Dr. Spiker: Welcome, everyone, to the Arthroscopy Association's Arthroscopy Journal podcast. I'm Dr. Andrea Spiker from the University of Wisconsin. Today, I have the privilege of speaking with Dr. Megan Bishop, who is a sports medicine surgeon at Rothman Orthopaedics in New York. Dr. Bishop was the first author of the publication titled The Arthroscopic Surgery Skill Evaluation Tool Global Rating Scale is a Valid and Reliable Adjunct Measure of Performance on a Virtual Reality Simulator for Hip Arthroscopy, which was published in the June, 2021 edition of the Arthroscopy Journal. Her coauthors include Gabriella Ode, Daniel Hurwit, Stephen Zmugg, Ryan Rauck, Joseph Nguyen, and Anil Ranawat. Welcome, Dr. Bishop, and thank you very much for joining me.
Dr. Bishop: Hi, Andrea. Thanks for having me.
Dr. Spiker: So, Megan, can you tell us a little bit about your practice, and then how the evolution of this study idea began?
Dr. Bishop: Sure. So, I'm sports medicine surgeon. I practice at Rothman Orthopedics, both in Manhattan and in Westchester. I actually started this project when I was in my fellowship at Hospital for Special Surgery a few years ago. And I kind of fell into this project, starting fellowship, as one that I was hoping that is the prospective study that could potentially get done during my fellowship year, and was relatively interested in resident education and training, in that respect. So, it was something that I was interested in, and it turned out to be a pretty good project.
Dr. Spiker: Great. And tell us a little bit about what specifically spurred your interest in studying virtual reality simulation in a procedure like hip arthroscopy, compared to some of the other sports medicine procedures that you were learning and training in your sports medicine fellowship.
Dr. Bishop: Well, I think some of that's kind of led into... The only simulator that we had in my fellowship was the hip. So, that's kind of where we got geared to doing a lot of our studies looking at hip arthroscopy, specifically. And like I said, the goal was to be able to get a project done quickly, and be able to kind of see it through, from start to finish in that year that I was at HSS, and then hopefully we would be able to kind of branch off and come up with some new studies from there.
And this initial study was really looking at what we call the construct validity of grading these stimulators. And this ASSET score, or the arthroscopy surgery skill evaluation tool, had been looked at using knee scopes before, shoulder, wrists. It really hadn't been thoroughly investigated using hip arthroscopy yet, so we thought that was kind of a good starting point to look at for using the simulator to validate previously used and validated scoring system for other arthroscopy simulators to look at specifically for the hip.
Dr. Spiker: Yeah, that's great. And I think one thought as to why the hip arthroscopy simulator might have been the only simulator at HSS, and I, too, was a fellow once at HSS-
Dr. Bishop: Yes, you were.
Dr. Spiker: ... is perhaps the utility of these virtual reality simulators and their utilization in procedures that are a little bit less straightforward, like a hip arthroscopy, when compared to something like an arthroscopy. So, can you describe for the listeners the components of the hip simulator, and what the training modules consisted of?
Dr. Bishop: Sure. So, we used a specific simulator called the VirtaMed hip simulator, and it was an anatomic left hip model, so it was only designed for the left hip, that had an external rubber component, and previously made arthroscopic portals were already made on the model. You were able to put traction on the hip, put the hip in flexion, and actually simulate positions that you needed for positioning to see the potential for a full compartment. You were able to use the instruments, so obviously there was an arthroscope, which was similar to the exact one you would use in the OR. There was a shaver, you can use a grasper and a punch, they had a probe, and then you can even do like normal fluid management. Fluid didn't get pumped into the actual simulator, but you could simulate bleeding and things like that to actually make it seem more real.
So, for our actual setup for the study, we kind of did two basic tasks. We did a diagnostic module where we had essentially just a diagnostic arthroscopy of both the central and peripheral compartments, where the participants had to identify different anatomic landmarks. And essentially, when you put the scope over top of the landmark, it would kind of trigger that you actually identified it correctly. And then we also did a surgical module, which actually was a loose body retrieval. So there were two loose bodies that were both in the central compartment, and you had to use the grasper and be able to pull them out of the actual hip. So, those were the two tasks that we had all the participants do.
Dr. Spiker: Great. And you mentioned a little bit earlier the ASSET tool. So, the arthroscopy surgery skill evaluation tool global rating scale. And in the paper, you mentioned that the ASSET had been the gold standard metric in knee and shoulder arthroscopy since about 2013. So, as you mentioned earlier, it had not yet been evaluated in the hip arthroscopy setting. So, can you tell the listeners just a little bit about how this rating scale is used and how it was scored in this study?
Dr. Bishop: Yeah. So, the ASSET surgical tool consists of eight different domains that are scored from... Seven of them are scored between a scale of one to five, with one being a novice, three being kind of in the middle of competent, and five being designated as an expert. And then the age domain is actually just scored from one to three, and that's actually called autonomy, which basically, were you to complete the task without any help from anyone else? So, overall, it goes from 9 to 38 is the scale. And it covers things like safety, field of view, camera dexterity, instrument dexterity, manual dexterity, flow of procedure, quality procedure, and autonomy. So, those are the main things that we look on that score.
Specifically for this study. We wanted to kind of determine whether or not the people that are less experienced, like the medical students or first- and second-year residents, kind of fit the mold of the novice, versus the more experienced kind of residents, the chief fellows, and then the experts that we had kind of fell into the role of the scoring fours and fives based on the ASSET global rating scale. So, we made arbitrary cutoff based on their... One is not experienced, competent, and five is expert, to kind of set a threshold for competency with our participants performing this two modules.
Dr. Spiker: Okay. And, prior to the study, I guess, I'd be curious to know what your own personal experience was with virtual reality simulation throughout your own residency. You mentioned that in sports medicine, this was in fellowship training, this was one of the only modules available. But what other types of virtual reality simulation had you been exposed to prior to this?
Dr. Bishop: In all honesty, really not much. So, I did residency at Jefferson in Philadelphia, and we actually didn't have any kind of simulators there. We did most of our skill sessions using cadavers. So, obviously there's a lot of benefits for using a cadaver over a simulator, but simulators are much more accessible, to be able to frequently go in at any time and practice. So, I think that there's benefits to both types of training, and they probably can be complimentary to each other.
Dr. Spiker: Yeah. I had a very similar experience where I knew these simulators existed, but we weren't really integrating them into our education and didn't spend a lot of time on them. And that's an important idea, because one of the things that you were looking at was whether your participants had had prior experience on these simulators. And interestingly, one other thing that you had looked at was whether they had had prior experience with video games.
And so, one of the limitations that I think you mentioned was that there is this learning curve for the simulator usage, outside of the learning curve for the actual procedures and maneuvers that were being evaluated in the study. And so, speaking to those participants with video game experience, for example, they had scored higher on the total simulator score and the ASSET for both diagnostic and surgical modules.
So, I'm just curious what your thoughts are on how something like video game experience plays a role in your VR simulator performance, or even into real-life arthroscopy performance.
Dr. Bishop: Yeah. We talk about a learning curve with the simulator, and actually, if you looked up the results of the study, the experts doing the loose body retrieval actually initially did worse than some of the more novice participants. And that's part of the learning curve, kind of just learning how the simulator works, and getting used to the haptics of it, and the instruments and things like that. So, there's definitely a learning curve that's necessary for the simulator.
And when you look at things like video game experience, and things like that, I think that people that had video game experience probably are a little bit more used to those types of haptics, which the cartilage that you see in there, just the appearance of the simulator being through a computer, and things like that.
Additionally, I think that you can actually can kind of start to cheat the simulator once you start to use it more often, almost like a video game. So, once you get more experience with it, you kind of learn the tricks on ways to get those bodies faster, and things like that, that aren't necessarily a improvement in your skills. It might be more just learning how the simulator works.
Dr. Spiker: That's a great point. I think also, that might apply to arthroscopy though, too.
Dr. Bishop: Yeah.
Dr. Spiker: The more we do arthroscopy, sometimes we learn those tricks and the different ways that you can kind of get there faster and more efficiently. So, maybe it also has some real-world application in that sense, too.
Dr. Bishop: Yeah. That is true. But I do think that some of them are really actually kind of just cheating the system. But you do get lucky in arthroscopy sometimes, too.
Dr. Spiker: Yeah, that's absolutely right. So, you had a chance to use this simulator. How real did you feel this hip arthroscopy simulator was, compared to the live operating room setting, when you were performing hip arthroscopy?
Dr. Bishop: I mean, obviously there's a lot more elements at play when you're in the actual OR. So, you've got the full patient setup on the Hana table. If you want to bring in C-Arm, there's a lot of things that you can't simulate with the simulator. But some of the good things are, the simulator actually allows you to practice positioning the leg, putting traction on. So, some of them is just learning the basic ideas and principles behind positioning, and then one of the downsides, too, of the simulator is that the portal's already created. So, you don't get to create the portals, but you can at least get an idea of where the best viewing portal is to see certain structures, you can practice triangulation, and things like that. And then, just get a good familiarity of what the inside of the hip looks like. And it is at least a good, basic introduction to hip arthroscopy, and might allow you to achieve competency in these basic skills.
Dr. Spiker: That's a great point. The question I was going to ask you, of course, is what is the biggest benefit of hip arthroscopy VR simulators? And I think you've really touched on it. While there are a lot of limitations, the ability to perform these repetitions, to actually have the instruments in their own hands, and get the basic skills of a more complex surgery like a hip arthroscopy, really seems to be a benefit. And from my understanding, these simulators also have that arthroscopy screen that the participants are looking up at, in order to see all of these. So, there's a little bit of a component of a setup that's similar to what would be seen in the operating room. Is that right?
Dr. Bishop: Yeah, that's exactly right. Yeah. So, it's set up with the actual leg, and then the above, you have a screen. So, it is relatively similar to looking at the screen in the OR.
Dr. Spiker: So, what is your opinion on how much you think we should be involving these VR simulators, in the education of our residents and sports medicine fellows, when it comes to arthroscopy? I think you and I have both had pretty similar experiences that we didn't have much exposure to these simulators. Your study has found that there are some good correlations with the actual performance of hip arthroscopy if you base it on novice versus more experienced surgeons. So, do you think that you and I were at a disadvantage? I mean, is this something that we should be incorporating into our training education going forward?
Dr. Bishop: I don't necessarily think we were at a disadvantage, but I do think there are great benefits to be able to incorporate this into training, especially early training for our first- and second-year residents that are learning arthroscopy and probably not getting those repetitions in the OR as much as they would like. I think the benefits of these are really just to learn the basics of hip arthroscopy.
Like I said, what portals to use, what instruments to use, triangulation, learning the anatomy, those are, I think, the biggest benefits. Really for experts, in more complex procedures, something like labral repair, things like that, I don't know that we're there yet with the simulators. But I think that for the early education and basic skills, that the simulators can be a really good benefit to resident education at this point.
I think that the eventual goal will be able to come up with curriculum using these, and then potentially translate these skills from the simulators to the OR. So, I'm sure there probably are some people that are out there doing that, but I think that's kind of the next steps.
Dr. Spiker: Yeah, that's great foresight, and I think that your study really helps build that foundation, being able to say that you've noticed these differences, that there are quantitative measures, like the total simulator score and the ASSET score, that can be used. So, I think that's definitely a step in the right direction.
And I think you're spot on with those junior residents, especially. When it comes to arthroscopy, as you know, there's really only one person who can be holding the scope at one time. And so, unlike learning open procedures it is a much longer process to become adept at working the scope, because they just get less hands-on time in the operating room when there's an attending who is actually operating the scope as well.
Dr. Bishop: For sure.
Dr. Spiker: So, you mentioned a little bit about next directions, but based on your experience and your findings with this study, what would you be most interested in studying next, related to the VR simulator, and either hip arthroscopy or in arthroscopy in general? What do you think we should study in relation to how we can better integrate this into education, in especially those junior residents and early trainees, as you were mentioning earlier?
Dr. Bishop: Yeah. I think that we should try to come up with a potential learning curriculum using these, using the simulator itself, kind of putting it into practice. And then we can compare this to cadaveric skills lab, and seeing how trainees do that have learned on a cadaver versus learned on a simulator, and putting those actually into practice, so then we can kind of validate that the simulators are just as good, if not better.
I think that would be a useful thing. Or even just comparing. Getting actual people that got a simulator curriculum, and get them to the OR, and seeing how it translates. I think those are the next steps, but we need to come up with that curriculum and be able to get those resources to be able to do those studies.
Dr. Spiker: Yeah, that's great. Well, thank you so much, Dr. Bishop, for sharing your thoughts with us today. It's really been a pleasure to speak with you, and I'm really looking forward to finding out more about these VR simulators and hopefully integrating them into our practices and our education. So, thank you again.
Dr. Bishop: Thanks for having me, Andrea. And just, also, thanks to all my coauthors, I just wanted to say that, on all the work on this paper as well.
Dr. Spiker: Dr. Bishop's paper, titled The Arthroscopic Surgery Skill Evaluation Tool Global Rating Scale is a Valid and Reliable Adjunct Measure of Performance on a Virtual Reality Simulator for Hip Arthroscopy, can be found in the June, 2021 issue of Arthroscopy Journal, or online at www.arthroscopyjournal.org. This concludes our episode of the Arthroscopy Journal podcast. Thank you very much for joining us.
The views expressed in this podcast do not necessarily represent the views of the Arthroscopy Association or the Arthroscopy Journal.