Experience Is Not Proficiency: Measuring what surgeons actually do | Show Me The Evidence E10

In this episode, Professor Anthony G. Gallagher is joined by Dr Rui Farinha, a senior consultant urologist in Lisbon who has completed fellowships in Spain, Germany and Belgium in laparoscopic and robotic surgery, and who trained with Professor Alexandre Mottrie in Aalst and at Orsi Academy in Belgium. The two met at Orsi in 2019. The conversation begins with a practical question. Robots are expensive, so what do they actually give the surgeon? Rui sets out the case carefully: tremor filtering and motion scaling for precision, wristed instruments for dexterity in tight anatomy such as the pelvis, magnified stereoscopic vision, better ergonomics over long procedures, and a digital platform capable of recording and analysing performance. Then he adds the caveat that frames the rest of the hour. None of these technical advantages automatically produces a better clinical outcome. From there the discussion turns to how surgeons are trained. Rui traces his own path through three eras: an apprenticeship model in open surgery that depended on which cases turned up and which consultant happened to be supervising, a laparoscopic era in which he discovered that open skills did not transfer and that basic skills belonged outside the operating theatre, and a robotic era that was structured from the start around defined objectives, simulation, proximate feedback and a demonstrated standard. The heart of the episode is Rui's programme of research on robot-assisted partial nephrectomy (RAPN). He explains why he chose a technically demanding, high-risk procedure with clearly separable phases and direct consequences for the patient, and he sets out what the studies found. A complex operation can be deconstructed into observable phases, steps, errors and critical errors, with 100 per cent consensus from an international expert panel. Experienced surgeons made 69 per cent fewer total errors than novices. Within the experienced group, the low-error surgeons made 77 per cent fewer errors than the high-error surgeons, and that high-error expert group performed at roughly the level of the better novices. Procedure-specific binary metrics achieved high inter-rater reliability where a global rating scale did not. And a systematic review of partial nephrectomy training models found models widely rated as realistic and useful, but no randomised controlled trials and no evidence of skill transfer. Rui's conclusion is direct. Realism is not evidence. A simulator is a vehicle, not a training programme. Anyone building a curriculum should define the performance they want first and select or construct the simulation second, which is the opposite of what usually happens. He describes a model he developed deliberately as a delivery vehicle for a metric-based curriculum, using readily available animal tissue and emulating eight of the eleven phases of the human procedure, on the grounds that the useful question is not how realistic a model looks but how much high-quality measurable practice it permits. The episode closes on proficiency-based progression in the skills laboratory and in the operating room, on the value of proximate human feedback in an era of AI-delivered training, and on a central principle: the manufacturer's instructions for use teach the surgeon how the robot functions, while PBP determines whether the surgeon can use it proficiently. Key Topics Covered What the robot actually adds, and what it does not | 0:07 Guest introduction: senior consultant urologist in Lisbon, fellowships in Spain, Germany and Belgium, met Professor Gallagher at Orsi Academy in 2019 Robots do not replace the surgeon and do not operate independently; they act as an interface that translates the surgeon's movements Precision through filtering of physiological tremor and scaling of movement, valuable in delicate dissection, suturing and vascular anastomosis | 1:46 Dexterity, vision and endurance | 2:34 Wristed instruments provide additional degrees of freedom where rigid laparoscopic instruments cannot, which matters most in narrow spaces such as the pelvis Magnified high-definition three-dimensional view improves depth perception and tissue plane discrimination; the surgeon controls the camera directly | 3:25 An adjustable console reduces muscular strain and fatigue, supporting concentration and consistency through long procedures | 4:14 The digital platform, and the caveat that matters | 5:04 Because the surgeon's actions pass through a computer-controlled interface, robotic systems can record instrument movement, analyse technical performance and integrate imaging or navigation Rui's caveat: these technical advantages do not automatically produce better clinical outcomes. Performance still depends on training, case selection, team coordination and appropriate use of the technology Professor Gallagher returns to the Dwight Meglan episode and the view that the surgeon, not the platform, makes the decisions | 5:53 Three training eras: apprenticeship, laparoscopy, robotics | 6:43 Open surgery followed the apprenticeship model: observe, assist, then perform increasing parts of the operation under supervision The limitations Rui experienced: dependence on case availability, inconsistent quality of supervision, and progression decided by an individual trainer's subjective judgement | 8:29 Laparoscopy and the skills that did not transfer | 9:20 Competence in open surgery did not translate into competence in minimally invasive surgery Two-dimensional vision and reduced depth perception, the fulcrum effect, long rigid instruments with limited degrees of freedom, and bimanual coordination against an indirect image | 10:10 The realisation that basic laparoscopic skills could and should be learned outside the operating theatre, using box trainers, virtual reality, dry and animal laboratory work and standardised exercises | 10:58 Structured robotic training from 2019 | 11:48 Training with Professor Alexandre Mottrie: console controls, instrument management, camera control and clutching, multiple arms, collision avoidance, bedside communication, troubleshooting and emergency undocking Maintaining situational awareness while physically separated from the patient, supported by online modules, simulation, observation, bedside assistance, supervised console practice and procedural prompting | 12:39 From time served to a defined standard | 13:28 The question shifts from how many cases the trainee has performed to whether the trainee can perform the procedure safely and consistently to a defined standard Clearly defined learning objectives, procedure-specific benchmarks, objective assessment, simulation before patients, and deliberate practice with proximate feedback What simulation cannot teach | 14:19 Clinical judgement, decision making under pressure, recognition of abnormal anatomy, management of bleeding and complications, adapting when the plan changes, and leading the operating team Practice remains very different from centre to centre and department to department | 15:09 Simulation and the Halstedian model | 16:51 The apprenticeship model remains important but is no longer sufficient on its own Professor Gallagher's position: simulation does not end Halstedian training, it improves it, because the consultant now supervises a pre-trained novice who arrives with ...