New Paradigms for Developing Skills in a Technology-Driven Medical World

New Paradigms for Developing Skills in a Technology-Driven Medical World

Miriam Knoll, MD

Jul 08, 2019

Dr. Nabil P. RizkCoauthored by Dr. Miriam A. Knoll and Dr. Nabil P. Rizk

Going home 2 days after lung cancer surgery? Yes, you read that correctly. And it isn’t just cancer hype.

As a radiation oncologist, I work closely with thoracic surgical oncologists and thoracic medical oncologists to treat the #1 cancer killer in the United States: lung cancer.1 When I learned that patients who underwent lobectomy at Hackensack University Medical Center (full disclosure: this is where Dr. Nabil P. Rizk and I work) often go home after 2 days—or less—I was fascinated.

Truly, I wasn’t surprised with the speed of recovery—the progressive shortening of recovery time and hospital stay is a common goal for physicians and hospitals. My real inquiry was: How does a group of talented, busy surgeons find the time to change their surgical paradigm? So I sat down with Nabil P. Rizk, MD, MS, MPH, to find out more.

Dr. Rizk is a thoracic surgical oncologist with expertise in the treatment of lung cancer, esophageal cancer, and mediastinal tumors. He is a leader in video-assisted thoracic surgery (VATS) as well as robotic lung and mediastinal surgery. He holds a Master of Statistics and Clinical Research Methods and a Master of Public Health from the Mailman School of Public Health at Columbia University in New York City.

We had an enlightening conversation about cost, value, quality of care, and process improvement, which I am glad to be able to share with readers.

MK: Can you describe the impetus to develop the robotic-assisted video-assisted thoracoscopic surgery (VATS) program?

NR: I joined Hackensack University Medical Center over 3 years ago. During the first 3 years, our thoracic surgical oncology division’s goal was to optimize the value of the care we provided. We defined one aspect of improved value as cutting costs of the surgery and accompanying hospitalization. First, we focused on VATS lobectomy and VATS wedges, in lieu of the historical surgical approach of an open thoracotomy. We used process improvement methods, including Lean and Six Sigma, with the support of robust and granular data, including an outcomes database and a cost database. We were successful in cutting costs by 40%, lowering mean length of hospital stay (LOS) to 1.7 days for a lobectomy and 1.1 days for a wedge, lowering 30-day mortality to 0.3%, and keeping re-admission rates at 3%. 

Now that we optimized outcomes utilizing VATS, we decided to embark on a robotic-assisted VATS program to try and achieve even better results. Until this time, we had been doing robotics only for certain situations such as thymectomies, segmentectomies, and post-induction cases. In January 2019, we went “all in” and began doing all of our lung cases robotically.

MK: What was the biggest challenge in creating the program?

NR: Our biggest challenge in converting to robotics was to not significantly impact the excellent results we had achieved with VATS. We knew that overall, national robotic-VATS benchmarks were similar to VATS alone, but we set the bar much higher given that our institutional VATS results were significantly better than those benchmarks. We also recognized that it took us 3 years to achieve our VATS outcomes. So, we decided that while we would be willing to accept some initial increase in cost through longer cases and a longer LOS, we would not accept any decrease in quality. Ultimately, however, our goal will be to lower costs beyond VATS alone. Towards this end, we are closely monitoring our results and are constantly adjusting what we do to achieve our goal.

MK: How did you create the training paradigm for yourself and your partners?

NR: In order to optimize the intra-operative learning curve and to achieve the maximal learning possible per case, all three surgeons in our group have committed to be present in the operating room for every robotic lobectomy scheduled, until we consistently achieve the results we are seeking (whether we are all scrubbed-in on the case or not). We also record every case. Throughout each case, we also constantly interact and analyze our technique in order to modify things as needed, and we review the video recording afterwards when needed.

MK: You have a master’s degree in public health (MPH). Did that background play a role in this endeavor?

NR: Prior to completing my MPH, I typically did not think about the cost of care, nor did I know how to implement system changes to optimize value. My degree focused on public policy and management, which are two critical components in the process I described above. I also have a separate degree in clinical research methods and statistics, so I am pretty facile with the design and use of databases, which is very important to track our outcomes and results.

MK: What would you recommend to other physicians—whether surgeons, oncologists, or physicians in general—who are trying to develop new clinical skills?

NR: The primary goal must always be to maintain or improve the quality of care of patients. The only way to know if you are achieving the results you are seeking is to constantly monitor your outcomes. Given the societal and individual impact of the high costs of health care, it is also imperative to both be aware of the costs of what you do and to focus on lowering those costs whenever possible. If there is one thing we have proven through our VATS experience, it is that when properly done, lowering costs is strongly correlated with improvements in quality.


  1. Centers for Disease Control and Prevention. Lung Cancer. “Lung Cancer Is the Biggest Cancer Killer in Both Men and Women” Infographic. Available at: Accessed July 3, 2019.


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