Good afternoon everyone, thanks so much for being here. I'm Mary Mulcahy, I'm at Loyola in Chicago. I'm excited to moderate this, or help moderate. Dr. Boyd might be coming at some point. So we're just gonna jump into it. We have two papers and then a couple of related talks. So we'll move through that, and then there's a panel discussion to follow. So first up, we have Dr. Connor Hoag, who is at the Ohio State, going to be talking about back-to-school training, and, oh sorry, I lie, that's not his talk. Okay. But, where is, okay. Sorry, in-person versus virtual interviews for orthopedic surgery, sports fellowship, applicant. Oh my gosh, it's gonna come out. In-person versus virtual interviews for orthopedic surgery, sports medicine fellowship, applicant perspectives, Connor. Good afternoon everyone. My name is Connor Hoag, I'm a PGY-4 resident at the Ohio State University. And this article is titled, in-person versus virtual interviews for orthopedic surgery, sports medicine fellowship match, 2022 to 2023, and it's the applicant's perspectives. This research was conducted under the guides of Dr. David Flanagan. Disclosures are available here. So since 2013, over 90% of orthopedic surgery residents apply for fellowships. Many factors are cited as important for matching into one's desired fellowship. However, the quality of the interview has been cited as the most important factor. Recent data shows that applicants spend between, around $6,000 on interview travel and 10, between 11 to 15 interviews. The COVID-19 pandemic necessitated the switch to from in-person to virtual interview formats as a health and safety precaution. At this time, the AAMC issued formal recommendations for all applicants, citing a number of factors outside of health and safety that included improvements in equity, cost reduction, and increased opportunities for applicants. Of that, the orthopedic surgery fellowship interviews followed suit and conducted virtual interviews for 2020 to 2021 and 2021 to 2022. There's many benefits to virtual interviews. It saves time. It's less time away from training for residents. It allows residents to participate in more interviews and allows the residents to save money. There are cons of virtual interviews that include lack of interpersonal connection and inability to visit the faculty in the city as well as technical difficulties. So the purpose of this study was to look at the 2022 to 2023 Sports Medicine Fellowship application cycle as this offered a unique opportunity to assess perspectives of applicants who conducted both in-person and virtual interview formats. And the purpose of the study was to look at the preferences and we hypothesized that applicants would prefer in-person over virtual interviews. So surveys were sent one week after fellowship applicant matched through the AOSSM. Demographic data, yes, no questions, Likert scale and open-ended responses were included. Strongly agree and agree were deemed positive responses. And statistical analysis was done using descriptive statistics. Here's just a sample of the questions that was sent, those 38 questions. Other results, 38 of that, we had 45 responses. 38 of the applicants were male, seven were female, 39 were from allopathic, were allopathic graduates, six were doctors of osteopathic medicine. Most applicants applied to between 21 and 30 and 31 and 40 programs. 20 of the 45 applicants interviewed at between 11 and 15 programs and 11 interviewed between 16 and 20. One applicant interviewed at over 20 programs. Of note, 23 of the 45 applicants say that about roughly a quarter of their interviews were virtual. So these two data charts show essentially how much money applicants spent and how much they would feel comfortable spending. Roughly 50% of applicants say that they spent over $5,000 with 22% spending over $7,500. However, most applicants, 35.6% of them, fell between the $2,500 to $5,000. In regards to how much applicants were comfortable spending, there was a slight shift towards under $5,000 with 46.7% of applicants saying they would be comfortable spending between $2,500 and $5,000 on their fellowship interviews. Of note, we had 16 applicants say that they completed less in-person interviews due to cost and 23 applicants said that they would have interviewed less if there was no virtual options. 30 applicants say that distance was irrelevant to them when they decided to interview either virtually or in-person if given the option. So results of our survey, the question I was able to assess if this program was the right fit for me, 95.6% of applicants felt that this was able to do in-person versus 30.2% at virtual. I was able to gain insight into program's culture. 93% thought with in-person, 33% with virtual. Interviews allowed me to accurately represent myself. 95% of respondents thought that this was possible in-person versus 46.5% with virtual. Assess current fellows' happiness and quality of life. 95.6% thought this was possible with in-person versus 37.2%. Camaraderie at the program, 95.6% for in-person and 14% thought this was able to do versus virtual formats. Of note, able to connect and develop rapport with interviewees, 95% of people thought this was possible with the virtual versus 53.5% with virtual. Good understanding of kind of the facilities and the environment, 91% of patients thought this was through in-person versus 9.5% with virtual. Able to get their answers, easily get your questions answered. 95% of people thought this was possible with in-person and 90% with virtual. Then the last question was, was the interview format sufficient to create a rank list? Which 95% of people thought this was possible in-person versus 41.9% with virtual. So overall, applicants attended more interviews due to the virtual interview option. This allows interviews to get more exposure to programs. However, it increases the workload on programs. And there was one issue that's brought up that this increasing virtual options, excuse me, has a potential for allocation disparities going to more competitive applicants. And our study found there's still a significant financial burden to residents. So in summary, in-person interviews were superior to virtual interviews in allowing applicants to develop rapport, assess facilities and city, engage their fit. Only 40% of applicants thought that virtual interviews were sufficient to create a rank list. And overall, orthopedics, sports medicine, fellowship applicants do not feel that virtual interviews were adequate alternatives to in-person interviews. Here's references. Here's a picture of Dr. Flanagan in the COVID era. And on the left, we have our in-person interviews at the show. Thank you. Great, thanks Connor. Next up, we will have Dr. Ivan Wong from the Great White North in Halifax talking to us about virtual surgical training. Appreciate it. So I get to come out of my POW box. So yeah, we'll talk about virtual surgical training, my disclosure. So hopefully by the end of the session, you'll be more familiar with the use of remote education for surgery, the use of educational principles with this technology to be able to teach, the possibility of teaching complex arthroscopy in a distant lab, and then the future of perhaps distance-based, individualized, timely learning education. So you've heard actually just one of the talks so far. I don't know why there wasn't two of these out there talking about resident teaching. We're gonna have more of a trainee teaching going on here, but this talk is really about the fellowship-trained surgeon, okay? So this is more advanced teaching, and we're using this concept to be able to extrapolate this to other aspects. So what are the traditional methods of teaching? Well, we do have visiting surgeon programs where you can actually visit another surgeon and watch them as they perform. You have visiting traveling fellowships for something like this. And this really is the gold standard to watch another surgeon in their operating room do the things that they do to be able to get the outcomes that you want. But these are very expensive, right? Other options are cadaver labs. Again, in surgery, the real way to learn and practice something is to do it on a cadaver where you can learn the advanced techniques. This also usually requires traveling to some kind of course. It costs money. Nowadays, we obviously have YouTube. We have ViewMedi, so we can watch curated videos. These are always edited, so they're shorter than what you want, and it's harder to see the whole episode. So this is an example. Some surgeons actually learn, again, depending on the type of skill you're looking for, can learn how to do a surgery. This is one example of one watching an AAGR technique on YouTube, and the benefits obviously are it's short, it gets you highlights, it can remind you of certain steps. But if you're learning this from the beginning in some complex program, you're not gonna be able to interact with a surgeon who does this. You only get an arthroscopic view. Sometimes an outside view, so it's very difficult to be able to know all the nuances, all the tricks to be able to get through something like this. So is there an ideal way? And probably the right way to go back is to look at our medical education literature. And in this collaborative clinical education, we actually had to focus on the process of teaching, not just on the technology, because that's the way we're gonna be able to get something outwards. So for during the pandemic, when we couldn't travel, this distance-based education was essential, which created the new frontier to be able to do surgery with augmented reality. And what augmented reality allowed us to do is to be able to have, to be able to interact with another form with somebody in a virtual space, which allowed teaching to happen. And that's just augmenting, just like you can augment onto a slide. We have other examples of doing live surgery, right? We get the opportunity now this year to do live surgery in Annecy with Laurent Lafosse. Isha and other programs are doing live demonstrations of these, and they're using different technologies, such as this one. If you look on the literature, Stenson is probably the only one that's actually published on this. In 2022, he showed that he gets an inside and outside view using these towers to be able to transmit this information. And multiple other companies, such as Avail, Proxme, oh, did that disappear? It comes up again, okay. So have tried to create a platform to do this. We do know that Avail actually doesn't, that it no longer exists because it is not just technology, it requires the mentality of medical education. And why is this important? For example, TSN has this down. They don't just show you a picture of what to do. They have drawings to show you where the play's coming. They pan the camera to show you where the action is. They change the camera view so you can actually focus on what you wanna do, and that's the only way you can follow a game. So if you just have the outside view, just have the inside view, you're not gonna be able to understand how to do a surgery. So virtual learning for AAGR is what we wanted to figure out. We wanted to use augmented reality. So again, not artificial intelligence, not virtual reality. We want to use virtual images superimposed on real images, utilizing the physical environment, enhancing the aspects to understand the real object, something like that. So how's that look? Well, this is an example of one. So this is the start of what a virtual surgery broadcast would look like. We'd actually go through using augmented reality to sort of the surgeon point of view with augmentation of the bone, so we know where we're gonna make our cuts in our portals. Then we use multiple cameras, and then this is curated, just like TSN. We will focus on the appropriate camera angle to see what you wanna see at that time for portals. And these are the appropriate camera angles to be able to know how to do the bone graft in multiple views so you can see a three-dimensional aspect. And then we overlay the augmented reality to show you how you can template that piece to make sure it's exactly the right size for this specific patient. This is the typical inside, outside view you get the same time, so you can understand the nuances of how you're gonna create that. But the nice part of this is we can take that same technology, flip it around, and take all those cameras. So these are the cameras. You can see there's an outside view on the left. There's a front view on the right. There's a back room in the top middle. We have an inside camera as well. And having all those views simultaneously will allow a trainer to understand the nuances of what's going on in the learner space. And now using augmented reality, we can actually draw on top of those screens to be able to help guide a whole surgical process, learning something completely new. And then we can get feedback on this to see how these learners do to be able to do it on their own. So what we wanna do is figure out if this remote method works. As we actually see it, now we want to be able to describe how well it's working. Is it feasible, satisfactory, effective in our learning method? So our first question is trying to figure out is virtual preceptorship feasible and effective in teaching surgical education in this type of an example with AAGR? You can see these are the videos. There's a three-up view in this type of team where we're trying to get the graft in the right position. We looked at this. Again, these are fellowship trained experienced surgeons. So most of them, three quarters of them have more than 25 arthroscopic banker repairs per year. A quarter of them had about arthroscopic latter days. Most of them do open latter days. So these are experienced surgeons. All the blue represents before a live surgery feed. So you can see most of them are more on the uncomfortable side, whereas the orange shows the post broadcast feed where more of them are on the very comfortable, extremely comfortable. So you can see just having this view with inside, outside appropriate views, they're much more satisfied with being able to learn how to do the sequence of the procedure. Our second question, we wanted to figure out if we can assess surgeons, how they can effectively learn that complex skills using that augmented reality in a distance-based lab to be able to practice it using the cadaver specimen with videos, with augmented reality, and with all, again, all those different cameras so that the teacher can be able to help on those aspects. And the analysis of this was with the University of Southern California helping to do this education-based questionnaire really to focus on two different questions, the accuracy of graft preparation and the accuracy of the portal preparation, because those are the two difficult parts of this procedure. And here you can see those who were unable to verbalize. So if you didn't go through the video beforehand or watch what to do, if you can't verbalize it, you can't actually do it. So those on the blue, you could not prepare the graft. Those on the orange, you could prepare the graft the right shape and size. So again, if you can actually describe it before, they're able to do it. If you're able to verbalize it afterwards, you could also do it then. So learners, at the end of all this, with that lab, were able to get the graft in the right placement each and every time, almost all the time, using this type of method for teaching. So is this a future? We do think that we can teach complex skills remotely using AR. This is, as far as we know, the first time we've been able to demonstrate this, and AR with the principles of teaching can help do something like teaching in remote locations. If you're interested in learning this, we're actually gonna demonstrate this in the AOSSM course, the Global Innovations of Complex Shoulder Surgery. We're going to use this technology to do this through Colombia and Mexico simultaneously. Thank you. All right. Good afternoon. My name is Joel Boyd. I'm a co-moderator here. And our next talk will be the development of a novel orthopedic sports medicine fellowship surgical skills assessment by Anil Ranawat. How you doing, man? Not often rangers and vile doctors get along so well. That's a joke. And I think it's a good thing that we're able to do this. I think it's a good thing that we're able to do this. And I think it's very... Thank you, first of all, you guys coming here Saturday. It's education. It's not usually the... We threw some DTAs just to make it interesting. I love how the Canadians are showing all the advanced technology and the Americans are gonna be showing cadavers. That's just, there's a first for everything. So this was, here's my disclosures. I just wanted to disclose this was an AOSSM grant. And I really wanna thank my partner in crime, Jeff Dugas. This was a five-year project that started with me and Jeff at a board meeting. And it really is a labor of love and we really, I think, have created something here. So what do we have right now? Right now, in terms of our... We're not talking about advanced surgical techniques. We're talking about training our fellows. We have 207 sports medicine fellows in 2002. There's no formal surgical skill assessment for those fellows. We have a written exam. So every fellow takes a written exam at the beginning of the year and the end of the year. And we just had our fellowship directors meeting and we see, almost every year, on average, the fellows get like a 60% at the beginning and they get an 80%. There's always a bump. Now, that written exam is also just given to the fellowship directors. They never, there's no teeth to that exam, but we always wanna see, as a fellowship director, that there's a delta, and the majority of times there is. But really, we wanna see, is there a potentially, an opportunity to enhance surgical training? Well, why do we wanna enhance surgical training? I'm sorry. Because sports medicine is hard. Didn't we just hear that from our president, right? We need a surgical skill assessment for hard surgical tasks. There's psychomotor skills, there's procedural knowledge, there's technical proficiency. I am not talking about a DTA. I'm talking about an ACL and a rotator cuff. So what do we need to do to train our fellows to be the best, safest fellows they can be? Well, first of all, we're way behind the general surgeons. They have done this for almost 10 years. They have technical skill assessments for all their residency training through fellowship for laparoscopic techniques. So this is something that, you know, I knew about this, and this is something that Jeff and I were saying, we have to do better. And why do we have to do better? Well, how do you get your driver's license? Do you just take a written exam? No, you gotta get in the car, you gotta parallel park. It's the only time my kid has talked to me in the last two weeks, he's like, dad, you gotta teach me how to parallel park. I'm like, oh, you can't just use that button anymore? No, you gotta learn how to parallel park. And if we don't do it for ourselves, what's gonna happen? Somebody else is gonna do it for us. We are the best educators for our fellows, so we should do it ourselves. So what was the aim of this study? Was to develop a novel skill assessment to evaluate ACL and rotator cuff surgery. Then to deploy the tools in surgical strength and weaknesses of an incoming class, and then repeat the test a year later. So this was an auspicious goal, and thank you ASSM for that grant. So we first wanted to create a tool. You want to create a valid tool. So we had 14 board-certified orthopedic surgeons, sports medicine, all trained. We did a modified Delphi protocol. We're developing a grading rubrics and instructions. And then we created a test. Then we did a pilot test. We did one at HSS, one at ASMI, one in Cleveland, one in Stanford. We were gonna keep on going, and then there was a small thing called COVID that got in the way. Actually, on the way to ASMI, I couldn't go because the airport closed down, and I said, Jeff, you gotta do it by yourself. And then we did a basic scoring rubric, 10 surgical steps, and we used the core competency principles of one being deficient, three being competent, five being expert. This is how our residents are graded, and the reason why we did this is that this tool will not just be for fellowship. This tool can be a graduating tool to follow residents, sports residents, through their process, and then through fellowship. That's really the grill that we're gonna talk about with the residency directors again. And then we look at our maximum score and then our time to completion. This is a super small font, but this is the ACL. There are five steps in the first section, and then there's five more steps in the second section, so you get a score for each step, you get an overall score, and you get a time score. But you also get this, the proctor and the fellow get a procedural proctor instructions, and the fellow get instructions, and they get a case beforehand. They get an ACL case where they have to walk through. Likewise, same idea on the rotator cuff, five steps here, there's always a time stop where you have to create the injury. That's what the proctor has to do. Then another five steps for 10 total steps, and then instructions for both the proctor and the fellow. So, we took 14 sports medicine fellows, and we did an ACL and a rotator cuff. We did it again 12 months later, roughly at the OLC, and we evaluated all 10 steps. We evaluated their overall score and their time and used basic statistics to look at this. And although this is really small, the bottom line is here, that pre-fellowship and post-fellowship, the mean statistical significance for ACL was 13 points, and for cuff was 12 points. It was very interesting how we saw consistently that the ACLs were, they were better ACLs than the rotator cuff, which was interesting in itself, but that wasn't the point of the study. But also, time significantly reduced, and we did have a 90-minute max time interval. So, most of the times, these fellows were getting close to the max time that we have to administer this test, and by the end, they were doing it in about an hour. So, what are our takeaways? Fellows showed marked improvement in performance and efficiency, the assessment of the scores of value, the dedicated fellowship training. It's basically saying, we're doing the right thing. I'm not trying to put a microscope on our fellows. Neither is the written exam. What we're trying to do is to build, to understand outliers. You can send outliers who are amazing, but also guys who need help, and let's get them help early on in fellowship so we can train them better. The limitations of this is sample size, cadaver availability, and procedure, you know, variabilities. I really want to thank the fellows, because you can't do this without the fellows. So, thank you all. I really want to thank the proctors. You know, you're going to learn how to be a proctor, and that's something else that we can always do better. So, in conclusion, this was the first U.S.-based arthroscopic skill assessment for sports medicine fellows. It's a tremendous potential to supplement our written exam. Obviously, there's cost, logistics, buy-in. You know, I got Craig Moore here on the fellowship committee. I'm like, Craig, let's go do this. Let's work this out. I got to get Dean Taylor. Let's, you know, this is just the right thing to do, and we definitely need further validation. But I'm going to tell you this, my last point. Whenever I take my fellows out to play golf, and I go, what's your handicap? They gave me a number. And then, you know, we don't really keep score. It's graduation fellowship day. Then you play with your father-in-law, or your mother-in-law, and they're always keeping score. Wow, it's amazing how your score's up 20 more strokes. So, you don't really know how good you are at something until you actually objectively assess how good you are. Thank you very much. Thank you. Great. Thanks, Anil. One quick question for you. What do you see as literally the next step? Like, you know, what are you doing, or is there anything you're doing in your own fellowship as a result of this study, and, or sort of the broader, you know, fellowships across the country? What's the next step? So, I mean, I think the next step is, in my eyes, is pretty clear. Look, I'm a big fan of VR and augmented reality, and I think that's all the future. But we have a validated instrument now. So, as a testing instrument. So, I highly encourage all fellowship directors to do this in the front end. And all fellows want to get reps in the beginning of the year, and you do it at the end of the year. And then we're gonna collect that data. I would think over the next year or two, we will talk about cost, and talking about grants, and talking about mandating it. But right now, my goal is to highly encourage fellowship directors to use this program. And AOSSM has been very supportive. I mean, this goes back to CBJ when he was president five years ago. I mean, so this is, the board has been very helpful. I mean, ex-president Peter Delicato, he came and became a faculty. That's how this is such an incredible collaboration of our organization. And I think we really have something here. Yeah, that's awesome. Congratulations on that work. And then I was just gonna ask one quick question of Connor. I think you're way down there now. Great study, I think it's very interesting to see that transition, and now a little bit of a transition back. But, so when you interviewed for residency, you interviewed virtually, I imagine? Yes, my boss was the first. Can we turn on the mics down there, too? Sorry, I don't think your mic is on, Connor. So my class was the first of all. Virtual, so, sorry, yep, all virtual. Perfect, so just from your own experience, and then what you've seen from your classmates, and this study in general, what are you thinking is ideal at this point? Yeah, I think the study, the results of this study, and just anecdotally talking to people and having gone through it, people do support in-person interviews. Obviously, there are things that we can do to help mitigate the cost, because that does seem to be kind of the main driver of why people would do virtual. So I know certain fellowships do it, like they have interview options at their national conferences or regional conferences. I think it's something in the future that sports could consider doing to help mitigate costs for residents. But in general, I think residents are okay spending more to be able to go visit places and kind of know the faculty better. Great, thank you. All right, we'll move on with our papers. Our next presenter, Dr. Greg McCandry, developing an arthroscopic simulation lab. Thank you. I'm excited to be here today, and my charge is really to kind of go through more practical how one can develop a feasible arthroscopic simulation lab. I've been the director of the Kendehaven Lab for 15 years at the University of Rochester. I've been really lucky that that got endowed. It provided a tremendous opportunity for me to, over the years, teach lots of residents and play with lots of different simulators, technologies, cadavers. And what I'm hoping to do is share our rationale for kind of how we do it now and how I think folks may be able to take some of that to their home institutions. My disclosures are on the website. So we start with principles. So as Ivan said, it's not really about the simulator, it's about what you're teaching. And so we practice simulation at its core to improve our patient outcomes. And so the patient's at the center of everything we do. When we are developing our curriculum at the University of Rochester, we think about, well, what procedures are the most common ones that we do and that our residents do? And what is it about those things that we need to simulate and teach our residents? Simulation is a curriculum, a simulator, and as Dr. Ranawat just showed, an assessment. Without those three things together, you're gonna just have a coat hanger that sits in the corner of your simulation lab. And I will say this is hard. And so my advice is you can't do a ton of it. You need to do what you do well and make sure that it has a solid curriculum and is tied to an assessment. The other thing I'll say is surgery is a psychomotor skill set, and simulation can be used to improve cognitive skill, technical skill, or both. Despite what all the vendors will tell you, there is not an ideal simulator for actual real surgery. They all have pros and cons, and you gotta figure out how you adapt that simulator to your curriculum and the skills you want to teach. I'll get into this in a minute, but all simulation actually is mixed fidelity. So there was previously kind of this argument back and forth about is high fidelity best? Is low fidelity best? I'm gonna show you that it's really all mixed fidelity, and that should play into your mental model about how you're developing your lab. So we'll get into how do we apply these principles now to really establish, again, a feasible program within orthopedic residency. So it starts again with what do we need to teach? And I said, okay, we've got technical skills and we've got cognitive skills. And both of these things are something that residents will learn throughout their career. But I will say that early on, one may be important or more important than the other. So just by a show of hands of all the surgical educators in the room, if you have a PGY-2 resident that you need to train, would you rather have that resident show up and know all of the steps of the procedure, know the anatomy and the pathology and all of the goals, but not know how to hold a saw or screw in a screw? Or would you have that resident show up to your OR able to actually saw and screw, but not maybe know all of the steps down pat? So folks, raise your hand if you would rather have resident number one in your OR who has all of the knowledge, but maybe has all thumbs. So a couple. How about folks who would rather have them have the technical skills in the OR? So we're seeing a little bit more in that group. And that's generally what we see, right? If you've got a young resident, you can kind of coach them through the other parts of the procedure if they have decent hands. If they show up to you with poor hands to start, what we learn over time is that just kind of compounds itself and gets worse. Because actual OR time, where you have the opportunity to practice hands-on skills with your hands on the instruments is a limited and valuable commodity in orthopedic surgery residencies. So if you look at our residencies, basically I had a resident or a medical student follow all of our residents around and kind of time track how much the resident actually had their hands on an instrument during their surgical day. And these numbers are pretty sobering and I think probably represent what other folks see. When you add it all up, it's about 1,470 hours per residency and so if you think about that, to be a commercial airline pilot, you need to do 1,500 hours before you get your pilot license. And not to poo-poo the job of being a commercial airline pilot, but that's just to fly a plane. We've got to do all kinds of different procedures and so I would argue that it takes more than that and if you're a Malcolm Gladwell fan, I think everybody's kind of heard the 10,000 hours. So we're far short of that. So how do we supplement that for skills? This is an example of what folks would call low-fidelity simulation, but I would actually argue that this is high-fidelity for technical skills. So we're using real instruments, we're using a real arthroscope to get visualization, we're screwing in real screws, we're using the actual implants and devices that you would use in the OR. Now does the environment look realistic? No, but for teaching technical haptical skills, which are more generalizable to all procedures, these models are probably sufficient. This is another model. So Danny will go into this before. So this is the immersive VR and so that person is tapping in a nail. Well, they're not holding a hammer. Does that make this a bad simulator because you're just kind of waving your hand around, you're not really learning that technical skill? No, these simulators are really good for other things, learning the steps of the procedure, learning what the anatomy looks like, learning what the repair construct looks like. And if you already know how to hold a hammer, you don't need to simulate how to hold a hammer. So I would argue that maybe you do this type of simulation a little later in training when you already know how to hold a hammer, know how to saw, know how to screw screws. And so this is how we've set up our simulation. So early on, PGY1, PGY2, we focused more on the traditionally called low-fidelity simulators where you're using real tools and real instruments because those skills are generalizable. Like when you learn how to visualize in a knee, you can also visualize in an elbow, you can also visualize in a shoulder. And then we step up to medium or mixed fidelity VR with one of the trainers. And then we do a self-directed program in immersive VR. And then we have a supplement program with catabaric training. And so this is our PGY1 program. We just use the FAST. And again, we start with those fundamentals. So if you can't see, you can't do surgery. And so I can't hand my patient or my resident a scope if they're not gonna be able to visualize. And so we want them to learn that before they get in the OR. So we start that first, then it's, okay, can you kind of move around safely? And then after that, okay, we're gonna put something else in your other hand. You need to be able to have that bi-manual dexterity. You're gonna probe. Then you're gonna kind of have those gross motor skills to be able to hit a target. And then eventually we're gonna start working on more fine motor skills, grasping, passing, simulating loose body removal. And then finally, you're gonna put it all together. Tying an arthroscopic knot is a great way to kind of have to do all the things below that. I said before, it's gotta be a curriculum and testing modules. And so FAST is set up to do that. There's a web-based curriculum. There's a workstation for you to deliberately practice to proficiency. And then you can test yourself with the different testing modules. This is what it looks like. So we have them scan a QR code, gives them a little video so they know what the objectives are. And then basically they go through the model and I'll go into more detail. And we've done studies on this showing that if you can teach the residents through this methodology to achieve benchmarks, they'll be able to outperform faculty in terms of the quality of their knots. So that's what we do in our intern curriculum. What do we do PGY2 and beyond? So we have a rotating curriculum. We still feel cadavers are great. And we have a two-year rotating curriculum for that. The problem with that is it doesn't line up with your rotation schedule for every resident. And you're not able to test a proficiency using a cadaver. And so you need to augment that with something. And that's where these virtual reality simulators come in. And so I said, designing these things and developing these curriculums are hard. These are ready-made for you. And so you can allow the residents to augment their practice doing kind of a self-directed proficiency-based program using these simulators as part of their rotation requirement. This is what our lab looks like. So we leave the fast setup. Again, you got to make it easy for the instructors. You got to make it easy for the learners. People's time is extremely valuable. So this stuff is as simple as it can be. You scan the QR code, the thing's right there. You just go to work and you progress your way through the simulations. On the other side of the room, we've got the other simulator again with its instructors and it's already core curriculum and benchmarks. And then we've got the VR modules on the other wall as well. How much does it cost? The cadaver saw bones cost about 10 to 15. And this is for our entire program, arthroscopy and open procedures. The medium fidelity is the most costly thing at about 150,000 plus. Immersive VR, about 10,000. And then the fast basic skills, about 10,000. Thank you. Next speaker, Danny Goal. Augmented and virtual reality and surgical training. Make sure to move, remove bias. Thank you very much, everybody. Thanks for the opportunity to speak today. So I'm going to talk and take a little bit of a different approach, surgical education. I'm not going to talk about AR because Ivan's done a nice job there. I do have a disclosure. I'm the founder and CEO of an immersive medical education company. So this is the objective today for me, is to describe surgical education. It's very complex, but I'm going to take a little bit of a different approach that's been mentioned. I'll introduce VR only and I'll talk about some evidence. So when I think of surgical education, there's three things that I think we need to consider. We have something to teach, we have someone to teach, and we have something to use to teach those two things, or the people and the product. Now, when we look at the generation of learners, I'll start from there, people are getting smarter over time. So if I look at, I went to HSS a couple of months ago and I was looking at the profile of the residents, I don't think I'd match the residency today because of how accomplished some of those residents are. This is a Flynn effect. So if you look at this graph, you can see that over the last 10 years, the IQ increases every decade. And this multifactorial, of course, and much of this has to do with nutrition access and technology. Now, for those of you in the audience, who's been teaching for more than 20 years? Raise a hand. 15 years? Now, when we think of surgical education, we have a gen Z and a gen Y. They have different requirements for how they want to learn, which are extremely important. So if you have not adapted your teaching methodology to the learner, something's not right. So somebody's not connecting the dots, and it's probably us. Now, when we think of surgical education, I said it's extremely complex. It's not just about learning how to become a surgeon. What we're going to talk about is technical performance. Now, technical performance should be broken up into three specific things. One thing that people focus on a lot is haptics. That's on the far right, dexterity. You should learn how to drill on a PVC pipe with a drill or the nice models that Dr. Nakandari showed as an example. That's dexterity, how tightly to tie a knot, how to hold a knife, etc. That looks like a rotator cuff tear. That looks like a fracture. Judgment is really what the most interesting thing to me is, because judgment is directly related to expertise. So if you can't see when you're doing a diagnostic shoulder arthroscopy, your judgment should tell you, I either need to change my portal, change the camera or scope, or I need to move the arm. That's judgment. That's during surgery. So we wanted to evaluate this. This is a study we did in Vancouver. We looked at all the residents and asked them, over five simple or common fracture cases, how often were you the primary surgeon? But importantly, how often did you do particular parts of the case 100% of the time? And we broke these down into the relevant decisions. So we picked, this is the first, this is the second allocation, but for a bimalleal ankle fracture, you can see that the resident decided where to mark the incision only 4% of the time. The PGY-5 only got to decide where the incision was 30% of the time. And as you go through this, you can see the R1 didn't ever get to do or obtain the reduction, and they very rarely got to fix the fracture. So if you think about that, if I was the man of the reamer while nailing a femur while the attending put the guide wire in, passed me the reamer and said, now you do the reaming, I felt like I was doing 100% of that part, but it's not the critical part of the case. Look what happens when things get more complex, a distal humerus fracture. The PGY-1, 2, and 3 did zero parts of the critical aspects of the case. These are the parts of the case that directly relate to judgment that's going to help them propel to the next level. So our summary from this is that the critical steps of each case, and you can break each case down into a critical and non-critical part of the case, are usually infrequently carried out by the residents. So think about that as you're teaching your residents or your fellows. Is this part of the case that's critical that would directly impact the patient outcome and who's doing it? So what happens when they do exercise judgment? This is a study that also came out of Canada that looked at radiation exposure across PGY-1s through 5. And I'll summarize this for you. So over the course of a year, they measured how many OR days and what was the radiation exposure. This was the finding. On average, all the residents who were exposed to 1 chest X-ray equivalent every 10 days, the PGY-2s and 3s had the highest exposure. When left to their own devices, the PGY-5, who actually did less cases in their last year, were exposing themselves to the equivalent of 1 chest X-ray every 2 days. So that actually signifies a bigger problem with a combination of learning, which is they saw something on the Flora machine, had to adjust their hand and make a decision, which means they're zapping over and over and over again. So if I talked about if the OR is the best place where learning occurs, wouldn't it be ideal if we could digitize that environment and collect data on critical aspects of the case? This is where VR comes into play. So the value of VR is that it permits a digital experience that allows you to measure judgment without patient harm, and you can do it anywhere, anytime, at certainly a cost-effective way. So here's an example. So we talked about that imaging. This is something that the AO has put together. So when you're in the case of a pelvic fracture, in your mind, what you're doing is you're trying to create these mental models of what this complex fracture looks like. Now, without irradiating yourself immensely if you're in the OR, this environment allows you to decide, are you happy with that obturator oblique, ily oblique view, and then it gets to save it in that virtual environment and compare it to what's actually real. So you're actually getting that feedback instantaneously as you're learning, and i.e. making a critical decision about this case that's gonna help you put your SI screw in, et cetera. Now, this is, we can turn the volume down here if it's not, but this is sort of the sort of capacity of things we can do in virtual reality in general, where we're allowing you to put the scope in the knee, and I'll talk about arthroscopy, decide how much flexion of the knee is required before you put the femoral guide wire in and exactly where you would put the guide wire in, and you can measure that in millimeters across the board. Cam resection is the most, the number one reason for revision in hip arthroscopy. You can measure how much of that cam resection is actually removed. So here's an example of measuring metrics through this technology. When you put an anchor in, whether it be a cadaver or a generic model, it doesn't give you any information. The judgment part of this would say, if I could measure where on the humeral head exactly that was going, what was the angle of approach, what was the arm position when you put that anchor in, what location was the scope in, which hand was the scope in, and where exactly were you were looking, that's starting to get into and analyzing detail about judgment. I'll share some quick data. I know I'm running out of time here, but I'll actually skip through this and get to them a little bit over. But I'll share this study here, which was done out of New York. This compared practicing in VR versus practicing in a lab using this high-fidelity simulator. And these people were tested, these residents were tested in a cadaver. The VR group practiced at home. It took them less time to learn this hip arthroscopy. They performed the same on the cadaveric experience when they were evaluated by experienced hip arthroscopists in New York. And of course, from a cost analysis, it was significantly less. I'll skip through this, but I wanna show this video as a final, and this volume can go up. This is a really good video showing the time that the resident needs to make judgment out of a particular problem. Can you turn the volume up, please, on this? A little bit. Correct, so now what do you think you need to do? I don't know if that volume can go up any higher. This is dry tape. Okay, fine, sure. So it's showing you the position you wanna be in. So think about, by looking at that x-ray, what you need to do with that right hand to mimic putting in that pin at the correct position. So count the seconds he's looking at that x-ray. And really, this is the purposeful practice part of this, which I think is the most obvious. He's still deciding how long it's gonna take him, or where his tension is. And Gus Buzaka is watching this because he can see through his eyes on the monitor. So if I adjust this way. So that's a really good example of allowing someone the time to actually make judgment. Final study, this is a case study at a JOS experienced surgeon pinned a slipped epiphysis in the wrong place. This surgeon's been in practice for 30 years. He transferred the case to the Children's Hospital, where the resident actually practiced in a virtual reality environment. These are his x-ray images during his virtual reality training. He got much faster at putting the guide pin into a moderate to severe slip. His score actually went up, and he did the case the next day, which they report is unsupervised in this patient. What was most notable as the amount of x-rays he took during the actual case were eight times lower than the original surgeon. So when we think about where VR plays a role, I think we have to consider all these different things. And I think it plays a role right in the middle of tech, education, and this new generation of learners. Thank you very much. Thanks, Danny. So at this point, that concludes the first part of this session. I really wanna give a huge thank you to those that presented papers and the talks. Everything was excellent. We're gonna actually turn it over to Dr. Chuck Bush-Joseph for the second part of this, which involves a panel discussion. And Dr. Ranawat, you can stay up here as part of that. We're also gonna invite up Dr. Kathy Koiner, Jeff Dugas, and Rick Wright to participate in that discussion. Thank you so much. Just gonna set the mic right here. Would you mind putting up my talk real quick? Oh, is it up? Let me help you. Oh, sure, thanks. Just a little bit. I think I'm gonna go to that talk now. Yeah, I'm sorry. Sorry, sorry, sorry. Appreciate it. Okay, back out. Two minutes each. Yeah. Okay. Great. What time is it? It's supposed to be. I'm gonna stand up there. Thank you. Thanks, everybody, for sticking around, and I appreciate it. I thought the last lecture was just fabulous. I mean, just the advancement of technologies of where we're going. I'm gonna run through just my talk a little bit quick, and I'm gonna get the input from our panels before we sort of go through a series of topics real quick. You know, I have no disclosures, other than the sense that I've been around training 160 residents, 110 fellows. And so the goals of who is the team physician, the current role, and more importantly, I think the questions we wanna ask today, where's the next generation, and how do we make those transitions to evidence medicine? You know, I mean, we all know the role of the team physician is really the care and safety of the athlete. And for those of you who saw the afternoon sessions today with Tiki Barber and Ronnie Barnes, really some excellent, excellent talks. You know, as a team physician, and the higher level you get, we practice good medicine, but we just practice it at a much different speed. We have to go faster and faster. And the level of the competition, or athlete that we're taking care of, usually sort of dictates our willingness to pursue off-label treatment. So you can see in this decision tree, we get closer and closer to those red boxes, as Tiki Barber said, doing some wacky things like sleeping underwater. And over the last couple of days, we've talked a lot about these topics. Our world is much more complex than it's ever been, and we have a lot more to think about, and worry about. And just like the player, we do have to be willing to expect that everything we do is open to some criticism, criticism to some degree. And I hate to say it, we just have to suck it up. That's just part of the game, because what we do is fun, and you have to put up with it. And so when we get these kinds of headlines that scare the hell out of us, we just have to say, all right, how can I, what can I do to mitigate? So it's like anything, what we control and what we don't control, and the things on the side of what we do control, you can see those, those are the things we have to focus on. What we don't control, or really can't manage, we don't know what sometimes outside consultants will say, and the value of the contract, or the perception of the player's ability. These are the ones I just did want to get to the point, who is a team physician? And if you can see, that in board certified orthopedic specialists, family practice physicians are actually have a higher number of certification than actually we do. And I think many of us here in the room have heard that we believe that the subspecialty certification examination is critical, and your current board is doing everything in the world to make that easier for our young fellows and residents to attain as they move through the system. But if you look at the actual number of participation of participants in the, who's taking care of athletes, AOSSM members actually represent a very small percentage of that. But yet nonetheless, we have great influence there, and it's our job. So there's 5,200 AOS members who self-identifies as sports medicine specialists. 2,300 of them currently hold the certification. 1,100 of them are members of the AOSSM. So these numbers, we think we've got to do a much better job of getting up and understanding that this organization should be the premier responsibility. And as was alluded to earlier by Dean, that we're seeing some movement now that many of these professional leagues and are moving towards. Now, there's going to be resistance. The Physiatry Association has strongly filed critique against that policy of having board certification to participate in the care of athletes. And I'm expecting to see more of that. And again, we're trying to do different things to mitigate that. And your board, as I talked to earlier today about the option of having a, not a board certification certificate, but at least for foot and ankle or other specialists to be able to undergo our level of education, to be able to participate and have some validation. There's been a lot of studies here. You can see, I think this data has been showing up over the last couple of days. Who's currently the team positions? Yeah, they're mainly white, mainly male. Their mean service time is 17 years. So that this is, it takes a while, 17 years in practice before you sort of get to that position. And same thing in baseball. A lot of males, few females. The data is similar for both primary care and the head team physician. It sort of mirrors that same element. Same thing on the other, the concentration of where our training or our current team physicians are coming from. In this document, certainly on the left, they're showing that a number of fellowship programs really seem to train the bulk. And we needed to open this up to a more of a democratic opportunity process. And that has to be intentional by all of us to open the door for all of those. And so it's the 49% of team physicians graduated from a top 10 sports medicine fellowship in the, again, found a significant gender disparency. Of applicants who's applying to our process, 1,400 applicants into orthopedic residencies, 875 positions. And the DO side, 197 applicants and 111 positions in the average board score when we are still measuring board scores, ultimately quite low. So I'm gonna stop here because I think part of their job is mentoring in how do we open up the category to those younger or those that don't come from, quote, the power five of orthopedic training grounds. So I'm gonna start right at the number one of the power five training ground. And Bill, the floor is yours. If you ask, you set me up here a little bit. Sorry. No, I mean, look, I think our job is to train the next generation. It's one of the things that we look for in our fellowship applicants. So I don't necessarily think we have to penalize the power five. I think we should just promote the other ones. Some fellowship programs don't look at team coverage as much as other programs do. So I mean, we highly regard it. And although there are a lot of problems that you've presented, I still think my biggest role of mentorship, and we had a great meeting in this room with residents and fellows in a mentorship program, and then they asked me that question, and I'm like, just be a good doctor. Do all the things that you take care of your regular patients for and your athletes, and just remember the one rule is that they're not your friends, they're your patients, and then all the turmoil that's going around this subject I think can be mitigated. Rick, what are the thoughts you have about expanding the pool? How do we open the door to more people? Or I hate to say it, maybe I misplayed it, the question to Anil, which I apologize. How do we get more of our members involved about being more intentional about being a team physician? And essentially, I guess one of the ways I'm almost getting back to is regaining the ability as AOSS members leading the team as opposed to being that technical member of the team, which unfortunately I think many of our members have evolved into. Yeah, I think that's a real issue that's become more and more of an issue as you see, and I think it's how people wanna spend their time, and most orthopedic surgeons can make more money by operating and seeing patients in the clinic, and so they will abdicate. I think some, not as many, still wanna stand on sidelines on Friday nights and Saturday and Sunday afternoons or whatever and cover teams. That's why I went into sports medicine. It wasn't because of arthroscopy, it was because I wanted to contribute to a team, and I picked a fellow, I didn't go to one of the so-called power five, but I went to Minneapolis where Joel was where I knew I was gonna get great education with the Twins and the Vikings and the Timberwolves, and I learned a ton, but now I think that these, if you look at a lot of the colleges and a lot of these NFL teams, the people that are the so-called head team physician are now the non-orthopedics because they may get remunerated for it better than they do for seeing patients in clinic, and they seem to have more time, and we're abdicating that, right or wrong, and that may come back to haunt us. It was really the impetus, if you think back, Chuck, when Bergfeld and Chris Harner and everyone started talking about the CSQ, it was because we were losing the risk of losing the chance to take care of the athletes, and it hadn't panned out quite as bad as they worried about at the time, but I think it's an even bigger problem than it was 25 years ago when they were initiating that process. I would agree with that. We had a discussion, I think, at this meeting almost 10, 15 years ago about many of our young surgeons wanting to give up the MD and just be the technician, which is, I think that has stemmed a bit, but certainly that's something. Kathy, I'm gonna ask you, one of the things that I think we all have to learn is being a team physician are those soft skills, and Tiki Barber alluded a lot to that. You just don't run up to an athlete and start blurting out facts, or how do you transition soft skills? Soft skill learning, it's not like simulation training where you can put on some goggles and then start moving your hands. Yeah, I think that's a really difficult question. It's been really fun to talk to the residents and say, oh, what are you looking at in fellowship? And so many of them say, I wanna cover a professional team. And I think there's a lot of value in that, and I'll just explain sort of my experience at Duke. I took care of Duke basketball and traveled with the men's team and had a wonderful experience, and then I went across town to the Historically Black College, and I was the doctor, and it was the first time someone said doctor, but I was able to translate the skills that I saw with Dean Taylor and Allison Toth just being an innocent bystander, and maybe I didn't get a lot of hands-on, but then I was able to practice those skills. And I think it's something that I constantly strive at UConn to improve the development of our fellows. So I think it needs to be both something with autonomy, but also seeing good people having those soft skills to be able to translate that education so when they go out into practice, they've seen the right way to do it. And I do worry a little bit about sort of the future generation because they just seem to want everything now. And I think when I got to UConn, I had been in practice for five and a half years. I'd taken care of the Dallas Stars, and it was a very slow process, and eight years later, it's paid off for me, but I think people want it very quickly, and I think observing that in a fashion where you have great mentors is really important. Yeah, I would think that soft skill translation, when I talk to my young residents and fellows over the years, I think it is a matter of observation, and maybe it's a little similar to the previous presentation we had about R1s and R2s just watching where to put that intramedullary rod. I do think that soft skill is an observational event that eventually trans into a operational event where yes, I sort of finally learned that I'm gonna take over and have those conversations watching the reactions. Jeff, I wanted to ask you about the other thing that comes into play is resilience and confidence. You know, obviously you're very experienced now, but early in your career in training, how did you handle failure? Well, I had the very unique experience of being told that I had to do all of Andrew's cases before I could do any of my own, so when I was failing, I learned to teach, and I became a teacher because I was still teaching the fellows as I worked with him, and I think if you're in a fellowship program and you're gonna teach, learning to teach is important, and that means learning how to succeed and how to fail, and I learned from probably one of the best communicators ever in our profession, and whenever you hear people talk about Andrew's, they talk about what a great surgeon he is, but you know any team doctor from any point in our sports medicine history that answered their phone or reached out and talked to the other team docs or was always available, that was him, that he learned to communicate successes and failures, how to talk people through problems they were having. People call him all the time and say, hey, I'm having this issue, and he's always willing to talk to you no matter what, and I think as educators, that's part of our role, and I learned how he dealt with failure and how he dealt with adverse outcomes or people that were unhappy, whether they were high school athletes or professionals, and I think he instilled that in us, and I wanna point out that Greg McAndrey is heading up a task force, joint task force with the NNASM on surgical skills, and as we move closer together, the fellowships, the arthroscopy part of this, the haptics part of this, the technical skill part of this is super important, as is the professional part of sports medicine, and the 93 programs are all different. There are programs that really their focus is being a team doc, and there are programs where that's less of a focus, and I don't think we wanna necessarily beat that out of all the programs, because some programs need to be more focused on technical skill training, and some programs need to be more focused on training the team docs of the world. And Neil, I'll give you a last word since I gave you a bad question up front. What's your approach for your trainees at HSS on resilience and dealing with failure? Yeah, I mean, I think it's less of a team physician, more just of a fellowship director kind of concept, and I think, you know, it's kind of what we heard from the general today is that, you know, a bad case for an attending, I always tell, is the best case for a fellow. I'm like, you want your bad day to be with me, and then I can show you the three things to get out, because I've had this bad day before, and that concept of learning from your failures gets you more confidence, gets you more experience, and I keep on repeating one of my lines my father taught me, but the I see what the mind knows. The greater your library is, you then can avoid that complication, and then you get more confidence, and, you know, and then my last pearl is always the top gun pearl is that, you know, if you do have a bad day, you operate pretty quickly. You get back, get back in that fighter pilot, you know? That's what you are. Learn, do a root cause analysis, but then get right back in there. Well, it's 3.20, I don't want to hold any longer, and I want to appreciate the panel and Mary for putting on this symposium. Hopefully we can all pick up some lessons. I would tell you that I'm going to call Gus. His virtual reality training just looked outstanding, so thanks very much. Thanks, Chuck.

Joel L. Boyd, MD

Mary K. Mulcahey, MD

Anil Ranawat, MD

Connor Hoge, MD

Ivan H. Wong, MD,

Gregg Nicandri, MD

Charles A. Bush-Joseph, MD

Danny Goel, MD, MSc, MBA, FRCSC

Katherine J. Coyner, MD, MBA

Jeffrey R. Dugas, MD

Rick W. Wright, MD

orthopedic surgery

sports medicine

augmented reality

virtual reality

surgical training

fellowship interviews

assessment tools

arthroscopic simulation

team physicians

mentorship