Hospital of Special Surgery (HSS)

Dr. Anil S. Ranawat

My interest in augmented reality and virtual reality (AR/VR) and simulators in medicine grew out of my interactions with fighter pilots I have known. You can’t fly an airplane without first spending countless hours in a simulator. Why I thought, would I let someone operate on someone’s mom or sister if they haven’t done the same thing?

The military has appreciated the value of simulator training for half a century or more. In 1972, analysts for the Navy and Air Force predicted that advanced simulators would help cut nearly in half the amount of flight time their pilots would require to become combat-ready. The Air Force recently launched a program to dramatically increase its reliance on VR trainers -- the cost of which is so low that would-be fighter pilots can now use in their dorm rooms to practice.

I wish I could say that medicine has had the same commitment to quality improvement as military aviation. Still, over the past ten years, we at Hospital for Special Surgery (HSS) have made significant progress at incorporating simulators, and AR/VR into our training and assessment of our physicians.

We meet about once a month to review our assessment efforts and consider new technologies we might like to integrate into our training program. At the heart of every discussion is the basic equation: Will what we’re doing or thinking about doing lead to higher-quality care at a lower cost -- which is the definition of value. If a new spine simulator that looks cool and seems to produce decent results, but costs $1 million, then maybe it’s not such a good value. That calculation should be central to everything we do in healthcare.

One of the points I stress in these discussions is that I am not trying to replace conventional training but rather supplement what works well with what works better. The approach is gradual, and these technologies exist on a spectrum. I believe this strategy is crucial in healthcare because we can’t prove beyond doubt that simulation and AR/VR do indeed improve quality. To be sure, the evidence supports their use, and I can point to roughly ten published studies showing that clinicians who use these technologies learn more efficiently than those who do not. But a randomized controlled trial -- the gold standard of studies -- is not possible, so we can’t draw a bright line between computeraided training and better outcomes for patients.

That doesn’t mean all systems are created equal. Any new assessment technology I consider bringing into the hospital must be both externally and internally valid. Does it reliably reproduce the procedure? Are the feedback mechanisms helpful, and do they reflect real-life functions, like limb motion and blood pressure? And, are there smaller measurement tools in the system to help grade people?

Four years ago, we started the Surgical Games at HSS, and now we have longitudinal data for five common surgical procedures for our trainees. Ideally, of course, residents will improve over time. But if they struggle, we have objective evidence to show them that they’re not ready to move on. And if a trainee needs significant improvement, we can point to their performance on the assessments and say to them that the simulator says you’re failing -- which eliminates the vagaries of subjectivity. I liken it to golf: If you play with your friends and never keep score, at the end of every round, you think you’re a great golfer. But when you keep score, you realize you’re not as good as you thought you were and -- at least in theory -- you’re inspired to go out and practice. That, to me, is the fundamental value of objective assessment.

Look around our society: objective skill assessment is everywhere. Want a car? You’ll need a driver’s license to use it, which requires not one but two tests, written and road. Even baseball umpires and football referees are monitored for performance. It’s past time to bring that attention to quality to medicine.

Dr. Anil Ranawat, orthopedic surgeon at HSS, focuses his clinical and research interests on joint-preservation surgery of the knee and hip, robotic surgery, partial knee replacement and mobile-bearing technology.