For anyone pursuing a career in medicine, surgery is one of the most challenging paths to follow – and one of the most important to get right. Especially today, with so many new procedures to master, surgeons need to practice and practice again before they can meet the necessary standard.
In recent years, a solution has emerged that could greatly improve surgical training. Taking their cues from the aviation industry, where flight simulators are the norm, hospitals have begun to introduce simulators for trainee surgeons. This allows them to learn new skills, ask ‘what if’ questions and make mistakes, without posing any risk to patient safety.
However, the quality of the training here is only ever on a par with the quality of the simulator. While it may help boost their skills, a low-fidelity simulator is unlikely to prepare the surgeon for what it’s really like in the operating room. On top of that, many simulators come at an exorbitant cost, and can only model a single type of surgery.
A flight simulator for surgery
Medical start-up FundamentalVR is looking to change that picture. With the aim of delivering a ‘flight simulator for surgery’, the company develops software suitable for use on any off-the-shelf, virtual reality (VR)-enabled hardware. It combines VR with haptic feedback. This means that, as users interact with the virtual patient, they receive the same tactile cues they would during a real procedure.
“Surgical simulators are normally pretty bespoke and probably cost £100,000, with an ongoing cost every year of £20,000 or £30,000 to maintain,” says Richard Vincent, CEO and co-founder of FundamentalVR. “Our equipment is about a tenth of that cost to acquire, and we want it to sit within the department, because we think simulation and practice and rehearsal should be a daily event.”
The system is a software as a service (SaaS) based model, which can be used on an ongoing basis once a hospital client has bought a license. Each user gets their own unique data dashboard, and can log in whenever they like.
“I’m always delighted when I see log-in data showing someone using the system in the middle of the night,” says Vincent. “The suggestion is they’re in between operations and they’ve used an hour or two of downtime to refine their skills.”
The company also works with medical device manufacturers and pharma companies to support their own training requirements.
The road to success
Vincent founded the company around five years ago, together with his partner Chris Scattergood. Since both are technologists by background, they assembled an expert panel of surgeons to guide the company’s direction.
“They help us decide where should we be going and what are the future directions of surgery,” says Vincent. “And when we need to simulate a procedure in a particular discipline, we have at least one expert who’s doing that on a daily basis. We have a really rich and deep seam of medical expertise, which is the starting point for all our development processes.”
Their platform, Fundamental Surgery, was launched in the US in August 2018, and was named one of Time magazine’s best inventions of 2018. It received accreditation from England’s Royal College of Surgeons in April 2019, and has since been deployed by a number of NHS hospitals.
In October 2019, the company announced it had closed a €5m (£4.3m) series A funding round, with backing from venture capitalists and medical institutions. This included Downing Ventures, EPIC Private Equity and Brighteyes Ventures on the venture capital side, along with the Mayo Clinic and SanaKliniken (the third largest hospital network in Germany) on the medical side.
“The VC money helps us with our next stage of growth as a technology business, and the institutional medical money gives us much more than just the investment,” says Vincent. “It gives us their expertise and infrastructure in those countries. The US is our primary market, and we want to expand there, as well as building out into Germany and a few other markets.”
The thinking behind haptics
It’s easy to see why haptic feedback would be so useful for trainee surgeons. For one thing, it dramatically boosts the fidelity of the experience. For another thing, it is likely to lead to improvements in accuracy. In a recent meta-analysis of the evidence, the validation for using haptics seemed clear: six out of nine studies showed that tactile feedback significantly improved surgical skill training.
“With haptics as part of the training experience you see about a 30% increase in the speed of skills acquisition and up to a 95% increase in accuracy,” says Vincent. “It’s essential to know what it feels like when you push too far or you don’t push enough, or you cut in the wrong way. What we also see is it lowers the trainee surgeon’s cognitive load because by using your motor skills, you’re activating different parts of your brain.”
All this said, he doesn’t believe haptics need to be there every time – especially not at the cost of accessibility. The team is now building out its technology so that it’s compatible for use with standalone, low-cost devices. This means you could access the platform at home on a system like the Oculus Quest.
“This doesn’t deliver the same level of haptic learning, but what it does develop is convenience,” says Vincent. “It’s a modality you can use in your downtime, before you go onto the haptic system. So it’s a cross-modality education system, and however you access it, it’s got a rich data pool allowing you to see exactly where you might improve your knowledge or skills.”
Practice makes perfect
With their recent funding round, FundamentalVR will be able to funnel additional investment into the platform, boosting its capabilities from a technological perspective. They are also looking to move into new areas of surgery.
“At the moment we’re very much in the orthopaedic, spine and joint space, but this investment will allow us to move into general surgery,” says Vincent. “We’re doing a lot work around creating haptic actions within a soft tissue environment. We’re also working on quite a lot of ophthalmology procedures, which is exciting for us because it’s the first area where we can easily transition into some of the less developed markets.”
Regarding the latter, the company has partnered with the eye charity ORBIS International to develop a training platform for ophthalmology students. This will benefit doctors in places where standard simulators are too unwieldy or expensive to be deployed.
“Orbis specialises in doing things like cataract removal in developing countries,” says Vincent. “Now our systems are going with them to train surgeons so they can leave those skills behind.”
Although it’s early days for Fundamental Surgery, it’s clear that the platform has disruptive potential. Low-cost, high-fidelity surgical simulations could soon be an everyday event.
“We think this is a dramatically different way of learning, and the driver behind that is practice makes perfect,” says Vincent. “The more your rehearse your skills, the more competent and confident you become.”