpatient treatment formulations. Each module, along with the operative objectives, focuses on appropriately planning and presenting a procedure. As a variety of teaching methods are needed for effective learning, every attempt was made to include more than 1 teaching/learning activity for each desired ILO. This is especially true for the core modules, where 67% of the ILOs (12 of 18) are aligned to more than 1 activity; in the elective modules, 27% of the ILOs (12 of 44) are aligned to more than 1 activity.

Evaluation is incorporated into the curriculum from the beginning (Figure 2). Many assessment tools are used to encompass data, analysis, judgments and interventions.12 The evaluation plan utilizes criteria provided by the major HPB surgery governing bodies. The focus is shifted mainly to the first (learner’s satisfaction), second (knowledge acquisition) and third (knowledge implementation) levels of evaluation. This promotes habits of improvement by engaging fellows with challenging clinical cases and via quality-improvement and patient-safety initiatives. It supports formation of professional identity by offering feedback, reflective opportunities and multi-aspect assessments.13

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Fig. 2

Template for construction of a cumulative summary (CUSUM) learning curve. ERCP = endoscopic retrograde cholangiopancreatography; N/A = not applicable; PD = pancreatic duct.

In concert with the competence-based education idea, the cornerstone ILOs aim to produce highly specialized surgeons who are able to perform simple and complex HPB operations.14 To this effect, all core modules contain an ILO described by the phrase “perform an operation.” The HPB surgery governing bodies define the key steps of all relevant operative procedures and suggest the minimum number of each procedure that should be performed to obtain the competence required to become an independent performer. However, these standards exist only for open classic laparoscopic HPB procedures. The learning curves for performing index robotic HPB surgical procedures are largely unknown and could vary substantially from trainee to trainee. For that reason, we incorporated cumulative summation (CUSUM) to plot the learning curve of each procedure for each individual trainee (Figure 2).15 Adopting ILOs assessed by CUSUM analysis might require less time to achieve competence.16 In addition, this type of individualized analysis allows identification of specific deficiencies in technical performance of each trainee, leading to suitable interventions for improvement. The curriculum employs both vertical and horizontal integration of disciplines to link theory to practice and to provide a “real” learning environment. The combination of core with various elective modules provides a comprehensive approach to building an HPB robotic surgery personality — an endeavour that requires interprofessional collaboration.

The emergence of robotic surgery into general and specialized surgical practices, including HPB surgery, continues to expand and holds considerable promise for future development. However, residencies and HPB fellowships provide an array of exposure to robotic surgery, resulting in inconsistent technique and ability among HPB surgeons. Often, the only structured training received is through the fundamentals of robotic surgery, designed to deliver only basic knowledge and skill. Thus, the training and exposure required to perform complex procedures is often lacking and, as such, it is important that robotic fellowships be created to allow for an appropriate transition of autonomy and acquisition of a safe and effective skill set. Our curriculum was developed and implemented for this exact purpose. We encourage any individuals who seek to widely incorporate robotics into their practice to seek out or create similar curricula that can provide the appropriate problem-based learning and complex skill acquisition.

• Accepted February 4, 2021.