Published 4/26/2024
Tyler Madden, MD; Karl Roberts, MD, FAAOS, FAOA

See One, Simulate One, Do One, Teach One

Technology continues to be a driving factor in transforming resident surgical education

Over the past two centuries, surgical education has dramatically changed. Prior to the 1800s, aspiring surgeons were trained with the same methods as any tradesman of the time—through apprenticeships. Often beginning at age 12 and continuing for as long as 7 years, surgeon trainees could expect to learn through direct observation and imitation of their mentors with the option to pursue a fellowship, or “journeymanship,” for further training.

Unregulated and disorganized compared with today’s standards, this process was the predominant method for surgical training until the pivotal work of William Halstead, MD, at the turn of the 20th century at Johns Hopkins Hospital. Influenced by Germanic surgical training philosophy, which incorporated a regimented curriculum, scientific discovery, and graduated responsibility, Dr. Halstead’s surgical principles have become the foundation of surgical residencies. His famous adage of “see one, do one, teach one” emphasizes the competency-based requirements expected of a proficient surgeon.

Many argue that this method of teaching is no longer relevant due to concerns for patient safety, largely due to an inability for residents to adequately perform an operation after seeing it only once. Combining this concern with growing healthcare quality–based initiatives that emphasize surgical efficiency, safety, timeliness, and cost, the important question becomes: How will surgical residency training continue to adapt?

It is important to acknowledge the expansive opportunities offered by technology and simulations. At one end of the spectrum are low-fidelity simulators, which function to help trainees develop fundamental motor skills and incorporate elements that may be adapted in multiple surgical environments. This modality relies on educational theory in which level of fidelity is less impactful on a novice learner. The benefits include lower cost and accessibility. In a 2015 AAOS exhibit selection published in the Journal of Bone and Joint Surgery, Lopez et al showcased the Fundamentals of Orthopaedic Surgery board. For $350, supplies that may be found at a local hardware store can be used to develop psychomotor skills that translate to the OR.

Other modalities include higher-fidelity surgical simulators, which provide realistic anatomy and tactile feedback, as well the ability to explore complication management. Melcher et al used entirely synthetic models, which included anatomic structures such as paraspinal muscles, ligamentum flavum, and dura, to improve surgical metrics of trainees for minimally invasive unilateral laminotomy for bilateral decompression for lumbar stenosis. The unique benefit of these surgical simulators is the ability to practice nuances of different surgical approaches and mindful handling of soft tissues to potentially minimize wound complications. However, increased simulator authenticity can lead to increased cost, totaling more than $1,000 for some models.

Over recent years, more studies exploring virtual reality (VR) and augmented reality (AR) have emerged and shown the technologies to be uniquely beneficial in orthopaedic surgical training. VR and AR use 3D imaging through a head-mounted display to create interactive environments, with a wide range of uses. VR is a completely immersive experience that replaces OR and hardware with entirely virtual images, whereas AR relies more on holograms that augment surroundings and allow for authentic tactile feedback.

VR platforms in particular have been used more frequently in orthopaedic training programs recently. This technology offers a safe and accessible platform to develop surgical skills, with potential benefits for patient safety. By using VR, residents can expect to learn the individual steps and sequences of various surgeries. This tool allows residents to develop critical skills from surgical planning and execution to the nuances of hardware implantation.

Applications continue to expand from arthroscopy to arthroplasty, with several studies demonstrating VR-trained residents outperforming conventionally trained residents in metrics such as improved instrument handling, less guidance from instructors, and less overall time in procedure-based assessments. One of the unique benefits of VR is its portability, giving trainees the ability to develop surgical skills in any location. No other equipment is required, and VR platforms have developed instructional modules to walk anyone through the steps of several different surgeries. One of the other unique benefits of VR is the ability to measure competency in real time and compare one’s skills among other residents and learners across the world.

The technology is not without limitations, and VR does not replace the educational value of real surgery and real-time feedback from mentors in person. Limitations include imperfect tactile feedback, costly implementation of programs and headsets, restriction to only certain procedures, and little virtual simulation incorporating surgical skills with an intraoperative team. Still, VR can help fill an educational void regarding initial comfort with surgery steps and instrumentation as well as surgical case repetition.

Technology continues to be a driving factor in transforming resident surgical education. With a variety of platforms to explore, there is great potential to improve surgical skills in a safe, efficient, and low-risk environment.

Tyler Madden, MD, is an orthopaedic surgery resident at Corewell–Michigan State University in Grand Rapids, Michigan.

Karl Roberts, MD, FAAOS, FAOA, is the program director for the Corewell Health/Michigan State University orthopaedic surgery residency program, chairman of the AAOS Evidence-Based Quality and Value Committee, clinical advisor in orthopaedics and joint replacement for Corewell Health, and president of West Michigan Orthopaedics.


  1. Matsumoto ED, Hamstra SJ, Radomski SB, et al: The effect of bench model fidelity on endourological skills: a randomized controlled study. J Urol 2002;167(3):1243-7.
  2. Chauvin SW: Applying educational theory to simulation-based training and assessment in surgery. Surg Clin North Am 2015;95(4):695-715.
  3. Lopez G, Wright R, Martin D, et al: A cost-effective junior resident training and assessment simulator for orthopaedic surgical skills via fundamentals of orthopaedic surgery: AAOS exhibit selection. J Bone Joint Surg Am 2015;97(8):659-66.
  4. Melcher C, Hussain I, Kirnaz S, et al: Use of a high-fidelity training simulator for minimally invasive lumbar decompression increases working knowledge and technical skills among orthopedic and neurosurgical trainees. Global Spine J 2022;21925682221076044.
  5. Hasan LK, Haratian A, Kim M, et al: Virtual reality in orthopedic surgery training. Adv Med Educ Pract 2021;12:1295-1301.
  6. Walbron P, Common H, Thomazeau H, et al: Virtual reality simulator improves the acquisition of basic arthroscopy skills in first-year orthopedic surgery residents. Orthop Traumatol Surg Res 2020;106(4):717-24.
  7. Hooper J, Tsiridis E, Feng JE, et al: Virtual reality simulation facilitates resident training in total hip arthroplasty: a randomized controlled trial. J Arthroplasty 2019;34(10):2278-83.
  8. Logishetty K, Rudran B, Cobb JP: Virtual reality training improves trainee performance in total hip arthroplasty: a randomized controlled trial. Bone Joint J 2019;101-b(12):1585-92.