By Dr. Michael Ast
Surgery has significantly changed in the last several decades, thanks to the rapid introduction of breakthrough medical devices. This has posed two main challenges: keeping up with the latest surgical technologies (of which there are thousands) can make surgical training considerably more complex, and surgical residents have more material to learn and need more hands-on practice during residency. Advances in simulation, including Virtual Reality (VR) technology, can provide a way for surgeons of all levels to increase their experience with the latest devices and techniques and for residents to increase practice hours.
Advances in diagnostic capabilities and surgical tools have provided more value and more applications of surgery, but with this increased capability comes a startling amount of complexity. The complexity stems mainly from the medical devices that are commonly used in orthopedic procedures. There are now multiple devices for each procedure type, making it crucial for surgeons to know their benefits and efficacy, as well as how and when each is used. The commonalities between today’s medical devices can make them appear very similar, but in reality, they may have separate surgical applications and their own set of steps for proper use.
In addition, the amount of material for residents to learn is constantly increasing with no signs of slowing. Coupled with less time to fit it all in, due to factors such as the length of residency and the changes in work hour regulations, surgical residents are now exposed to less hands-on surgery and have fewer opportunities to observe and to be involved in surgical procedures across multiple subspecialties than was the case just a short time ago.
The natural result of observing and participating in fewer surgeries is reduced proficiency, as demonstrated in a recent groundbreaking study which measured the ability of residents to operate autonomously throughout their training up until graduation (George, 2017)1. At the time of graduation, about 30 percent of residents were still unable to operate independently. It’s also been stated that one must practice an activity for 10,000 hours in order to become an expert. Therefore, to enable surgeons to learn, watch and perform every variation of every procedure would take thousands of hours and many more years of residency, which is not possible in today’s healthcare environment.
As these studies demonstrate, orthopedic surgery now involves more complicated procedures and medical devices and less time to operate and train. Accessible, repeatable and measurable surgical training is the key to overcoming these obstacles. Advancements in simulation technology make it a viable option for surgeons of all levels to increase practice hours. For the last two years, our (Hospital for Special Surgery (HSS)) residency training program has begun implementing a VR technology platform, Osso VR, in order to provide surgical trainees with additional training on common procedures and specific medical devices.
The technology provides haptic feedback to create an immersive environment that truly makes a surgeon feel as though they’re in an Operating Room (OR), with each medical device and surgical tool looking and feeling identical to the way it presents in reality. One of the enormous benefits of VR is its ease of use, allowing surgeons to utilize the Oculus headsets in one of the labs on a break or in between shifts, thus enabling them to work on a module as frequently as they prefer. This is ideal for regular skill refreshment when a surgeon might not have performed the surgery in some time. It is also essential for residents, who can use this to repeat a procedure and take as much time as needed to master the steps. Perhaps the biggest benefit of the technology, though, is that it allows surgeons to practice safely where patients aren’t at risk without requiring limited and costly resources, such as cadavers. Updates and changes can be made quickly, and new modules can be added as needed to the same system to correspond with new procedures and devices. These benefits have made integrating VR into our medical training invaluable for our team.
Currently, HSS encourages residents to complete several modules on Osso VR, including fixing a broken tibia, a common procedure. The software tracks each resident’s completion rate and assessment scores, making it easy to monitor how many times they’re practicing and how they’re performing. In order to continue making progress with our residents, we’ve started to evaluate their performance in relation to themselves and to one another. Our early findings have indicated that training in VR has helped residents feel more comfortable and perform more efficiently. We have seen that trainees who first conduct a procedure in the VR experience were notably quicker, knew the steps better, and didn’t have to refer to outside resources for guidance when performing the same procedure in the OR. They also easily recognized each of the instruments and knew how and when to correctly use them.
To further test VR’s training efficacy, we conducted an informal experiment with two medical students. We gave one ten minutes with the VR technology practicing a procedure, and another student didn’t have any VR practice before the procedure. The student who had practiced with VR was dramatically more efficient at operating a model tibia, knew each of the steps in order, and completed the procedure approximately five times faster than the student who hadn’t practiced in VR.
As surgeons continue to become busier while technology’s evolution shows no signs of slowing, changing our surgical education and training system to keep up is essential. VR has been a breakthrough technology in many industries, and I see healthcare as no different. VR provides the opportunity for a fundamental shift in the way we learn and master the latest in medicine so that we can safely offer patients the best treatment options available.
Dr. Ast is an Orthopaedic Surgeon at Hospital for Special Surgery (HSS) in NYC and an Assistant Professor of Orthopaedic Surgery at Weill Cornell Medical College. His primary specialty focus is rapid-recovery, short-stay and outpatient joint replacement surgery. Dr. Ast has extensive experience with and has published research on patient-specific instruments and implants, computer navigation and robotics in joint replacement surgery.