Orthopedic surgeons debate the pros/cons of VR surgical training.


This week’s Orthopaedic Crossfire® debate was part of the 35th Annual Current Concepts in Joint Replacement® (CCJR®), Winter meeting, which took place in Orlando. This week’s topic is “Simulation Training: This is the Future.” For is Kenneth A. Gustke, M.D. – Florida Orthopaedic Institute, Tampa, Florida. Opposing is Thomas S. Thornhill, M.D. – Harvard Medical School, Boston, Massachusetts. Fares S. Haddad, M.D., F.R.C.S. – University College Hospital, London, United Kingdom is moderating.

Dr. Gustke: I’m in favor of simulation training. I think it is the future.

Historically, resident and fellow training has followed the apprenticeship model where trainees enhance their skills under supervision by more experienced mentors.

In this model, residents got to do many surgical procedures and work long hours with no hour restrictions. And we were less aware of legal ramifications and complications. Also, the hospitals weren’t all over us about surgery times.

This historical training model is now in conflict between best surgeon training, patient safety and OR efficiency.

Reduced resident work hours in the United States has meant decreased learning opportunities and longer learning curves for our residents. Multiple studies now report that residents are actually graduating without sufficient exposure and technical ability to perform some key procedures well (Zuckerman, et al. JBJS-Am, 2005; Bell, et al. Ann Surg, 2009; Mauser, et al. Int Orthop, 2014).

One interesting study surveyed senior orthopedic surgeons who took on junior associates that just finished their residency training program and asked them what they thought (DiSegna, et al. J Surg Orthop Adv, 2018). The consensus of those surveyed said that junior associates had inferior technical skills, required more assistance completing cases and had more major operative complications. Their recommendation was that the residency training programs have competency milestones and also increase the role of simulators.

Attending orthopedic surgeons as part of this paradigm have learned new procedures by going to conferences like this. Watching how surgery is done. Maybe watch a surgery in person. Watch a video. Or perhaps do a procedure at a cadaver course. And then they go do surgery on a patient.

Cadaver labs, which probably are the best mechanism that we have today, lack pathology, have minimal repetitive practice opportunities and they’re very expensive.

So, the advantage of simulation training is that you’re able to learn new skills with no impact on patient care. You can practice as often as you want. You have no time pressures. You can make mistakes and you get feedback. You can also improve your performance prior to actually working on patients. These also can be adjusted for fidelity so that the skill level of the learner can be appropriate for that particular training.

The classic example of a simulator—a flight simulator—there’s no pilot in the world that’s flown a plane without going through a simulator first. And they have to keep retraining on simulators.

n medicine we do have simulators. They’re either one of three types. They’re mannequins, screen-based simulators, or virtual reality simulators. They have mannequin simulators for advanced life support; infant care. And they are increasingly being incorporated into training programs to supplement clinical learning.

Arthroscopic type simulators teach triangulation, meniscectomies, ACL [anterior cruciate ligament] reconstructions and give you the ability at the end of the procedure to have your technique critiqued.

There are also open-based simulators that are now being used for total joints. They use 3D glasses, simulator screens, and most importantly, haptic guidance. So, you can actually have tools in your hands which are the same tools that you would use in the operating room attached to a haptic arm. You can actually feel the texture of the bone and going through a cutting slot so that you can actually learn how to do a total knee replacement before you ever get to the operating room.

The other type of simulators is those that use virtual reality goggles. These are fun, but they lack realism and haptic feedback. So, you’re actually simulating doing the procedure with some tools in your hand, but the problem is you can’t feel texture. You can’t feel actually going through a bone or cutting a bone.

The real question is going to be whether simulators improve clinical performance. There are 14 studies now in the literature on knee, shoulder and hip surgery that demonstrated major constructive and transference validity and an improvement in technical skills.

There’s a randomized blind study with an arthroscopic simulator that shows, again, that they do provide skill transfer (Howells, JBJS-Br, 2008; Cannon, JBJS-Am, 2014). But in order for simulators to be effective they must be realistic. They have to have quality of device that’s similar or better than cadavers. They have to have haptic or force feedback to give a sense of texture and shape of bone. And they must provide spatial orientation.

So, in summary, we need to change the surgical skills training method for orthopedic surgeons. Because we have to be cognizant of patient safety and efficiency. I think it’s a perfect method to supplement clinical learning and decrease the learning curve.

They will replace real experiences with guided experiences. And over time, they will get more realistic.

You may wonder why the two persons debating are old and we’re talking about the future, when, perhaps, we don’t have much future of our own. But the two of us each have about 40 years of experience with residency and fellowship training.

So, I think we’re qualified. The only difference is I can see the future more clearly.

Dr. Thornhill: I’ve got a bit of a problem—the fact is that simulation is here to bridge the increasing gap in resident education.

I do simulation. I was involved in starting it, but I have one serious concern. The challenges Ken talked about—the technology, the sub-specialization, the workload, the financial pressures, and also the ASCs [ambulatory surgical centers] and satellites—oftentimes don’t have residents and they don’t get the exposure with the easiest cases to really do.

The elephant in the room, though, is duty hours. Malcolm Gladwell talked about “10,000 hours” in his book Outliers: The Story of Success and if you stratify, 48 weeks, 80 hours a week in 5 years, they get about 25% surgery, under 5,000 hours of surgery, which does not meet Malcolm Gladwell’s standards.

More work in less time. Fewer patient interactions. Reduced operative experience. And the OR constraints for the attendings now—their outcomes are being measured, time is money, and it takes time to educate a resident.

Here’s my concern. Simulation cannot recreate the stress of independent surgery on real patients. We call it “The relaxed attitude of the non-combatant.” As a resident, I was very sure when I had an attending with me. When I did it myself for the first time, I wasn’t as sure.

William Halsted believed in complete immersion. Interns should be interned. Residents should be resident. The fact is that you graded responsibility with every other night call. Then you advanced when the faculty told you you should. It was see one, do one, teach one.

My American philosopher, Yogi Berra said, “The future ain’t what it used to be.”

There are whole bunches of different types of simulation. Ken went through them. I think the most important thing is we use mannequins, we use cadavers, we now have full procedure simulators, virtual reality, artificial intelligence and a whole bunch of things.

But they don’t really give you the recreation of what happens to a patient who is under anesthesia in your hands. It’s called a learning curve, I think, because if you get in trouble in surgery and you can’t become more calm, you’re going to be a problem.

And when you get your comfortable zone and those surgeons in the audience will know, it’s a wonderful feeling you have knowing that whatever you do, you can get out of it. There’s sort of a moral hazard…we treat cadavers extremely well. But if you really harm them or a mannequin, it’s not like a real patient.

I like Henry Ford’s quote about the need that we must innovate much more than we do now with simulation. Henry Ford said, “If I’d listened to the customers, I would have given them a faster horse.”

And now we have virtual reality and …Ken showed some in orthopedics… one in the airline industry which he talked about…these simulators are terrific. People have actually been able to fly planes.

ow the residents expect simulators. They get into medical school. It’s part of the USMLE Step II and Step III. National requirements. It’s required. Yesterday at the Brigham we had Dr. David Martin from ABOS talking about all of the new requirements. This is something that’s coming. Simulation is clearly going to be here.

We have a boot camp where all the interns have an uninterrupted month. There’s a curriculum based on particularly orthopedic skills to make sure that when they start their PGY-2 they’re all roughly at the same level. Our core curriculum has a combination of labs and exercises. And there is the progressive credentialing experiment based upon the milestones.

Our boot camp basically is full time. They have stuff in basic skills, fractures, arthroplasty and arthroscopy. Much of it by simulation.

So, the “see one” is now practice many on simulation showing competency. Do one, teach one. The fact is Halsted’s thing now includes simulation, coaching, curriculum and validated assessment.

My major concern is it not a surrogate for operating on live patients.

Moderator Haddad: Ken, can you actually teach the patient interaction, the patient journey, and the reality of dealing with the problem live under stress?

Dr. Gustke: Absolutely not and I totally agree with Tom that this is the first step to get the resident or fellow to the operating room with a learning base that is higher than what they come with currently. You still have to have the real patients, the real tissues, blood in the field…all the issues that we all go through on a surgical basis.

It’s hard to simulate every single scenario that you’re going to have in the operating room. I totally agree that this is not a substitute for training. This is an assistant to get the doctor to the operating room in a better fashion.

Moderator Haddad: We have agreement that simulation has a role. Tom, what bits are missing? What do we need to fill around simulation? The hours are only going to go down…the outlook of the residents is going to change?

Dr. Thornhill: It’s getting us through both areas. The fact is …ASCs and satellites, everybody there works for you, and people work together…you go to many of the academic medical centers where the residents train and you can learn inefficiency. You’ll have a different scrub nurse every time and it becomes very frustrating. But it is also one of the burdens of all of us. It is what we must do in order to have the next generation of orthopedists work. Simulation ain’t there yet.

Moderator Haddad: In terms of surgeons getting more robotic, more computer-assisted tools, is this going to become more relevant to arthroplasty?

Dr. Gustke: Yes, I think it because we get more information on screens. If we can actually have simulators that go through the balancing aspects of total knee replacement, for example, and show different scenarios on the screen, I think that will be better and help them utilize this information.

Dr. Thornhill: You’ve got to have a downside for everything and whether it is showing competency in simulation and transferring over to the operating theater, or whether it is some other downside in terms of advancement, if you don’t pass those requirements. It’s the real people that I think are important.

Moderator Haddad: Gentlemen, I think we’ve learned that simulation is important, but it’s not the whole answer. Thank you very much.