Laparoscopic Cholecystectomy Re- Education Course

Using advanced medical technology, The Advanced Medical Technology Institute (AMTI) seeks to implement innovative medical education by using objective-based skill acquisition with standardized training protocols for surgeons who perform minimally invasive surgery on patients with common bile duct injuries. These laparoscopic procedures, when performed poorly, cause great harm to patients; the financial damage it causes doctors and health care institutions also is often severe. AMTI, under the leadership of one the nation's most experienced minimally invasive surgeons, will deveop a model training program that will provide standardized skill acquisition for five physicians that will assure mature proficiency of this procedure, which has been absent from the art form of surgery and is long overdue. This training program -- which will utilize distant learning, onsite training, and post training mentoring -- will provide surgeons with a solid foundation to decrease the risk of committing injurious complications and, thereby, enhancing patient safety.

Dr. James “Butch” Rosser was Director of the Yale Endo-Laparoscopic Center and Associate Professor at Yale’s School of Medicine. Dr. Rosser is one of the world's leading authorities in the field of minimally invasive surgery, as well as computer assisted medical training. He is a recognized leader in the field of remote care for patients (telemedicine). His pioneering technique of remotely guiding surgeons with little or no experience to successfully perform advanced laparoscopic procedures (telementoring) has afforded him recognition as a “Cybersurgeon". Dr. Rosser is founder of the non-profit organization, Modern Day Miracle, Inc., which seeks to enable underprivileged countries to participate in advanced developments in laparoscopic surgery. Dr. Rosser is the author of one standard and ten CD-ROM electronic books and has published numerous articles in medical journals.

Hypothesis:
Common bile duct injuries cause great harm to patients and the financial damage it causes doctors and health care institutions is often severe. Similar problems occur from laparoscopic cholecystectomies and the laparoscopic Nissen fundoplication. Instead of revoking a surgeon’s laparoscopic privileges, we propose to provide strenuous and standardized training to “rehabilitate” them through a remedial education program. This training, which will involve pre-class preparation, an on-site class, and a telementored guide for student's next surgery, is a method of training that we believe will ensure the well being of patients with this common medical problem. We believe that this model can be replicated and advance standardization for surgeons who provide minimally invasive procedures.

Methodology:
More and more surgeons are performing advanced minimally invasive surgical techniques, but patient quality assurance has not yet been fully attained. There has been a great debate as to why this “failure to thrive” phenomenon exists. There is no one answer, but the lack of availability of widespread mentoring and preceptoring in order to guide surgeons through their initial experiences is very significant. Similarly, this is true for physicians once they begin to practice this surgery and find themselves in need of remedial skills. Physicians that have a documented or perceived quality assurance problem with a minimally invasive procedure currently experience disciplinary action without having available a remedial education option. Concerns are primarily related to the common bile duct injuries and laparoscopic cholecystectomy, as well as other emerging procedures such as the laparoscopic Nissen fundoplication have similar quality concerns.

Dr. Rosser has designed an innovative objective based skill and clinical judgment maturation program. He first developed and tested this program on-site at Yale Laparoscopy, which he founded before coming to Beth Israel Medical Center. The skill component he plans to use is his internationally renowned "Top Gun Laparoscopic Skill Boot Camp." This training program has been featured at the American College of Surgeons in 1996 and 1997, about which articles have been published in the Archives of Surgery, Scientific American and CBS news. He uses a micellular operative technique instructional strategy that establishes procedural tendencies to avoid trouble. Operative technique and decision making is then challenged by Objective Based Clinical Competency Evaluation Scenarios (OCCES). This modern knowledge transfer tactic uses digitized video of actual clinical cases with anatomic, instrument selection, a technique that challenges physicians to answer questions instantly with an interactive keypad system. This places the participant in a simulated real-time clinical situation where they are challenged to make immediate medical decisions. At the end of the exercise, physicians are judged by the number of questions they answer right and wrong. This gives a percentage score that can be used to compare the students to their peers, or as a yardstick to evaluate their own progress.

Before students attend the on-site Top Gun program, they will receive Computer-Based Instruction (CBI) via the Internet and a CD-ROM prepared by Dr. Rosser. Using CD-ROMs as the storage medium offers consistency and increased cognitive knowledge transfer rates. The multimedia format allows the presentation of a sophisticated, deconstructed review of the procedure. This review is reinforced with moving and still images, text, and interactive gaming (entry level simulation) challenges. This instructional modality is not designed to assist and enhance the educational process. This type of computer based training, which features a high level of entertainment, allows participants to learn with greater enjoyment. This educational packaging array provides a vehicle to achieve more effective distant education.

The on-site Top Gun program course is five days long. Dr. Rosser wishes to test this model with a small class size (five-person limit) that will assure a large amount of intimate attention and provide AMTI staff with the ability understand the most effective way to replicate this training program more broadly. This course will consist of extensive inanimate lab drills and intracorporeal suturing training, as well as computer-assisted teaching by an instructor. Intracorporeal suturing is necessary to accomplish a laparoscopic Nissen fundoplication and many other advanced procedures. Subsequently, the instructor will review this technique with the surgeon, which the surgeon will have had an opportunity to study before attending the class. This course will expand surgeons' procedural options by exposing them to laparoscopic common bile duct explorations, in addition to suturing and anastomotic techniques.

This will provide the ultimate safety net for patient quality assurance with the establishment of these options to the surgeon’s armamentarium. This is the standard in open surgical procedures, and should be the standard in a minimally invasive setting. At the end of the course, the surgeon will have accumulated a mass of objective based data, which confirms the establishment of enhanced skill and judgment capabilities.

When the surgeon returns home and is ready to conduct his/her next laparoscopic common bile duct, Dr. Rosser will be there via telemedicine to mentor the surgeon. Telementoring is a sophisticated telemedicine application that stretches current educational, clinical, and technological capabilities to their limit. It involves the remote guidance of a procedure where the student has limited or no experience with the featured technique, but to deploy this promising application successfully, specific training methodology must be utilized. These include: pre-procedural assessment and enhancement of laparoscopic surgical skills, telementoring simulation, establishing a standardized approach to the procedure, creating an adequate communication link, and executing the procedure while aided by teleguidance tools and applications. Using telemedicine -- which affords a real-time human connection via a two-way interactive video communication -- between the surgeon operating (and the patient being operated) and Dr. Rosser, who can observe from an AMTI platform. Participants are able to see and hear one another much like a face-to-face encounter; laparoscopic monitors of the patient's internal organ also can be observed from a distance. This concept has gained recent notoriety because of great advances in telecommunications and increased cost effectiveness associated with its utilization.

In this way, the physicians trained will be assured of achievement from a remedial education program that contributes to patient health.

At the end of the course, the instructor will submit a letter to each participant's Chief of Surgery. It will include the results of the following:

• ___Cognitive testing
• __ Video testing (surgeons must submit 3 videos prior to course)
• ___Basic laparoscopic skills evaluated by comparison with our database
• ___Animal lab videos from during course
• ___Judgment evaluation by OCCES
• __ Laparoscopy under Local Anesthesia