The New Normal of Surgical Interaction Post-Pandemic: Virtual Proctoring and Remote Training Poised for Growth

Before the COVID-19 public health crisis, momentum was already building to transform operating rooms into digitally connected environments where surgeons could collaborate and medical device companies could share best practices and products. Over the past year, social distancing mandates have further accelerated these efforts, leading to widespread adoption of virtual reality and remote training technologies.

The value proposition of connected surgical care—accessibility, efficiency, and affordability—is making virtual proctoring and training poised to become the "new normal" for surgical interactions post-pandemic, a trend experts predict will continue.

Compared to the virtual collaboration that emerged out of necessity in 2020, traditional in-person observation and proctoring is a resource-intensive task for medical technology companies, involving travel costs and personnel logistics. Flexibility and scalability are two advantages offered by virtual surgical guidance technology. Meanwhile, the sense of personal connection that comes with in-person work may be lacking in a virtual environment.

Although the digitalization of the operating room environment was previously thought to take five to ten years, the challenges posed by the pandemic in connecting experts have created a demand for faster digitalization of surgery.

Nadine Hachach-Haram, CEO of tech startup Proximie, says one of the challenges of virtual surgical collaboration is that operating rooms have traditionally been "inherently analog environments" that are not digitalized or data-driven. Hachach-Haram, a reconstructive plastic surgeon, said, "Imagine if we could digitalize the operating room and connect every operating room," allowing surgeons to collaborate and medical device companies to share best practices. "Getting these teams to work together is a multidimensional and experiential immersive interaction. For complex cases, having a proctor virtually present is significant."

Proximie is a platform that leverages artificial intelligence, machine learning, and augmented reality, enabling clinicians to "virtually scrub in" to any operating room or catheterization lab from anywhere in the world. The London-based company is building a global network of operating rooms and other clinical environments so that every interaction can be captured, digitalized, cataloged, and analyzed.

Houston-based orthopedic surgeon Stefan Kreuzer is actively involved in surgical training and uses the Proximie platform. An expert in robotic joint replacement surgery, Kreuzer praised the technology's high-quality real-time video transmission, which allows him to interact in real time with surgeons, engineers, and device developers. Kreuzer said, "We expose other surgeons to new device technology, and they can observe and ask questions." He has been part of the development team for Stryker's Mako robotic system (used for anterior hip replacement and total knee replacement). "In the past, they would fly to Houston, scrub in, observe the next day, and then fly back. Now, with this platform, we can do it all virtually."

Kreuzer is currently involved in multiple design teams for next-generation knee and hip implants, serving as a consultant to several medical device companies, and also uses the technology as a product development tool to connect virtually with engineers around the world. He added, "Engineers from Boston and London are observing surgeries and communicating with me. They can be virtually with me in Houston, get feedback, and then go back to the drawing board to adjust plans as part of the device development cycle."

Due to pandemic travel restrictions, demand for such virtual technologies has grown exponentially. Proximie has seen usage increase by more than 400% in the past few months. During the pandemic over the past year, Proximie has facilitated more than 10,000 surgical interactions across 300 hospitals in over 40 countries, and has enabled medical technology companies such as Johnson & Johnson, Medtronic, and Stryker to have their proctors enter operating rooms to assist surgeons with their products.

Hachach-Haram said, "Our platform enables (medical technology companies) to have their expert physicians and representatives dial into operating rooms, stay closely connected with surgeons, and support them during this challenging time. We have also been able to enable the transfer of expertise from one catheterization lab to another."

Another startup, ExplORer Surgical, offers intraoperative case support and workflow platforms including remote proctoring. The company said it added more than 10 medical device clients in the first quarter, a company record. Robert Stineman, Vice President of Operations at ExplORer, said in a statement that the record quarter "validates the critical need for technology like ours as healthcare shifts toward virtualization."

Abbott Laboratories is combining virtual reality with traditional training techniques to give physicians a complete experience of being in a catheterization lab. In December, Abbott launched its first virtual reality-based training program for interventional cardiologists, using optical coherence tomography imaging technology that allows physicians to view and assess coronary arteries from inside the vessel.

The medical technology company claims that its OCT intracoronary imaging platform, which uses the Oculus Go virtual reality headset, is helping physicians make better decisions in the catheterization lab and improve the quality of stent placement in patients with arterial blockages. Nick West, Chief Medical Officer of Abbott's vascular business, said, "It is used to help physicians understand the nature of the stenosis being treated and the size of the vessel to achieve more accurate and appropriate treatment and stent sizing." He added that the technology is also used after stent placement to ensure it is well positioned.

West noted that data released by Abbott in 2020 showed that after using OCT imaging, physicians changed their treatment decisions in 88% of coronary blockage cases. In terms of post-stent placement, physicians in the study changed their treatment of 31% of lesions based on information provided by OCT, to address arterial damage that was previously invisible with angiography alone (which provides a two-dimensional view of a three-dimensional structure). According to West, compared to standard angiography, OCT-guided percutaneous coronary intervention improved procedural outcomes by better helping to determine stent size and optimize placement. Nevertheless, he noted that currently about 10% of PCI procedures in Europe and 20% in the United States use OCT rather than traditional angiography, while in Japan that number jumps to 90%.

Abbott's LightLab Initiative in the United States is a company effort to integrate OCT imaging into the PCI workflow, aiming to get clinicians to use the technology. West acknowledged, "There are various barriers to adoption, one of which is training." However, he believes virtual reality training can increase learning engagement and knowledge retention among catheterization lab staff, while also enabling those trained in VR to achieve higher medical accuracy in practice. During the COVID-19 public health crisis, in-person training has become impossible, but Abbott's VR-based program offers a remote alternative.

West said, "The idea of remote proctoring existed before the pandemic. The pandemic just accelerated the program because there was suddenly an unmet training need." However, in the post-pandemic future, West believes virtual proctoring and virtual training will become the "new normal" because they are far more efficient than traditional techniques. He argued that augmented reality and virtual reality technologies now enable healthcare professionals to virtually scrub in, collaborate, mentor, and coach each other during surgeries or hands-on medical education, and medical technology proctors can remotely assist surgeons in the operating room.

Before the pandemic, New York City's Mount Sinai Health System began using a head-mounted display VR application for advanced cardiac life support training in mid-2019. ACLS is aimed at healthcare professionals from multidisciplinary and specialty fields involved in the management of cardiac arrest and other cardiovascular emergencies. According to Daniel Katz, Vice Chair of Education in the Department of Anesthesiology, Pain, and Perioperative Medicine at Mount Sinai, virtual reality is more operationally cost-effective and time-efficient in educational efficiency compared to high-fidelity mannequin-based simulation. Katz said, "As VR gains more mainstream traction, its role in medicine will continue to expand. The applications go far beyond the basics of medical education. As the technology becomes more efficient and cheaper, it will take off. Physicians tend to be a very tech-savvy group."

Proximie's Hachach-Haram believes the COVID-19 pandemic has permanently changed medical practice, including the adoption of telemedicine and virtual care. She said, "We are not going back to the way things were."

Remote technology in the operating room is not slowing down. Intuitive Surgical CEO Gary Guthart said on an earnings call last month that the company's "telepresence program" supported 45% of all case observations in the first quarter, compared to less than 5% a year earlier. Guthart called it "a significant achievement accelerated by the pandemic, improving customer convenience and reducing costs for our team." Additionally, the CEO noted that surgical simulation usage increased approximately 46% year-over-year in the quarter, "validating the power of digital tools."