Simulations in Ergonomics and Intraoperative Decision-Making May Help Change Culture of Surgery

Clinical Congress is one of the largest gatherings of surgeons in the world, and it offers everything one might expect from a preeminent conference with a 113-year history: nearly 300 sessions, many of which will present exciting surgical research findings and cutting-edge education; 11 Named Lectures by some of the field’s brightest minds; and innumerable professional and social connections between surgeons. This ACS signature event also will offer two innovative Exhibit Hall opportunities for hands-on learning that can be immediately helpful to surgeons, advance innovative research, and change the culture of surgical training and practice.

Surgical Metrics Project

The Surgical Metrics Project is bringing to light new data streams that can help practitioners engage with one another in ways they’ve never engaged before. “In addition to creating a digital rendering of complex technical skills and intraoperative decision-making, participants will be able to share tips and tricks, interact with expert surgical coaches, and contribute to a performance database for resident learning,” said project leader Carla M. Pugh, MD, PhD, FACS, director of the Technology Enabled Clinical Improvement Center at Stanford University in California.

The project invites surgeons to participate in simulated surgical procedures while recording their own movements and brain waves to better understand the critical physical and mental maneuvers that underpin the best outcomes in the operating room. Digital performance data allow the development of something surgery has had very little of to date: objective comparisons and digital mapping of successful and unsuccessful techniques and the mastery of specific surgical tasks by individual surgeons.

Dr. Pugh explained, “One of the first goals of the project is to build a database of surgical performance. What operative decisions do you make and why? What is the variance in those technical decisions that experts make?”

Individual Learning and Inverted Conference Research Model

To participate, interested surgeons can come to the project’s location in the Exhibit Hall whenever they like. Each surgeon will complete a brief survey and consent form and then will apply sensors to their fingers (worn under surgical gloves to record hand motions) and forehead (to record electroencephalographic [EEG] data on their thought processes while operating). A simulated surgery using inanimate tissues follows, as well as a chance to see the digital data generated from their efforts.

If this activity sounds familiar to some, it is because the Surgical Metrics Project appeared at Clinical Congress in 2019 and 2022,¹ the past two times Clinical Congress was held as an in-person event. In 2019, it had more than 250 participants.^2,3 In 2022, more than 110 attendees participated (completing a longer procedure than the one used the previous year).

The Surgical Metrics Project offers an opportunity for individual surgeons to learn more about the future of digital healthcare and optimizing their practice. The project also is the basis for research and inverts the usual pattern of conferences—in which researchers present the findings of studies completed offsite—by giving conference attendees the opportunity to become research participants themselves.

The work is ongoing, and findings from the 2019 Clinical Congress cohort published in the Annals of Surgery have highlighted the capture and characterization of individual surgeon preferences with wearable technology.⁴ Dr. Pugh noted, “The 2019 results showed that there is more than one way to complete a procedure, but some approaches are more efficient than others and lead to fewer errors. This was a unique opportunity to confirm that surgeon’s individual preferences are linked to procedural outcomes.”

This year’s iteration of the project will collect new data from surgeons completing simulated procedures while integrating expansions of the project’s questions by using coaches and new technologies and expanding simulations to three short but challenging operative tasks. The brief survey before the surgical simulation will incorporate details such as each surgeon’s specific surgical discipline, years of experience in surgery, and self-reported familiarity and skill level with the type of operation simulated onsite. These points will become part of data subanalyses on the efficacy of specific surgical techniques.

In addition, while the new exhibit will continue to collect motion sensor and EEG data from surgeons completing simulated operations, this year’s data collection also will include EEG sensors on expert coaches observing the simulated operations. This will permit data collection on the thought patterns that well-established surgeons exhibit when observing an operation, to better characterize varying levels of surgical mastery.

Extending the Project Worldwide

A further change in the Surgical Metrics Project this year is an expansion of the project’s reach. Dr. Pugh explained that the project is now connected to the West African College of Surgeons (WACS) and the College of Surgeons of East, Central, and Southern Africa (COSECSA). These international organizations work to provide education and training in several Western and sub-Saharan African nations. With industry support, WACS and COSECSA will partner with the ACS Member Services Division and work with the Surgical Metrics Project on establishing how to efficiently use data-driven training methods with surgeons in low- and middle-income countries.

“How do you build low-cost simulations and provide feedback and access to a database of experienced healthcare practitioners so that they can see where they are on the learning curve to competency or to mastery?” said Dr. Pugh about the purpose of the collaboration. With that question answered, “Then you can start to benchmark what it is that you need to partner with the leaders in those countries to help them to train more surgeons and increase access to care.”

Advancing Surgical Education

In any country, the benefits of the Surgical Metrics Project are fundamentally the same: The project offers the opportunity to update the way surgeons are trained.

A database on what surgeons do in a standardized simulation and the operating room (OR) can help surgeons understand where their present skills fall on a spectrum of competence, helping them reach mastery and maintain their skills over time. “It enables surgical trainees to have an objective digital measure of where they are and where they should be, so they know exactly where they are on the learning curve to mastery as they progress throughout their career,” Dr. Pugh said.

Beyond simply improving individual surgeons’ skills, this option can update the length and efficacy of all surgical education and training, Dr. Pugh said, by ensuring surgeons receive the feedback they need much faster than they currently do.

“What if you had a database of that surgeon’s procedures and you knew exactly what they needed to expedite obtaining a certain level of quality and mastery? You could train specific procedural skills in 1 month as opposed to infrequent exposure and training over a 5-year period because right now, in our current mode of training, you’re waiting for the mistake or the less efficient operative approach to happen. But if we had a digital database of that person’s top five cases, they could review key moments in an hour,” potentially transforming the time it would take to complete surgical training.

Eliminating Bias in Surgical Training

Dr. Pugh also noted that the Surgical Metrics Project is meant to aid in ensuring more surgeons learn to operate without “the bias in human observation and feedback” hampering their progress.

She explained, “Making assessment digital helps because you actually have objective metrics. The sensor doesn’t know whether it’s a female or male or a tall person or a short person. The sensors and video data know only what your working volume is, the anatomical region where you spent most of your time, how many times you paused when you were thinking, and if you, at a critical moment, found interesting or exciting anatomy or unexpected bleeding. That’s all this determines.”

The departure from subjective assessments to measuring skills through digital data opens the door to an objective, more efficient surgical training environment. “In terms of the dream and the vision of the future,” Dr. Pugh explained, “This will just be something that’s incorporated into our daily workplace.”

Surgical Ergonomics Clinic

Not far from the Surgical Metrics Project in the Exhibit Hall will be a second, fully independent simulation-based project. The Surgical Ergonomics Clinic will offer surgical stations simulating the operating room environments to show surgeons how best to stand, move, and collaborate with their teammates to maximize surgical efficiency while maintaining their own musculoskeletal health.

According to the project’s organizer, Gyusung Lee, PhD, Assistant Director of Simulation-Based Education and Training in the ACS Division of Education, the clinic is about “bringing ergonomics education to the surgeon with hands-on experience, rather than just asking them to read something published elsewhere.”

Meaningful Help for Individual Surgeons

Dr. Lee emphasized that the ergonomics clinic’s first mission is proactive help: “What we really want to do is not just try to help the surgeons who are already experiencing physical symptoms or complications from ergonomically incorrect operating, but we want to prevent or at least delay the onset of such problems even for the younger surgeons as much as possible.”

Surgeons walking into the Surgical Ergonomics Clinic area in the Exhibit Hall will find themselves in a large, open space set up with stations simulating operating rooms for open, laparoscopic, and robotic surgeries. After a brief sign-up process, participants will have the opportunity to try out the adjustable OR components of each station, such as an OR table or laparoscopic monitor, and receive personalized feedback on body positioning, movement, sightlines, and other ergonomics issues from the ergonomics coaches on hand, including ACS Surgical Ergonomics Committee members and physical therapists.

While no medical care or referrals can be given (a constraint imposed by state-level licensing requirements), general recommendations on beneficial stretching and strengthening exercises and other surgery-specific ergonomics basics will be available to all.⁵

Follow-Up for the Greater Good

In addition, the Surgical Ergonomics Clinic is conducting research. As with the Surgical Metrics Project, this study invites Clinical Congress attendees to become the study’s subjects. For participants, the project will entail a brief survey onsite, plus a series of four follow-up surveys over the course of 9 months, which will seek details of the surgical ergonomic interventions that surgeons have implemented in their practice, the sustainability of these interventions over time, and the interventions’ impact on any ergonomic symptoms.

The Surgical Ergonomics Clinic also is working on directly expanding the number of people their projects reach. The project hopes to connect with more than 100 simulation sites that the ACS has accredited worldwide to bring evidence-based ergonomics clinics directly to them. “We hope to develop something for them, so that the ergonomic education can also take place onsite at each of the academic medicine and simulation centers and that they don’t have to come all the way to Clinical Congress every single year to learn something easily shared,” Dr. Lee said.

In addition, Dr. Lee is working to draw together industry partners to share the project’s data. These meetings will point out which surgical instruments are improperly designed for use by surgeons of different heights, body sizes, or strength levels, in the hopes that this will lead to the creation of surgical instruments that function more efficiently, more comfortably, and with less injury risk to surgeons.

Changing the Culture of Surgical Practice

The overarching work of the program goes beyond advice to individuals, published research, and even worldwide institutional partnerships, however. Dr. Lee said, “The one item I really talk about is the change of culture between the resident and the faculty members.”

He retold a story of an attending surgeon who was 5’3” working with a surgical resident who was 6’10”. The taller surgeon had to bend nearly to his waist to operate alongside his shorter superior.

“They were told just to accommodate what the attendings are using,” Dr. Lee said.

The standard in ergonomics, however, is to adjust the operating table to the height of the taller individual, accommodating the shorter one with a stepstool—the problem being that this may invert a hierarchy and ask an attending surgeon to alter their own long-established approach to operating. Other difficulties can arise for surgeons who are shorter than average or pregnant, Dr. Lee noted, which can require similar unsettling of power relationships to solve.

Dr. Lee said there is no way to fully address ergonomics without gently discarding adherence to hierarchy. “I was asking almost every single faculty member to talk to residents or trainees and ask about their ergonomics: ‘So, from the last case, was the operating table height good for you or the standing locations or postures? Did that work for you or not? Is there something we can do to help?’”

He suggested a similar approach for junior colleagues: “Not necessarily during the procedure in the OR, but afterward, you may just express that you have some challenges, have a discussion respectfully with your attending, and just let them know. They may listen to you and come up with some solutions.”

In addition, he noted that a cultural change involved a shift in the expectations of individual surgeons: “Surgeons were trained to ignore everything happening with them to take care of the patient. It’s a long, long process of building that habit. In my study, I asked why they do when they feel the pains and physical symptoms in the OR, and they said, ‘I simply ignore them and just keep going.’ Well, we want to change the culture, and there are more ergonomic options available now to do that.”

This is particularly true because ergonomics-related aches and pains are not confined to older surgeons. Dr. Lee said his analyses to date have shown that “the increased workload, or case volume, was the factor predicting the likelihood of a surgeon developing or reporting an ergonomic issue.”

The Future Is Back

If the Surgical Ergonomics Clinic sounds familiar, like the Surgical Metrics Project, it is because it has appeared at Clinical Congress already. Beyond reiterating the successes of its first version (in 2022), however, the clinic will be visibly improved. In specific, its area in the Exhibit Hall will be four times larger than the one at Clinical Congress 2022. The change is meant to eliminate waiting times, as the project had more than 400 participating surgeons last year, a group large enough to occasionally cause lines of surgeons eager for ergonomic advice.

Dr. Lee said, “Some of the most common comments were, ‘Where have you been?’ and ‘Why did it take so long?’”

This year, the clinic is designed to eliminate waiting—and previous attendees are welcome to come back for hands-on simulation and proactive advice once again. Dr. Lee said, “We encourage them to come back together, learn again, and recap what was learned last year.”

Aligned with Historical Purpose

Both the Surgical Ergonomics Clinic and Surgical Metrics Project present intriguing offers to anyone at Clinical Congress interested in knowing more about how to operate safely, optimize effectiveness, and sustain a productive career—or those who want a quick break from meetings and didactic lectures at Clinical Congress for the hands-on tasks many surgeons enjoy.

The forward-looking Surgical Ergonomics Clinic and Surgical Metrics Project also reinforce a storied past. Clinical Congress was among the first events that brought American surgeons together to improve the field of surgery. The success of the first event, in 1910, created the momentum necessary for the founding of the American College of Surgeons in 1913. The mission of improving surgical quality through meaningful innovation is an unbroken thread through the entire Clinical Congress—and, in the upcoming conference, both the Surgical Ergonomics Clinic and Surgical Metrics Project, too.

If you haven’t registered yet for Clinical Congress, there’s still time. Visit facs.org/clincon2023.

M. Sophia Newman is the Medical Writer and Speechwriter in the ACS Division of Integrated Communications in Chicago, IL.

References

1. ACS Bulletin. Surgical Metrics Project returns to Clinical Congress. September 1, 2022. Available at: https://www.facs.org/for-medical-professionals/news-publications/news-and-articles/bulletin/september-2022-volume-107-issue-9/surgical-metrics-project-returns-to-clinical-congress. Accessed September 14, 2023.
2. Armitage H. Tracking the movements, minds of surgeons to improve performance. Stanford Medicine. December 11, 2019. Available at: https://med.stanford.edu/news/all-news/2019/12/tracking-the-movements--minds-of-surgeons-to-improve-performance.html. Accessed September 13, 2023.
3. Pugh CM. The quantified surgeon: A glimpse into the future of surgical metrics and outcomes. Am Surg. 2023;31348231168315. Epub ahead of print.
4. Mohamadipanah H, Perumalla CA, Kearse LE, et al. Do individual surgeon preferences affect procedural outcomes? Ann Surg. 2022;276(4):701-710.
5. American College of Surgeons. Surgical Ergonomics Recommendations. 2023. Available at: https://www.facs.org/media/cezf1xvo/surgicalergonomicsrecommendations.pdf. Accessed September 6, 2023.