Virtual Interactive Presence (VIP) technology allows users to deliver real-time virtual assistance to other physicians in geographically separate locations via the internet. This technology moves a step beyond simulation and assists the operating surgeon during a real case with live consultation from a remote colleague, instructor, or expert. This technology has the potential to enhance orthopaedic education and improve procedures in academic and community centers. In this article, we interview Brent A. Ponce, M.D., a pioneer in orthopaedic VIP technology.


Please tell us a little about your background and how you became involved in VIP technology.

Brent A. Ponce: I am an Associate Professor of orthopaedic surgery at the University of Alabama at Birmingham (UAB) and work at the Veteran Administration (VA) Hospital. Dr. Barton Guthrie, a neurosurgeon at UAB who also works at the VA, developed this technology over the last decade. He said the technology allowed the instructor to “reach into the surgical field” to provide instruction and guidance during surgical procedures. He asked if there were any orthopaedic applications and if I would like to help develop the technology. Arthroscopic surgeries are one of the most common orthopaedic procedures. When I am teaching arthroscopy, it usually involves an operating surgeon performing the arthroscopic procedure and another physician observing on a screen as an instructor. This setup was ideal for testing VIP technology.

In your pilot study, published in The Journal of Bone and Joint Surgery, instructors and physicians-in-training described the technology as beneficial and did not prolong surgical times. These early results demonstrate that telementoring could be used within the same academic center, between centers, and even internationally to facilitate patient care. Where is VIP headed next?

Brent A. Ponce: VIP Technology has great potential to be utilized in many different settings. This technology is different from basic video conferencing in that it is interactive. The greatest application is in education. This involves hands-on training with remote guidance from an expert. The technology could be used with Continuing Medical Education credits, experienced surgeons learning new techniques, or in resident training. The technology also has implications for the military. A combat medic, already equipped with basic medical knowledge and skills, could be guided through more complex emergency procedures for the first time with this technology. This technology continues to be developed and is distributed by Vipaar (, a company that was founded on this work from UAB.


What are some of the implications for medical training of orthopaedic residents?

Brent A. Ponce: Residents can do more independently and with greater autonomy with this technology. At the same time, I am able to provide greater guidance when I am in the operating room. For example, I can touch the middle glenohumeral ligament in the shoulder to identify the structure and enhance teaching variable presentations of the ligament in the shoulder without having to take control of the arthroscopic camera and probe from the resident physician. An important part of resident education is meeting surgical milestones. This technology could potentially improve the speed at which they attain these milestones by providing more operating time. This could have important implications, especially with recent resident work-hour restrictions. One of our next projects will involve validating the educational impact of the VIP technology.

How would this technology benefit practicing orthopaedic surgeons?

Brent A. Ponce: VIP could be used for intraoperative or surgical planning consultation with a colleague or expert. VIP can be utilized as a safety net that allows a surgeon to work with an expert during the first few cases of performing a new technique. The expert can be in another hospital, in another city, or another country. VIP allows them to view and interact with the local operating surgeon during the case.

What is the cost of implementing this technology?

Brent A. Ponce: The cost of being away from my patients for teaching engagements, whether clinic time or operating room time, can be significant. Advancements like this can provide another option at a time when global surgical education is growing in importance. The package is comparable or cheaper than many haptic feedback simulators on the market today and other video only systems.

How does the VIP enhance or differ from current educational surgical simulators?

Brent A. Ponce: Simulators are great for medical students and junior residents. Cadavers are ideal for senior residents and practicing physicians. Once a surgeon-in-training has the basic skills of performing arthroscopic procedures, this technology is most useful. With VIP, I am able to take a resident with some basic arthroscopic experience and skills through the entire procedure. I have greater confidence that they understand exactly where I want anchors placed, tissue resected, and other techniques performed during the case.

Augmented reality has already been used in the operating room for general surgery applications. Do you think products like Google Glass and other augemented reality headsets have a role in the orthopaedic operating room with VIP or are they a passing trend?

Brent A. Ponce: We have actually integrated the VIP technology with Google Glass and used both technologies at UAB last year. (For further information on this experience, click here. Although Google Glass has great potential in this area, the current image does not provide a high definition image of the surgical field. The battery life is also not ideal for longer surgical procedures and the audio can be difficult to hear with the noise of an operating room. As this technology develops, it has the potential to enhance surgical procedures when combined with VIP technology.

Medical state licensure laws have complicated some aspects of telemedicine. Do you believe telementoring through the VIP program would also place the remote physician at a theoretical liability risk?

Brent A. Ponce:  VIP is on the cutting edge of technology. At this point, our research team and legal advisors place the responsibility on the physician performing the procedure. These are potential issues we will have to address in the near future as the technologies utility expands.

Thank you very much for your time and insight into this exciting new technology. We look forward to following your progress and look forward to experiencing the educational benefits of VIP technology.

Further Reading:
Brent A. Ponce, MD; Jonathan K. Jennings, MD; Terry B. Clay, BS; Mathew B. May, BS; Carrie Huisingh, MPH; Evan D. Sheppard, BS. “Telementoring: Use of Augmented Reality in Orthopaedic Education.”J Bone Joint Surg Am, 2014 May 21;96(10):e84.