Today, most surgical training is completed on cadavers and in operating rooms. Unfortunately, the number of available cadavers does not satisfy demand, cadavers require expensive facilities and regular maintenance, and they are not reusable following most procedures. Furthermore, changes in the climate of surgical education are requiring a new method of training that is more accessible and effective, high-fidelity, and does not require actual patients. This method appears to be virtual reality, which is an immersive, interactive, computer-generated image and environment. This technology is an effective surgical simulator because it is able to properly train the necessary psychomotor skills for surgery, a trainee can practice a surgery several times, and it can generate an objective assessment of the surgery. However, unlike cadaver-based surgical simulation, virtual reality does not train empathy or teamwork skills, both of which are important qualities of a good surgeon today. Will those qualities still be considered important characteristics of a surgeon in the future? If not, what is the impact of that change? Virtual reality technology will inevitably become a significant part of a surgeon’s training, and it has the potential to change the way we view surgery, the type of person who can become a surgeon, and the meaning of a “good” surgeon.
In the past, it may have been most effective for medical students, trainees, and residents to practice surgery exclusively on cadavers and in the operating room, but the climate of surgical education is changing. Because of changes occuring in the healthcare systems around the world, there has been an increasing demand for surgical training outside of the operating room (Badash et al). Operating room space is expensive, and reimbursements offered are decreasing in value. Regulations passed by the Accreditation Council for Graduate Medical Education in 2003 have restricted the number of hours that surgical trainees in the United States can work. Most significantly, because of greater emphasis on patient safety, it is less common for novice surgeons to be welcome in the operating room. All of these changes necessitate “the development of training strategies that do not involve actual patients” (Badash et al). Furthermore, surgery itself is changing, which means that “residents and practicing surgeons not only need to learn the operations performed by their predecessors, but to learn entirely new and different types of skills and procedures” (Haluck and Krummel). In other words, they have more to learn in less working time. For example, laparoscopic and minimally invasive surgery is becoming increasingly prevalent. Because surgeons will need to learn and become comfortable with laparoscopic surgery, they will need to grow comfortable with computer technology in their work. For this reason, it makes sense for them to gain experience with a computer-generated surgical simulator. Fittingly, virtual and augmented reality technology will be increasingly integrated into medicine as we move toward the future. This technology has many useful medical applications. Virtual reality may satisfy the demand for a new way to train surgeons by developing in a practitioner the technical skills required in surgery, but it may not be able to train other skills required in surgery; consequently, it may change what it means to be a good surgeon.
Currently, students work with cadavers as one method of anatomical and surgical training. Not only does working with cadavers teach about the human body, but they also teach teamwork and empathy. In most operating room situations, surgeons must lead a team in the operating room. The efficacy of this team is important in keeping the patient safe. When working with a cadaver, a surgical trainee works in a team. This helps him or her develop teamwork and communication skills. Without this operating room teamwork training, will virtual reality properly prepare trainees for real surgery? How necessary is teamwork training? Additionally, empathy is an important quality in a good surgeon. In cadaver-based surgical training, trainees develop their empathy skills by learning how to treat a patient with respect and care. However, as virtual reality is used more, cadavers will be used less. Virtual reality may be capable of teaching the necessary psychomotor skills used in surgery, but will it teach clinical empathy? How important is experience with cadavers to a surgeon’s empathy training? How important is empathy in a surgeon-patient relationship? What defines a “good” surgeon? How will virtual reality change the definition of a good surgeon, and what is the impact of that change? These questions will be addressed and explored throughout this paper.
Surgical Training Today
The current training requirements to become a general surgeon include four years of undergraduate school, four years of medical school, and three to ten years of residency or fellowship. Medical students, residents, and other surgical trainees use cadavers to understand the human body and practice operations through dissection or surgery. Cadavers are corpses that are donated to the field of science. In medical school, it is common that, at the beginning of the year, groups of four to six students are given their own cadaver to practice on over the course of the year. Some residency programs also involve cadaver-based surgical training. Most cadaver-based training involves “the actual dissection of cadavers by medical students under the supervision of qualified instructors and the study of prosected specimens” (Huat). This method of learning, while not perfect, has been seemingly effective in the past.
There are many benefits to cadaver-based training. By practicing a surgery on a cadaver, a person can obtain a feel for the human body and begin to grow comfortable with it. One can truly see and touch the parts of the body. It is the only surgical simulator that is currently completely anatomically accurate. Cadavers are good surgical simulators because they are high fidelity, which means that they are highly realistic. Students who practice with cadavers can also learn empathy, as they respect and care for the cadavers like they would respect and care for a living patient. Furthermore, because students often work in groups when they work with cadavers, it encourages peer- and group- learning, fostering the development of teamwork skills (Huat). Cadavers are certainly an adequate simulator for training good surgeons.
However, there are many downsides to using cadavers in surgical training. Unfortunately, cadavers are not widely accessible. There is a limited number of cadavers available. This is in part due to low supply, as there are fewer unclaimed bodies because of improved communication and there are many places around the world where deceased bodies are revered and, consequently, not donated. This is also because not every cadaver is suitable for medical study; the body must be young, fully intact, not too overweight, and not too diseased. While cadavers have always been scarce, the number of donations are steadily decreasing. For instance, The Anatomical Gift Association of Illinois “has seen annual donations fall from 7600 in 1984 to 520 [in 2015]” (McCall). Most likely, this trend will only continue. While there is a decreasing number of cadaver donations, there is an increasing number of medical students. For example, “first year medical school enrollment is projected to read 21,304 by 2019-2020, a 29.2 percent increase over enrollment in 2002-03, according to a report from the Association of American Medical Colleges” (McCall). Likewise, this trend is prone to continue. Already, many trainees have little to no access to cadavers; for example, some medical students have only one opportunity to go to a remote cadaver course. Furthermore, “cadavers require regular maintenance and special facilities, and are not reusable following certain procedures” (Badash et al). Also, cadavers are not perfect for practicing surgeries. Because they are deceased, they cannot react or respond, and they “have poor compliance that makes some surgeries difficult” (Badash et al). Lastly, in work with cadavers, there is always a risk of infection. This creates a need for a more alive, accessible, high-fidelity method of surgical training. Perhaps that method is virtual reality.
Surgical Training with Virtual Reality
Virtual reality is a fully “immersive, completely artificial computer-simulated image and environment with real-time interaction” (Khor et al). It engages a person’s natural senses and skills. It achieves a sense of presence, which can be described as feeling like one is in a different physical environment than he or she actually is and the notion that that environment is interactive. Sense of presence is subjective, and can be achieved by different means, like by reading a book, but the immersiveness of virtual reality is objective and unique. Presence is achieved by giving false information to several of a person’s senses, including sight, hearing, kinesthetic, and balance. This promising technology has many possible applications, including integration in surgical training.
Virtual reality technology is already in use for surgical training. When a medical student or surgical trainee uses virtual reality, he or she wears a head-mounted display and noise-cancelling headphones, and he or she uses joysticks that function as tools in the virtual surgery. Force feedback gloves are also worn to “give practitioners the realistic feel and touch needed, for example, to determine how much force is needed for certain incisions” (Meinhold). Virtual reality is able to digitally create an operating room environment. Users can practice and train the psychomotor skills necessary for real surgery. Many surgical simulators are created for specific surgical specialties and procedures. For example, simulators exist to practice endoscopic foreign body removal or cleft palate repair. Almost any surgery can be simulated outside of the operating room using virtual reality (Badash et al).
The advantages to using virtual reality for surgical training solve many of the disadvantages presented when cadavers are used. Virtual reality can be a high fidelity simulator for surgical training. It can also be low fidelity, somewhat unrealistic. Variance in fidelity allows the technology to be more accessible to all students. For example, a low fidelity simulator may be sufficient for a student’s first practice because it is less expensive, whereas a high fidelity simulator may be necessary to prepare a more advanced student for real surgery. Furthermore, virtual reality takes minimal setup time, and a person can practice the same surgery several times, allowing for skills growth. There is a part-task approach, which means that users can focus on specific parts of the surgery. The operations have varying degrees of difficulty, which allows a practitioner to improve over time. Unlike a cadaver, the virtual body can respond and react. Additionally, the computer records the virtual surgery and can play it back later for review from the user or a mentor. It also gives feedback, analysis, and an objective assessment, measuring precision, accuracy, and error rates. Most compellingly, a 2002 study at Yale proved that the use of virtual reality as a surgical simulator to achieve specific target criteria vastly improved the operating room performance of residents during laparoscopic cholecystectomy. The study found that “residents who trained on MIST VR[, a brand of virtual reality surgical simulation,] made fewer errors, were less likely to injure the gallbladder and burn non-target tissue, and were more likely to make steady progress throughout the procedure” (Seymour et al). Errors are a significant issue in medicine today, particularly in surgery, with one study quoting an annual incidence rate of adverse events among patients as 3.0%, of which half were preventable (Sarker and Vincent). The use of virtual reality in surgical simulation promises fewer mistakes in future surgeries. In general, there are advantages to training outside of the operating room. The learning environment is easily controlled and adjusted, and learning is able to occur in a stepwise way, leading to positive results and fewer errors.
However, there are many drawbacks to using virtual reality for surgical training. While the force feedback gloves try as best as possible to mimic the feel of an actual surgery, there is no way to truly gain a sense of what organs and bodily material feel like. For example, in virtual reality, veins are blue and arteries are red, and the two are not distinguishable by touch, but in a real-world situation, veins are similar in color and different in feel. Not only that, but there are most likely many unknown aspects of the human body; these features would be included in a cadaver, but not in a virtual body. Furthermore, cadavers allow for empathy training, but virtual reality removes the humanity from the practice. The trainee does not get the experience of caring for a human body. Lastly, medicine has not traditionally been a technological field, and many surgeons, students, trainees, residents, ad mentors may have computer anxiety. Likewise, virtual reality is often seen as a gimmick and not taken seriously by those using it. These are only a few of the many challenges involved in integrating virtual reality into surgical training.
Virtual reality is a promising alternative for surgical training, but it is also significantly different from past methods of surgical training, namely cadavers. How will this technology change what it means to be a good surgeon, and what is the impact of that change?
What defines a good surgeon?
To analyze how virtual reality technology changes what it means to be a good surgeon, we must first determine what makes a good surgeon. He or she must have technical skill in order to successfully perform the surgery. Furthermore, he or she must have teamwork, leadership, and communication skills. Teamwork is an important component of operating room efficiency, quality of care, and patient safety (Sexton et al). A lack of communication and collaboration can lead to errors in the operating room which may have catastrophic consequences for patients, families, caregivers, and entire institutions (Sexton et al). Lastly, a surgeon must also have empathy. Empathy allows for more effective doctor-patient communication, and it facilitates trust (Halpern). Additionally, “studies have linked empathy to greater patient satisfaction, better outcomes, decreased physician burnout, and a lower risk of malpractice suits and errors” (Boodman). Therefore, a good surgeon is a surgeon with precise and accurate technical skill, the ability to collaborate and communicate, and a deep sense of clinical empathy. However, after virtual reality becomes more prevalent in surgical training, will this definition change?
I) Teamwork: By using virtual reality in surgical training, are we training surgeons with weaker teamwork skills? Will this change what it means to be a good surgeon?
Teamwork is one of the most humane aspects of operating room work, and it is now recognized as an critical component of healthcare (Salas and Frush). Can it be simulated by a computer? A surgeon is responsible for leading the team of nurses and other operating room personnel present during a surgery, and the success of this is part of patient safety. Surgery is an ensemble activity. The surgeon and the patient are rarely alone in the room during an operation. Cooperation, communication, coordination, leadership, and monitoring are important to working as a team, which is necessary to a patient’s safety and efficient surgery (Healey et al). For example, lack of proper communication and collaboration among operating room team members has resulted in retained sponges, mismatched blood transfusions, wrong-site surgeries, sentinel events, delays in treatment, and medication errors (Sexton et al). Therefore, teamwork training is an important part of a surgeon’s overall training. It is typically included through cadaver work, because when medical students operate on a cadaver, they typically work in groups of four to six. Cadaver-based teamwork training is not the only form of teamwork training; some surgical trainees take teamwork courses, and many trainees gain teamwork skills in mentorships, residencies, and other real-life situations. Even so, most surgical trainees gain most of their operating room teamwork experience while working on cadavers; this prepares them for later work as real surgeons.
While team training scenarios can also take place in a virtual reality operating room, it is moderate fidelity at best. In reality, the person training is still having a solitary experience. Interactions with virtual “people” are not the same as interactions with humans; humans have lives, personalities, and feelings, and they are more likely to make mistakes. Furthermore, virtual reality technology may progress to a point where it is possible for multiple players to use together, like a multiplayer video game. Then, teamwork would be trained through virtual reality, but it would most likely not be a sufficiently effective method of training. Without operating room teamwork training, virtual reality may not properly train trainees for surgery, which compromises patient safety.
However, it may not be necessary to include teamwork training in virtual reality surgical simulators. There are other forms of team training for medical students, residents, and surgical trainees. These programs optimize the communication, coordination and collaboration of healthcare teams through information-based, demonstration-based, and practice-based methods (Weaver et al 2014). These programs may properly train the necessary collaborative skills in a surgical trainee who primarily practices operations using virtual reality. Furthermore, it is possible that because surgeons gain experience in teamwork and communication while performing real operations, it is not necessary to develop these skills while they are trainees. As a surgeon gains real-life experience, he or she will develop all the skills necessary to be a good surgeon. Additionally, it may not be necessary for surgeons to have teamwork skills at all. As we move toward the future, there will not be large groups in the operating room because robots and other technology will increasingly replace nurses and surgeons. If it is reasonable that the surgical environment will change, then perhaps virtual reality training will properly prepare surgeons. Perhaps the lack of teamwork training in virtual reality surgical simulators is insignificant.
However, in my opinion, while virtual reality can provide moderate fidelity teamwork training, it is not enough to prepare a surgical trainee for a real operation. Virtual reality training should be completed in conjunction with other teamwork training, whether it includes cadavers or not, because patient safety is at risk. Even though residents and surgeons will practice teamwork skills in their work, they should begin developing these skills earlier so that they are somewhat experienced before working with real patients. The ability to work with and lead a group is necessary to the quality of a surgeon’s work and a patient’s safety.
A good surgeon must have leadership, collaboration, and communication skills. Teamwork in the operating room is an important part of efficient surgery and patient safety. A surgeon is responsible for leading the others in the room, and he or she is responsible for the patient’s safety. Unfortunately, virtual reality surgical training can only provide moderate fidelity teamwork training at best. This may not be a problem because, as we move toward the future, robots will replace most of the operating room team. Trainees may also be able to find other methods of teamwork training. Either way, teamwork training is currently necessary and not adequately provided through virtual reality.
II) Empathy: By using virtual reality in surgical training, are we desensitizing future surgeons? Will this remove empathy skills from our definition of a good surgeon?
Clinical empathy is different from everyday empathy. While empathy is generally defined as the ability to share another’s feelings, “the Society for General Internal Medicine defines [clinical] empathy as ‘the act of correctly acknowledging the emotional state of another without experiencing that state oneself’” (qtd. in Halpern). This definition suggests that doctors’ empathy does not require emotion; it is purely intellectual. However, I would argue that empathy does require emotion and sensitivity, which are human qualities difficult to train using a computer-generated system. Patients expect empathy from their doctors, and studies have shown that “a lack of empathy and poor communication drive many malpractice cases” (Boodman). Clinical empathy is an important aspect of healthcare.
In the past, there was a concern that medical school desensitized students to human pain. As a response, medical schools began to include the teaching of empathy in their cadaver work. Today, students are expected to respect and care for their cadavers as they might respect or care for a living patient. A student’s first experience with a cadaver is considered his or her first experience taking care of a human; it is a rite of passage and a significant part of preparing to be a doctor. When students are first given their cadavers, several institutions have ceremonies, often with a moment of silence, to pay respect to the person who donated his or her body to science. At the end of the year, they perform a ceremony to give thanks. Over the course of the year, they are encouraged to call the cadaver by the name its person went by when he or she was alive, rather than giving it a demeaning nickname. Many students are also encouraged to develop a relationship with the family of the deceased. This may cross an ethical boundary, as giving medical students access to a cadaver donor’s personal information violates a donor’s and a donor’s family’s privacy. On the other hand, the cadavers are donated with informed consent. While the cadaver work at many institutions does not involve as much empathy training as others, all cadaver work involves some form of empathy training, whether it is intentional or not.
Will a shift towards mostly virtual-reality-based surgical training desensitize trainees? It may, because cadavers are important to a surgical trainee’s empathy training. A computer-based method of training may not be able to offer the same type of human-to-human interaction. However, it may not desensitize trainees. Perhaps virtual reality is high enough fidelity that the user should still take the experience seriously. In fact, virtual reality may help sensitize trainees, because the virtual body is responsive. It is possible that virtual reality may have a negative effect on the clinical empathy skills of some trainees and a positive effect on others.
Similar to team training, cadaver-based empathy training is not the only method of empathy training. There are clinical empathy courses, both online and in person. Most of the curricula “focus on self-monitoring by doctors to reduce defensiveness, improve listening skills (one study found that, on average, doctors interrupt patients within [eighteen] seconds), and decode facial expressions and body language” (Boodman). Additionally, some programs involve actors as simulated patients, and they provide feedback to individual doctors (Boodman). These programs have already been developed over many years, so perhaps students training with virtual reality instead of cadavers can use these programs to learn empathy. A person can also practice his or her empathy skills while working with a mentor or through personal experience while working with real patients. Thus, cadaver-based training is not necessarily required for a surgical trainee’s empathy training.
I believe that clinical empathy is immensely important because it impacts patient safety, and patients are significant stakeholders, so empathy training is important as well. Therefore, if a student, resident, or other trainee primarily trains for surgery with virtual reality, he or she should take a clinical empathy course in addition. Similar to teamwork skills, empathy skills will be practiced by residents and surgeons when they work with real patients, but these skills should have started developing earlier. Cadavers are not necessary for clinical empathy training, but virtual reality does not offer adequate empathy training either; in fact, it may desensitize trainees, so surgical trainees who have limited experience with cadavers should develop empathy training in another way before working with real patients.
Clinical empathy is integral to modern-day healthcare. Over time, empathy skills training has been increasingly integrated into cadaver-based surgical training. As virtual reality becomes a more prevalent surgical simulator, it may have a negative effect on surgical trainees’ empathy skills because empathy is a humane quality difficult to train using a computer-based system. It may also have a positive effect because a virtual body is responsive and high-fidelity. Additionally, surgical trainees can take clinical empathy courses aside from their cadaver-based or virtual-reality-based training, which may provide them with the empathy skills they need. Virtual reality alone does not properly train a person’s clinical empathy abilities they need to be a good surgeon.
How does virtual reality in surgical training change what it means to be a good surgeon?
Today, a good surgeon is described as a surgeon with a balance of technical and interpersonal abilities. He or she should have well-trained psychomotor skills, teamwork skills, and clinical empathy skills. However, the application of virtual reality to surgical training may change this definition. Training with a virtual reality surgical simulator is a solitary experience, and it does not develop teamwork skills. Especially since we may not need a full team in the operating rooms of the future, collaboration, communication, and leadership skills may not be considered important in a surgeon in the future like they are today. Furthermore, virtual reality as a surgical simulator does not include clinical empathy training, and it may desensitize surgical trainees, as it removes the humanity from the practice. As a result, in the future, empathy may not be considered a necessary skill for a surgeon to have. A consequence of virtual-reality based surgical training, we may eventually stop including humane qualities in our definition of a good surgeon. Top surgeons will be those with well-trained, intuitive mechanical skills but possibly little to no empathy or teamwork abilities if they are no longer valued and, therefore, barely trained. A good surgeon may become viewed as a person who can perform surgery like a robot: efficiently and near perfectly, but without the ability to think critically, communicate ideas, or truly understand the needs of the patient.
Previously, surgical training was primarily cadaver-based. However, due to changes in the climate of surgical education, advancements in the field of surgery, and problems presented by the use of cadavers, there is a need for a new method of surgical training. Virtual reality may be this method because it is able to train mechanical surgical skills. However, it may not be able to train other skills required in surgery, like teamwork or clinical empathy, which are trained through cadaver work. Therefore, the integration of virtual reality technology to surgical training may change what it means to be a good surgeon.
Virtual reality can simulate almost any surgical operation. It has many benefits and promises fewer errors in surgery, which solves a major problem. It also has many drawbacks, including a lack of teamwork and empathy training. Focusing on that disadvantage, how will virtual reality change what it means to be a good surgeon, and what is the impact of that change?
Today, a good surgeon is largely considered to have a balance of technical skill, teamwork skills, and clinical empathy. Teamwork is important in surgery because a surgeon must lead a team of operating room personnel during a surgery, which is necessary to a patient’s safety, and a lack of proper communication and collaboration can lead to significant errors. Most medical students obtain most of their experience with leadership in surgery through cadaver-based training, though they can also take courses and gain experience in mentorships, residencies, and other real-life situations. Unfortunately, it is difficult to train teamwork skills using virtual reality. Even if technology progressed towards a multiplayer virtual reality surgical simulator, it would most likely not be able to successfully develop teamwork skills in practitioners. However, it may not be necessary to include teamwork training in virtual reality surgical simulators because of other teamwork training programs, the real-life experience that trainees will gain, and changes in the future surgical environment. In my opinion, teamwork development should be included in an aspiring surgeon’s training prior to residency, and it is not properly provided through virtual reality. Additionally, clinical empathy is important in healthcare because it allows for improved doctor-patient communication and it leads to fewer malpractice suits and errors in surgery. Many surgical trainees gain empathy training through cadaver-based surgical training. However, as virtual reality increasingly replaces cadaver work, it may desensitize many trainees because it is computer-based instead of human-based; it may help sensitize some trainees because virtual bodies are high fidelity and responsive. The effect of a virtual reality on a surgical trainee’s empathy also may not matter, as surgical trainees can build their empathy skills by taking specific courses or through their real-life experiences. I believe that virtual reality does not provide sufficient empathy training and that it is an important component of healthcare, so surgical trainees should practice empathy skills using cadavers or otherwise before working with real patients. Because virtual reality surgical simulators may not be able to give surgical trainees the same teamwork and empathy training as cadavers are able to, the top surgeons of the future may have underdeveloped interpersonal skills and exceptional psychomotor skills. This may change our definition of a good surgeon from a person with a balance of different types of skills to a person who is able to operate like a robot.
Training robot-like surgeons shifts surgery from a personal activity to a technical activity, and this changes the field of surgery. Will surgery remain an art, or will it be considered more of a transaction? If surgery becomes considered more of a transaction, how will that impact the way insurance companies cover it? How will that impact the way patients feel about it?
Furthermore, if the same few computer programs teach all surgeons, surgery will become more standardized. Rather than each surgeon having his or her own way, everyone may roughly perform surgery in the same way. This may not be a disadvantage, but if surgeons are used to carrying out surgery in a specific and mechanic way, they may not be able to think on their feet. How will they act if something goes unexpectedly wrong? Virtual reality may or may not prepare surgeons for these situations. Likewise, future surgeons may not be capable of taking advice, as they may be used to performing surgery in a specific, well-practiced way that has produced desired results up until a certain point.
Having a computer-based technology as a teacher may not only change our definition of a good surgeon, but it may also change our definition of who can be a surgeon. Perhaps tomorrow’s surgeons are today’s video game enthusiasts, or tech-savvy people. Perhaps the gender gap in the field of surgery will begin to reflect the even greater gender gap in technology fields; there may be even less women in the field. Perhaps anyone will be able to become a surgeon, and the virtual reality will be able to train individuals starting from as basic a level necessary and progressing in a way that fits the individual’s learning style. If significantly more people are able to become surgeons, this might impact the economy or a surgeon’s wage. Perhaps a divide will form between surgeons trained mostly by virtual reality and surgeons trained mostly on cadavers, and one type of surgeon will be more expensive than the other, creating a class divide in surgery. These are only a few of the potential consequences of virtual reality in surgical training.
I believe that the full integration of virtual reality into surgical training is inevitable and, overall, helpful to society. I suggest that medical schools aim to provide students with both cadaver-based and virtual-reality-based surgical training. This will balance out the advantages and disadvantages of both and create a generation of experienced and capable surgeons. I also suggest that the methods by which specific surgeons are trained are made known to their patients prior to operations so that patients are aware of the type of experience their surgeons have. Lastly, I suggest that completion of one empathy course and one teamwork course becomes a requirement to become a surgeon in countries where virtual reality technology seems to dominate surgical training. We, as a society, are only just now beginning to explore virtual reality, and as we dive deeper into its potential, we must also consider the ethical implications. It is necessary to progress forward and use technology to our advantage, but not at the expense of our intrinsic values and principles.