Background

A hallmark of undergraduate surgical education is active student participation in the operating room (OR) [1]. The increasing prevalence of robotic surgery [2], has disrupted this traditional student learning model. Whereas open and laparoscopic cases enable proximity of the surgical team, the robotic OR is defined by large machinery and physical separation of team members. In the present configuration, students have limited roles in these cases and, as a result, the robotic OR does not offer a motivating learning environment [3]. As robotic surgery continues to grow, legitimate medical student roles are needed to enhance the educational value of robotic cases. The bedside assist role may represent one such opportunity. While surgical interns at some facilities serve as bedside assists from the outset of residency, students have not filled this role due to implications for patient safety. Incorrectly introducing laparoscopic instruments into the abdominal cavity or prematurely removing robotic instruments risk damage to internal structures. To actively engage students as bedside assists would require new curricula to prepare students for this role as well as an OR culture conducive to this change.

An OR culture with effective communication among team members is critical for patient safety [4]. The ability to “stop the line”[5] relies on team members feeling sufficient psychological safety to speak up without fear of embarrassment, shame, ridicule, or retribution [6]. Yet, research shows medical hierarchy interferes with team members’ ability to raise concerns about patient care [7, 8]. Researchers identify poor timing of information transfer, incomplete or inaccurate information transfer, unresolved issues, and exclusion of key stakeholders in decision-making as common communication failures among team members of open and laparascopic cases [9, 10]. Such failures have been attributed to hierarchical structures[11] and team dynamics [9, 12]. Environmental factors such as noise also can play a role [13]. However, given the unique configuration of the surgical team within the robotic OR [14], communication barriers in this context warrant particular attention as effective communication between the console surgeon and bedside assist is especially important given their physical separation and high-stakes of surgical error [15]. Thus, effective engagement of students in this role must address this critical element. We explored student perspectives on communication with a console surgeon during a bedside assist simulation to inform bedside assist curricular design.

Methods

This study was conducted during a semi-annual resident robotic surgery training event. A da Vinci Xi trainer and simulation console are loaned to our institution’s surgical simulation center for at least two weeks a year to support this recurring event. Historically, surgical faculty and Intuitive Surgical (IS) trainers have led training and simulation sessions for surgical residents when the robot is on site. In June 2021, three half days were reserved for medical student sessions. Students practiced on the robot and simulator and took part in a simulation requiring communication with a surgeon at the console. To maximize the hands-on nature of the course, we capped enrollment at six senior medical students per session. UCSF’s institutional review board approved the study and informed consent was obtained from all participants.

Structure of course

Overall course objectives included the introduction of students to robotic features, functionalities, and roles. In advance of the in-person session, students completed a 1-h online module from the Intuitive suite of offerings, “Essential multiport system fundamentals and da Vinci technical skills. This required component was intended to familiarize students with fundamentals of the da Vinci Xi platform, terminology, and basic features. Prior to starting the in-person session, students completed a pre-session questionnaire, which included basic demographic information, planned surgical specialty, and prior experience with robotic surgery. The 4-h in-person session consisted of three parts. The first 1.5 h included a hands-on overview of the main robotic components by an IS trainer. During this period, the IS trainer reviewed standard terminology, pointed out features, and demonstrated functionality of the vision cart, the patient cart, and surgeon console. Students could practice docking, undocking and repositioning the robotic arms and exchanging instruments. The surgical faculty member augmented the standard IS trainer led portion with commentary to provide examples of when, by whom, and in what surgical context these functionalities would be employed in the OR.

To provide the vantage point of the console surgeon, students were introduced to advanced robotic skills at the two consoles during the subsequent 1.5 h. After a short demonstration by the IS trainer, students took turns attempting ring transfer and suturing at the robot trainer console. Simultaneously, other students completed various SimNow tasks at the simulation console with guidance from the IS trainer.

During the session’s final hour, each student completed a simulation exercise with the surgical faculty (woman, colorectal surgeon, tenure-track faculty at the Professor level at our institution, and Director of the Surgical Skills Center), who served as the console surgeon during the simulation. The simulation exercise was focused on the bedside assist role. Students not actively participating in the simulation exercise waited in another room and students individually were called to the robot. The console surgeon asked the student to introduce a laparoscopic instrument through a laparoscopic port in a model abdomen to initiate the simulation. Students were expected to communicate with the console surgeon while attempting to advance the instrument into the field of view, while navigating around obstacles placed within the model abdomen.

Focus groups

After each session, a non-surgeon researcher conducted an in-person post-course focus group (FG). All students who attended were invited to participate in the FG, though participation was optional. The focus groups followed a semi-structured script containing open-ended questions about the participants’ simulation experience, followed by probing questions to elicit further perspectives based on participant responses and explore participants’ perceptions about communication during the simulation (Online Appendix 1). The three focus groups were audio-recorded, transcribed, and analyzed using inductive thematic analysis techniques [16]. Two authors read one transcript (PO’S and AG), and codes were identified using an inductive approach. The authors came to a consensus on the codebook and then applied the codebook to the other two transcripts. Codes were iteratively reviewed, discussed, and refined by the two authors. The coded transcripts were uploaded to Dedoose, a computer-assisted qualitative software [17]. Codes were reviewed to generate themes in the context of current aims. Team members noted their evolution of thinking about themes and considered their own reflexivity. One of the coders is an educator and the other is a medical student. Together they addressed potential biases from their respective perspectives as they generated themes.

After preliminary analysis was completed, member-checking was conducted to establish credibility of the findings. Emergent themes were sent to two study participants, who were asked to indicate their impression of the findings.

Results

Fourteen medical students (50% female, 86% in their fourth year) completed the training (Table 1). Nine (64%) indicated their residency application plans (7 to General Surgery, 1 to Urology, 1 to Neurosurgery) whereas five (36%) were deciding between two surgical specialties. All participating students had exposure to robotic surgery (7.6 robotic cases on average), with roles assumed including observing (100%), performing skin closure (79%), and serving as bedside assist (57%).

Table 1 Characteristics of participating medical students
Full size table

Thirteen (93% of total course participants, 46% female) students participated in the three focus groups, two groups with four participants and one group with five participants. The researchers identified two themes regarding student experience communicating with the console surgeon during the simulation: tension between hierarchy and patient safety and opportunities to enhance communication. Study participants who took part in the member-checking process concurred that the themes reflected their views of the FG conversation.

Tension between hierarchy and patient safety

The first theme is the internal tension between hierarchy and patient safety that drives student behavior and communication tendencies. Students cited pressure to follow instructions quickly and obediently from their superiors.

“When you’re told to do something, as a student, my instinct is “I’m going to do it.” Because what if the next question is “Why is it not done yet?” But then, responding right away is not always the right course of action. And I do think that considering safety in other higher order thinking is necessary before really doing that action.” (FG1-participant1)

“One thing for me is that realization of “Oh, wait, is this safe?” Because when a surgeon in the OR tells you to do something, your instinct, I think, oftentimes is “I got to please the surgeon.” Because you’re in training and this is the person that is evaluating you or is your superior or whatever…you might lack the anatomical or the surgical or whatever knowledge, but ask yourself as a sanity check “Is what I’m about to do safe?” And if that’s your guidepost of your hierarchy and then it’s like, “Do what the surgeon says, because they know what they’re doing” [vs.] “It’s okay to take your time. It’s better to get yelled at than do something that’s unsafe.”... because if they’re just like “Put the thing in.” and I just stabbed right through and hit something, they might have expected me to think about things at a higher level than what they said. So ask yourself at each moment, “Is this safe?”“ (FG1-participant2)

They also acknowledged their inherent tendency to assume that the console surgeon request is “correct”.

“I understand that [console surgeon] is at the machine. I understand that she’s in charge. I know I’m a medical student that doesn’t know much about the robot beyond today and going into the field of view I see what [console surgeon] instructs me to just grasp. I can’t really see the screen because it’s blocked by the arms of the robot. I just assumed that whatever [console surgeon] is telling me is correct, and that I could just go and grasp. But maybe there might’ve been things I could have optimized to make it easier on my end and maybe make it safer for the patient.” (FG3-participant1)

However, they simultaneously recognized that rote following instructions in the face of their uncertainty was a threat to patient safety, and furthermore understood the unspoken expectation to always act in a safe manner.

“It was like a five-year-old [was told] “Do this.” And the five-year-old just does it versus someone understanding the complexity of that statement. Hidden within the statement, “Do this” is “Do this safely.” And that’s your first [question] “Can I do it safely?” And then from there I could do it.” (FG1-participant2)

Moreover, students felt trepidation about revealing knowledge gaps and tended to self-blame for struggling with the simulation, both of which were cited as barriers to communication in the context of a hierarchical dynamic.

“I tend to not vocalize because I feel like I should just know. I feel like I should be good enough to do this by now. But I think actually thinking through the steps of it in the times that I’ve done that, I actually learned more in the moment and don’t make the mistake later.” (FG2-participant1)

“I felt a bit of the hierarchy issue where I felt like I was failing her by not being able to [advance]... She couldn’t see me and I felt the need to solve that problem and … I was struggling with having enough position to say, “I don’t feel comfortable. I don’t want to advance. Is there something else we can do?” So I think that’s a complex dynamic.” (FG2-participant2)

Opportunities to enhance communication

The second theme, opportunities to enhance communication, was predicated on student recognition of its importance. Students reflected that effective communication adds an element of predictability and trust.

“I think, as a student, saying exactly what you’re doing, right before you do it, also adds this element of predictability. And so whoever you’re working with knows exactly what you’re doing, even if they can’t see, watch you like a hawk kind of. And so I think it builds an element of trust.” (FG1-participant1)

“Especially if it’s my first time just trying to verbalize every step that I possibly can and saying what I see. Seeing if it’s what they see. I feel like if I was the surgeon, it would make me feel a little bit more comfortable with hearing from the bedside person whenever I instruct them to do something.” (FG3-participant1)

They felt this was particularly important given the unique set-up of robotic surgery where the surgeons cannot directly see what students at the bedside are doing.

“[The simulation] really highlighted for me the need to verbalize what I’m thinking and doing. Because, I guess, consciously thinking about the fact that the other person is not watching me in the same way [as during laparoscopic surgery], I need to say every step that I’m doing.” (FG1-participant3)

Students raised having shared vocabulary and effective team dynamics as mechanisms to address communication barriers.

“But importantly, [I want] to make sure I’m communicating well with [the console surgeon] in that moment. And so I want to make sure I had language to do that and I felt, other than being able to just say, “I feel like I’m hitting resistance”, I wanted to be able to then say why I’m feeling the resistance, what I think it is, how to reposition, those sorts of things.” (FG2-participant1)

“And, I guess, familiarity too, with your team. I think that’s why a good team dynamic is so important and what I think makes good team function is being able to have an open line of communication, regardless of if you’re a first year medical student to a senior, senior, senior attending. To be able to have that conversation outside the OR I think makes communication inside the OR easier. And so I think, as much team dynamic and team building that can happen outside, can also facilitate inside the OR too.” (FG2-participant1)

Students also indicated that more communication from the console surgeon would be beneficial.

Specifically, they indicated they would benefit from console surgeon recognition of their novice status, which may translate into normalizing statements and increased direction; explanations of the rationale behind their actions; and proactive guidance on what can reasonably be expected of the bedside assist at a given moment.

“I mean, we’re fourth year med students being asked to automatically first assist in this robotic case with an attending who’s at the console. And so I think as a teacher, it might’ve been helpful to also say, “I know you’re new to this, try and find the angle of the camera. Try and tilt your hand down...” In the OR they’ll say, “Tilt your hand down”... the stronger, I think, teachers on the service, “Try and angle into the pelvis, follow the angle of the camera.” I think would’ve been helpful to have more specific direction.” (FG2-participant3)

“It was helpful when [the console surgeon] said that she couldn’t, based on the orientation of the robot,... She wasn’t going to be able to see that port. Which, at least, helped me understand why we couldn’t adjust the camera. And so that was helpful.” (FG3-participant2)

“[It’s important] to understand what’s a reasonable expectation of the [bedside] assist. Because I’ve had things asked of me that I was not able to really do. And I started to feel really deficient.” (FG2-participant3)

Discussion

This study aimed to assess medical student perspectives on communication with a console surgeon during a bedside assist simulation. The results reveal hierarchy emerging as a central tenet and identify barriers to communication between students at the bedside and an experienced console surgeon. Given the integral role of communication in ensuring patient safety [4], any medical student bedside assist curriculum should be developed with this in mind. This is especially critical given the physical distance between the console surgeon and the bedside assist that prevents face-to-face communication between members of the surgical team, a barrier not present in open or laparoscopic surgery [14].

Many surgeons regard the hierarchical structure as necessary to surgical training [18], with evidence around its role in attending-resident communication failures inconclusive. In fact, a hierarchical organizational structure has the benefit of a clear line of authority, responsibility, and accountability. Our findings suggest that, for medical students in a bedside assist simulation, hierarchy is an important driver of behavior, which can be at odds with patient safety. Relatedly, concerns over appearing incompetent [19, 20] or facing negative consequences [21] have been identified repeatedly among trainees and this sentiment was present in our cohort as well. Though status asymmetry has been identified as a key factor of communication breakdown in the OR [22], prior studies have found that faculty are often unaware of intraoperative communication barriers between them and trainees [18, 23].

Our study offers insights into student perspectives of barriers to communication that can be targeted through a deliberate curriculum for students. In addition to an introduction to robotic features and basic safety practices, such a curriculum may include explicit instruction of communication best practices when serving as bedside assist. Like didactic and technical skills, communication is a competency that can be taught [24, 25]. However, it is a domain that has received limited attention in surgical training [26, 27]. When available, effective communication instruction for physicians focuses on practicing skills (e.g., via simulation, role play) and receiving feedback [25, 28]. Based on these findings and those in the present study, an effective robotic bedside assist curriculum may rely on simulation and focus on teaching specific terminology relevant to the role. Importantly, such a curriculum may acknowledge barriers to communication raised by students, proactively expose “hidden statements” that may be encountered in the OR and provide students with tools to respond in a way that maximizes patient safety in the context of the surgical hierarchy. Though it is plausible that these principles may also apply to student participation in laparascopic surgery, this was outside the scope of the present study and deserves further study.

A student-focused bedside assist curriculum alone cannot address communication challenges. Opportunities to improve communication through other strategies should also be considered. Students focused on a culture where they are welcomed and their questions encouraged.

While we conclude that addressing communication barriers that work within the surgical hierarchy may contribute to patient safety and enable an active role for medical students in the robotic OR, our study has limitations. First, as this is a single-institution study, student perspectives were limited to their experience predominantly in the setting of a particular surgical culture. Examining communication barriers in other settings will be important. Second, our study included only senior medical students who elected to participate and are planning to pursue surgical specialties, which may introduce bias. While perspectives from students who are pursuing a specialty outside of surgery would round out our findings, concerns expressed by senior medical students are likely to appear with other students. Finally, only student perspectives were obtained as part of this study. Understanding the perspectives of the console surgeon, surgical scrub technician, and other members of the robotic OR team is a critical next step in codifying robotic bedside assist education for medical students. Despite these limitations, our study reveals important insights that may help expand the development of robotic curriculum for medical students.

Conclusion

Barriers to effective communication between physically distanced medical students and surgical faculty exist. However, by teaching relevant terminology and communication strategies, surgical educators may be able to safely expand the role for students in the robotic OR and also formalize bedside assist education.