by Danny Goel MD
During my residency, I assisted a surgeon in performing a femoral nailing procedure. The surgeon handled the critical steps requiring judgment and precision, such as managing the reduction, identifying the correct start point for the guidewire, and inserting it. Once the critical start was achieved, I was handed the reamer to perform the preparatory steps. The surgeon then placed the femoral head guidewire in the exact location and passed me the instruments to ream and insert the screws. For the distal locking screws, they meticulously aligned the circles for perfect lateral views using the C-arm, drilled the holes themselves, and finally handed me the measuring device and screws to place. I was elated that I got to do the case.
At the time, I left the case feeling like I had contributed significantly. However, upon reflection, I realized that my participation was limited to non-essential, less critical steps. The most technically demanding and outcome-defining portions of the case—the reduction, guidewire positioning, and alignment for distal locking—were completed by the surgeon. While I was involved, I wasn’t advancing my ability to independently perform this procedure in the future. In fact, I didn’t actually improve my decision-making ability or judgment, which are crucial for surgeons and essential for patient care and outcomes.
This experience highlights the distinction between critical and non-critical steps in surgical procedures. Critical steps—those that directly impact implant position and patient outcomes—require precise execution and deep judgment. Allowing trainees to engage in these key aspects is vital for skill development and confidence. Conversely, relegating residents to non-critical tasks risks creating a false sense of accomplishment while delaying their progression toward true competence. Recognizing this balance and providing incremental opportunities for residents to take on critical responsibilities is essential in surgical education.
The New Reality of Orthopedic Training
1. A Loss of 5,000 Clinical Hours Over 5 Years
Duty-hour restrictions have reduced the average resident’s clinical exposure by 5,000 hours—essentially an entire year of training. While important for the physical and mental health of trainees and patient safety, this reduction leaves residents with significantly less hands-on experience, creating critical gaps in their preparation for independent practice.
2. A Shift Away from Critical OR Tasks
To preserve efficiency, avoid disrupting workflows, and mitigate the heightened litigious environment, residents are often assigned less critical tasks. This deprioritization of decision-making and hands-on surgical skills stifles growth and hinders autonomy development.
3. The Resident Who Struggles Will Get Worse
Every resident comes with strengths and weaknesses. When strengths are emphasized, weaker areas often go unaddressed. There is currently no model for residents to practice with purpose in a safe, non-threatening environment.
4. The Rise of Ambulatory Surgical Centers (ASCs)
The proliferation of ASCs has transformed surgical care for patients. However, in prioritizing efficiency and outpatient procedures, ASCs often exclude residents from participating in cases, reducing training opportunities.
5. Increasing Failure Rates on the ABOS Part II Exam
The failure rate for the American Board of Orthopaedic Surgery (ABOS) Part II exam has increased by 200–300% in the past two years, signaling a potential systemic issue in current training methods and judgment maturation.
6. Fellowships Aren’t a Safety Net
Fellowships, once seen as a way to fill training gaps, are diminishing. Many fellowship cases have shifted to outpatient facilities, limiting in-depth learning opportunities.
7. Surgeons Are Doing More but Making Less
Declining reimbursements and a healthcare system driven by efficiency work against robust resident education. ORs focused on fast turnovers leave little room for teaching.
The Urgent Need for Transformation
Orthopedic residency programs must rethink their approach to education. Reliance on sporadic clinical exposure or online resources may not be enough. A comprehensive strategy is needed—one that prioritizes developing judgment, 3D spatial intelligence, and decision-making. Virtual reality (VR) offers a solution that is accessible, scalable, and designed to bridge the gaps in traditional training.
How VR Can Transform Orthopedic Training
1. Building 3D Spatial Intelligence
3D Visual-Spatial Intelligence is the ability to perceive, understand, and mentally manipulate objects or environments in three dimensions. VR can enhance this critical skill for orthopedic residents.
2. Bridging the Gap Left by Reduced OR Hours
With fewer opportunities in the OR, Virtual Reality surgical training allows residents to repeatedly simulate procedures until mastery is achieved.
3. Preparing for Efficiency-Driven ORs
Today’s ORs prioritize efficiency, leaving less room for hands-on learning. VR orthopedic surgery simulation enables residents to perfect core skills outside the operating room.
4. Practicing Complex Cases
Residents may miss exposure to rare or complex cases during training. VR provides access to a wide range of scenarios, ensuring comprehensive preparation.
5. Affordable, Scalable Training
Unlike costly cadaver labs, Medical VR Solutions offer an affordable and repeatable solution, making it accessible to more programs.
6. Exam-Ready Preparation
Beyond clinical skills, Vitual Reality surgical training helps residents prepare for exams like the ABOS Part I and Part II.
7. The Surgeon Educator Also Has a Learning Curve
Virtual reality ensures that both residents and educators stay up-to-date with evolving training methods.
8. More Procedures, Less Time
VR surgical training offers an efficient and scalable solution to the challenge of limited time for hands-on practice.
Not Leaving Anything to Chance
With over 30% of US orthopedic programs integrating virtual reality surgical training, it’s clear that VR is becoming essential in reshaping orthopedic education. Residency programs must embrace innovation to ensure graduates are prepared for the realities of modern practice.
By integrating VR surgical simulation into their training strategies, programs can:
- Address lost clinical hours.
- Prepare residents for efficiency-driven ORs.
- Build critical skills, judgment, and independence outside the OR.
The path forward is clear: Virtual reality surgical training is no longer a luxury—it is a necessity.
About Dr. Goel
Dr. Danny Goel, is an orthopedic surgeon specializing in shoulder procedures and the CEO of PrecisionOS, a Vancouver-based company pioneering virtual reality solutions for surgical training. He earned his medical degree and a Master’s in Science from the University of Manitoba, followed by orthopedic surgery training at the University of Calgary. Dr. Goel completed fellowship training at Western and Harvard University, with additional experience in complex shoulder tendon transfers at the Mayo Clinic. As a Clinical Professor at the University of British Columbia’s Department of Orthopedic Surgery, he contributes to advancing surgical education. Under his leadership, PrecisionOS has developed innovative VR platforms that enhance surgical readiness and patient outcomes.