VR offers new approaches to 'democratize' access to surgical training while improving performance and accelerating the learning process.
With elective surgeries halted or postponed during the past year, the coronavirus pandemic could have yet another unanticipated impact on the future of healthcare by delaying training for surgical residents.
To address this issue, a virtual reality (VR) training program used by the orthopaedic surgery residency program at Marshall University Joan C. Edwards School of Medicine suddenly has gained more relevance. The way Marshall is using VR today shines a light on some inherent challenges with surgical training and how this evolving technology could prepare a new generation of surgeons for the increasingly complex repertoire of procedures they are now expected to perform.
The Huntington, West Virginia, medical school adopted a VR training and assessment platform from Osso VR about three years ago after Matthew Bullock, DO, MPT, assistant professor of orthopaedic surgery at Marshall University and associate program ddirector for the orthopaedic surgery residency program, met Osso VR co-founder and CEO Justin Barad, MD, at a conference.
Barad is a board-eligible orthopedic surgeon with a bioengineering degree from UC Berkeley, and a medical degree from UCLA. After completing his residency and a fellowship in pediatric orthopedics, he discovered a way to merge his original career yearning to become a game developer with a desire to "democratize" access to surgical training.
Since their meeting, Bullock has worked closely with the company to refine the product. He says that VR helps residents not only get the experience they need to become better trained and more efficient, but unlike real surgery, it also allows them to "practice" to improve their skills.
For the uninitiated, VR users don a headset and hand sensors, which are connected to a laptop. A new model introduced by Osso VR this year features a wireless connection. The user "sees" lifelike animated images of a surgical procedure, and their hand movements control what happens in the visual field.
Bullock and Barad say this form of training offers a number of advantages.
1. Enables Surgical Training to Continue During the Pandemic
"When COVID hit, it kind of shut down all of our operations," Bullock says. "Our residents are not really operating right now because our hospital's not up and running at full capacity. We couldn't operate on patients, but then we also couldn't be in close quarters to attempt cadaver lab training."
"We have almost a crisis of education right now, where we not only have limited ability to train based on limited volume of in-person cases and inability to get together to train traditionally, but also this will cause downstream ramifications," Barad says. "If our residents are under-trained for a significant period of time, they will have to make up that training at a later date, but that removes training from another resident."
With traditional methods of training "jettisoned," virtual reality training has assumed new relevance at Marshall University. By setting up the equipment in a dedicated room, "people can take their time and maintain social distancing," Bullock says. "They can jump on the virtual trainer and practice their skills, so we don't lose their skillset."
2. 'Democratizes' Surgical Education
Even before the pandemic, issues existed with training programs due to limited access to the variety of cases residents need to experience. This challenge is compounded in programs that serve large rural areas, such as Marshall, where patient volumes may not be as high as urban, more densely populated settings.
"Obviously, operating on patients is the best way to train," Barad says, "but, one, you don't want to be 'practicing' on people, and, two, there's a limited supply. It's random what you'll be doing." Barad shares an example of a colleague who was enrolled in the same general orthopedic residency program, yet was never able to conduct a distal radius fracture, open reduction, internal fixation procedure during his hand rotation, which Barad says is "one of the most critical procedures we do as a general orthopedic surgeon. So now he's going out in the world, never having done what is a very critical case to do. That just highlights that there's very little control over our case exposure and the sometimes limited nature of in-person training."
VR can level the playing field and help democratize access to training, which benefits providers as well as the patients they serve, Barad says. "We need to make sure that everyone across the U.S. has access to the same quality of care and that their providers can train on whatever procedure that they think is going to be best for their patient. It's not based on where you trained, who you trained with, and what patients you're exposed to—so many random variables that are hard to control."
3. Offers Some Advantages Over Cadavers
While practicing on cadavers has long been the "gold standard" for surgical residents, Barad says, "there are a lot of limitations." In addition to religious and cultural prohibitions for some, issues include:
- It is unlikely a cadaver has the problem a resident is trying to address surgically. "When we're operating on people, it's because something's wrong with them," Barad says. "They have arthritis, they have cancer, they have a broken bone. When we're operating on a cadaver, oftentimes, there's nothing wrong with their bones or musculoskeletal system."
- "The tissue itself is different," Barad says. In addition, Bullock says that some layers of tissue in cadavers are no longer present because the body has been preserved.
"The VR trainers do a very good job at identifying those layers and different regions that we'd have to be cognizant of," Bullock says." VR helps the user learn to avoid nerves or blood vessels, for example.
However, "Once you get that and get familiar with the steps, there are several things that even a robot can't replicate," Bullock says. Even with lifelike renderings, VR is unable to simulate the tactile or haptic feedback that real surgery provides, such as seeing how tissue lays or peels off. So, while VR is becoming more realistic, neither VR nor cadavers can exactly replicate a real surgical experience.
"There are just some things that you can't really simulate unless you're on an actual surgery on an actual human being," Bullock says. "But virtual training gets you thinking in the right direction—what to anticipate and look for when you're in the real world."
4. Provides a Way to Tame the Growing Number of Complex Surgical Procedures
It takes dozens of experiences before a surgeon becomes proficient performing a particular procedure, Barad says. And, due to advances in technology, a greater quantity of complex procedures are being added to the surgical repertoire.
Procedures using "enabling technologies, minimally invasive approaches, or robotic surgeries have a much longer learning curve," Barad says. For example, a traditional total hip replacement might require 20 to 40 procedures to become proficient. The newer anterior total hip replacement, which is rapidly becoming a standard, he says, takes 50 to 100 procedures to attain the same proficiency.
"Accelerating science and technologies massively expanded the library of procedures we're expected to know how to do on demand," Barad says. "There's simply too much for us to learn right now."
Bullock agrees. "There's been an explosion of interest in techniques using different implants, from hip replacements to using the new OrthoGrid, which is something we can use during a hip replacement to ensure adequate leg lengths and positioning of the implants," Bullock says. VR offers an opportunity to broaden one's surgical range. "Various techniques and different procedures can be tried—or at least attempted in practice—in the virtual world."
5. Improves Accuracy and Accelerates Training Process
According to a study published August 2020 in Clinical Orthopaedics and Related Research, researchers at University of Illinois College of Medicine at Chicago found that VR increased procedural accuracy and completion of an intramedullary tibial nail procedure, compared to traditional guiding training techniques.
Another study, conducted by University of California Los Angeles and presented at the 2019 Current Annual Meeting of the Western Orthopedic Association, demonstrated a 230% improvement in participants’ overall surgical performance when prepared with VR training.
In addition to VR's ability to improve accuracy, it also accelerates the training process, Bullock says. Osso VR's system includes a "mastery meter" with capabilities to assess performance such as the time it takes a resident to complete a procedure, the ability to complete each step accurately, and the user's related knowledge.
"When you're training a resident, you have no idea what they know or don't know," Barad says. "You have to often spend weeks trying to assess and understand where someone is at, to the point where you're like, 'Okay, I'm going to hand you the knife; I'm going to hand you a drill and [let you] operate on this person who's entrusting me with their care.' It's a huge responsibility. You want to be sure that the steps that you're allowing residents to do under observation are ones that you feel competent they can accomplish."
Traditionally, "residents are with you for eight weeks," Bullock says. "You're training them for four weeks and then letting them have the knife. VR training enables a surgeon to assess a resident's skills before trusting them to perform in the operating room."
"Now, when my residents come on rotation with me," Bullock says, "we require them to practice several of the [VR] modules for hip and knee replacements before participating on our service. They get a brief overview and a really solid grasp and understanding of what's required during surgery as to step and placements of retractors. It walks them through what they're going to be experiencing in the operating room."
"That's such a game changer, especially in residency programs," Barad says. "It gives you objective insight into what someone does and doesn't know so that you don't have to spend weeks or months understanding where someone is at."
“VR training enables a surgeon to assess a resident's skills before trusting them to perform in the operating room.”
Matthew Bullock, DO, MPT, assistant professor of orthopaedic surgery, Marshall University
Mandy Roth is the innovations editor at HealthLeaders.
Photo credit: Image provided courtesy of Osso VR
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