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From Fighter Jets to Forceps: The Science of Learning Under Stress

As we seek to reduce both risk and cost of surgical training, VR may offer an innovative solution.
Published June 13, 2019

Claudette Lajam, M.D., Langone Health

Read the full article here.

Colonel John Boyd (1927-1997) was the fighter pilot who “changed the art of war” (Coram). Col. Boyd flew the F-86 Sabre and commanded a fighter group during the Korean War. He was a USAF Weapons School instructor and wrote the school’s tactics manual. In an effort to improve his students’ tactical decision-making, he developed the O.O.D.A. – Observe, Orient, Decide, Act – concept (Figure 1). The pilot who moves through the OODA loop faster would gain the tactical advantage in combat.

Combat situations are rare and not reproducible. Pilots could study accounts of air combat missions, could learn how to operate the aircraft, and could participate in air combat training exercises. These exercises are high cost and high risk to pilots and equipment. Flight Simulation existed in some form as early as the 1980’s. As technology improved, Virtual Reality (VR) offered a true 3-D immersion with haptics and thus a very real combat environment in which the pilot-in-training could improve motor skills, decision-making, and reaction time.

OODA in Surgery

OODA is not only for pilots. Any high-stress situation during which decisions must be made quickly, and where decisions must lead quickly to action, can employ OODA as a teaching strategy. Surgical training has a lot in common with flight training. Surgeons must employ quick decision-making with technical skills, often under stress, in order to effectively perform their work. During surgery, the surgeon goes through the Observe-Orient-Decide-Act sequence thousands of times. Each surgery and each step of a procedure requires different reactions and actions.

Elements of Procedural Learning

Motor sequence learning is complex. The primary motor cortex, the parietal lobe, and the angular gyrus are all involved in sequence learning (Rosenthal et al). Further, complex sequence learning involves motor, visual, and spatial elements (Rosenthal 2, et al). Motor memory of limb, core, and eye movement all contribute to learning development of tools which engage all elements of learning is ideal.Haptic motor feedback engages the motor cortex and improves motor learning. Virtual Reality, a collection of technologies that allow humans to interact in 3-D with computer databases in real time using their visual, motor, and deductive skills, may satisfy these learning elements with less risk, less cost, and with unlimited reproducibility.
Surgical trainees may be able to master the technical skills required to perform a surgery, but lack the ability to make decisions based on visual and haptic feedback. The use of a system which provides this feedback — and where both skill and decision making can be measured and repeated– could enhance current models of surgical training.


Combat situations are rare, so simulation gives the opportunity to practice without the danger of true combat. Danger exists not only for the pilot, but for other pilots who participate in live training exercises. When the surgeon must learn on a live person, there is theoretical increased risk to the patient. The goal for surgical training would be to improve both deductive and technical skills without placing live patients at risk for harm.


In most surgical residency programs, this is achieved through graduated responsibility (Teman, et al). However, some trainees require many more repetitions before autonomy, and others may never reach autonomy because of patient safety concerns. VR allows trainees to repeat procedures or certain steps of a procedure without the need for real patients. The user can examine and improve performance with repetition while minimizing harm.

Learning occurs not only during surgical training, but throughout the surgeon’s career. New approaches and technologies must be learned by the practicing surgeon. VR allows surgeons to train with new technology and on new approaches without risk of harm to live patients.


Like military training, surgical training is resource-intensive. It is a challenge to find live patients with suitable pathology for practice, especially for rare or complex conditions. Current increased focus on hospital costs and surgical efficiency are barriers to surgical trainees’ achieving autonomy during training with a graduated responsibility model. Surgical training on cadavers, especially in fields like orthopedics, where implants are costly, is equally restrictive. The development of affordable VR interfaces can allow surgeons to perform, analyze, and repeat a variety of procedures with a range of complexity. One simulator can serve many trainees, and can present and repeat many clinical situations.

Further, VR gives surgical training programs the ability to assess trainees’ skills in a consistent environment. VR programs may be adapted to measure trainees’ performance – which can be compared with prior training sessions and can help hone motor and deductive skill. VR can also document performance to satisfy training oversight agencies.

Consider other technological advancements, such as surgical navigation and robotics. A substantial cost for these products lies in the human capital required to sell and teach them to the surgeon. These, too, can be integrated into VR learning modules. VR can be used to teach trainees and practicing surgeons to use new technology without waste of costly implants and systems, and without the use of live sales representatives.

Value-based Care

Value is calculated as Quality/Cost. Assuming new technology increases both quality and cost, institutions rely on the Incremental Cost Effectiveness Ratio (ICER). This looks at the cost and effectiveness of the intervention with and without the new element. If we consider the cost of training in surgery with live patients or on cadavers, the cost of VR learning is minimal, with similar or increased learning potential.


As we seek to reduce both risk and cost of surgical training, VR may offer an innovative solution. Partnership between surgical training programs and Virtual Reality training companies will allow this technology to realize its potential to optimize both technical and deductive learning for the complex art of surgery.

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