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Dr Ruben DeGroote, From Proficiency to Wisdom in Surgical Training

Dr Ruben DeGroote, From Proficiency to Wisdom in Surgical Training

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Show Me the EvidenceGuest: Dr Ruben De Groote Topic: From Time to Competence: Proficiency-Based Progression and the Reinvention of Robotic Surgical TrainingEpisode SummaryIn this episode, Professor Tony Gallagher sits down with Dr Ruben De Groote, consultant urologist at OLV in Aalst, Belgium, CEO of 4Health and its digital learning platform Surgquest, and the researcher behind a recently completed PhD on Proficiency-Based Progression (PBP) robotic surgical training across three surgical disciplines. Ruben and Tony first met in 2019 while developing and validating the metrics for the robot-assisted radical prostatectomy.Together they examine an uncomfortable reality: the century-old Halstedian apprenticeship model can no longer produce surgeons who are ready to operate independently. Reduced theatre exposure, rising bureaucracy, and working-hours legislation have hollowed out the "see one, do one, teach one" paradigm, leaving as many as one in three residents unready for independent practice. Ruben makes the evidence-based case for PBP: a standardised, metric-driven approach that measures what a surgeon actually does, gives explicit formative feedback, and trains to a benchmark rather than to a clock. The conversation moves from the failings of subjective assessment through a multi-specialty randomised controlled trial, and on to the harder question of how surgeons progress from proficiency to genuine wisdom.Key Topics Covered1. Why the apprenticeship model is breaking down (0:50) The Halstedian "see one, do one, teach one" model relied entirely on graded theatre exposure. Over the last 15 to 20 years, bureaucracy and a legal cap on working hours (departments are penalised for exceeding roughly 60 hours a week on average) have eroded that exposure. The result is a vicious circle in which trainees get less time in the operating room, and fellowships originally meant for super-specialisation are being repurposed simply to reach independence.2. Where the bureaucracy came from (6:06) A wider shift in medicine towards risk aversion and defensive practice. Tasks that were once handled verbally now require written orders, increasing the administrative burden for everyone and pulling ambitious residents out of theatre for half a day or more.3. Robotics as both a challenge and an opportunity (7:52) Robotic surgery combines complex procedures with the mastery of technology, which raises the training bar. It also places a computer between the surgeon's eyes and the patient, making it possible to store video and surgical data, review procedures, give formative feedback, and measure kinematics. This makes robotics a powerful tool for objectively measuring and improving surgical quality.4. Exposure is not enough: the case for structure (9:31) Watching a procedure is not the same as being trained to perform it. Ruben and Tony agree that robotics demands the structure the Halstedian approach once imposed, but delivered through universal, evidence-driven standards and benchmarking, rather than the reputation of a single centre or trainer.5. The systemic problem: a lack of standardisation (12:39) Without standardised curricula, trainees are dependent on the goodwill of whichever consultant they are assigned. Ruben describes a fellowship with six fellows and nine consultants, each teaching the same procedure differently, and warns that patients are effectively used as training models for consultants who were not well trained themselves.6. Who should set and police the standards (17:37) Standards should be set by rigorous scientific research, not opinion. Scientific societies should define the benchmark and authorities should make it mandatory, in the same way prescribing rights follow formal qualification. Ruben cautions against a large role for industry, citing the conflict of interest in paid proctoring, where a proctor can be pushed to guide a novice through complex steps they have not earned the right to attempt.7. The multi-specialty randomised controlled trial (23:15) A blinded RCT deliberately included urologists, general surgeons, and gynaecologists to test the belief that some specialties are inherently more skilled. At baseline all three performed equally, and after training all three performed equally well. The methodology, not the specialty, predicted the skill set. As reported in the episode, 67 per cent of PBP trainees reached proficiency by the end of the day, compared with 17 per cent trained by the apprenticeship model. [See PROVESA / De Groote RCT publications below.]8. Quantifying intraoperative performance: why subjective scales fail (28:18) Likert-based tools such as GEARS are subjective and prone to drift, with a trainer's scoring shifting depending on the video seen just before. For validity, inter-reader agreement should be 80 per cent or higher; in Ruben's study GEARS reached only around 30 per cent, which by default makes it invalid for assessing surgical quality. Binary metrics are the ...
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