There is a constant and growing need for education in new medical procedures and the use of new devices. This is especially true for surgeons who are constantly being equipped with better methods and tools for dealing with the challenging job of repairing the inside and outside of the human body. To meet this need, there are a number of institutes for graduate medical education around the country. Florida Hospital joined these ranks with a focus on educating surgeons and an emphasis on emerging new techniques in robotic, laparoscopic, and orthopedic surgery. Serving as a living laboratory for healthcare advancement and innovation, the Nicholson Center is dedicated to three major goals: the learning of medicine, the science of medicine, and the business of medicine.
The Learning of Medicine
Nicholson Center courses in medical practice are guided by the six core competencies established by the American College of Graduate Medical Education (ACGME):
- Competency in patient care - compassionate, appropriate, effective;
- Competency in medical knowledge - biomedical, clinical, cognate sciences and their application;
- Competency in practice-based learning and improvement - investigation and evaluation, appraisal and assimilation of evidence;
- Competency in interpersonal and communication skills - effective information exchange, teaming with patients and families;
- Competency in professionalism - carrying out professional responsibilities, ethics, sensitivity; and
- Competency in systems-based practice - awareness and responsiveness to the larger context and system of healthcare and the use of system resources.
In 2001, Florida Hospital opened the Surgical Learning Institute, the original name of the Nicholson Center, after two years of planning and investment. The first courses were coordinated through industry sponsorships from Karl Storz Endoscopy-America, Johnson & Johnson Ethicon Endo-Surgery, GE Healthcare, and Getinge USA. The initial focus was on Women’s Health and Urology, but has expanded far beyond this in 10 years. The Institute provided fully equipped teaching laboratories, didactic education spaces, and experienced surgeon-instructors who were able to share their knowledge and techniques with younger or less experienced colleagues. In the first five years of operation this institute trained over 17,000 surgeons in a large number of specialty programs.
In October 2006, Tony and Sonja Nicholson, prominent real estate developers in Central Florida, pledged $5 million to expand the institute and it was formally renamed the Nicholson Center for Surgical Advancement (NCSA) in recognition of their generosity. In February 2008, the center expanded into Robotic Surgery training through a partnership with Intuitive Surgical Inc. With the simultaneous addition of a number of world-class robotic surgeons to the Florida Hospital system, this new emphasis led to world-wide recognition of the Nicholson Center as one of the leading surgical education institutes for robotic and laparoscopic training.
In October 2011, the Nicholson Center opened a new free-standing $35 million education facility. The 54,000 square foot building contains a 500 seat didactic center, twenty-five surgical stations, two fully equipped operating rooms, and dedicated space for at least six surgical robots. This new facility will allow the in-house training of 20,000 plus surgeons per year and the ability to extend its services globally through advanced video production and teleconferencing.
The Science of Medicine
In 2010, Congressman Alan Grayson (D-FL) directed a federal grant for $4.2 Million to the NCSA to further expand robotic and telesurgery research. This grant is currently supporting three distinct projects. First, NCSA is leading the development of a national Fundamentals of Robotic Surgery (FRS) curriculum for certifying all surgeons in these leading edge procedures. The core knowledge, skills, and curriculum that should be mastered by any aspiring robotic surgeon are being identified through meetings of leading robotic surgeons from around the world. The products of this work will become the basis for future national certification programs in robotic surgery, and will be managed by an authoritative and unbiased national medical society just as the Fundamentals of Laparoscopic Surgery (FLS) is today.
Second, NCSA is investigating the effectiveness of simulators in developing and maintaining surgical skills in robotic specialties. It has been shown that surgeons who perform hand-eye coordination exercises prior to robotic surgery improve their performance during the procedure. Working together with Mimic Technologies Inc. we are creating a simulation system that will allow a surgeon to perform an operation in a simulator that contains a digital model of the patient’s actual anatomy. The data file from an MRI of the real patient will be converted into a digital model that can be operated upon in the simulator. The surgeon will rehearse on digital physiology that exactly matches that of the patient. This kind of patient-specific surgical rehearsal may improve the performance of the surgeon even more than the generic warm-up exercises that have been used in the past.
Finally, the grant is supporting advanced experiments in telesurgery using robots. We believe that surgical procedures that are performed at a distance will have some fundamental differences from those performed in a local setting. The communication lag that exists between two facilities will always impose a limitation on the ability to perform delicate surgeries. We accept these limits in the technology and are focusing on modifying surgical procedures so that they are tolerant of this lag and safe to the patient. We are identifying the communication lag that exists between key pairs of cities and facilities where telesurgery will be performed in the future. Then we are measuring the level of latency that can be tolerated by the small atomic movements that make up an entire surgical procedure. Some of these movements will be safe under the levels of lag found between city pairs, but others will be so delicate and precise that they cannot tolerate the lag that is created in the robotic, computer, and communication infrastructure. Our experiments will call upon the expertise of robotic surgeons to redesign these key movements and actions so that they can tolerate longer latency in communication between the surgeon and the patient. In doing so, we are seeking to invent new procedures that will define how surgery will be performed safely when the technical, regulatory, legal, and medical delivery systems are ready to allow telesurgery.
The military is a major proponent of this concept because it will eventually allow an expert surgeon anywhere in the world to apply his skills to save the life of a soldier in a remote military hospital. But before telesurgery can reach around the world, it must reach across a city. Short-distance telesurgery across a metropolitan area will be very valuable in its own right. It will allow expert surgeons to provide their services to multiple regional hospitals without physically commuting between facilities, converting wasted commute time into productive surgical time.
Finally, near the end of our research calendar we will combine the results of the surgical rehearsal experiments with those from telesurgery to explore the concept of automatic surgery. When a surgeon performs an operation on a digital model of a patient in a simulator, all of the movement and action commands will be recorded to a computer file. In essence, this file is a detailed instruction set on exactly how to perform the surgery. We will then prepare a physical model or real tissue under a real robot in exactly the same position that existed in the simulator. We will then inject the surgical movement command file into the real robot and allow it to repeat the surgery on the tissue, without the intervention of a human surgeon. The robot will be running on auto-pilot. These experiments will allow us to determine how many variables in this environment can be controlled and how many are still beyond the reach of the current tools.
The long-term goal of this capstone project is to contribute to a system that can perform surgery in extreme environments where the communication link is so unreliable or so delayed that no other technique for telesurgery will work. This could be the means through which surgeons on the earth operate on astronauts in Moon colonies or Mars missions. It would allow surgical instructions to be sent to a submarine in the depths of the ocean or to scientific outposts on the polar cap of Antarctica. It could also allow medical missionaries to bring surgical specialties into the most remote and primitive places on earth.
The research enabled by this grant is far-reaching. Some of it will impact the practice of robotic surgery in the next few years, while other pieces will plant the seeds of surgical change that will require decades to mature.
The Business of Medicine
The Florida Hospital System is one of the largest by patient volume in the country. It is also one of the leaders in adopting and practicing robotic surgery with business methods that recoup the huge investments required for this type of practice. The tools and techniques that make this possible are shared with hospitals and surgeons in a number of consulting services and conferences offered by the hospital. Each of the sponsored medical conferences from Florida Hospital includes a track on successfully designing, staffing, operating, and marketing a robotic surgery practice.
Acquiring advanced equipment is never a guaranteed path to business success. There are many variables from local demographic of the population, to the selection of surgeons, to the design of the operating rooms that contribute to making these methods financially viable. Florida Hospital employs classic techniques in operations research and optimization to design its robotic surgical practices. These are supported by changes within the administrative structure of the system, as well as a very robust marketing strategy to educate the public on the benefits of new techniques and effective surgeons.
The Nicholson Center is the conduit through which the Florida Hospital System provides all of these valuable services in the learning, the science, and the business of medicine.
Dr. Roger Smith is the Chief Technology Officer for Florida Hospital's Nicholson Center for Surgical Advancement where he is leading a team of researchers in applying simulation devices to the process of surgical education. He was previously the CTO for the U.S. Army Program Executive Office for Simulation, Training and Instrumentation (PEO STRI) and a Research Scientist for Texas A&M University. Prior to this he served as a Vice President and CTO for defense contractors Titan Inc. and BTG Inc., leading teams to develop software for both training and combat operations. He is a Graduate Faculty Scholar at the University of Central Florida and has served on the faculties of four universities. He has published over 150 technical and management papers, developed four commercial courses on simulation technologies, and published several books on technology and management. Dr. Smith holds a Ph.D. in Computer Science, Doctorate and Master's in Business Administration, M.S. in Statistics, and a B.S. in Applied Mathematics.