Emerging Surgical Technology: The Problem & The Solution for Improving Outcomes
I have been astonished by the pace and number of recent advances in our ability to treat disease and injury. Many of these advances often come in the form of new technologies. Amazing innovations in the fields of endoscopy, catheterization, robotics, imaging, navigation, 3D printing and more allow us to do things that were previously not believed to be possible. What we also did not foresee though are the complications that have come with them. In general, these new technologies are far more complicated than simpler techniques from the past. But the real challenge is not simply that technology is more complex; it’s that these solutions are being released into a system of medical training that has not changed in over a century, and unfortunately, is beginning to fail us. This problem, or training gap, is only increasing over time, and ironically, technology is also one of the only ways to address it.
In order to understand this pressing issue, we must first better understand how surgical training works. Surgical trainees, or residents (also interns and fellows), are responsible for taking care of patients and participating in their surgeries in an apprenticeship training model. The cases a resident participates in are typically dictated by the schedule of the attending they are assigned to be assisting. They are usually relegated to holding retractors, or just watching, depending on their level of seniority, and from time to time, they get to take the lead in certain key parts of the case.
In the past, this was a perfectly serviceable system of training, but dynamics are leading to an unsustainable situation that is already starting to manifest itself. This growing training gap is a simple math problem wherein the number and complexity of procedures that a trainee must learn is always increasing, but the time that they have to learn them is less than ever. Why do they have less time? There are a multitude of reasons, but some major factors include new work hour restrictions (residents may only work a max of 80 hours per week), which, while completely reasonable, have lost residents around a year of hands-on training time. Additionally, some studies have shown that 50 percent of a physician’s time can be spent on entering information into Electronic Medical Records systems. Research has further supported that this gap in training is significantly affecting the surgical ability of our graduating residents.
In 2017, Dr. Brian George and his collaborators published, “Readiness of US General Surgery Residents for Independent Practice,” in Annals of Surgery. This groundbreaking study measured the ability of residents to operate autonomously throughout their training up until graduation. The results were alarming to say the least. At the time of graduation, about 30 percent of residents were still unable to operate independently. This phenomenon is leading to a vicious cycle in which these young, undertrained attending surgeons are still spending their time training themselves instead of operating at a level where they can train the next round of young residents counting on their coaching and education.
New surgical technologies are increasingly contributing to this dynamic. For example, the Da Vinci surgical robot is an incredibly exciting technology that may unlock the potential for improved outcomes and treating conditions that were previously untreatable, but learning to use it is not simple by any means. Numbers vary between studies, but in general, a surgeon needs to perform at least 25 cases to perform at a basic level of safety, and around 75-80 to achieve optimal proficiency. There are also some very counter-intuitive training challenges that appear because these new technologies are too good at what they do, meaning the surgeon needs less help from residents and the medical team. As described in his excellent analysis of robotics surgical training, Matthew Beane points out that because surgeons are now able to perform these procedures almost completely independently, residents don’t have an important role in the case, as they would in a “traditional” surgery. This leads to a lack of engagement and participation that ultimately results in residents graduating with very little, if any, actual hands on experience.
In the conclusion of his groundbreaking paper on the ability for graduating surgeons to operate independently, Dr. George has an idea of how to break the cycle:
Operative performance might be improved by providing residents the opportunity to use simulation to rehearse component skills before applying their knowledge in the OR. This could be expected to support a virtuous cycle whereby trainees achieve more autonomy earlier and thereby further accelerate their learning.
Simulation allows trainees to practice procedures BEFORE treating patients so that they have a safe place to make mistakes and work their way up the learning curve at their own speed. Simulation also has the ability to standardize training, so that we can quickly disseminate best practices and techniques from governing professional bodies, through the cloud down to a simulator. Finally, simulators can accurately assess a surgeon’s objective technical skill. In this way, we can actually ensure that we are training quality providers who can safely and effectively care for patients.
While simulation is not new in the medical field, previous generations of technology have been limited in their effectiveness and distribution. These older simulators in general were large, expensive, and limited in functionality. What is needed is a simulation platform that can be used anytime, anywhere, and simulate any procedure and is affordable for surgeons and hospitals. That platform is virtual reality.
It may be time to fight fire with fire. Technology may be the only solution to the problem that other technologies have created. At Osso VR, we are providing the platform, content and tools from a multi-disciplinary team bridging medicine and tech. Our goal is to improve patient outcomes, increase the adoption of high value medical technologies and democratize access to surgical education around the world.
About the Author
Co-founder and CEO of Osso VR, Dr. Justin Barad, is a board-eligible orthopaedic surgeon with a Bioengineering degree from UC Berkeley, and an MD from UCLA where he graduated first in his class. He completed his residency at UCLA, and his fellowship was in pediatric orthopaedics at Harvard and Boston Children's Hospital.