With elective procedures on hold in many jurisdictions during the pandemic, surgeons and nurses have been discovering the benefits of virtual interactive tools to keep their skills sharp and to learn new techniques, and two Vancouver-based tech companies behind such tools are getting greater attention as a result.
When elective surgeries such as hip and knee replacements were cancelled last spring, and in-person learning stopped, many medical teaching faculties converted to Webex or Zoom lectures for surgical residents. With limitations to such platforms, many institutions were prompted to reconsider the possibilities of virtual reality tools for training students and helping doctors and nurses keep their skills sharp.
“Surgeons have stopped operating, and the trainees have stopped operating. As they get back to their scheduled procedures, the surgeon has to acquire his or her skills again,” says Danny Goel, orthopedic surgeon, CEO and co-founder of PrecisionOS, a virtual reality surgery platform he created together with game developer co-founders Colin O’Connor and Rob Oliveira.
With PrecisionOS, surgeons and surgical students can experience a simulation that provides the opportunity to saw or drill a virtual patient’s limb using VR goggles and simulated tools such as surgical drills, scalpels and other tools.
VR more effective in medical learning
Learning is a life-long endeavour for everyone these days, but it is of particular importance in health care because new science is always emerging and there are always new technologies and procedures to learn.
Skill decay over time is a significant concern for surgeons like Goel as the pandemic drags on. He says that VR has been shown to be more effective for medical students retaining information over established methods such as reading and watching videos.
“It’s not something we talk about in health care because it’s never really happened before. If you don’t do something over time, your skills are decaying — you may not think so, but your motor skills are changing, so as you ramp back up as a surgeon, you have to get there first before your trainee can learn,” says Goel.
Goel says surgical education is largely done on the apprenticeship model, which includes going into the operating room as a trainee with an experienced surgeon to do parts of a medical case. Students never really get to do the entire case by themselves as a trainee.
“Being a surgeon myself, I have always been challenged with that approach to education — I always thought there would be a better way. When I experienced VR for the first time, it was pretty incredible. Once you put on the headset, it’s entirely immersive and full active engagement — it’s fully engaging, and you’re in the digital operating room and there to do some work,” he says.
PrecisionOS was initially developed to train surgeons and is now being tested at Burnaby Hospital to help train orthopedic nurses, supporting traditional mentorship-based training while practising in realistic virtual environments.
“They have started using it in Burnaby hospital for nursing education, and the reason is that what we do in the OR is very much a team-based approach to patient care. Everybody is involved, whether it’s a nurse, the medical device representative, and surgeon — they are all part of the same team,” says Goel.
PrecisionOS is now in use at 10 medical schools in North America, including the University of Toronto and the University of British Columbia. The University of Toronto purchased 12 units to help keep surgical students learning during the pandemic. Several nursing programs in Canada, such as Ryerson University in Toronto, have incorporated virtual learning into their curriculum, using gamification to complement other teaching methods.
Taking the apprentice model to the next level
“Because VR allows you to watch what a resident is doing, you can watch them via a phone or iPad performing surgery. We make the experience as authentic as possible. It looks and feels real, so when you put a guide pin into a bone, you can do it any particular location you want, and then we give you data on that performance,” says Goel.
Data provided by the VR system will tell instructing physicians how a student performed to the millimetre, and then they can ask more in-depth questions about a student’s level of understanding and why they made certain decisions.
Goel says PrecisionOS did two randomized controlled trials with senior surgical residents — the first comparing reading a surgical paper to learning with VR and the second compared watching a video of the surgery to doing the same surgery in VR. Based on the students performing the procedures on cadavers, the VR group outperformed the non-VR group in both studies.
“More importantly, the VR group performed 50 per cent less critical surgical errors than the non-VR group. Experiential education is so powerful,” says Goel.
Goel says that because Vancouver has led the way in gaming development, PrecisionOS has had access to top talent in the area of virtual reality.
“We’ve been pretty fortunate in Vancouver that the ecosystem here has been ripe for high-quality developers, so we have a pretty large team now on the technical side that’s led by our two other co-founders Colin O’Connor and Roberto Oliveira,” he says.
The virtual health care market was valued at US $2.14 billion in 2019 and is projected to reach US $33.72 billion by 2027, growing at a compound annual growth rate of 41.2 per cent to 2027, according to a report issued in July from Verified Market Research.
“If anything, what the pandemic did was bring to light the idea that education needs to be accessible even for resource-rich countries, and that has essentially stopped. The problem VR is solving existed before COVID, and that’s why we have seen adoption even before COVID, but it’s certainly accelerated the need for it because people need the education to deliver high-quality care,” says Goel.
PrecisionOS is selling its systems to universities and hospitals in North America and beyond. “We have priced it low enough that price isn’t a barrier because we put the value of simulation and open surgical experience all in a digital format you can take in a backpack. It’s extremely affordable,” he says.
Simulation learning tools more widely adopted
The pandemic has also fuelled a greater interest in finding other ways to determine if a medical professional is competent to practice. Experts question the effectiveness of the traditional Objective Structured Clinical Examination (OSCE) used to assess health care professionals in a clinical setting and first introduced in the late 1970s. With OSCE, actors are trained to perform as patients, and students ask questions and do physical examinations.
“About a month ago, there was much noise about the efficacy of OSCE examinations,” says Dr. Karim Qayumi, a cardiac and thoracic surgeon, and professor of surgery and founder of the University of British Columbia’s Centre of Excellence for Simulation and Education and Innovation. Qayumi is also the founder of CanHealth International, a Canadian not-for-profit that developed CyberPatient, a web-based learning platform that gives students the ability to interact with animated patients in a virtual world.
He says the OSCE is becoming an expensive and complicated event to organize.
“Many now use CyberPatient to replace OSCE — it’s 90 per cent cheaper than OSCE and can provide for a variety of diseases. With OSCE for every disease, you have to train the actor and have many of them,” Qayumi says.
CyberPatient was first designed for undergraduate medical school students, and it has many applications for both undergrad medical school students and nurse practitioners and assistant physician groups. He says large educational organizations are looking to use CyberPatient in various new applications, including the Canadian Alliance of Nurse Educators Using Simulation (CAN-Sim).
“We are working with nursing faculty at UBC, and we’re trying to develop more programs for nursing with CAN-Sim. They have applied for a grant to make most of the nursing curricula online, and they have chosen CyberPatient to be one of the partners,” says Qayumi, noting that eight nursing schools are involved in the grant application. “If it goes through, we will be working with the lead nursing schools in the country.”
For nurses and physicians practising in northern communities of 10,000-20,000 people, they may have a particular kind of case one or two times a year or not have that case at all, so they forget about what they have learned. CyberPatient can be a way to practise and keep skillsets fresh.
Qayumi says CyberPatient is also being considered for use in long-term flights to space.
“It’s weightless, it can be updated from earth at any time, and doctors and nurses can practice while they are inside the spaceship travelling to a destination,” he says.
It seems the applications for virtual medical learning tools are now being realized beyond their developer’s original dreams.