In 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.
