A total of ten expert robotic surgeons, working across the Intuitive Surgical® (n = 9) and Cambridge Medical Robotics®(n = 1) platforms participated in the focus group. The majority of participating surgeons were expert surgeons having been practicing consultant surgeons for a significant period of time, with over 60% practicing as a robotic trainer for over 6 years, with significant annual volumes of individual robotic cases (Table 1). Half of the proctors had undertaken a specific robotic train the trainers’ course, with a third of proctors having a formal educational qualification (i.e. diploma or certificate of medical education). Most proctors were considered to be high volume proctors having proctored over 30 surgeons (n = 6, 60%) and undertaking more than 20 proctored cases per annum (n = 6, 60%).

Table 1 Proctor characteristicsThemes

A total of 180 unique codes were categorised into eight themes. These themes are proctor selection, proctor responsibilities, proctored training, accreditation, challenges, industry–proctor partnerships, emerging technologies, and network and support. These themes are interlinked and reflect the complexity of robotic proctoring within the UK (Fig. 1).

Fig. 1

Themes relevant to robotic proctoring

Proctor selection

Proctor selection is currently undertaken and driven by industry partners and representatives, based on arbitrary criteria. The key considerations at the time of selecting proctors include number of robotic cases performed, robotic case-mix, overall robotic platform and clinical experience and co-existing industry relationships. Robotic surgeons who are over the learning curve and within the proficiency phase are generally selected to be proctors.

‘…you have to be over the learning curve. The learning curve is around somewhere between 40 to 80 cases or 100 seems to be a safe figure... you have to have seen it all. You have to be comfortable with different techniques and then you can become a proctor’.

There are no set selection criteria for proctors due to the evolving and dynamic clinical landscape of robotic surgery, with expanding clinical and operative indications coupled with new and emerging platforms coming to market. The increase in acquisition of new robotic systems and the associated need to train new surgeons, coupled with the limited pool of available robotic proctors, leads to broadening the selection criteria for proctors to fulfil the overall demand.

‘...there is a huge uptake in robotics. The number of proctors is limited’

Proctor responsibilities

The industry appointed proctors assume the role of ‘robotic trainer’ to established consultant surgeons, with the main emphasis being of platform-related training. The overall aim is of peer-to-peer knowledge transfer regarding the use of the robotic platform, its utility, its key advantages, and appropriate tips and tricks. The aim of robotic proctoring is not to provide clinical or operative training. Therefore, the overarching responsibility of the proctor, from an industry perspective, is to ensure safe use of the robotic technology.

However, the proctors perceive their responsibilities to be broader than just platform related training, and assume they are three-fold; clinical, patient safety and training. The proctors pride themselves on delivering high quality operative training to enhance overall clinical care and prioritise patient safety. During proctored cases there is often an exchange of operative approaches, strategies and ideas between proctors and the training surgeon. The role of the proctor is not to dictate intraoperative strategy, guide operative decision-making or to perform component parts of the operation. However, there are occasions, whereby the training surgeons’ operative knowledge and/or ability do not allow them to complete a complex operative task on the robotic platform i.e. specific anastomotic technique. In these relatively rare instances, proctors do not feel it is appropriate for them to intervene operatively, as this is beyond their remit. However, in the interests of patient safety, they may encourage the training surgeon to assume their default operative approach i.e. laparoscopic or open surgery.

‘If you feel that the person who's being trained on the system is putting the patient at risk by persevering with using that system because they cannot complete the operation (robotically) or perform a robotic technique, then they should convert to the technique that they know whether or not that's open or laparoscopic. And then your responsibility is to ensure patient safety…its taken me a while to come to terms with where my role in these things but I think for self-preservation, you have to be quite clear about it, your job is not to perform the operation or tell them to how to do something they are not competent to perform’.

Proctored training

Robotic proctoring is unique in that it involves delivering platform related training to established surgeons, who have been accredited through a national training programme and have an independent clinical practice. Training is often delivered in a variety of forms from case observations, dry and wet labs and proctored training on live cases. There is no formal competency based ‘curriculum’ or assessment underpinning proctored training. Training styles vary from proctor to proctor based on their individual experience and expertise and relationship with the training surgeon. Some proctors prefer to take a ‘hands-on’ approach, performing key components of the operation to demonstrate robotic technique, whereas others prefer to teach platform related skills alone. Some proctors meet the training surgeon prior to proctoring to establish shared objectives and develop an understanding of the training surgeons’ needs. Occasionally, the proctors maintained a relationship with training surgeons following the completion of proctoring to provide advice and guidance over a longer timeframe. Training styles and approaches were often personalised to the capabilities, skills and needs of the training surgeon.

‘I find it very difficult when you are there to just have a verbal communication… sometimes you have to set it up for them to allow them to progress...and that's the job that you show them some tips and tricks and the moves that they can do to get from A to B, so keeping hands off is very difficult for me.’

‘We should accept that the people we are teaching are competent laparoscopic surgeons who are moving to a robotic platform. And so, my view is if that we are teaching the platform not the operation.’

There are no specific training or educational requirements to become a robotic proctor, with no requirement for a formal qualification in training. Proctors tend to demonstrate interest in education and training, they have usually held posts as clinical or educational supervisors, and have significant enthusiasm for robotic training and education. Proctors are not required to complete feedback forms, have periodic mandatory performance reviews or go through a ‘revalidation’ process. Although there is no formal process for feedback and assessment, the majority of proctors collect their own clinical and proctoring data to ensure quality assurance.

‘Quality assurance comes from our outcome data and your feedback from your trainees, this is collected for all (proctored) cases’.

The proctors often find their scope of training extends beyond formal industry-based training, as they often provide training in-house to consultant colleagues or as part of wider fellowship training programmes. Their position as an industry appointed proctor often allows them to have a wider sphere of influence within the surgical community in the delivery and direction of robotic training due to their overall experience.

Accreditation

Proctors believe their role is to ensure the safe dissemination of robotic technology through high quality training. As part of this process, they are expected to ‘sign off’ and accredit surgeons as being competent. Accreditation is a complex process, which ensures surgeons are appropriately trained and recognised for reaching a particular standard. The difficulty with ‘sign off’ and accreditation with the proctoring process is the small number of supervised cases i.e. 1–5 and the types of cases supervised. This is further complicated when there are multiple proctors training a single surgeon, leading to a lack of continuity in training standards and assessment. Difficulties in the sign off process arise when the basic robotic platform related competencies have been achieved, however, the overall robotic operative standard is considered to be suboptimal. In these instances, the proctors occasionally find it difficult to sign off training surgeons as individual entities responsible for robotic training and would like broader professional sign off. Overall, there is a lack of a standardised framework for sign off and accreditation for robotic surgery.

‘…we've been asked to write an email to say that we are signing off for them to do the procedure. But I find this a really difficult and hard task because often I have only seen a few cases, and they are all different procedures…’

Proctor challenges

Proctors face a unique set of challenges, which are environmental, interpersonal, clinical, ethical, and medicolegal. The environmental challenges are related to working within an unfamiliar clinical setting, with an unknown theatre set up and team, and limited knowledge and understanding of the training surgeons’ operative capabilities and prior experience. Poor case selection by the training surgeon often compounds these challenges. Interpersonal challenges are related to differences in opinion, personality clashes between proctors and training surgeons, and the delivery of feedback. The lack of an objective and standardised process to deliver open and honest feedback to training surgeons can be challenging. Clinical challenges include complex or inappropriate case selections, unexpected intraoperative complications, and proctors needing to maintain their own clinical practice and balancing this with proctoring. The ethical and medicolegal challenges relate to patient safety, avoiding clinical harm, and unclear boundaries regarding overall responsibility for the patient. At present there is no clear guidance with regards to this, which can lead to proctors feeling uncertainty regarding their medicolegal position when difficult situations arise, with no official organisational or regulatory body to seek guidance from.

‘The challenges are all significant...you go to an environment which is alien. The case selection is poor…the trainees don’t have enough overall colorectal experience or volume….and then there are issues that you have there with some personalities.’

Industry–proctor partnerships

Overall, the proctors view their relationships with industry partners as positive, welcoming the opportunity to teach and train consultant colleagues, develop new training skills and in having a broader impact on the adoption of robotic technology beyond their own hospital. This partnership between proctors and industry partners is considered to be essential in disseminating high-quality, peer-to-peer robotic training and knowledge transfer to novice surgeons. The proctors are broadly transparent with their relationship with industry partners and are happy to disclose this as appropriate.

The robotic proctors are selected and remunerated by industry partners to deliver platform related training. Given the financial relationship between the proctor and the robotic platform provider, the priorities and objectives of both parties are expected to align. Often, the robotic industry partners have already established a relationship with the hospital, prior to the commencement of proctoring, having been involved in the procurement process, and occasionally, in the selection of surgeons. There is no predefined selection criteria regarding institutional or individual surgeon volume or expertise prior to commencing a robotic colorectal program, which is often guided by the host hospital and relevant clinical leads. The proctors have no involvement in this process. The role of proctors is to execute the final part of the initial implementation process, by training the pre-selected surgeons. This can occasionally lead to difficulties, when the pre-selected surgeons are considered by the proctor to not be suitable for robotic training or to not have achieved an acceptable surgical standard.

Occasionally, there is an ‘expectation’ for proctors to showcase and demonstrate all key components and instruments associated with the robotic platform and promote these irrespective of the cost or financial implications. This can sometimes lead to a misalignment in objectives between proctors and industry due to differing priorities. The proctors believe they should be able to transfer their knowledge and skills to the training surgeon based on their own experience and robotic expertise and should not be expected to ‘sell’ or ‘showcase’ instruments not routinely used in their own practice.

‘you have to work out where your loyalty lies… there have been instances when I’ve been expected to open five or six different instruments…but industry expects you to use X-Y instruments so that you can promote them…’

Emerging technologies

Robotic surgery is an evolving landscape with new platforms and technologies coming to market. This leads to further complexities for proctors as they navigate delivering training across new platforms and in new ways. Remote telementoring has been employed in robotic surgery to help deliver platform based and operative training. This is associated with unique challenges, including geographical location, communication, technological challenges, and patient safety. Delivering of remote telementoring must be carefully considered with this modality of training reserved for training surgeons with prior experience with the robotic platform and not for index cases, or for complex cases, whereby additional surgical support is considered valuable.

‘We had to think about how we were going to deal with the trainee including how you teach on the system, especially when dealing with telementoring part, especially for the difficult cases and training and how you were going to do this safely.’

The introduction of new platforms into the clinical arena will pose unique proctoring challenges, due to the limited overall experience with the new platform, unique technologies, and differing system designs i.e. modular versus mainframe. Proctor selection for new platforms is likely to be based on limited experience with the new platform, early adoption of the new platform, or established robotic surgeon on a different platform. Early adopters of new robotic platforms should be developed as robotic proctors of the future by sharing their experience and facilitate the onward dissemination of new technology. Established robotic proctors and surgeons should demonstrate agility in learning the intricacies and mechanics of new systems to help develop the robotic landscape further. Understanding the platform-to-platform interactions by working across multiple robotic systems will provide unique and valuable insights to the robotic surgical community and requires early adopters and experienced proctors to work together in tandem.

‘…he was an early adopter, and has practiced quite early on without having done hundreds and hundreds of cases... he knows how to operate and how to use the equipment…so I think he should be developed as a proctor for the new system…’

‘We should be willing to learn when a new platform comes up. You may be an expert on robotics and a particular system, but when the system changes completely, you may have to unlearn certain things that you've done and be humble enough to learn the new technique.’

Network and support

There is a small pool of established robotic colorectal proctors within the United Kingdom, consequently, an informal network has developed to provide support and advice. The proctors use this network to discuss challenging cases, difficult proctoring sessions or when specific medicolegal issues may have arisen. Established proctors tend to provide informal mentorship and support to new and upcoming robotic proctors. There are several industry run forums for proctors to exchange ideas, collaborate and learn new teaching/training techniques. Overall, the proctors feel relatively well supported by robotic industry partners. There is, however, a sense of feeling of a lack of support from organisational bodies, such as surgical societies and associations. This is mainly due to the lack of guidance and regulation regarding the medicolegal and ethical aspects of proctoring.

‘I have spent many hours speaking to other proctors about proctoring, cases, outcomes etc.….it is very useful.’