Why the surgical backlog starts with how surgeons are trained [PODCAST]

Listen and followApple PodcastsSpotifyYouTubeMore apps · Browse all episodes

Surgical training still runs on the model it did decades ago. Everything around it has changed. Danny Goel walks you through what that mismatch costs. He is an orthopedic surgeon, and this episode is based on his article “In 2026, the surgical backlog has a training bottleneck,” published on KevinMD. You will hear why he counts surgeons themselves as a constraint on capacity, alongside operating rooms, beds, and funding, once residents have shorter hours in the hospital, operating rooms are under pressure to be efficient, and cases move to outpatient centers. He explains why cadaver labs, single-purpose simulators, and industry-funded courses have not closed the gap, and why graduates now add fellowship years on top of residency. He describes the simulation company he co-founded, which puts residents in a virtual operating room where mistakes carry no cost. He also tells patients exactly what to ask a surgeon. Stay to the end for his warning that exposure is not competence.

This episode is brought to you by ModMed.

Welcome to your new AI-Powered Practice from ModMed. We’re transforming specialty care by embedding AI Assistants across your entire workflow. Our all-in-one platform of EHR, patient engagement, practice management, and RCM helps reduce repetitive work while keeping you firmly in control.

Trained on de-identified data from nearly a billion patient encounters, this isn’t just smarter software. It’s a new way of working for specialty medicine, more efficient and more connected to the patient experience.

Start building your AI-Powered Practice at modmed.com.

VISIT SPONSOR → https://www.modmed.com/

SUBSCRIBE TO THE PODCAST → https://www.kevinmd.com/podcast

Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Danny Goel. He’s an orthopedic surgeon in Canada. Today’s KevinMD article is “In 2026, the surgical backlog has a training bottleneck.” Danny, welcome to the show.

Danny Goel: Kevin, thank you for having me. It’s a pleasure to be here.

Kevin Pho: All right. Let’s start by briefly sharing your story, and then we’ll jump right into your KevinMD article.

Danny Goel: Great. Kevin, again, thanks for having me. As mentioned, I’m an orthopedic surgeon, and I practice in Vancouver, Canada. My area of interest is the shoulder specifically, as a specialized orthopedic surgeon. I’ve spent a lot of my career thinking about surgical education and how we prepare the next generation of surgeons.

When I trained, we had a lot of time in the operating room, and the model was apprenticeship-based, which it continues to be. You learned by reading, observing, and then eventually doing procedures, all under the auspices of a mentor who spent time with you. That model really hasn’t changed in all those years, but the system around the trainee has. It’s not something we talk about enough, and I think that’s part of why we wrote the article.

Over the course of my career, which has been about sixteen years, I’ve watched residents get fewer duty hours, meaning they’re spending less time in the hospital. The operating rooms are under tremendous pressure to be efficient, which is actually excellent for patient care. And many procedures, including those in my own practice, have moved into outpatient surgical centers, also referred to as ambulatory surgical centers.

Historically, the model relied on experienced surgeons teaching and training the young surgeons, but their practices have evolved over time as well. As I mentioned before, none of those changes are wrong. It’s just that there’s a consequence to them that we should talk more about, and that is that the fundamental system the model was built on for teaching and training residents is no longer the same.

Kevin Pho: All right. So your article is titled “In 2026, the surgical backlog has a training bottleneck.” You’re saying that practice has changed, of course, and I’m in primary care, where it’s changed for us as well. But the surgical education model hasn’t really evolved or adapted to these changes. Tell us more about some of those consequences, and about the article itself for those who didn’t read it.

Danny Goel: The article really came together from something I was seeing clinically and also hearing from my colleagues in educational facilities and academic medical centers, and it’s mostly about surgical capacity. We tend to think of capacity in terms of operating rooms, nurses, beds, and funding, and those are really, really important, don’t get me wrong. But there’s another capacity constraint that sits upstream of all that, which is the surgeons themselves.

As you know, it takes years to train and build a competent, skilled physician, and a surgeon specifically. The time it takes to become truly comfortable in the operating room and to work there independently is also a health capacity issue.

What struck me, and this is why we put the article together, is that we’re asking a training system designed for a different era to produce surgeons for today’s environment. That’s the really important part, because we still count cases for trainees, we still measure time in training, and we rely heavily on knowledge examinations and subjective assessments. Those things have value, but none of them really answers the question: Is this surgeon ready for independent, safe practice?

Kevin Pho: And one of the things you bring up, of course, is the duty hour restrictions, the eighty hours a resident is allowed to practice in a hospital. Specifically, how are those duty hour restrictions affecting residents’ surgical experience?

Danny Goel: Importantly, they’re a really important constraint that preserves a resident’s mental and physical health. I don’t think that should be undermined. In fact, it should be highlighted that the reason for these limits was to preserve residents’ general health.

How it manifests, though, is this: If I have only a certain amount of time in the hospital, the time I’m spending in the operating room or the procedure room is de facto reduced, because the one thing that hasn’t changed is the service I have to provide as part of my training. I still have to round, I still have to go to the emergency room to see patients, I still have to write notes, and I still have to take call. So while the service component hasn’t changed, the part that really gets constrained is my time in the operating room. That’s how the reduction in clinical hours directly manifests.

Kevin Pho: I’m sure this has been an ongoing issue for decades now. Tell us what has been tried historically to alleviate some of this experience backlog due to the restrictions in hours. What has been tried in the past?

Danny Goel: Well, there are things we do that create environments for people to practice outside the operating room. Those include cadaver labs, which are an issue on their own because they never really represent what you would see in an operating room. On top of that, cadavers are becoming more scarce, and the cost to procure and use them is becoming prohibitive for many academic medical centers.

The other option is simulators, which are generally very unipolar, meaning they have a specific focus. We’ll have a simulator that does just arthroscopy or laparoscopy, or one that just teaches you fractures. Mostly they’re constrained by access, meaning you can’t use them unless you go to a sim lab. And as you probably remember from residency, the last thing we wanted to do was come back to the hospital after hours to practice a skill we might need in the future.

The other thing that has been tried, and continues to be pushed, is that we rely heavily on the medical device industry, which provides significant value for us. They finance the courses we learn from and bring experts together. But of course, the constraint there is that it’s not scalable, meaning there are many people in the world who just don’t get access to these courses. So while they’re doing their best, those are the things we’ve tried in the past.

Kevin Pho: Now, in your article, you cite a 2026 American College of Surgeons bulletin reporting that senior surgeons believe more than half of their younger colleagues were unprepared for attending roles. In terms of other data, are we seeing poorer surgical outcomes because of this lack of preparation in today’s surgeons? What kind of data do we have to back that up?

Danny Goel: Well, I think it manifests in a couple of different ways. Outcomes are such a hard thing to pin on one particular input, such as technical skill. There are many ways it manifests, and complications show up in both the short and long term. What I can say generally is that if the percentage of complications hasn’t dropped, then by raw numbers that volume is going up, because 3 percent of, say, 100,000 surgeries versus 3 percent of 250,000 surgeries is still significantly higher from a raw number perspective. So I think that’s something to consider.

Now, I don’t have any data to suggest that litigation is going up, but I think it’s a big, big concern for physicians who are training residents in hospitals, because there is, I would say, a general feeling of increased litigation in the world right now. So it’s a tough one to answer whether complications are directly affected by the way surgeons are trained, but the adjacent signals suggest that residents aren’t ready when they graduate.

The second thing I would say is that residents are spending more time in training. Historically, surgeons who graduated after five years of training were ready to go into independent practice. Now everyone is really doing an extra two years of training through fellowships. And then there’s another period of time where they’re still taking on cases, and maybe not getting the challenging cases they once would have after graduation. So I think these metrics of how we evaluate readiness are surfacing in different ways that may not necessarily show up as an immediate bad outcome.

Kevin Pho: Now, for the patients who may be listening to us today, what should they make of all this information? Should they be looking for, and I’m not going to say older, but more seasoned surgeons versus someone who’s younger? How should patients interpret what we’re talking about today?

Danny Goel: I think patients are the primary consumers of their health, and they’re the biggest advocates for themselves. So the way I would interpret this, and how I’d educate them, is that it’s OK to ask your practitioner questions like, “How many of these procedures have you done? What are the bad outcomes you’ve personally had?” Because at the end of the day, our outcomes are our own. If we quote the literature, we’re actually misrepresenting, to some extent, what we’re able to do versus what a high-efficiency center like the Mayo Clinic can do.

So I think it’s important to ask, to be an informed consumer about who your physician is, and to feel free to ask them questions. I think that’s a very reasonable request, the same one we would make of a car mechanic or someone we’re trusting with our finances or our child’s education. The same mentality applies here.

Kevin Pho: Now, you’re also the CEO and co-founder of PrecisionOS Technology, which is an AI immersive medical education company. So I’m interested in hearing about some of the technological solutions you’re bringing to the table to address this issue.

Danny Goel: Yeah. When we look at the problem in more detail, as I mentioned, first, we need a place for trainees to practice outside of the operating room and outside of clinical hours, something that’s accessible and aligned with how this generation expects to access things.

Second, from a performance perspective, if we look at medicine, we’ve been evaluating people subjectively. When someone says, “Kevin, you’re ready to do this procedure,” that has been a purely subjective assessment of your skill. So bringing in something more data-driven is good for you, because you get to see which areas you’re strong and weak in, but it’s also good for me, because it validates my subjective impressions.

The third thing is that education has generally been one size fits all. If you’re a second-year resident, you’re classified as knowing X, Y, and Z because you’re a PGY-2. When you’re a resident in your third year, that volume of knowledge increases. We now have an opportunity with AI and technology to personalize education just for you and just for me. That’s what our software is delivering: accessible, hands-on training that’s data-driven and personalized for you, so you can improve over time and maximize the experience you have when you do go to the operating room.

Kevin Pho: So how does it work in terms of getting this experience outside of the operating room?

Danny Goel: It’s connected to your phone, your mobile device. You ask your AI mentor, which we’ve named Delphi, a question: “I want to practice a shoulder replacement.” The system knows who you are because it has a memory of you. It knows you’re a second-year resident in orthopedics and which rotations you’ve done, and it’ll say, “You’ve done this and this in the past. Here’s a procedure you should do. Here is exactly how you should do it. Here are the skills you should practice. Here’s a video you might watch, and here’s some literature to support what you’re about to do.”

After the phone, you put the VR headset on, and you’re launched directly into an operating room with a virtual cadaver lab and a virtual procedure where you can actually practice a shoulder replacement. What’s really unique is that you preserve your freedom of decision-making, meaning you get to make mistakes in that environment with no consequences. If you put the guide pin in the wrong place, or if you make the wrong cut, that’s OK, but all the data you generate is captured and delivered back to you on your phone.

So it combines a hands-on experience that allows you to make mistakes with analysis of your data, delivered back to you on your mobile device on an ongoing basis, while keeping a memory of you. If I were to summarize it, imagine having your own AI attending with you for the rest of your career, evaluating you, monitoring your performance, and making suggestions on an ongoing basis, in addition to having your own virtual operating room.

Kevin Pho: Now, how immersive is it? When I hear about VR headsets, I think about all the things Mark Zuckerberg has done, and to me the technology isn’t quite there yet. So tell me how immersive it is, and as a shoulder specialist yourself, how accurate is the virtual environment?

Danny Goel: We’ve made it as authentic as possible, meaning that you’re in an operating room, and when you’re holding tools, it feels like you’re holding tools. They sound and perform the way they would in the real world, to the point where we’ve had practicing surgeons try our software and actually drop the hand controller that comes with the Meta Quest headset on the ground, thinking they were setting the instrument down on a Mayo stand. Now, realism is a very subjective feeling, so we push the limits of the headset to make it as authentic as possible.

But there’s a nuance here that I think is important. When you go to a cadaver lab, you’re thinking in three dimensions, meaning you wish you could see what you’re doing in layers. You want to turn the skin off, and you want to turn the muscles off. In this immersive environment, because we allow you to behave authentically, we can also go deeper and offer you more value from an educator’s perspective by letting you turn the skin off and turn the muscles off. You can see where that nerve is. You can see in detail where you placed that guide wire or cut that bone by pulling the bone out of the body. So not only are we making it lifelike, we’re pushing it even further to give you a deeper understanding of things you just can’t get in today’s models of learning.

Kevin Pho: Now, what is your metric of success, and how are you measuring it? For instance, when you talk to program directors and academic institutions, how are you measuring success?

Danny Goel: Success at an academic medical center starts with, first, realizing that the system we live in is a problem. I think that’s undeniably where we’ve seen the most success with programs integrating our solution. They realize that what the system has done is a real, actual problem that’s going to affect their trainees in the future, regardless of what they subjectively think of those trainees from a skill perspective.

The second is that the trainees also believe this. They say, “I have five years of guided mentorship, and after that I am on my own, and I’ll be independent with no guidance and no backstop to save me should I make a mistake.” So they understand that they want to make the most of those five years.

When the programs, the faculty, and the residents understand that, we’ve seen a massive behavior change in how this solution is used, to the tune of thousands and thousands of simulation sessions done per year by residents. And the timeline is really interesting, because it’s not as though they’re spending hours in simulation. They’re spending between five and fifteen minutes, because it’s so immersive. You can go into the environment, do exactly what you want to do, get out, see your data and analyze it, and then go back on a different day.

So we’ve seen a massive shift in how simulation is used at these programs, programs that believe the problem exists, because it does, and residents who believe they have only a fixed period of time to become the best resident they possibly can before they have to go and become the best fellow. They know they have access to this software whenever they want it, and it’s mostly used at home.

Kevin Pho: As with all technological solutions, what do we have to look forward to? What are you currently working on when it comes to this simulation-based solution to surgical training?

Danny Goel: We started in orthopedics, and I think access to this software has to be global, and we’re making it so it can be. The price of headsets has gone down, thanks to Zuckerberg and other organizations that have really brought the cost of the hardware down, which makes it even more accessible.

Where we’re going with this is broader. We’ve already expanded into podiatry, and we’re looking at other specialties, to provide this level of organic, accessible intervention so people can practice procedures regardless of where they are. So where we see this going, and where we are going, is broader and broader expansion across health care. We see someone placing a catheter benefiting, as well as someone doing a lumbar puncture or a pain procedure, all the way to someone doing an orthopedic procedure like a total knee.

The other thing is more and more personalization. I don’t want to know the data on how someone else did this. I want to know how I did it, and that education-to-one mentality is what I’m most excited about. When I think of my own children, it’s why some people get tutors: It’s a personalized experience for that one individual. We can now do that in medicine, which I think is the most exciting part of this, and AI is going to help us do it, because frankly, we don’t have the human resources to provide education-to-one at a procedural level. But I think AI will help us get there.

Kevin Pho: We’re talking to Danny Goel. He’s an orthopedic surgeon and a physician executive. Today’s KevinMD article is “In 2026, the surgical backlog has a training bottleneck.” Danny, let’s end with some take-home messages you want to leave with the KevinMD audience.

Danny Goel: Thanks, Kevin. What I would leave the audience with is the one thing I wish I had known earlier: We shouldn’t confuse exposure with competence. I think that’s a really, really big thing. Seeing something is not the same as doing it, and doing something isn’t the same as understanding it. Doing something successfully once doesn’t mean you’re going to be able to do it again, and I think we need to think well beyond that from a data perspective. We live in a world of data in health care, and this is true well beyond surgery as well, I would say.

The second lesson I would leave the audience with is being comfortable with the idea that education doesn’t end when formal training ends. We all know that. As physicians, we’re lifelong learners. The rate at which medicine, technology, devices, and evidence are expanding allows us, and frankly requires us, to keep up to date on all of it, so it really doesn’t end. I think most practicing physicians appreciate that.

And finally, when we talk about AI, and I’ll refer to all of health care here, clinicians shouldn’t think about AI as simply giving us the answers. At the end of it all, the more interesting part of AI is that it will help us understand, as individuals, what we don’t know and what we should learn next.

Kevin Pho: Danny, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.

Danny Goel: Thanks, Kevin.

Listen and followApple PodcastsSpotifyYouTubeMore apps · Browse all episodes