Video-based Coaching Improves Trainee Robotic Technical Performance

doi:10.21203/rs.3.rs-4963695/v1

Purpose

While video-based surgical coaching (VBC) can improve operative performance, it is not widely utilized in surgical training due to limited video access. New robotic platforms enable automated access to operative video and performance metrics. The aim of this study is to evaluate the effect of structured robotic VBC on technical skills of surgical trainees.

Methods

Surgical resident participants were randomized to control or coaching groups over a 1-year intervention period. Both groups obtained operative assessments (RO-SCORE) during rotations, and active control time (ACT) robotic case participation metric was also analyzed. The coaching group received 1-hour VBC with trained robotic faculty coaches between operative assessments. Wilcoxon, paired t-tests, and descriptive statistics were applied.

Results

Fourteen residents completed the study (6 control, 8 coaching). Overall technical performance on RO-SCORES improved for coached residents (median 2.0 v 3.0, p = 0.031) with greatest improvement in procedural efficiency and flow (median 3.0 v 4.0, p = 0.0156). Overall technical performance did not change for the control (median 3.0 v 3.0, p = 0.50). Although mean percent ACT increased for the coaching group (44 ± 9.0 v 49 ± 20, p = 0.42) this was not statistically significant. Mean percent ACT was unchanged for control (49 ± 12 v 48 ± 38, p = 0.92). Most coached residents (88%) found VBC very or extremely valuable and were highly satisfied with coaching feedback.

Conclusions

This study demonstrates that VBC within robotic surgery can accelerate resident technical skill development. Residents who received coaching reported high value and satisfaction compared to traditional teaching. With improved video access, training programs should implement VBC to support competency development in minimally invasive technologies.

surgical coaching

video-based coaching

robotic surgery

With expansion of video technology, there has been increased interest in using operative video to enhance feedback and coaching for trainees. Video-based coaching (VBC) methods employing individualized goal setting and feedback with operative videos have been shown to improve resident technical performance across a variety of skill and procedure types [, ]. VBC has been most effective as an education intervention when applied using a structured coaching framework such as PRACTICE [], GROW [], or the Wisconsin Coaching Framework []. Thus far, laparoscopic surgery has been a natural target for VBC efforts given its inherent reliance on surgical video. The use of VBC in laparoscopy specifically has been shown to advance resident skill acquisition beyond standard methods [, ].

Although an increasing body of evidence supports the value of VBC approaches, wider uptake and implementation across residency programs for both coaching and assessment have been limited. While many program directors show support for video coaching of residents, perceived barriers to implementation include technology availability, program expense, and time requirements []. The video recording and editing processes at some institutions have presented a major challenge to more widespread video use for coaching []. Even amongst minimally invasive surgeons who frequently have the opportunity to utilize video in the operating room, significant barriers remain from the video recording stage to the transfer, storage, and eventual editing and annotation of video files [].

In the minimally invasive surgery space, robotic-assisted laparoscopic surgery (RALS) has emerged with a unique platform that may more easily facilitate elements of the VBC process. RALS at many institutions has now progressed to include advanced video recording and sharing capabilities as well as the automated collection of objective performance indicators [], both of which could potentially alleviate some of the barriers associated with VBC at the trainee level. Concomitant with its increasing clinical use, RALS has also been a focus for curriculum development in many surgical training programs with a combination of online didactics, hands-on simulation training, and observed operating room components [].

Despite the immense growth of robotic curricula nationwide, there has been limited application and investigation of VBC within robotic surgery. We hypothesized that incorporation of video review in a coaching framework for robotic procedures would facilitate high-quality operative feedback for trainees and promote robotic performance enhancement, as it has done when previously applied in laparoscopic surgery exclusively. The aim of this study was to evaluate interest in and the effect of a structured, robotic video-based coaching program on feedback and technical skill of surgical trainees.

Participants

General surgery residents from post-graduate years (PGY) 3, 4, and 5 at a single university academic training program were recruited to participate in the study during their minimally invasive surgery (MIS) rotations. Data from participants who did not complete matched case types as outlined below or simply observed robotic cases during the study period were excluded. PGY-1 and 2 residents were also excluded given limited participation as the active surgeon in robotic cases. Trainees included in the study had completed the existing robotic training curriculum at our institution including completion of online Intuitive training modules, hands-on bedside assist training, and completion of da Vinci simulation modules. General surgery faculty from MIS and colorectal surgery sections at the same academic training program were recruited to serve as faculty coaches in the study. These sections were targeted given their volume of robotic cases and heavy involvement in resident education. Faculty without robotic credentialing or those who rarely perform robotic approaches were excluded from participation. Both residents and faculty provided written informed consent to participate in study procedures as approved by the Institutional Review Board at [institution name] (IRB #202208082).

Study Design

Following enrollment, faculty completed a participant entry survey to characterize their baseline experience with surgical coaching, feedback, and robotic surgery. Each faculty participant then completed a formal 1-day surgical coaching training offered through the Academy for Surgical Coaching (A4SC) []. This organization and its training foundation is grounded in the Wisconsin Surgical Coaching Framework [5]. After completion of this training, faculty were assigned to individual resident participants to serve as their surgical coaches over the course of MIS rotations.

Following enrollment, resident trainees were randomized into either a coaching intervention group or a control group. Trainees in both groups completed a participant entry survey to characterize their baseline experience with surgical coaching, feedback, and robotic surgery at the start of their MIS rotations. Trainees in the coaching group (“coachees”) then completed an online training module, Surgical Coaching 101, offered through the A4SC for an overview of surgical coaching definitions and goals []. During the first 1–2 weeks on their MIS rotations, coachees completed one robotic case as the primary trainee. Cases could be drawn from a variety of MIS procedures including hernia repairs, foregut cases, or biliary cases depending on case volume and availability during those weeks. At the conclusion of the case, both coachees and faculty completed a Robotic Ottawa Surgical Competency Operating Room Evaluation (RO-SCORE) to evaluate case performance []. Coachees then met for a separate 1-hour video-based coaching (VBC) session with their assigned faculty coach in person or over Zoom teleconferencing (Zoom Video Communication, Inc.). Case videos were accessed via Intuitive Hub [] (Sunnyvale, CA) during coaching sessions to guide goal-setting, feedback, and action-planning. Coaching sessions were audio-recorded for eventual qualitative analysis. Following the session, during the final 3–4 weeks on their MIS rotations, coachees completed a second robotic case of the same procedure with an additional RO-SCORE evaluation at case conclusion. Finally, following their rotation month, coachees completed an exit survey to characterize their experiences with the robotic coaching program.

Resident trainees in the control group similarly completed one robotic case as the primary trainees during the first 1–2 weeks on their MIS rotations and obtained both self and faculty RO-SCORE evaluations at case conclusion. They were subject to standard intra-operative teaching from faculty but did not meet for a designated VBC session. During the final 3–4 weeks on their MIS rotations, trainees then completed a second robotic case of the same procedure with an additional RO-SCORE evaluation at case conclusion. A summary of the study design for both control and coaching groups is depicted in Fig. 1. All trainees in both groups received a $30 Visa gift card in compensation for their participation in the study.

Outcome Measures & Analysis

RO-SCOREs were evaluated in terms of overall technical performance as well as individual skill domains including camera control, energy control, needle control, tissue handling, instrument control, efficiency and flow, and communication. In addition, trainee objective performance indicators (OPIs) that had been automatically generated from the da Vinci Surgical System were retrospectively reviewed for all included cases performed on the Xi robotic system. The primary OPI of interest was percent active control time (%ACT) defined as the amount of trainee console time spent in active robotic instrument manipulations over the total active time from both the trainee and faculty consoles combined. This metric has been previously studied as an objective measure of trainee participation in robot-assisted cases [].

GraphPad Prism statistical software version 10.1.0 (GraphPad Software, San Diego, CA) was used for quantitative data analysis and figures. Descriptive statistics were evaluated, and data were expressed as either raw scores or percentages as noted in each section. Chi-squared and unpaired t-tests were applied to evaluate participant demographics, and Wilcoxon and paired t-tests were applied to evaluate outcomes with results expressed as median versus mean $\pm$ standard deviation throughout. A two-tailed p-value was used for all analyses and considered statistically significant if p < 0.05.

For the qualitative data analysis, audio recordings of coaching sessions were electronically transcribed and subsequently reviewed for transcript accuracy. Transcripts were redacted of any identifying participant or other names. Author [name] who has formal education training (MHPE) and previous instruction in qualitative research methods reviewed transcripts. Transcripts were deductively coded in Microsoft Word using pre-determined codes derived from domains of a previously expanded video-based coaching model for surgical residents [18]. Given this study’s aim to assess how coaching impacts technical skill, we chose to include analysis of goal-setting and technical foci domains only. Full qualitative analysis across all video-based coaching domains was excluded as is beyond the scope of the current study.

Demographics

Six general surgery faculty were recruited and completed surgical coach training through the A4SC. Four of these faculty ultimately served as coaches in the study given scheduling conflicts; 3 were members of the MIS section at the institution, and 1 was from the section of Colon and Rectal Surgery. Of these, none had previously received any type of coaching personally, including surgical coaching. One faculty had previously served as a career coach. With regards to robotic experience: 1 faculty (25%) performed robotic-assisted surgical cases in practice for 12 + years, 2 faculty (50%) for 3–6 years, and 1 faculty (25%) for 0–3 years. When asked to estimate their average number of robotic-assisted surgical cases performed per month, 1 faculty (25%) reported at 1–5 cases, 1 faculty (25%) at 11–15 cases, 1 faculty (25%) at 16–20 cases, and a final faculty member (25%) at 21 + cases.

Between January and December 2023, 18 general surgery trainees were recruited for the study during their MIS rotations and randomized to control or coaching intervention groups. Of these residents, 14 completed the study with 6 residents in the control group and 8 residents in the coaching group. In the control group, data from 2 residents were excluded given absence of 2nd robotic case performance for comparison; another 1 resident was excluded as only observed during robotic cases for the study. In the coaching group, data from 1 resident were excluded given absence of 2nd robotic case performance for comparison. Demographic information for both trainee groups is summarized in Table 1. Differences in PGY level, trainee gender, and robotic case numbers in the 6 months preceding participation in the study were not statistically significantly between control and coaching groups even with the above data exclusions.

Table 1: Demographics for resident trainee participant groups.

	Control Group (n=6)	Coaching Group (n=8)	p-value
PGY level
PGY3	1 (17%)	3 (37%)	0.43
PGY4	1 (17%)	2 (25%)
PGY5	4 (66%)	3 (37%)
Gender
Female	4 (67%)	4 (50%)	0.53
Male	2 (33%)	4 (50%)	0.53

Robotic Case Numbers (preceding 6 months)	8.0 (range 3-18)	9.7 (range 0-21)	0.68

Table 2: Robotic Ottawa Surgical Competency Operating Room Evaluation (RO-SCORE) case comparisons between A) control and B) coaching participant groups.

	A)					B)
	Control Group					Coaching Group
	Case 1		Case 2			Case 1		Case 2
	Median	IQR	Median	IQR	p-value	Median	IQR	Median	IQR	p-value
Overall technical performance	3.0	1.8 – 3.3	3.0	2.5 – 4.3	0.50	2.0	2.0 – 3.0	3.0	3.0 – 3.8	0.031
Camera control	3.5	3.0 – 4.3	4.0	2.5 – 4.3	0.99	4.0	3.0 – 4.8	4.5	3.0 – 5.0	0.75
Energy control	3.0	3.0 – 4.0	4.0	2.0 – 5.0	0.99	3.0	3.0 – 4.0	4.0	3.3 – 4.8	0.37
Needle control/ suturing	2.0	2.0 – 3.0	3.0	2.0 – 4.0	0.50	3.0	2.8 – 3.3	3.5	3.3 – 4.0	0.37
Tissue handling/ respect for tissue	3.5	3.0 – 4.0	4.0	2.5 – 5.0	0.99	3.0	3.0 – 4.0	3.5	3.0 – 4.0	0.76
Instrument control/ wrist movement	4.0	2.8 – 4.3	3.5	2.5 – 5.0	0.99	3.5	3.0 – 4.0	3.5	3.0 – 5.0	0.37
Efficiency and flow	3.0	1.8 – 4.0	3.0	2.5 - 4.3	0.75	3.0	2.0 – 3.0	4.0	2.3 – 4.0	0.015
Communication	3.5	3.0 – 5.0	3.5	2.8 – 5.0	0.99	3.0	3.0 – 3.0	4.0	3.0 – 4.0	0.12

Performance Evaluation

Paired RO-SCORE evaluations for the control group were completed for the following robotic case types: inguinal hernia repair (n = 2, 33%), cholecystectomy (n = 3, 50%), and hiatal hernia repair (n = 1, 17%). Overall technical performance from attending-assessed RO-SCORES did not significantly change during the rotation month for residents with received standard teaching (median 3.0 v 3.0, p = 0.50, Table 2A). While there was some improvement observed in individual technical domains such as camera and needle control, these changes were not statistically significant. There was no change observed in procedural efficiency and flow (median 3.0 v 3.0, p = 0.75) or procedural communication (median 3.5 v 3.5, p = 0.99).

Paired RO-SCORE evaluations for the coaching group were completed for the following robotic case types: inguinal hernia repair (n = 2, 25%), cholecystectomy (n = 1, 12.5%), hiatal hernia repair (n = 4, 50%), and ventral hernia repair (n = 1, 12.5%). Overall technical performance from attending-assessed RO-SCORES significantly improved during the rotation month for coached residents (median 2.0 v 3.0, p = 0.031, Table 2B). Significant improvement was observed in procedural efficiency and flow (median 3.0 v 4.0, p = 0.015). There was some improvement observed in most other individual technical domains, however these changes were not statistically significant.

Finally, mean percent active control time (%ACT) was unchanged between matched cases during the rotation month for residents in the control group (49 ± 12 v 48 ± 38, p = 0.92). Mean %ACT slightly increased between matched cases during the rotation month for coached residents (45 ± 8.6 v 50 ± 18, p = 0.31), but this did not reach statistical significance.

Coaching Content

For the 8 residents in the coaching group, 7 of the coaching sessions were successfully audio-recorded and subsequently transcribed and de-identified. One coaching session could not be included given technology failure in the recording process. On average, coaching sessions lasted mean of 54 minutes, 18 seconds (SD ± 21.9). Transcripts were deductively coded based on a previously expanded video-based coaching model for surgical residents []. When asked to define a focus for the coaching session, all residents highlighted goals from within the technical skills content domain (Table 3). Relevant sub-domains included focus on robotic dissection planes, ergonomics, tension, needle handling, speed, and efficiency.

Table 3

Qualitative summary of specific goal-setting for residents in coaching sessions.
PGY level	Goal-setting focus	Technical skill sub-domain
PGY4	“I think my main goal is maybe twofold. One, tips on dissection and improving my dissecting ability, knowing which planes are the correct planes. And the second goal would just be efficiency… which moves robotically can I do to be more efficient.”	Dissection plane Efficiency
PGY4	“I really want to work on kind of just being slicker and more ergonomic in my movements and more efficient with my movements because that's such a great use of the robot with wrists and whatnot.”	Ergonomics Efficiency
PGY5	“Something that I want to become more comfortable with is the dissection and becoming more comfortable with the anatomy around it, understanding the planes around it.”	Dissection plane
PGY3	“So one of the biggest things… is I really struggle with the tension, in holding tension appropriately but not putting too much tension on things.”	Tension
PGY3	“I think goals would be to just improve, I guess being quicker on the robot… I don't know if it's confidence related or not, but I feel like when I look at my videos, I'm doing the right things, they're just slow.”	Speed Efficiency
PGY5	“The main thing that I wanted to talk about and review was my needle handling.”	Needle handling
PGY3	“I think the cholecystectomies are actually a little bit easier for me in terms of the anatomy. So I thought this allows us to really focus more on robotic maneuvers.”	Psychomotor maneuvers

Coaching Program Evaluation

Faculty and residents who participated in coaching were asked to evaluate the program (Fig. 2). All faculty coaches described coaching as extremely (n = 2, 50%) or very valuable (n = 2, 50%) for professional development in surgery. Most residents described coaching overall as extremely (n = 2, 25%) or very valuable (n = 4, 50%) for professional development in surgery. Most residents who were coached found the experience in the program to be either extremely (n = 3, 38%) or very valuable (n = 4, 50%). Most residents reported being extremely (n = 5, 63%) or very satisfied (n = 2, 25%) with operative feedback in coaching compared to standard feedback. Finally, most residents were extremely (n = 3, 38%) or very (n = 4, 50%) interested in continuing to work with a surgical coach if given the opportunity.

Faculty and residents from both participant groups were also asked about perceived barriers to long-term participation in a surgical coaching program. Faculty coaches most frequently reported inadequate time overall (n = 3), too many other current commitments (n = 2), inadequate incentive to participate (n = 1), and inflexible program requirements (n = 1) as factors that would limit their participation. Residents similarly reported that inadequate time overall (n = 6), too many other commitments (n = 3), and inflexible program requirements (n = 3) would limit their participation; a minority of residents noted that the program was not a good fit (n = 1), not interesting to them (n = 1), or not a good use of their time (n = 1).

In this study, we observed improvement in robotic technical performance for trainees who received formalized surgical coaching in addition to standard teaching methods at our institution. Greatest improvements were noted in the domains of robotic procedural efficiency and flow. Overall, both faculty coaches and residents found high value in surgical coaching methods and conveyed interest in continuing with such a program should it be sustained. These results are consistent with previous studies examining VBC for trainees [1, 2, 6, 7], but provide new evidence for VBC application in robotic surgery specifically.

Coaching sessions in the study were primarily focused on technical skill goals related to robotic dissection, ergonomics, and efficiency. This finding is consistent with previous qualitative review of video-based coaching sessions for trainees that included mainly laparoscopic case types [18]. This coaching series confirms a similar, and potentially expected technical focus in robotic surgery. Average robotic case experience in the 6 months prior to participation was 8–10 cases for both control and coaching groups, suggesting that most trainees were in the early phase of the robotic learning curve. Amongst novice learners, cognitive load of surgical procedures is typically higher, particularly in minimally invasive or novel techniques []. In this cohort of PGY3-PGY5 residents, focus on robotic technical skills alone likely consumed mental capacity, leaving less for non-technical foci such as operative decision-making, communication, or teamwork. With increased robotic experience, we anticipate that the content of coaching sessions and learning agenda set by resident coachees may shift toward more non-technical domains.

Importantly, resident participants in the study were also highly satisfied with coaching feedback compared to standard methods. Historically, surgical trainees have reported feeling unsatisfied with provision of faculty feedback [, , ], and our program is no exception to this. As we transition from traditional time-based training with emphasis on case requirements to competency-based models, the need for timely and specific feedback only increases. Entrustable Professional Activities (EPAs) in general surgery have been ideally described as potential touchpoints for formative, real-time feedback [] yet simultaneously criticized for uncertain effect on the current quality of this feedback []. More widespread faculty coach training or dissemination of coaching methodology could help to elevate trainee feedback globally and promote a shift toward growth mindset. In the long-term, coaching has the potential to be incorporated with EPA assessments to accelerate achievement of critical competencies.

With growing evidence to support the utility of coaching at the trainee level, next efforts must focus on scaling and broader application of coaching across residency and fellowship programs. Previous review has outlined personnel, technology support, physical resources, and an organizational process as necessary components for successful video-based coaching implementation []. Additional components such as high-quality cameras with capability for immediate video review and/or automated video editing have been recommended for optimal VBC and video-based assessment programs [9, ]. In our study, we capitalized on a secure robotic platform—Intuitive Hub [16]—for automated video storage and access, which alleviated this burden for participating residents and coaches. Manual download, video transfer and storage are time-consuming and potential security threats. These elements risk long-term sustainability of video-based coaching efforts. For other training groups considering coaching programs, we highly recommend upfront investigation of and potential investment in technology that would streamline this process. While Intuitive Hub is specific to robotic surgery, other platforms such as Proximie or Black Box may provide wider video applications [].

This study has several limitations. Due to the realities of patient care and other clinical obligations as well as variable case coverage between MIS team members from month to month, there were several resident participants who were excluded from the analysis. These residents were unable to complete a 2nd matched robotic case for comparison during the study period which ultimately decreased our final coaching and control group sizes and altered their composition (Table 1). High heterogeneity of included robotic cases also limited additional analyses of robotic performance metrics. Smaller sample size likely impacted some of the non-significant statistical trends observed between control and coaching groups. Another limitation is that this study was performed at an academic surgical program with a high volume of robotic general surgery. Results may be not transferable to other institutions with newer robotic programs or less experienced robotic faculty surgeons.

Finally, the coaching sessions performed in this study were based on faculty training in the Wisconsin Surgical Coaching Framework via the Academy for Surgical Coaching [5, 13]. This model was initially developed to support peer-to-peer surgical coaching amongst practicing surgeons, but more recently has been applied to coaching for surgical trainees. Faculty-to-trainee coaching has a unique, natural power differential due to the training relationship, and the effects of this are only recently being investigated [18]. While ideally our participants felt safe and comfortable in sessions to outline individual goals and areas for improvement, we recognize that trainees may feel unintended pressure to appear competent and confident with faculty. This may have contributed to participant response bias during sessions.

Given the demonstrated benefit of coaching for robotic surgery shown for trainees in this study, our future work aims at broader enrollment of residents in the coaching program with a focus on sustainability. We hope to track active control time and other performance metrics such as console handoffs and path lengths, for example, more longitudinally to determine if improvements are observed within a larger cohort of coached residents. While robotic video technology allowed us to eliminate time for video download and storage, inadequate time overall for coaching sessions is still viewed as a primary barrier to participation long term among faculty and residents alike. One solution to this challenge is intermittent use of protected education or conference time for dedicated coaching sessions, which we plan to investigate further in future versions of the coaching program. Compared to more traditional didactic curricula, this may be particularly helpful for senior residents who seek individual performance improvement in robotic and minimally invasive approaches.

This study demonstrates that VBC applied within robotic surgery can accelerate resident technical skill development. Residents who received operative coaching reported high value and satisfaction when compared to traditional teaching and feedback approaches. With improved video access, training programs should consider implementing VBC as a resident education method to support competency development in minimally invasive technologies.

Data Availability Statement

The dataset generated during and/or analyzed during the current study is not publicly available but may be made available from the corresponding author on reasonable request.

Acknowledgements

Authors wish to thank the faculty coaches who underwent formal training with the Academy for Surgical Coaching and subsequently served as coaches during the study period, contributing to a successful coaching pilot.

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Video-based Coaching Improves Trainee Robotic Technical Performance

Status:

Version 1

Abstract

Purpose

Methods

Results

Conclusions

Figures

Introduction

Methods

Participants

Study Design

Outcome Measures & Analysis

Results

Demographics

Performance Evaluation

Coaching Content

Coaching Program Evaluation

Discussion

Conclusion

Declarations

References

Status:

Version 1