Practice operating without risk

Would you let a trainee surgeon practice a procedure on your body during an operation? Most people are likely to answer the question in the affirmative, if at all, with some skepticism. But in the past, training depended on the willingness of patients: In the "see one, do one, teach one" model, they learned the craft by first observing a procedure, then performing it themselves, and finally demonstrating it to fellow students. Bruno Schmied of the Kantonsspital St.Gallen (KSSG) says that this is no longer the case. "The approach comes at the expense of patients being put at risk," says the chief of surgery. In addition, assisting costs a lot of time. "Surgery that is assisted takes 20 to 30 percent longer," Schmied explains. "That goes into the money immensely - because the operating room is the most expensive place in a hospital."

Innosuisse flagship project

As one of three clinical partners, the KSSG is leading the "Proficiency" project launched in 2022, which will comprehensively modernize surgical training in Switzerland. Hand in hand with a comprehensive update of the corresponding curricula, continuing education courses for aspiring medical specialists will be completely redesigned with state-of-the-art simulation technologies such as virtual reality (VR) applications, augmented reality (AR) glasses or high-end simulators by the beginning of 2025. In addition to the three hospitals, several companies as well as the ZHAW, ETH Zurich and the University of Zurich (Balgrist) are involved in the Innosuisse flagship project, which is being funded by the national innovation agency with 12 million Swiss francs.

"The technologies integrated in the program open up entirely new possibilities," says Helmut Grabner of the ZHAW School of Engineering. The professor of Data Analytics and Machine Learning and deputy head of the ZHAW subproject cites the high-end infrastructure in Operating Room X (OR-X) at Balgrist University Hospital as an example. The simulation infrastructure in the hypermodern teaching and research center allows for the realistic education and training of physicians. "Here they can learn the surgical skills without any risks. The setting also allows to practice interventions that, in real people, would first have to be approved by the ethics committee."

Replicas of organs

In addition to high-end platforms such as the OR-X, the project also includes simpler applications, such as Box Trainer. These are replicas of organs or body regions on which, for example, minimally invasive procedures can be practiced. In combination with a smartphone or laptop, such box trainers can also be used at home and thus represent a low-threshold training option. "The Proficiency project envisions prospective surgeons going through a Journey as they practice a procedure - from low-end to high-end simulations," explains Philipp Ackermann, ZHAW project leader and deputy head of Human-Centered Computing at the School of Engineering. Surgical interventions could be compared to playing the guitar. "You don't learn the craft by watching - you have to practice, practice, practice." It was only through the repeated performance of hand movements that muscle memory was formed, and with it the skills that surgeons needed in the operating room.

The simulations for various interventions are developed jointly by the companies and the universities. The ZHAW plays a "bridging role" in this, says Ackermann. "For example, we are incorporating the algorithms developed by ETH into the project." In addition, the team from the School of Engineering is responsible for tracking the surgical instruments in the simulations. "We make sure that the instruments are correctly located in AR or VR." In addition, the team is working on grading the movements, i.e., scales that can be used to grade the movements during a procedure. "Grading enables data-based and therefore objective feedback - with Proficiency you get away from medical judgment, where there is a risk of arbitrariness and randomness," Helmut Grabner elaborates.

More favorable after initial investment

For Chief Physician Bruno Schmied, the residents will be the main winners of the new training model - not only because it allows for fair assessment. "Standardization allows you to get the best out of all trainee surgeons. It takes into account individual skills and weaknesses."

According to Schmied, "Proficiency" also makes it possible to complete continuing education more quickly in the future - simply because procedures can be practiced much more often. "Considering that surgeons are 40 to 45 years old when they receive their residency, this is a strong incentive," Schmied said. Overall, he calls the new continuing education model a "win-win-win situation." In addition to residents and patients, hospitals also benefited from simulation-based continuing education. "Hospitals, many of them loss-making, primarily cost money to train surgeons." And because of the flat rates per case, they cannot charge for these costs.

Supraregional centers for training

Cost pressure is also one of the main hurdles to implementation. "When it comes to investment for equipment, jobs and manpower for training, it gets difficult," explains Bruno Schmied. The solution, he said, lies in supra-regional centers "so that expensive simulators don't have to be in every hospital." And in low-cost platforms like Box Trainers, which would allow residents to train in a low-threshold, low-cost way.

"Proficiency" requires some initial investment, he said. "After that, however, continuing education is significantly less expensive than before," Schmied said. Hospitals also seem to be aware of this. For example, a survey conducted as part of the project among the hospitals involved in continuing education showed great interest in modernizing curricula and using simulation technologies.