The AO North America ‘Secret Sauce’: A Recipe That Creates Great Learning Experiences

A new educational model with the same traditional spirit is destined to go beyond the COVID-19 pandemic

25 May 2021

Some call it the AO NA secret sauce, the AO NA magic, or the AO NA spirit. Whatever you call it, it conveys the same ideas: passion and leadership from surgeons, the dedication of a high-performing staff, and the tireless support of committed partners. After more than a year of waiting, this incredible recipe is once again working to create memorable experiences for residents at AO NA principles courses. Let’s explore the journey that got us to this point.

Surgeon Training and COVID-19

The COVID-19 pandemic created challenges for learners of all types, including surgeons. Hospitals around the world imposed a variety of health and safety measures to reduce the spread of the virus and redirect resources towards treating those affected.

While these measures were critical to fighting the deadly disease, several had direct impacts on resident and fellow training (1,2). Elective cases were cancelled or postponed. Participation in clinics was limited to essential personnel. Surgeons were redeployed to serve in pandemic-related roles and operating theaters were changed to isolation rooms for patients with COVID-19. Considering musculoskeletal surgeries are some of the most common surgeries in the United States (3), North American orthopedic surgeons were dealt a significant blow in 2020 and 2021.

Within a few months of the pandemic, residents had lost over a quarter of the cases they would have performed during an average year. Surgical trainees were no longer getting the hands-on experiences needed to support their specialized education.

The wellbeing of surgeons suffered along with educational opportunities. When surveyed, a majority of member respondents from the American College of Surgeons Resident and Associate Society (RAS) and Young Fellows Association (YFA) reported feelings of depression and burnout, with 21% of respondents answering ‘yes’ to every screening symptom (4).

COVID-19 as Catalyst for Digital Transformation

As in-person courses became less and less frequent, and eventually postponed entirely, AO North America had a unique opportunity not only to adapt in response to COVID-19 but to evolve into spaces and roles we had never occupied. The first stage of this evolution was digital transformation.

AO had begun preparations for improving live and online experiences in months prior. COVID-19 acted as a catalyst, pushing these changes to the foreground and giving us the chance to test out new learning solutions in real time.

Most AO North America (AO NA) courses were transitioned to online formats employing didactic and interactive group discussion models. Our website, social media, and information technology received major overhauls. New online learning series, such as CMF LIVE and Trauma Journal Club, were developed with attention to the strength of virtual spaces in bringing together surgeon expertise from all over North America and the world. In 2020 alone, AO NA held 162 events with 40,700 participants.

Still, AO NA encountered the same issue as medical institutions: a severe lack of hands-on clinical and laboratory experience. There was no escaping the gaps in surgeon training left by COVID-19. Online learning activities allow surgeons to interact with global experts but they can’t provide the tangible, practical skills developed through working with peers on cadavers and bone models.

Solution: A Regional Model

No longer could residents or fellows, now inundated with the healthcare demands of a global pandemic, take an entire weekend away from their institutions to travel and attend a course hundreds of miles away. Nor could they join dozens of other surgeons at a cadaver lab in a hotel conference hall and possibly become vectors for the spread of disease.

Our education committees, surgeon leadership, and learners dedicated weeks of meetings and hours of working into the night to a singular question: how do we provide traditional AO experiences for residents and fellows within the careful limitations of their health, safety, time, and energy? The answer they found can be broken into three primary components.

1) Mobilize faculty and resources to locations closer to home and remove the burdens of travel, time, and health risk from learners.

2) Leverage existing successes and familiarities with online educational formats to deliver necessary preparatory materials and enable remote supervision of lab exercises.

3) Deliver the same quality of learning at smaller scales to several distinct locations at around the same time and ensure that residents and fellows receive the training they need and possibly benefit from learning in a familiar, and therefore more comfortable, environment.

These courses would be labelled “regional” events, and pilot sessions were planned and executed for three separate courses usually taught as large-scale cadaver labs: AO CMF NA Management of Facial Trauma (MFT), AO Spine NA Minimally Invasive Spine Surgery (MISS), and AO Trauma NA Basic Principles. Below are brief descriptions of each pilot’s highlights and challenges compiled from comments by AO NA staff, faculty, and participants.

AO CMF NA MFT Regional Pilot

Accessibility of lecture content was a significant highlight of the MFT regional pilot. Rather than spending an entire day in person attending lectures, residents were tasked with viewing the pre-recorded content on their own time via our learning management system, Totara. 

Delivering lectures in this form meant residents could be more flexible with how they approached the content and more engaged as a result. The ability to have insights from experienced surgeons available whenever and wherever you want is an extremely valuable asset and a key component of the success for each of the regional pilots.

Salvatore Lettieri, MD, FACS remarked “the residents in the class were very happy with the course and learned a great deal. As for the future, it is my vision that we continue with the hybrid model. It makes sense to get the lectures done ahead of time and over the course of two to three weeks.”

Regional events like the MFT pilot also affords opportunities for new surgeon educators to join the ranks of AO faculty. Mark Pogue, MD, DDS, PC, who made his AO debut at the course, said “I enjoyed it!” and stated, “there was no issue with the teaching, just timing,” citing the unique challenge of condensing craniomaxillofacial knowledge and skills into a single day of learning.

AO Spine NA Regional MISS for Fellows Pilot

As Eric Klineberg, MD, MS, FAAOS, lecturer and co-chair of the MISS regional pilot, explains, Spine fellows have experienced a severe lack of specialized training during COVID-19, especially in the realm of minimally invasive surgeries. AO Spine NA worked to address this during their hybrid and localized events by employing a terrific new technology in the lab exercises—Real Spine.

Real Spine is a plastic model with precise representation of spine anatomy and a system of pouches and tubes that simulate blood flow that would occur during surgery. These models allowed participants to perform the same operations they would have on cadavers with the added benefit that they could be shipped and assembled onsite.

“The experience was awesome,” said one participant. Staff from Real Spine and DePuy Synthes (DPS) noted the participants seemed to enjoy using the Real Spine model and that participants were highly engaged throughout the course.

Roger Härtl, MD, provides an excellent analogy for the value of AO Spine NA MISS Regional that encompasses the importance of the new format in general. “Instead of going to a restaurant and eating there, you’ve got delivery—you can stay at home with a five-star meal.”

Remotely planning and coordinating MISS sessions with medical institutions provided a unique challenge for AO NA staff. Traditionally, AO NA and DPS staff would collaborate with hotel employees directly to organize an in-person course, and faculty would plan their attendance around the sequestered time.

Working with medical institutions and faculty that each hold numerous responsibilities meant course logistics were far from easy to navigate. As regional pilot programs continue and working relationships between AO NA and partner institutions develop further, these processes will become much smoother.

AO Trauma NA Basic Principles Regional Pilot

Participants noted the great degree of faculty engagement. Smaller groups and a full staff of local faculty meant each learner had plenty of time for direct instruction, with neither the worries of lacking nor receiving too much attention towards their work.

Compared to traditional Basic Principles courses, in which participant numbers are high and staff spread out, it seemed that educator-learner interaction benefited greatly from the regional model.

Taking part in the Basic Principles course alongside familiar individuals and in familiar environments appeared to be a plus for all involved. Residents felt comfortable conversing with each other and faculty, and well-equipped clinical settings provided greater learning opportunities than makeshift hotel labs.

Having a significant gap in time between virtual pre-course materials and the in-person lab meant some of the latter was devoted to reviewing foundational material. Future regional programs will have built-in reflection sessions to ensure that all participants complete the course with the required knowledge.

Improving and Expanding the Regional Model

There is no question the regional pilot programs were successful. Participants and staff at various courses remarked on the quality and efficiency of the events. Those who attended noted, despite the unique format, that sessions had the same look and feel of their traditional in-person, centralized counterparts. Regional and national surgical experts as well AO NA and DPS staff made immense sacrifices with demonstrable payoffs. But the journey does not end there.

Each step taken into expanding educational opportunities for our surgeons has shown us how much farther we can go. More feedback and more data from faculty and participants will help streamline our approaches to digital and in-person content and illuminate ways to best combine the two. More partnerships with different medical institutions enable a greater understanding of how we can cater our respective resources to surgeon learners. And more localized sessions across North America allows us to reach an even greater population of dedicated educators and students.

We have the boots on the ground. We have the five-star meals. Let’s continue delivering quality learning experiences no matter the obstacles.


Thanks to all the faculty and staff who dedicated their time and energy to this landmark program.

Special thanks to Karen Geesey, Debra Goldberg, Roger Härtl, Eric Klineberg, Salvatore Lettieri, Brenda Lowry, Mark Pogue, Charisse Sinkler, Chitra Subramaniam, Carol Yambrick, and the faculty and participants of Harvard’s Trauma Basics Regional Pilot for providing comments.


  1. Implications of the COVID-19 pandemic on orthopaedic surgical residency and fellowship training: lost opportunity or novel experience?
  2. Effects of coronavirus (COVID-19) pandemic on orthopedic residency program in the seventh largest city of the world: Recommendations from a resource-constrained setting
  3. Surgeries in Hospital-Based Ambulatory Surgery and Hospital Inpatient Settings, 2014
  4. COVID-19 Pandemic and the Lived Experience of Surgical Residents, Fellows, and Early-Career Surgeons in the American College of Surgeons

This article was written and produced by the AO North America Digital Communications team, which consists of Josh Block, Jakob Bower, Nida Fatima, MD, and Joshua Okumura.

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