How PBP is Transforming RAS Training

An outcomes-based approach to surgical-skills training that defies convention

Robots have been showing up in surgical settings for nearly 20 years now. Yet, training for robotic-assisted surgery (RAS) still hasn’t been integrated into standard medical school curricula. Currently, surgeons who want to work with robots generally attend a procedural skills course, often co-facilitated by experienced surgeons and device manufacturer consultants. These sessions tend to follow a more traditional approach, where the trainee learns first by observing, then by doing. For Professor Anthony Gallaher, Director of Research and Skills Development at Orsi Academy, there’s a better way.

A Transformative Approach

Developed by Professor Gallagher in early 2000, the Proficiency-Based Progression Methodology, or PBP, ushers in the new era of surgical training. This innovative, scientific, outcomes-based methodology builds a trainee’s skill, knowledge and proficiency around a robotic-assisted surgery (RAS) procedure. And it requires trainees to demonstrate their proficiency before they can perform the task in a real-world setting.

“If you do it properly, this approach to training produces performances that are 40 to 60%1 better than the traditional approach.”

–Prof. Anthony Gallagher, Director of Research and Skills Development at Orsi Academy

One Step at a Time

PBP goes farther than the conventional method of “watch, learn, do.” The emphasis for the trainee is that they know what to do and can do it to a quantitatively defined performance level. Proficiency-based progression follows a step-by-step approach to skill-building based on three key principles:

  1. Trainees must know what to do – and what not to do.
  2. They must demonstrate to a defined performance level that is based on the performance of practicing surgeons.
  3. They must achieve a specific proficiency benchmark for each phase of training before they can move to the next.

This process goes beyond developing competency. It’s not about simply making sure students know how to perform a procedure. It’s about building their knowledge, skill and proficiency around a procedure, one step at a time.

Every Step is Measured

When new surgeons are being trained in a procedure, they are required to demonstrate they can perform the procedure safely against a set of clearly defined, objective metrics. These metrics have been developed from proficient surgeons who are benchmarked as the standard. Applying these metrics is akin to mathematising a procedure:

  • The procedure is divided into phases and steps.
  • Each step has a specific, clearly defined metric, which includes the expected result, as well as errors and critical errors.
  • As trainees perform the step, errors and critical errors are tracked and results are tallied at the end.
  • Only when trainees reach the benchmarked proficiency — for example, only two errors and no critical errors — can they move to the next phase of training.

The entire process allows trainees to progressively build skills that are assessed and measured in a way that is objective, transparent, and fair. The metrics are also used to give the trainee timely, explicit, constructive formative feedback — all of which supports the development of true, demonstrable proficiency.

Results Translate to Patient Outcomes

When Gallagher first developed the Proficiency-Based Progression Methodology, there wasn’t much evidence linking a surgeon’s skills or training outcomes to the resulting patient outcomes. However, over the years, studies have shed new light on this relationship.

For example, in a 2013 study published in the New England Journal of Medicine2 (opens a new window), a research team demonstrated a striking connection between very experienced surgeons skills and patient outcomes. “These were experienced surgeons who were doing a laparoscopic gastric bypass procedure,” says Gallagher. “And for the surgeons in the bottom quartile (i.e., those surgeons assessed as having the lowest skill scores), their outcomes — meaning morbidity and mortality– were 50 to 80% worse than those in the top quartile. 50 to 80%!”

In addition, studies published in the Journal of Arthroscopic and Related Surgery3 (opens a new window) and in the BMJ Journals4 have shown that applying the PBP approach to surgical training can result in lowering patient complication rates by as much as 50%. That makes the Proficiency-Based Progression Methodology a timely and relevant catalyst for change.

Transformative Training We Believe In

As a leader in innovative technology and engineering the extraordinary, we’ve teamed up with the experts at Orsi Academy to connect more people around the world with innovative training and expertise. Together, we have found new ways — including virtual reality and augmented reality simulation — to train surgeons in the nuances of robotic-assisted surgery techniques. When in-person training is not an option, we’ve pulled PBP techniques into an app that provides free mobile access to video overviews, instruction manuals, and other training materials for surgeons and hospital staff.

Whether you have invested in a new surgical robotics program, or if you are upgrading your existing robotic system, we believe that proper training — with measurable and provable outcomes — is of the utmost importance. When a surgeon wants to use a robot, look for verification that he or she has gone through more than the basic technical training. Certainly, they must possess a demonstrable understanding of the buttonology and tool manipulation. But as research has shown, proficiency requires much more.

Sign-up now to continue learning from experts who are building best practices in RAS training and program development. And download the free Touch Surgery App to explore our library of surgical procedures.


  1. Mazzone E, Puliatti S, Amato M, et al. A Systematic Review and Meta-Analysis on the Impact of Proficiency-Based Progression Simulation Training on Performance Outcomes. Annals of Surgery: LWW, 2020.
  2. Birkmeyer JD, Finks JF, O'Reilly A, et al. Surgical skill and complication rates after bariatric surgery. New England Journal of Medicine 2013; 369(15):1434-1442.
  3. Angelo RL, Ryu RK, Pedowitz RA, et al. A proficiency-based progression training curriculum coupled with a model simulator results in the acquisition of a superior arthroscopic Bankart skill set. Arthroscopy: The Journal of Arthroscopic & Related Surgery 2015; 31(10):1854-1871
  4. Breen D, O’Brien S, McCarthy N, et al. Effect of a proficiency-based progression simulation programme on clinical communication for the deteriorating patient: a randomised controlled trial. BMJ open 2019; 9(7):e025992.

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Refer to the Instructions for Use for detailed information regarding the instructions for use, indications, contraindications, warnings, precautions and potential adverse events. In Australia and New Zealand, Hugo™ Robotic Assisted Surgery System is currently indicated for certain urologic surgical procedures, gynaecologic laparoscopic surgical procedures, and general laparoscopic surgical procedures. (Please refer to Hugo User Guide for a full list of specified procedures).