When I finished my orthopedic residency, I thought I was ready. I had awards, published a few papers, passed my exams and had a logbook full of cases I had “done”. I realized that there were many procedures I only partially performed or realized I did many of the non-critical steps of the case. But when I stepped into the OR on my own, it hit me like a tonne of bricks. There were plenty of cases I didn’t do, an assist who wanted me to tell them what to do and a patient who entrusted me with their care. Those 5 years in residency flew by and it may not have fully prepared me for the real world. That was 2003.
Residency today? It’s a whole new ballgame. Work hour restrictions, more complex cases, less autonomy in the OR and the move to high-efficiency surgery centers have created challenges I didn’t have to face. And yet, the pressure to perform hasn’t eased. In fact, it’s harder now to get the experience you need in the time you have.
So, here’s the question: how do you maximize your training when the odds feel stacked against you? The answer might be that one needs a VR strategy. Here’s why it could change everything for orthopedic residents and their training experience.
1. You Only Get One Shot in the OR
The OR is not the place to “figure it out.” Mistakes aren’t tolerated, and you rarely get a chance to retry. Picture this: the attending hands you an instrument. You either know how to use it, or you don’t. And if you don’t, there’s no time for fiddling or learning on the spot.
This is where VR shines. You can walk through the steps, handle the instruments, and make sure your muscle memory kicks in when it matters most. When I first held an arthroscope, I couldn’t triangulate quickly (milliseconds), that was not only frustrating for me, but my attending and impacted the case. Being able to practice those skills on my own with VR would have allowed me to step into the OR with the skills to progress.
2. You’re Working With Less Time
Work hour restrictions for training were necessary and important (some may disagree) but that is our world today. If I started work at 6am on Monday, I wouldn’t go home until Tuesday night at 6PM. Those days are over. I remember falling asleep once while I was dictating a note I was so tired. To preserve mental and physical health, the restrictions have (by my calculation) removed approximately 5,000 clinical hours from residency. That’s equivalent to losing an entire year of hands-on experience. And while residencies have adjusted, it doesn’t change the fact that one is being asked to learn what used to be perhaps six years of skills (i.e.. a 5 year residency with insane hours) in what now may be four years stretched into five.
So, how do you fill the gap? You can’t control how many cases you’ll get, but you can control how prepared you are for every single one of them. Given one can’t increase their clinical hours, the only option is to maximize the time you do have. With VR, you’re not waiting for opportunities to land—you’re creating them for yourself and setting yourself up to maximize your time in the OR.
3. Surgeons Are Busier Than Ever
The OR today is about efficiency. It certainly was as well when I was a resident, but this seems like a whole new world. Surgeons are juggling packed caseloads and administrative work, and teaching moments can feel rushed or secondary. What’s even worse is imagine that every year you are a practicing surgeon, the same case you did last year, is being reimbursed less the year after? I’ve been in cases where the attending wanted to teach but had a long list of cases to get through.
You don’t have to wait for those rare teaching moments. VR allows you to practice skills, build your clinical reasoning, and develop your confidence—without slowing anyone down in the OR.
4. The ASC Model
Ambulatory Surgery Centers are here and efficient. I never heard the word “hyper throughput” as a resident. That efficiency comes at a cost. Bread-and-butter cases including many under hip, shoulder, knee, spine, foot and ankle, i.e. the ones you need to master, are now being done with an accelerated efficiency in ASCs. Twelve to twenty cases in a day make it challenging to teach. I see that in my own practice now and it’s tough to teach in those moments. Teaching in an ASC is analogous to changing the tires on a moving car or worse, think of an F1 pitstop.
VR bridges that gap. It’s your chance to get hands-on practice in a low-pressure environment, preparing you for the high-efficiency settings you’ll face both as a resident, fellow and ultimately an attending surgeon.
5. Complex Cases Are the New Normal
As ASC’s take on the common cases, the cases left in hospitals are no longer routine—they’re complex, high-risk, and often require advanced skills. Revision surgery is not decreasing (in general). If you’re not ready for those, or are struggling with the basics, those cases are not only hard to understand, but it’s also challenging to contribute meaningfully and extract valuable learning. VR gives you the chance to build a solid foundation of basic skills so you can extract more from the complex ones.
6. Mistakes Belong in Practice, Not in the OR
We all know mistakes are a crucial part of learning, but the risk of performing them in the OR is too great (and frankly not allowed). Think back to when you did something “wrong” in the OR as a resident (I can). It never ends well, and you wish you could go back. VR gives you that space. Make the mistakes, learn from them, and go back to practice again and again until you get it right.
7. Don’t Rely on Fellowship to Fix This
A lot of people (including myself) thought fellowship will fill in the gaps, but here’s the truth: fellowships are just as fast paced as residency (maybe even faster) and the expectation is that you already have a solid foundation. Your residency is the foundation, and fellowship is like putting gas on your technical skills. It’s challenging if you are catching up and can impact your experience when one should be mastering subspecialty skills. Maximizing your time as a resident can allow one to get ahead now, so you can thrive later.
8. Master Your Anatomy
This is a big one. From medical school, anatomy has become less and less of a priority (at least that’s what I’ve seen). Cadavers are more expensive and it’s a focus only in year 1. As a surgeon, these are the A,B,Cs of surgery. The number one foundation of a career in orthopedics. Knowing anatomy isn’t just about memorizing the innervation of muscles—it’s about truly understanding how structures relate to each other in 3D. When you know the anatomy, you’re not second-guessing yourself in the OR. You’re confident, precise, and focused and it impacts where you put retractors and make incisions. Imagine having your own virtual 3D cadaver? That’s possible now with VR.
9. Trust Is Earned, Not Given
This is a big one. Why is the attending going to pass me the knife? Well, they need to trust that I’m ready. Performing a physical skill should be preceded by practicing a physical skill. The analogy of shooting free throws before the game is a very akin to this. Imagine walking into a hip scope case having practiced hip arthroscopy the night before or the morning of? Same thing for a knee replacement, shoulder or placing in pedicle screws. Maybe even a fracture? VR affords one to do unlimited reps, practice triangulation, take 100s of C-arm images with no risk and hone in on the principles you need to prove yourself. When you’re confident, they’ll be confident.
10. Think Differently About Your Career—Because the System Demands It
The race is no longer about running 26.2 miles on a clear course (in fact it never has been). Today however, there are clear and visible obstacles —mud pits, walls to climb, and unpredictable turns. It’s important to adjust and thrive in the new environment
That’s exactly where we are in orthopedic residency training (I hope someone will disagree). The educational environment has changed. Work hour restrictions, high-efficiency surgery centers, lack of independent surgery and volume of complex cases have rewritten the rulebook.
Preparation and Trust: Lessons From My Mentor
One of my mentors once told me during a case, “Danny, I’ll be the best surgical assist you’ll ever have.” And you know what? They were right. But looking back, I realize that probably wasn’t great for my learning. I didn’t need them to be the best—I needed them to let me drive the bus. I needed to struggle, to make decisions, and to build my independence. But the system didn’t allow for that kind of freedom (in fact it never will as there is too much at stake). So, while I missed out on some critical opportunities to grow, it’s the system we live in for patient safety.
That lesson has stuck with me ever since. It’s a reminder that preparation and trust go hand in hand. When you’re prepared, people trust you to step up. And when you step up, you take control—not just of your training, but of your career.
The System Has Changed, and So Must You
Residency isn’t what it used to be and it’s not just a phase—it’s the foundation of your career but the hours are fewer, the OR time is more competitive, and the cases are more complex. But at the end of the day, this is your career, and I realized that no one is going to hand me the skills or the confidence to succeed in the OR. One must take ownership of one’s training and adapt to this new environment. That means thinking differently, practicing smarter, and finding ways to prepare yourself outside of the OR.
This isn’t just about surviving residency—it’s about building the foundation for the surgeon you’ll become. When you take control of your learning, you don’t just sleep better at night—when it’s all said and done and you are in your own OR, your team and importantly your patients will need you to be.
–Don’t leave your future to chance—Join the hundreds of residents who are investing in themselves, their skills, and ultimately the care they will provide for their patients.
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