The end of "see one, do one, teach one" — Prof Stefano Puliatti | Show Me The Evidence Episode 9

Professor Stefano Puliatti is Professor of Urology at the University of Modena, a practising robotic surgeon, a faculty member of Surgquest, and the former Medical Director of Orsi Academy in Belgium, where much of the PBP research discussed here was carried out.

Key takeaways

• Training quality should not depend on the luck of being assigned a gifted trainer. A shared methodology makes good outcomes reproducible.
• Errors, not speed or step count alone, are the real indicator of surgical quality. Process measures on their own do not guarantee it.
• A proficiency benchmark set at expert level is reachable by nearly all trainees, and usually faster than conventional training allows.
• Good simulation does not have to be expensive. A validated methodology on a low-cost model can outperform costly kit used without one.
• Diluting the method, for example by dropping the pre-lab benchmark, measurably slows learning and raises cost.

Evidence and further reading

The figures cited in this episode come from the peer-reviewed studies below. Please confirm the exact papers you want listed for this episode before publishing.

• De Groote R, et al. Proficiency-based training and evidence-based methodology: a systematic review and meta-analysis. BJU International. doi:10.1111/bju.70333
• Mazzone E, Puliatti S, et al. A Systematic Review and Meta-analysis on the Impact of Proficiency-based Progression Simulation Training on Performance Outcomes. Annals of Surgery, 2021. PMID: 33630473
• Puliatti S, et al. Can all surgical trainees be trained to proficiency for a robotic urethro-vesical anastomotic task using a chicken model? A prospective, randomized trial. PMID: 40351291
• Randomised trial on the economic impact of proficiency-based progression versus conventional robotic surgical training. PMC12907777
• Development and validation of the objective assessment of robotic suturing and knot tying skills for a chicken anastomotic model. Surgical Endoscopy, 2020. doi:10.1007/s00464-020-07918-5
• De Groote R, et al. Proficiency-based progression training for robotic surgery skills training: a randomized clinical trial. BJU International, 2022. doi:10.1111/bju.15811

Credits

Show Me the Evidence is hosted by Professor Anthony G. Gallagher and produced by Flux Learning. 

What is Show Me The Evidence?

Most training is sold on confidence. Show Me The Evidence is built on data.
In every episode we take a single study, clinical trial, or systematic review and work through what it found, how it was designed, and what it means for the way we teach and assess skill. We focus on metrics-based training and proficiency-based progression, the approach that asks learners to demonstrate measurable competence before moving on, and we trace its results across surgical, medical, and professional education.
This is a podcast for learning professionals and medical educators who want more than opinion. Expect plain-language breakdowns of the research, honest discussion of what the evidence does and does not support, and conversations with the people behind the studies.
If you make decisions about how people are trained, we think you deserve to see the evidence first.

My guest today is Stefano Puliatti.

Stefano is a professor of urology at the
University of Modena in Reggio Emilia.

He's a robotic surgeon, he's a faculty member of
SurgeQuest with my colleague Ruben De Groote.

And he's former medical director at Orsi Academy
in Belgium where I met him in 2019.

Very welcome, Stefano.

Thank you, Prof. It's a pleasure for me.

You were a resident in Modena during a time when
robotic surgery was expanding rapidly.

Did you and the surgical leadership
in Modena realise how pivotal

our robotics would be for the future
of surgical practice?

Yes. We had the fortune to start
robotics in 2007 in Modena.

It was one of the first robotic
platforms in Italy

And the robotic leadership at

the time was my mentor, Professor
Gianpaolo Bianchi,

full professor in urology and the former director
of the urological clinic here in Modena.

And he saw very soon the potential of this new
technology applied to the urological field.

Because the urological field is a very, very

specific field of surgery, we
have the pubic bone

that obscures the anatomical view. And
the robot is really able to

avoid conflicts to improve the visibility and
to improve the technical possibility to do,

for example, an anastomosis. So really from the
very first moment, he saw the potential

and we followed up with the implementation of the
robotic surgery in our city and in urology.

So robotics is quite different, but I mean,
something that you started out

your surgical experience learning laparoscopic
and open procedures. So how did you learn

a laparoscopic and open procedure?
Traditional Halstedian?

Yes. It was a kind of a Halstedian model. It was
typically still the standard way of training

a lot of centres in Europe.
So I had the fortune

to have a great surgeon teaching
to me. So I was

able to learn watching and then doing when I
was allowed to do directly on the patient,

directly in the OR. And this was the setting.

So we saw the procedure done
by a very, very good

surgeon and we were allowed step by step to do
some part of the procedure done under the

supervision of the trainer directly on
the patient directly in the OR.

And did you attend subsidiary courses in laparoscopic
or were they ran in the hospital or

they were apprenticeship type
training as well?

Yeah, there were some courses run in Europe or

in Italy and I attended some courses in my first
and second year of the residency school in

laparoscopic and endo-urology around Europe and
around Italy, mainly based on theoretical

lessons and some life surgeries that we were
allowed to follow and some surgical skills

but not with a methodology, a theoretical methodology
on the base of these courses.

So during your time as medical
director at ORSI,

looking back on it now, what
are the key lessons

that you learned about surgical training and
learning skills? Yeah, it was really

mind-changing because it was something really
different what we did in ORSI Academy because

there were some very important key points, I

think. First of all, there was
ORSI Academy. ORSI Academy

is a fantastic place in which we have a lot of
simulation operative rooms, we have a lot of

robotic platforms, we have everything
to simulate

a real operatory room without
the risk of operating

directly on a patient. This is a kind of

wonderful place in which you have
all the video games,

all the possibilities that you wanted to learn

but I think this is not enough.
The other key point

that I found was a methodology.
That was, I think,

the thing that is missing in
Europe, also nowadays,

in the training setting. So we learn watching

other surgeons and doing steps
of the procedures

directly on the patient but without a

methodology that is on the base.
It means that if you have

a very very good surgeon that
trains you, you can

learn really well how to do surgery.
But if you have

a quality that is not enough in your trainer ship
probably you will be not a very very good

surgeon because it is difficult to implement

your skills if you don't have very
very very good surgeons

teaching to you. What I found in ORSI Academy

was a methodology. So the methodology
is a kind of

way that standardised the way
we do training and

we have methods, so we have
rules to respect and

are the same for all the trainees.
And this means

that it is possible to reach
a very very high level

of skills at the end of the
training. So it was

not only about the training
setting and in that

case was ORSI Academy that is a very very high
level training setting but was also about the

methodology applied to the
training that you do.

And this methodology, those
metrics, those rules

that you have to respect, those arrows that you
have to avoid are really the key points that

are probably in my mind able
to democratise and

standardise the level of the training and make

the possibility for everybody
to reach a certain

level of performance at the
end of the training.

So at the start of your time in ORSI
if you can think back to 2019,

what did you make of proficiency based progression
training when you first encountered it?

At the beginning it was very difficult because
you were the leader and I was a little bit

difficult to understand your accent but this

was probably the first big problem
but after three

months I had a feeling with your accent, I had
a feeling with you and I had a feeling with

the methodology and this was for me really

something crazy, really something
very good because I saw

a methodology that in the beginning seemed not
so simple but when you enter into it and you

understand the methodology in depth it becomes

really simple and really straightforward
and it

was really simple for me to understand how to apply
the methodology in the different training

models and to really understand
quickly that if

you are able to focus the errors
and the critical

errors and to avoid the errors
and the critical

errors then your performance becomes
straightforward,

becomes faster, becomes more,
I don't know if it

is possible to say like this
but it is good looking.

So you can see that there is a flow that is more
fast, more beauty to see and at the end

the results represents this
beauty and you have

an improvement in the results
and at the end it

is really fast to reach a proficiency
level so a

very very high level of performance.
So to make

a long story short at the beginning seems complicated
the methodology but it is not,

it is simple, it is easy to apply on different
tasks and the results are really fast

to be recognised at the end of the training performance.
So five to six years later, okay

you were working with robotics
in ORSI academy, so

five to six years later what
do you make a PBP now?

Now it is a guidance and it is a must to have. I
have the fortune that all the robotic groups

here in Modena was allowed to have a one-year
fellowship in Orsi academy and they were all

trained accordingly to the PBP methodology so

also when we start here in the
OR to do part of the

procedures when they come back from the

fellowship and they start to do part
of the procedure it is

accordingly to the PBP methodology
and only who

has a benchmark proficiency
already demonstrated

in the anastomosis task and in the other task of
the procedure we know that the robot assist

the radical prostatectomy is
probably one of the

first robotic procedures that
was metricised with

the PBP methodology and so
we have all the stats

with the metrics and we follow
this methodology

and those rules in the OR.
This makes the things

really easier for the trainer
and for the trainees

because it is more smooth the
learning curve on

the patient and without or with
really less risks

so it is a win-to-win for the surgeons for
the school and also for the patients.

I think Modena have had a fabulous engagement

with the proficiency-based progression
methodology

and I think it bodes very well for the future in
terms of the development of the department

and for the new professor when they come in. So
what for you are the essential features of

the proficiency-based progression
methodology that

make it effective? I think there
are three points.

That makes PBP methodology a
winning methodology.

The first point are the metrics.
The metrics are

the rules, are the receipt that you have to

follow to have good results at
the end of the training.

More than that are errors and critical errors that
you have to avoid. So when you focus the

critical errors that you have to avoid it is
really more simple to do a good procedure.

The second point is the deliberate practice because
the deliberate practice for me is key.

We did a study when we were in ORSI also with
Luca Sarkey and Pietro Piazza and other

Rui Farina other colleagues in which
we did a tele-mentoring.

The tele-mentoring with PBP,
PBP-based was really

successful. Why was that? Because we were able to
speak a really direct language based on the

metrics and this is the deliberate
practice. So

you give feedbacks that are
based on the metrics

with a clear language that is already written
on the metrics. This makes the feedback

direct, really understandable for the trainee

and deliverable also in a tele-mentoring
setting.

This is something different in comparison to

the Halstedian model because
in the Halstedian model

you use a language that is
your own language. So

it is different if I do the training,
if you do the

training or if another person
does the training.

With the metrics you have the
same language for

everybody and you can give really a direct

feedback to the trainee that is
able really to understand

in a very very short period of time what is
your message and how to fix the problem.

The third point that I think is key in the PBP
methodology is the proficiency benchmark

because we have a really high level that the
trainee has to reach because it is the mean

level of experienced surgeons, very very good
surgeons that did the same task. So at the

beginning when you see it you
say okay but it is

impossible that they reach the
same level of this

fantastic surgeons doing that task and it is

impossible that they reach that
level in one day,

nine hours or one day and half. But with the metrics
it is possible to reach this proficiency

benchmark really fast and at the end you reach
this kind of technical skills in the lab,

not directly on the patient and this is

something that allows you then when
you go on the patient

to have the confidence and the safety to

operate directly on the patient
with a very very high

level of technical skills and this makes the
trainee more confident but also the trainer

is responsible of the surgical, more confident
that we will not have damages on the patient.

Yeah I think one of the lessons that we learned
from your studies and from Ruben's studies

is that you also have to train
the trainers how to

deliver the delivered practice
because I remember

walking around the skills lab and watching the

different individuals deliver
delivered practice

and some of them are really good at it and some
of them are really shy and some of them

they didn't understand what proximate feedback

was. So it was I think it was
a huge, your time

in ORSI think it was a huge
developmental phase

for proficiency based progression
where we learned

a lot. One of the things you
talked about you know

practicing in the skills lab,
I mean do you think

simulation models for training
skills or robotic

surgical skills, do you think
they by default have

to be expensive? We tried to find something

that was less expensive because
there is a kind of

market also around the training models. There
are some really expensive virtual reality

simulators, there are plastic models that are

really expensive. What we tried
to do was to find

a model that is available worldwide, it is not

expensive and we found it using
a chicken model

and the chicken model in my opinion
that was already

acquired and studied as a training model
but without a training methodology.

It was not PBP based before. To apply the PBP
methodology to acquire the technical skills

using an inexpensive model like the chicken

model I think was a very very
good idea because the

chicken model is available worldwide. We use

the chicken that you can find
in the supermarket,

it is the same chicken that you buy to eat at lunch
or at dinner. So instead of using it for

feeding we use it for training
that I think is a

very very important thing to
do and the chicken

model has some advantages. It is a biological

model so has some elasticities,
some characteristics

of the tissue that really are similar to the human
tissue and it is more or less inexpensive.

The most difficult part in my opinion was to find
using a single model the different tasks

that were able to reproduce the basic skills that
you have to acquire to do then a very very

important surgery like radical
prostatectomy or

some genealogical or general
surgical procedures.

We found three main basic skills suturing and
knotting, dissection and coagulation tasks

that are really important to acquire and using
the chicken model we were able to find

different exercises that were able to train
these three skills that are the

elementary skills that you have to acquire before
going into the OR So I think it is

inexpensive, available worldwide,
really similar

to the human tissue training
model. It is really

important to have it and to use it. Obviously the
biological tissue and the biological animal

probably in the future will
be not allowed. Now

we have really technological
advanced 3D printers.

Probably this will be the way in the future to

try to really find not biological
tissues that are

able to reproduce the bio-mechanical information
and the bio-mechanical characteristics and

features of the human tissue. Yeah I agree with
you. I mean a lot of the models that I see

are very expensive and I'm
not too sure they're

very functional particularly
for the suturing and

knotting. I've yet to see, I am a huge fan of
physics based virtual reality simulation

but I have yet to see a simulator that

accurately or realistically simulates
needle thread tissue

dynamics, particularly one tie-in and knot.

Dwight Maglin and I were talking
some time ago and he

agrees that we don't seem to
be at that point yet

but he thinks that AI may help
in the development

of that but that could be years
off. So was the

development and validation of
the vesicoeurithral

anastomosis chicken model in Orsi? Was it an important
milestone for you? You've combined,

you've got this check, you've
got this inexpensive

chicken model for the vesicoeurithral
urethral anastomosis,

you've got a training methodology and you've combined
these so was it an important milestone

for you? Yeah it was super
important. It was for

me really a very important school
because with this

training

exercise. With this training exercise we were

able to apply the methodology
on the basic skill

setting in roboticsurgery. This was not done
before we did it. So it was a first time

and it was a first of all personally a very very
nice moment because we cooperated with your

guidance with other colleagues working on the
metrics, working together thinking about the

errors, the mistakes, the critical errors that

you can commit when you do
this kind of training

exercise and to apply the methodology on a

model. And this model is very
nice because you have a

stomach and the cloaca of a chicken that really
simulates the vesicle and the bladder and the

so the vesicle retral anastomosis it is really similar
to the stomach cloaca anastomosis that

you do in the chicken. So it
was a combination of

things and I think about that
as one of the most

important research I have done
so far and one of

the most important experiences
that I have done.

It taught me a lot about the application of a
methodology, about scientific research,

but also it is something that I still using day
by day in terms of really deliberate practice

and information that as a trainer
now I give to

the trainees and to the fellows
and it was really

useful for me. I remember the type, I thought
it was a very powerful vehicle for teaching

you guys about the methodology
but also how the

methodology applies to real
surgical procedures

and it was probably one of the most productive times
for me and probably for ORSI in terms of

the training models that we developed, the
publications that we had and so on and it

was fun doing it. So I mean in relation to
that and the papers you were the first

or the joint first author and the first
systematic review and meta-analysis

of all prospective randomised and blinded studies
that had used a proficiency based

progression methodology to train one arm and

compared it to the gold standard,
the conventional

Halsteadian approach to training robotic
surgical skills or skills in general,

systematic review covered all of them. So what
were the main findings of that study?

Yeah, I remember it as another fantastic
period, it was COVID period and we had,

it was really how to learn how to do science.
Again under your guidance we were I think in

Zoom calls every night thinking together and one
idea came because yeah we were applied at

the moment the PBP methodology
in robotic surgery

and the robotic surgery was
more or less the first

time that the methodology was applied but the

methodology was around from
20 years at the time

if I'm not mistaken and it was already used in
the medical field. So there were a lot of

studies in which PBP methodology was applied
in training for example in anesthesia,

in orthopedics, in a lot of other specialties.
So what we thought was to analyze the results

that PBP already demonstrated in other medical
fields in comparison to the standard way of

training because there were
a lot of data already

on the table and at the time
nobody analysed all

those data together. So the idea to do a meta-analysis
and a systematic review on those data

was I think a very very good idea and the

results were really something crazy
because we expected

something good in the comparison between the
PBP methodology and the standard training

but not with this magnitude of difference and we
found that with the PBP methodology applied

in the medical field the trainees
who completed

the training, the PBP trainees
in comparison to

the traditional trainees that were following the
traditional way of training were faster.

So there was a 50% difference in terms of velocity
in doing the exercise but we know that

to be fast is not the same to be high quality surgeons
but it was something. So the trainees

were faster in completing the task, completed
more procedural steps, 47% of difference and

more than that and it was really the thing
that was for us the most important. They

committed the PBP trainees, committed the 60% less
operative errors. It means that at the end

PBP allows the trainees following
this methodology

to be faster, to complete more
steps and to do less

errors. So we had already at the time before starting
really to apply it in robotic surgery

the demonstration that the PBP methodology was

working really well in the
medical field and was

really improving the results and the data were
all data coming for prospective randomised

trials. So it was not, it was probably all
papers were level 1A of evidence. So

we're really robust data that we cannot ignore.
Yeah and I mean what I was impressed was okay

it was a simple idea but it
was a fabulous idea

and I remember how well we actually
worked and how

strictly we adhered to the science including
the evaluation of the quality of the papers

and it forced me to rethink about and you the steps
of the procedure, the time it takes to do

a procedure, those are measures of process and

we know the process on its
own will not get you

quality and what that study forced me to

realize was that the errors were
the indicator of the

quality of that process and so that's how they

actually fit together. So I
mean it was fabulous

and I remember how well we worked together at

the time. I spent five years
in the US working in

surgery and cardiology and Frank Lewis was the
chief executive or executive director of the

American Board of Surgery.
The American Board of

Surgery they run American surgical
credentialing and so on

Frank was an old-fashioned trauma surgeon,
he was very smart, I liked him a lot,

we would get on really well. He liked the proficiency
based progression approach, he says

Tony I like that but number one you're never going
to get people, you talked about it earlier

setting the benchmark on the main performance

of good surgeons, he says you're
not going to get

everybody all of the trainees to the proficiency
benchmark. He said that it's really that the

benchmark is too high, so one benchmark is too
high and two that we were never going to get

everybody into proficiency. Now we're 20 years,
we're more than 20 years on, was he right?

I think that the PBP methodology can be applied
in all the fields and I think that it is a

methodology that really as I said is able to

democratise the quality of the
performance at the

end. If you think about the
proficiency benchmark

and you look at it before you
start training you

say it is impossible, so or almost impossible

because you think that the benchmark
is too high,

the benchmark is the same quality level of a

surgeon that has done thousands
of that kind of proceed.

But then you realise that if
you understand the

rules that are on the base of
the surgery, on the

base of the acquisition of the technical skills,
then it is possible to focus the errors, the

critical errors and then it
is possible to avoid

that. Obviously you have to
train, obviously you

have to fatigue, you have to put effort in the training,
it is effort for the trainees, it is

effort for the trainer, but it is a process

that makes the trainees really
in an easy way up to

a proficiency level. And so
the benchmark in my

opinion, the criticism that
were moved at the time

are understandable, are logics probably, but if
you try to do that accordingly to the PBP you

understand really fast that are not true

because it is possible to reach
that benchmark, it is

possible to reach it quickly and probably

faster than with a traditional
training methodology.

Probably or definitely. I think that that are

there, so you know that my
English is an Italian

so you have to take it a little bit with, you have
to understand me, but the data are there.

So the probability, probably the era of the

probability is finished and
now we have data that

cannot be ignored. Again our
all data coming from

a prospective randomised trials
so it is level 1A

of evidence and if we don't trust level 1A of
evidence probably we have to trash more than

half of the medical literature. Yeah, I think
your papers are some of the most important

in the proficiency based progression

methodology history because I mean
the question that Frank

asked me, I mean I like Frank, I still have

enormous respect for him and
he asked good questions

and you unambiguously answered
the question, okay

can we train everybody to proficiency?
Yes we can

and it or in comparison to the conventional
training it takes about one third the time

to get everybody to proficiency and only 58%
over three days got to proficiency with the

conventional approach to training. I would say
that's definitely and unambiguously answered

those two questions. Yes, the other thing, so
go ahead. No, when we started this trial in

ORSI Academy and we had as trainees naive
medical students in the trial that I

leaded the idea was that was
really difficult to

have everybody reaching the
proficiency benchmark

and with the PBP model so we were able to do

that. So probably if you are
able to do that with

medical students it will be really more easy
if you have more prepared people.

Yeah, the other issue that
surgical leaders and

industry leaders who actively
fund a lot of the

courses what they say to me is totally yes we like
the idea of proficiency based progression

but it's too expensive. It's
more expensive than

the conventional approach to
training the way that

you do. Is that correct? This was the other
very important point and really important

criticism that we tried to
answer together in my

period in ORSI was also another
very, very nice

study and it taught me another approach because
other than the medical and surgical

field that daily I have to
inquire there was the

economical field applied to
training that is not

less important than the technical field because
you can have the best technical methodology,

the best model but if it is too expensive it
is not applicable in the daily life.

And what we found again was a kind of surprise
because yes if you look at that

before starting to analyse
it in depth it seems

that the PBP is more expensive.
Why? Because you

have the cost of the metrics. Obviously you

have to develop the metrics
and you need a team of

experienced surgeons, you need a behavioural scientist,
someone that really knows how to do

science or how to do statistics
and you have to

put this team together. It
should be a team that

cooperates really well because
otherwise you can

have issues in the developing
of the metrics and

the application of the methodology on a training
task and it is effort and it is economically

costly at the beginning but then what we showed
is that using the PBP methodology you have

everybody reaching the benchmark so you have a

100% of success in having people
reaching a certain

level, a very very high level of performance and
you are faster. So the same task to reach

the proficiency benchmark in
the same task with

the traditional model, in the
suturing and knocking

task using the chicken model it was three and a
half days to have the 58% of the participants

in the traditional model reaching the proficiency
benchmark and using a full PBP methodology

we were able to have the same
results for the PBP

trainees in nine hours. It means
that you have two

and half days of difference in terms of time

spent in the training lab and
the training lab is

really costly. This was the magnitude of difference
in terms of time and as in life

time means money so if you are able to spare

time in the lab you spare money.
So the money that

you invest to produce the metrics if you have
a large scale of people that will be trained

using that methodology at the end becomes saving
of money and what we found is that the point

of equivalence is 25 trainees. So if you train
less than 25 trainees we used as a model the

suturing and knocking chicken model. So if you
think about that model so to learn how to do

suturing and knocking using
the PPP methodology

it is more costly if you train
less than 25 people

in comparison to the traditional
model but when

you arrive at 25 people you
start to spare money

and you think you have to think that a training
center as Orsi Academy or other important

training centers train normally
train thousands

of trainees per year. So at the end you have a

you are able to save billions and we found in

our study that it was not statistically
significant

but if you think about a company a big company
that delivers training at the end of the days

to spare billions per year in deliver the

training for their devices or
for the surgical skills

acquisition yes it is not probably
statistically

significant in the study that
we are on but it is

economically significant for companies and if
we think about the training that can be used

in the European community it will be really prepared
better surgeons with less economically

expensive. Yeah I was to be honest I was
surprised at the cost equivalence point

because I knew that question needed to be quantitatively
answered and I just assumed it

would be 100 or 200 or something but the 25 for
the cost equivalence was a surprise to me

and I remember we modeled using
your results we

modeled okay what's the cost equivalence point

for the development of the
metrics and training

using PBP for prostatectomy
and the metrics for

that procedure were much more expensive they

ran into the hundreds of thousands
and I think the

cost of equivalence point was
about 45 so I mean

I think the data that that you
published were very

powerful and the BJUI published it as an open article
so I think they must have thought it was

important too. So does the dilution of the PBP

methodology does an impact
on training outcomes

mean the PBP methodology is fairly strict in what
it prescribes you're supposed to reach the

proficiency benchmark well
you're supposed to do

the online learning you're supposed
to demonstrate

the proficiency benchmark and
the online learning

you're supposed to pass the
benchmark before you

get to the skills lab and so on what happens if
you dilute the methodology even just a little

yeah if you dilute the methodology then the
methodology becomes less powerful and less

efficient so there isn't honestly no reason to
dilute it but it was a study that we did

to understand if we needed all the parts that
you cited already of the PBP methodology or

there were some parts that were
not useful or not

important the answer was no
we have really to use

the PBP methodology the full
PBP methodology if

we dilute it for example instead of delivering

the learning theoretical preparation with a benchmark
at the end if we take out the benchmark

we already lose efficiency in the methodology

what it means it means that
then we need more time

to have people reaching the
proficiency benchmark

at the end of the training and
it means that it is

less efficient and more expensive imagine to deliver
the theoretical information about the

methodology the PVP methodology
applied to that

technical training skill in the lab in and not

online it is an inefficient
way to do that because

you use time in the lab so you
have to rent the lab

you are probably less efficient in the

communication of the information and
also you don't know really

if people are focused on the theoretical
information that you are giving to them

they cannot review it online you can as a trainee
you can review what you have already

watched you have a benchmark that you have to

pass at the end you don't need
a training facility

to do that so it is really inexpensive it is efficient
and there is no reasons to not use

this setting so what we found it is that the
methodology should be used in the more

completed form as possible if you dilute if you
remove some part of the methodology then it

becomes less efficient and
in the background we

had also comparison with the
traditional way of

training and we saw that it was by far the less
efficient way to deliver the training so yes

the PVP methodology also if diluted is better than
the traditional training but if we use the

PVP methodology why not use it in the complete

form yeah I remember discussing
the results with

Yurio Masuroni who was working in cardiology and
I was telling him I've shown him the data

and it took 14% longer to get to proficiency if
you if he just removed the benchmark from the

online didactics and he said well it wasn't statistically
significant he said yeah it might

have been significant for you he said but if you're
a company like Medtronic and you know 14%

of five to seven hundred and fifty million a year
which is what they spend on education and

training it doesn't have to be statistically

significant for you that's a
huge amount of money

and that was an important point for me so proficiency
based progression methodology is

in your experience a very powerful methodology
for training robotic surgical skills

and probably surgical skills does PBP have a role
to play outside robotic skills and surgical

training do other disciplines
do they will they

accrue a benefit from using
it yes I think it is

a methodology that can be applied in all the
different surgical medical and also

non-medical disciplines there are already the

data demonstrating the capability
of this methodology

of implement the way to do to do training to be
honest I was really happy that we developed

together the basic surgical
skills because that

that basic surgical skills
using an inexpensive

model as the chicken model are valid and are
important not only for urology are really

important for are for for all
the robotic surgical

disciplines because also if
you are a gynaecologist

also if you are a general surgeon also if you

are a cardiac surgeon using
robotics it is really

required to acquire the suturing and knotting
the coagulation the dissection so are really

training exercises that are valid for all the surgical
disciplines and this is in my opinion

is a very very nice thing that
we developed and

we did but other than the technical
skills then

you have really to metricise
that all the single

procedures this is obviously
an effort that the

different surgical disciplines have to do they

have to find that surgeons that
are really able to

create and to apply the methodology on the different
surgical procedures but for sure

methodology can be used for all the surgical disciplines
this will be a little bit a long

pathway because obviously the
procedures that we

have to metricise that are a
lot but in my opinion

when we will have the metrics for the most important
the most common procedures at that

moment we will have already
a decreasing in the

errors that can be done and
in the learning curve

that is for for the most common procedures and
it will be an implementation of the results

both for surgeons and for patients in the

different surgical disciplines
yeah yeah i mean a lot of

clinicians think that we have to develop the metrics
for every procedure not initially what

we need is index procedures you know that that

teach the important skills
that are benchmarked

and so on and i think but i think that's going
to take quite some effort what I've

what I've said before what
probably is required

with the level of evidence of
PBP and how effective

it is what's probably required is an effort
something similar to the genome where we

metricise the index procedures for the different
surgical disciplines for the different

procedure based disciplines
and so on somebody,

I gave a keynote in Melbourne
a few years ago and

somebody said to me Tony, if you've got all this
evidence it's how come PBP is not wider

practiced and I said to them, I think that's

because of a failure of leadership
but genuinely thats my view

and but I think that you're one of the

younger new generations that will
come along that have

they're here that come along who will lead

the application and implementation
of a proficiency

based progression approach to
training Stefano as

always it's been a pleasure
to talk to you thank you

Thank you Prof, for your guidance in all those years
thank you for your support thank you

for this interview and i hope to
see you soon in person