Virtual Reality Making Its Way Into Surgical Training

Increasingly, virtual reality simulations are finding their way into standard medical training. For instance, several years ago, the Hospital for Special Surgery (HSS) in New York started working with a company called Osso VR, which offers a surgical training and assessment platform to help residents and fellows practice surgical techniques.

Michael Ast, MD, hip and knee replacement surgeon and assistant professor of orthopedic surgery, is the vice chair of the HSS Innovation Institute and its chief medical innovation officer. In a recent conversation with Healthcare Innovation, he helped frame the issue.

HHS is an academic medical center focused on musculoskeletal health. It has a main campus in New York City and facilities in New Jersey, Connecticut and in the Long Island and Westchester County regions of New York State, as well as in Florida.

“If you ask a physician if they think that they have been adequately tested, they’ll say yes,” Ast said. “But if you ask them if all the other physicians have been adequately assessed, they’ll say no. So I don’t think it is a controversial thing to say we don’t have a standardized way to assess surgical proficiency.”

He says there are two main problems with training in-practice surgeons on a new technique or device. No. 1, they don’t have enough time to get any training on it. “And no. 2, let’s say they will take a day off from work, and they travel to one of these courses and they learn. Then they go home,” he says. By the time they figured out how to implement it, they’ve already lost all the value of that training. There is no continuity to that training and no method that allows them to retain that training well enough to actually implement it in their practice. “If you look at the number of people who learn robotics or a new technique vs. how many actually implement in their practice, the numbers are very different. And it’s because there isn’t a good way to bridge that gap,” Ast explains.

Another problem is assessing the proficiency of new surgeons. How do you know if somebody is good enough to perform a surgery on their own? “A certain percentage of graduating surgeons in all specialties probably shouldn’t be operating on their own, Ast says. “I get these forms about the delineation of privileges from healthcare systems for our former residents and fellows, and they ask should they do this surgery on their own? Just think about what a terrible system that is. Because I’ve got a vested interest in saying yes to that. If I say no, I’m admitting I did a bad job training them. At our hospital, if you want to do mitral valve replacements, I’ve got to see your virtual reality proficiency. Show me the last 100 that you did that you scored above a 70. It actually allows you to make sure people should be doing the surgery. We’re allowing them to do it in a much more formalized and standardized way.”

Osso VR seeks to solve that problem by offering on-demand, immersive modules that allow surgical teams to train in a virtual environment before ever stepping foot into a real operating room. Medical device companies also use Osso VR to introduce new techniques or devices.

Because HHS is one of the oldest and one of the most structured of all the residencies, Ast says, it is built to take on something new and see if it works, and it has a lot of surgeons in one building. “I’m not sure whether Osso VR solves a problem we already knew we had, or if it was just so interesting. Maybe we wanted to use it and then realized the problem. It’s a bit unclear, because this was eight years ago. But there’s no question now. We’re almost trying to figure out what did we do before — how did we do this before?”

Osso VR’s tech tool is used by more than 20 teaching hospitals as well as eight medical device companies in 11 countries. In addition to HHS, other hospitals include Brown University, HHS, Marshall University, The University of Hawaii, UCLA, University of Washington, Wake Forest Baptist Health, University of Kentucky, University of Utah, and New York University.

In a story on the Vanderbilt University Medical Center website, Jonathan G. Schoenecker, Ph.D., MD, a professor of orthopedic surgery and rehabilitation, said many simulators overshoot for absolute realism over mastery of technique. He said systems such as Osso VR that focus on the key steps of a procedure and technical skill development instead of trying to closely mimic reality, are preferable.

Vanderbilt’s orthopedic residency program teamed up Osso VR to educate and train residents on how to perform a range of surgical procedures. Donning Meta’s Oculus Quest headsets and handheld controllers to simulate operations, residents at Vanderbilt learn, practice, and master the proper steps of a procedure in 3-D.

Pediatric orthopedic surgeon Justin Barad, MD, Osso’s CEO and co-founder, said Osso VR has done studies with a variety of academic medical centers, including a study at UCLA involving 20 trainees. Ten were trained in Osso VR to a set level of proficiency, and 10 were trained traditionally. Then they came into a hands-on lab where they had to do the actual surgery. The group that was trained with Osso VR performed 10 points better on an objective structured assessment of technical skill, he said. Another study done at the University of Illinois-Chicago looked at the ability to perform surgery without needing supervision. They found that in the traditionally trained cohort, 25 percent of the group could complete the procedure without someone else stepping in to help. With the Osso VR group, that went up to 78 percent, he said.

Barad said one of the problems is that modern surgery is much harder to learn than surgery of the past. Most traditional procedures have a learning curve of 10 to 20 cases, meaning you need to operate on 10 to 20 people to reach a basic level of proficiency. But most modern surgery involving robotics, or minimally invasive techniques require around 50 to 100 cases. “So it is 10 times harder to learn, yet the way that we’ve been training is around the same,” he said. “We really lack a way to assess surgical proficiency in healthcare. In my career, I was asked to do the board game Operation and remove some plastic pieces without buzzing, which I did. That’s kind of state of the art in most places right now.”

“The emphasis of Osso right now is on the early career surgeon and we are working mainly with the medical device companies such as Johnson & Johnson and Stryker, but we also have about 20 residency programs where Osso is used,” Barad said.

“One of the questions we get is what’s next — what’s coming down the road for VR? And how is augmented reality involved? I say there’s a lot going on,” Barad says. “That’s really exciting. But the fact of the matter is that technology works today, as it is. We don’t need anything else. This works today; let’s just standardize it and get it to everyone.”