Robots and simulators: the future of otolaryngology?

Robotic surgery has already been used in otolaryngology, and simulators are being developed to enhance education. As with all new technology, early applications have been met with controversy as well as enthusiasm. Proponents of robotic surgery have been favorably impressed with surgical precision, visualization, and transoral access to areas that have been difficult to expose with traditional methodology. Skeptics have observed that they have been able to do everything without a robot that they are able to do with it, and that the prolonged setup time (sometimes longer than the surgical procedure) and cost of the equipment do not seem justified.

Such discussion and debate are to be expected as new technology is introduced into clinical practice, and such debate catalogs clinical and technologic advances. Undoubtedly, robotic surgery will have applications in otolaryngology. However, the technical application of robotics may not be the most important advancement associated with robots and other sophisticated technology.

Throughout history, most of medical training has relied upon "on-the-job" experience. Student physicians (ideally, that includes all of us) have studied anatomy and read about disease entities and treatment approaches, including details of surgery. In some cases, we have had opportunities to practice surgical techniques in advance before embarking upon patient surgical treatment. Such opportunities have come through the use of temporal bone dissection laboratories and cadaver dissection courses. However, these do not really prepare us comprehensively for our first encounters with living, human tissue. When new operations are devised, sometimes they, too, are practiced in a laboratory; but usually, the first really meaningful surgical experience is gained in the operating room. In the 21st century, are these approaches really the best we can do?

In discussions of patient safety, medical practice frequently has been compared with the airline industry. Sadly, medical practice is usually found wanting. The aerospace industry also has much to teach about acquisition of skills for complex tasks such as otolaryngologic surgery. For example, before a jet pilot or astronaut ever leaves the ground, he or she spends hours in a sophisticated simulator that mimics closely most of the experiences that the pilot will encounter in the air. Surely, simulators are an imperfect substitute for hundreds of hours of flight experience, but they are far superior to making one's first attempt at flight in the cockpit of a moving plane.

Technologic advances such as medical robots and, particularly, medical simulation are well on the way to offering doctors the same opportunity. Well-programmed simulators allow a student or surgeon to "do" an operation many times, with numerous, unexpected "patient" variations, before ever walking into the operating room. As both simulators and robotics become more advanced, such practice may become even more relevant, because eventually we may not walk into the operating room at all. It is conceivable that much (if not most) of our surgery will be done from behind a console. These technologic advances probably will be facilitated by the skills of young surgeons who have grown up playing sophisticated video games and who are exceedingly comfortable with the kind of skills that will be necessary to operate in this fashion. Otolaryngologists, and especially otolaryngologic educators, should make every effort to maintain current knowledge about developments in robotics and simulators and should be open-minded about applying them to patient care.

It is also worth remembering that simulators offer another extraordinary educational opportunity, especially now while they are in the development stage. As much can be learned from working on a simulator, even more can be learned from involvement in developing simulators. It takes extraordinary knowledge about the details of what we do diagnostically or surgically to define the steps of our procedures well enough to program a simulator. For the otolaryngologist, becoming involved with simulator development teams poses a challenge and an extraordinary opportunity for us to understand and define our surgical experience with unprecedented precision, and to gain insights into details of our clinical care that we never realized we did not understand fully.

Use of simulators has another interesting implication for otolaryngologic education. Until now, virtually all graduate medical education has been time-based. Residents have a year or two of general surgery and four years of otolaryngology residency, sometimes followed by a fellowship. However, there has been an increasing tendency recently to think about criteria in terms of skill-based training rather than time-based training. For example, simulators could be used by premier surgeons, and their performance could be stored and used as the standard in evaluating resident and fellow performance. This would allow programs to permit resident surgery on patients only after the residents have demonstrated expert proficiency on the simulator. Some trainees would acquire undoubted expertise almost immediately, and some might take considerably longer. The notion of training based on demonstration of proficiency rather than passage of time is attractive and might alter substantially. Such technology would also permit otolaryngologists to demonstrate continued proficiency throughout the course of their careers.

As they evolve, robots and simulators will undoubtedly improve surgical preparation and education, precision, patient care, and patient safety. Close involvement in the process of that evolution offers otolaryngologists exceptional opportunities to better understand our patients and what we are currently doing to care for them, and to influence the otolaryngologic practice of the future. All of us should take advantage of the opportunity to be pioneers in developing the next generation of otolaryngologists.

Robert T. Sataloff, MD, DMA 

Editor-in-Chief

EAR, NOSE & THROAT JOURNAL