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Jarry Trujillo C, Vela Ulloa J, Escalona Vivas G, Grasset Escobar E, Villagrán Gutiérrez I, Achurra Tirado P, Varas Cohen J. Surgeons vs ChatGPT: Assessment and Feedback Performance Based on Real Surgical Scenarios. JOURNAL OF SURGICAL EDUCATION 2024; 81:960-966. [PMID: 38749814 DOI: 10.1016/j.jsurg.2024.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 03/06/2024] [Accepted: 03/15/2024] [Indexed: 06/11/2024]
Abstract
INTRODUCTION Artificial intelligence tools are being progressively integrated into medicine and surgical education. Large language models, such as ChatGPT, could provide relevant feedback aimed at improving surgical skills. The purpose of this study is to assess ChatGPT´s ability to provide feedback based on surgical scenarios. METHODS Surgical situations were transformed into texts using a neutral narrative. Texts were evaluated by ChatGPT 4.0 and 3 surgeons (A, B, C) after a brief instruction was delivered: identify errors and provide feedback accordingly. Surgical residents were provided with each of the situations and feedback obtained during the first stage, as written by each surgeon and ChatGPT, and were asked to assess the utility of feedback (FCUR) and its quality (FQ). As control measurement, an Education-Expert (EE) and a Clinical-Expert (CE) were asked to assess FCUR and FQ. RESULTS Regarding residents' evaluations, 96.43% of times, outputs provided by ChatGPT were considered useful, comparable to what surgeons' B and C obtained. Assessing FQ, ChatGPT and all surgeons received similar scores. Regarding EE's assessment, ChatGPT obtained a significantly higher FQ score when compared to surgeons A and B (p = 0.019; p = 0.033) with a median score of 8 vs. 7 and 7.5, respectively; and no difference respect surgeon C (score of 8; p = 0.2). Regarding CE´s assessment, surgeon B obtained the highest FQ score while ChatGPT received scores comparable to that of surgeons A and C. When participants were asked to identify the source of the feedback, residents, CE, and EE perceived ChatGPT's outputs as human-provided in 33.9%, 28.5%, and 14.3% of cases, respectively. CONCLUSION When given brief written surgical situations, ChatGPT was able to identify errors with a detection rate comparable to that of experienced surgeons and to generate feedback that was considered useful for skill improvement in a surgical context performing as well as surgical instructors across assessments made by general surgery residents, an experienced surgeon, and a nonsurgeon feedback expert.
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Affiliation(s)
- Cristián Jarry Trujillo
- Experimental Surgery and Simulation Center, Department of Digestive Surgery, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Javier Vela Ulloa
- Experimental Surgery and Simulation Center, Department of Digestive Surgery, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Gabriel Escalona Vivas
- Experimental Surgery and Simulation Center, Department of Digestive Surgery, Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | | | - Pablo Achurra Tirado
- Experimental Surgery and Simulation Center, Department of Digestive Surgery, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Julián Varas Cohen
- Experimental Surgery and Simulation Center, Department of Digestive Surgery, Pontificia Universidad Católica de Chile, Santiago, Chile.
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Horita K, Hida K, Itatani Y, Fujita H, Hidaka Y, Yamamoto G, Ito M, Obama K. Real-time detection of active bleeding in laparoscopic colectomy using artificial intelligence. Surg Endosc 2024; 38:3461-3469. [PMID: 38760565 DOI: 10.1007/s00464-024-10874-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 04/20/2024] [Indexed: 05/19/2024]
Abstract
BACKGROUND Most intraoperative adverse events (iAEs) result from surgeons' errors, and bleeding is the majority of iAEs. Recognizing active bleeding timely is important to ensure safe surgery, and artificial intelligence (AI) has great potential for detecting active bleeding and providing real-time surgical support. This study aimed to develop a real-time AI model to detect active intraoperative bleeding. METHODS We extracted 27 surgical videos from a nationwide multi-institutional surgical video database in Japan and divided them at the patient level into three sets: training (n = 21), validation (n = 3), and testing (n = 3). We subsequently extracted the bleeding scenes and labeled distinctively active bleeding and blood pooling frame by frame. We used pre-trained YOLOv7_6w and developed a model to learn both active bleeding and blood pooling. The Average Precision at an Intersection over Union threshold of 0.5 (AP.50) for active bleeding and frames per second (FPS) were quantified. In addition, we conducted two 5-point Likert scales (5 = Excellent, 4 = Good, 3 = Fair, 2 = Poor, and 1 = Fail) questionnaires about sensitivity (the sensitivity score) and number of overdetection areas (the overdetection score) to investigate the surgeons' assessment. RESULTS We annotated 34,117 images of 254 bleeding events. The AP.50 for active bleeding in the developed model was 0.574 and the FPS was 48.5. Twenty surgeons answered two questionnaires, indicating a sensitivity score of 4.92 and an overdetection score of 4.62 for the model. CONCLUSIONS We developed an AI model to detect active bleeding, achieving real-time processing speed. Our AI model can be used to provide real-time surgical support.
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Affiliation(s)
- Kenta Horita
- Department of Surgery, Kyoto University Graduate School of Medicine, 54 Shogoin-Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Koya Hida
- Department of Surgery, Kyoto University Graduate School of Medicine, 54 Shogoin-Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan.
| | - Yoshiro Itatani
- Department of Surgery, Kyoto University Graduate School of Medicine, 54 Shogoin-Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Haruku Fujita
- Department of Surgery, Kyoto University Graduate School of Medicine, 54 Shogoin-Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Yu Hidaka
- Department of Biomedical Statistics and Bioinformatics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Goshiro Yamamoto
- Division of Medical Information Technology and Administration Planning, Kyoto University, Kyoto, Japan
| | - Masaaki Ito
- Surgical Device Innovation Office, National Cancer Center Hospital East, Chiba, Japan
- Department of Colorectal Surgery, National Cancer Center Hospital East, Chiba, Japan
| | - Kazutaka Obama
- Department of Surgery, Kyoto University Graduate School of Medicine, 54 Shogoin-Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
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Dick L, Tallentire VR. Technical skills assessment: The expert versus the algorithm. CLINICAL TEACHER 2024:e13769. [PMID: 38690803 DOI: 10.1111/tct.13769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 03/05/2024] [Indexed: 05/03/2024]
Affiliation(s)
- Lachlan Dick
- Medical Education Directorate, NHS Lothian, Edinburgh, UK
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Ketel MHM, Klarenbeek BR, Abma I, Belgers EHJ, Coene PPLO, Dekker JWT, van Duijvendijk P, Emous M, Gisbertz SS, Haveman JW, Heisterkamp J, Nieuwenhuijzen GAP, Ruurda JP, van Sandick JW, van der Sluis PC, van Det MJ, van Esser S, Law S, de Steur WO, Sosef MN, Wijnhoven B, Hannink G, Rosman C, van Workum F. Nationwide Association of Surgical Performance of Minimally Invasive Esophagectomy With Patient Outcomes. JAMA Netw Open 2024; 7:e246556. [PMID: 38639938 PMCID: PMC11031683 DOI: 10.1001/jamanetworkopen.2024.6556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 01/31/2024] [Indexed: 04/20/2024] Open
Abstract
Importance Suboptimal surgical performance is hypothesized to be associated with less favorable patient outcomes in minimally invasive esophagectomy (MIE). Establishing this association may lead to programs that promote better surgical performance of MIE and improve patient outcomes. Objective To investigate associations between surgical performance and postoperative outcomes after MIE. Design, Setting, and Participants In this nationwide cohort study of 15 Dutch hospitals that perform more than 20 MIEs per year, 7 masked expert MIE surgeons assessed surgical performance using videos and a previously developed and validated competency assessment tool (CAT). Each hospital submitted 2 representative videos of MIEs performed between November 4, 2021, and September 13, 2022. Patients registered in the Dutch Upper Gastrointestinal Cancer Audit between January 1, 2020, and December 31, 2021, were included to examine patient outcomes. Exposure Hospitals were divided into quartiles based on their MIE-CAT performance score. Outcomes were compared between highest (top 25%) and lowest (bottom 25%) performing quartiles. Transthoracic MIE with gastric tube reconstruction. Main Outcome and Measure The primary outcome was severe postoperative complications (Clavien-Dindo ≥3) within 30 days after surgery. Multilevel logistic regression, with clustering of patients within hospitals, was used to analyze associations between performance and outcomes. Results In total, 30 videos and 970 patients (mean [SD] age, 66.6 [9.1] years; 719 men [74.1%]) were included. The mean (SD) MIE-CAT score was 113.6 (5.5) in the highest performance quartile vs 94.1 (5.9) in the lowest. Severe postoperative complications occurred in 18.7% (41 of 219) of patients in the highest performance quartile vs 39.2% (40 of 102) in the lowest (risk ratio [RR], 0.50; 95% CI, 0.24-0.99). The highest vs the lowest performance quartile showed lower rates of conversions (1.8% vs 8.9%; RR, 0.21; 95% CI, 0.21-0.21), intraoperative complications (2.7% vs 7.8%; RR, 0.21; 95% CI, 0.04-0.94), and overall postoperative complications (46.1% vs 65.7%; RR, 0.54; 95% CI, 0.24-0.96). The R0 resection rate (96.8% vs 94.2%; RR, 1.03; 95% CI, 0.97-1.05) and lymph node yield (mean [SD], 38.9 [14.7] vs 26.2 [9.0]; RR, 3.20; 95% CI, 0.27-3.21) increased with oncologic-specific performance (eg, hiatus dissection, lymph node dissection). In addition, a high anastomotic phase score was associated with a lower anastomotic leakage rate (4.6% vs 17.7%; RR, 0.14; 95% CI, 0.06-0.31). Conclusions and Relevance These findings suggest that better surgical performance is associated with fewer perioperative complications for patients with esophageal cancer on a national level. If surgical performance of MIE can be improved with MIE-CAT implementation, substantially better patient outcomes may be achievable.
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Affiliation(s)
- Mirte H. M. Ketel
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Inger Abma
- IQ Healthcare, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | | | | | | | - Marloes Emous
- Department of Surgery, Medical Center Leeuwarden, Leeuwarden, the Netherlands
| | - Suzanne S. Gisbertz
- Department of Surgery, Amsterdam University Medical Center, Location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands
| | - Jan Willem Haveman
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Joos Heisterkamp
- Department of Surgery, Elisabeth Twee-Steden Hospital, Tilburg, the Netherlands
| | | | - Jelle P. Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | | | - Pieter C. van der Sluis
- Department of Surgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Marc J. van Det
- Department of Surgery, Hospital Group Twente (ZGT), Almelo, the Netherlands
| | - Stijn van Esser
- Department of Surgery, Reinier de Graaf Groep, Delft, the Netherlands
| | - Simon Law
- Department of Surgery, Queen Mary Hospital, School of Clinical Medicine, The University of Hong Kong, China
| | - Wobbe O. de Steur
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Bas Wijnhoven
- Department of Surgery, Antoni van Leeuwenhoek Ziekenhuis, Amsterdam, the Netherlands
| | - Gerjon Hannink
- Department of Medical Imaging, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Camiel Rosman
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Frans van Workum
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
- Department of Surgery, Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands
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Zhai Y, Chen Z, Zheng Z, Wang X, Yan X, Liu X, Yin J, Wang J, Zhang J. Artificial intelligence for automatic surgical phase recognition of laparoscopic gastrectomy in gastric cancer. Int J Comput Assist Radiol Surg 2024; 19:345-353. [PMID: 37914911 DOI: 10.1007/s11548-023-03027-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 10/02/2023] [Indexed: 11/03/2023]
Abstract
PURPOSE This study aimed to classify laparoscopic gastric cancer phases. We also aimed to develop a transformer-based artificial intelligence (AI) model for automatic surgical phase recognition and to evaluate the model's performance using laparoscopic gastric cancer surgical videos. METHODS One hundred patients who underwent laparoscopic surgery for gastric cancer were included in this study. All surgical videos were labeled and classified into eight phases (P0. Preparation. P1. Separate the greater gastric curvature. P2. Separate the distal stomach. P3. Separate lesser gastric curvature. P4. Dissect the superior margin of the pancreas. P5. Separation of the proximal stomach. P6. Digestive tract reconstruction. P7. End of operation). This study proposed an AI phase recognition model consisting of a convolutional neural network-based visual feature extractor and temporal relational transformer. RESULTS A visual and temporal relationship network was proposed to automatically perform accurate surgical phase prediction. The average time for all surgical videos in the video set was 9114 ± 2571 s. The longest phase was at P1 (3388 s). The final research accuracy, F1, recall, and precision were 90.128, 87.04, 87.04, and 87.32%, respectively. The phase with the highest recognition accuracy was P1, and that with the lowest accuracy was P2. CONCLUSION An AI model based on neural and transformer networks was developed in this study. This model can identify the phases of laparoscopic surgery for gastric cancer accurately. AI can be used as an analytical tool for gastric cancer surgical videos.
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Affiliation(s)
- Yuhao Zhai
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, 95 Yong'an Road, Xicheng District, Beijing, China
- State Key Lab of Digestive Health, Beijing, China
| | - Zhen Chen
- Centre for Artificial Intelligence and Robotics (CAIR), Hong Kong Institute of Science and Innovation, Chinese Academy of Sciences, Hong Kong SAR, China
| | - Zhi Zheng
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, 95 Yong'an Road, Xicheng District, Beijing, China
- State Key Lab of Digestive Health, Beijing, China
| | - Xi Wang
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, 95 Yong'an Road, Xicheng District, Beijing, China
- State Key Lab of Digestive Health, Beijing, China
| | - Xiaosheng Yan
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, 95 Yong'an Road, Xicheng District, Beijing, China
- State Key Lab of Digestive Health, Beijing, China
| | - Xiaoye Liu
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, 95 Yong'an Road, Xicheng District, Beijing, China
- State Key Lab of Digestive Health, Beijing, China
| | - Jie Yin
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, 95 Yong'an Road, Xicheng District, Beijing, China
- State Key Lab of Digestive Health, Beijing, China
| | - Jinqiao Wang
- Centre for Artificial Intelligence and Robotics (CAIR), Hong Kong Institute of Science and Innovation, Chinese Academy of Sciences, Hong Kong SAR, China.
- National Laboratory of Pattern Recognition, Institute of Automation, Chinese Academy of Sciences, 95 Zhongguancun East Road, Haidian District, Beijing, China.
- Wuhan AI Research, Wuhan, China.
| | - Jun Zhang
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, 95 Yong'an Road, Xicheng District, Beijing, China.
- State Key Lab of Digestive Health, Beijing, China.
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Mitsui T, Yoda Y. Objective indicators of endoscopic submucosal dissection skills through electrosurgical unit analysis. Dig Endosc 2024; 36:28-29. [PMID: 37733463 DOI: 10.1111/den.14666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 08/20/2023] [Indexed: 09/23/2023]
Affiliation(s)
- Tomohiro Mitsui
- Division of Endoscopy, Saitama Cancer Center, Saitama, Japan
| | - Yusuke Yoda
- Division of Endoscopy, Saitama Cancer Center, Saitama, Japan
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Yu QX, Feng DC, Wu RC, Li DX. Auxiliary use of ChatGPT in surgical diagnosis and treatment - correspondence. Int J Surg 2024; 110:617-618. [PMID: 38315798 PMCID: PMC10793754 DOI: 10.1097/js9.0000000000000818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 09/24/2023] [Indexed: 02/07/2024]
Affiliation(s)
- Qing-xin Yu
- Department of Pathology, Ningbo Clinical Pathology Diagnosis Center, Ningbo City, Zhejiang Province
| | - De-chao Feng
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People’s Republic of China
| | - Rui-cheng Wu
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People’s Republic of China
| | - Deng-xiong Li
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People’s Republic of China
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Komatsu M, Kitaguchi D, Yura M, Takeshita N, Yoshida M, Yamaguchi M, Kondo H, Kinoshita T, Ito M. Automatic surgical phase recognition-based skill assessment in laparoscopic distal gastrectomy using multicenter videos. Gastric Cancer 2024; 27:187-196. [PMID: 38038811 DOI: 10.1007/s10120-023-01450-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 10/31/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND Gastric surgery involves numerous surgical phases; however, its steps can be clearly defined. Deep learning-based surgical phase recognition can promote stylization of gastric surgery with applications in automatic surgical skill assessment. This study aimed to develop a deep learning-based surgical phase-recognition model using multicenter videos of laparoscopic distal gastrectomy, and examine the feasibility of automatic surgical skill assessment using the developed model. METHODS Surgical videos from 20 hospitals were used. Laparoscopic distal gastrectomy was defined and annotated into nine phases and a deep learning-based image classification model was developed for phase recognition. We examined whether the developed model's output, including the number of frames in each phase and the adequacy of the surgical field development during the phase of supra-pancreatic lymphadenectomy, correlated with the manually assigned skill assessment score. RESULTS The overall accuracy of phase recognition was 88.8%. Regarding surgical skill assessment based on the number of frames during the phases of lymphadenectomy of the left greater curvature and reconstruction, the number of frames in the high-score group were significantly less than those in the low-score group (829 vs. 1,152, P < 0.01; 1,208 vs. 1,586, P = 0.01, respectively). The output score of the adequacy of the surgical field development, which is the developed model's output, was significantly higher in the high-score group than that in the low-score group (0.975 vs. 0.970, P = 0.04). CONCLUSION The developed model had high accuracy in phase-recognition tasks and has the potential for application in automatic surgical skill assessment systems.
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Affiliation(s)
- Masaru Komatsu
- Gastric Surgery Division, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
- Department for the Promotion of Medical Device Innovation, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
- Course of Advanced Clinical Research of Cancer, Juntendo University Graduate School of Medicine, 2-1-1, Hongo, Bunkyo-Ward, Tokyo, 113-8421, Japan
| | - Daichi Kitaguchi
- Department for the Promotion of Medical Device Innovation, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Masahiro Yura
- Gastric Surgery Division, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Nobuyoshi Takeshita
- Department for the Promotion of Medical Device Innovation, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Mitsumasa Yoshida
- Gastric Surgery Division, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Masayuki Yamaguchi
- Course of Advanced Clinical Research of Cancer, Juntendo University Graduate School of Medicine, 2-1-1, Hongo, Bunkyo-Ward, Tokyo, 113-8421, Japan
| | - Hibiki Kondo
- Department for the Promotion of Medical Device Innovation, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Takahiro Kinoshita
- Gastric Surgery Division, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Masaaki Ito
- Department for the Promotion of Medical Device Innovation, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan.
- Surgical Device Innovation Office, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan.
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Wu J, Hines OJ. Using Artificial Intelligence to Assess Surgeon Skill. JAMA Surg 2023; 158:e231140. [PMID: 37285127 DOI: 10.1001/jamasurg.2023.1140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- James Wu
- Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, California
| | - O Joe Hines
- Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, California
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