by Elizabeth Hofheinz, M.P.H., M.Ed., November 7, 2019
“The tree that does not bend with the wind will be broken by the wind.” – Mandarin Chinese proverb
A hallmark of a talented leader is bending with the winds of change. And these days, in the field of orthopedic sports medicine, the winds are indeed shifting. 
Michael G. Ciccotti, M.D., Director of the Sports Medicine Team at the Rothman Orthopaedic Institute and Director of the Sports Medicine Fellowship at Thomas Jefferson University, has discerned that change is afoot and is working with, rather than against, that reality.
“In a traditional learning situation, an orthopaedic mentee would watch, listen, and discuss what he or she is seeing, then go on to the OR under the direct supervision of an attending surgeon. The mentee might also go to a surgical skills training facility for cadaver work.”
But now, these “almost” surgeons are using “almost” reality…simulators and virtual reality.
This, says Dr. Ciccotti, President of the Board of Directors of the Orthopaedic Learning Center (OLC), “As all generations of orthopaedic surgeons move forward into the future it is important to respect tradition, but at the same time be open to how education is evolving. We have to accept that something we did for so long, i.e., cadaver training, will eventually take a back seat to more contemporary modes of learning.”
Describing the OLC as the premier surgical skills lab in the world, Dr. Ciccotti notes, “This venue offers traditional podium education and cadaveric skills work, but we also have simulators to help young doctors develop certain skills, particularly arthroscopic and surgical skills. These teach trainees how to navigate the joint space and see it with significant magnification, how small movements of instruments can cause dramatic movements on a monitor screen, as well as the concept of triangulating surgical instruments to perform a multitude of procedures. With this technology, trainees do not only gain a visual understanding, but they gain a tactile comprehension of the various musculoskeletal tissues, allowing them to assess, for example, ‘How firm/rigid/soft cartilage, ligament, muscle, tendon and bone are, thereby providing a more thorough perspective on surgical techniques.”
Each year, the OLC hosts a two and a half day “boot camp” where every orthopedic sports medicine fellow in the U.S. is invited to participate. Dr. Ciccotti: “The faculty members are from the American Orthopaedic Society for Sports Medicine (AOSSM) and cover the basic principles of being a fellow and a sports medicine physician. During the year there are other anatomic-specific courses that these fellows as well as residents and practicing orthopaedic surgeons may attend.”
“The addition of simulators at the OLC through the Arthroscopy Association of North America (AANA) has further enhanced the learning experience. They complement the traditional podium and cadaver based learning of OLC attendees. Specific Proficiency Based Training/Progression (PBT/PBP) courses are being developed by AANA for use with the simulators. This training is based on methodology utilized by NASA to train and then evaluate astronauts as they acquire necessary skills. Surgical procedures are deconstructed into specific steps that OLC attendees need to learn and master sequentially in order to complete the course.”
The essence of any surgical procedure, say, rotator cuff repair, follows the same basic principles. “You visualize all the major structures, assessing if they are normal or not. If something else is damaged, you look at the pathology and address any secondary issues. You do begin your repair perhaps with a simple stitch, then an elaborate stich, perhaps an implant … and that is where the algorithm branches out into complexity. These initial PBT/PBP courses seek to standardize the necessary surgical skills, and they have been hugely successful for attendees.”
The next step up from simulation is virtual reality (VR).
Dr. Ciccotti muses, “Perhaps it would be possible to create a variety of virtual pathologies such as a torn ligament, damaged tissue, or articular cartilage damage and educate surgeons in all those senses thus optimizing their ability to perform those procedures.”
But back to reality, reality.
“We’re not there yet. We do not yet have a good feel for how well VR in its current state simulates what happens in real life—visually, auditorily, and tactilely. And we are learning how to optimally combine podium education and traditional cadaveric skills with simulators and ultimately VR. Not to mention the issue of determining how to quantify the impact that such training has had on the attendee. This is a complicated question that transcends professions. But organizations such as the American Academy of Orthopaedic Surgeons (AAOS), AOSSM and AANA are all keenly focused on determining the answer.”
Brainstorming, Dr. Ciccotti states, “You would first have to identify the most common procedures that orthopaedic surgeons have to learn. For sports medicine fellows, in the knee it would be ACL surgery/meniscus; in the shoulder it would be labral surgery repair or rotator cuff surgery, etc. Then you would have to get granular and deconstruct each procedure by breaking it down into individual steps…the issue with this being that there is most often no absolute consensus on how to perform each step of these procedures.”
As for measuring progress, he notes, “You can have the attendees fix a rotator cuff on a cadaver/a simulator/perhaps in the future using VR prior to any education on these techniques; then they attend several lectures, watch videos, and return to the lab with an attending surgeon and do it again to obtain a post-instruction assessment. It is interesting how our certification as orthopaedic surgeons is based on book knowledge and patient evaluation. There is currently no skills component to the certification process in the United States. And so, this type of skills assessment is being considered by certifying medical boards such as the American Board of Orthopaedic Surgery (ABOS).”
There are drawbacks to simulator and VR training, however, says Dr. Ciccotti. “Knowing how you are doing as you progress through a skill training is critical. And these technologies have not all advanced to the point of providing the necessary feedback (tactile, auditory, etc.). For example, instruments such as a drill or shaver make certain sounds when they’re in contact with damaged tissue versus normal tissue. This kind of feedback is a vital component of training.”
The wind—one of nature’s original technologies—is indeed blowing more and more toward varying types of surgical simulation. And while these will likely go far to reduce medical errors and create highly-skilled surgeons, like any new technology, they won’t be a panacea. . . . and Dr. Ciccotti adds, “Therein lies the challenge of an evolving educational landscape. A challenge, though, that we absolutely embrace so that we can continue to improve how we educate and ultimately, most importantly, how we treat our patients.”