Telementoring: an application whose time has come

Virtual Skills Training Format for Teaching Intrauterine Contraception Insertion During Coronavirus Disease 2019

The coronavirus disease 2019 pandemic resulted in the curtailment of face-to-face clinical skills training in 2020. To meet Title X workforce needs, the National Clinical Training Center for Family Planning transitioned onsite intrauterine contraception training to a virtual format using online didactic material and livestreamed training and telementoring. Videos demonstrated the placement and removal of intrauterine contraceptives, and all necessary supplies were shipped directly to participants. Attendees reported a high level of skill uptake and impact on their practice. This pilot study suggests that virtual skills training is suitable for providers unable to travel to in-person events.

SAGES Reimagining Education & Learning (REAL) project

Background

The COVID-19 pandemic has presented multiple challenges for health systems throughout the world. The clinical priorities of redirecting personnel and resources to provide the necessary beds, care, and staff to handle the initial waves of infected individuals, and the drive to develop an effective vaccine, were the most visible and rightly took precedent. However, the spread of the COVID-19 virus also led to less apparent but equally challenging impediments for healthcare professionals. Continuing professional development (CPD) for physicians and surgeons practically ceased as national societies postponed or canceled annual meetings and activities. The traditional in-person conferences were no longer viable options during a pandemic in which social distancing and minimization of contacts was the emerging norm. Like other organizations, The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) had to first postpone and then cancel altogether the in-person 2020 Annual Meeting due to the contingencies brought about by the COVID-19 pandemic. As a result, the traditional hands-on (HO) courses that typically occur as part of the Annual Meeting, could not take place. SAGES had already begun to re-structure these courses in an effort to increase their effectiveness (Dort, Trickey, Paige, Schwarz, Dunkin in Surg Endosc 33(9):3062–3068, 2019; Dort et al. in Surg Endosc 32(11):4491–4497, 2018; Dort, Trickey, Schwarz, Paige in Surg Endosc 33(9):3062–3068, 2019). The cancelations brought about by COVID-19 provided an opportunity to refine and to innovate further.

Methods

In this manner, the Re-imaging Education & Learning (REAL) project crystallized, an innovative effort to leverage the latest educational concepts as well as communication and simulation-based technologies to enhance procedural adoption by converting HO courses to a virtual format.

Results and conclusion

This manuscript describes the key components of REAL, reviewing the restructuring of the HO courses before and after the spread of COVID-19, describing the educational framework underlying it, discussing currently available technologies and materials, and evaluating the advantages of such a format.

Overcoming the Impact of COVID-19 on Surgical Mentorship: A Scoping Review of Long-distance Mentorship in Surgery

BACKGROUND

Mentorship in the surgical field has been increasingly recognized as a crucial component of career success. Distance mentorship models may be utilized to overcome geographic limitations, increase mentorship access, and strengthen mentoring relationships in surgery.

OBJECTIVE

This review aimed to identify the scope of literature on distance mentoring in surgery, the range of its application, its effectiveness, and any gaps in the literature that should be addressed in order to enhance mentorship in the surgical field.

DESIGN

A comprehensive PubMed review was performed in January 2021 on distance mentorship of students, trainees, and surgeons in the surgical field. Reviews, replies, and non-English articles were excluded. Data was extracted regarding publication year, author's country, specialty, subjects, aim of mentorship model, and efficacy.

RESULTS

134 total studies met inclusion and exclusion criteria. Most studies were published in 2020, written by authors in the United States, from general surgery, and featured an expert surgeon paired with a more junior fully trained surgeon. In all, 93.3% of studies utilized distance mentorship to enhance surgical skill through telementoring and only 4.5% were focused on mentorship to enhance careers through professional development. The remaining studies utilized distance mentorship models to increase surgical research (0.7%) and clinical knowledge (1.5%).

CONCLUSION

The results of this review suggest successful implementation of distance mentoring in surgery through telementoring, but a lack of professionally aimed distance mentorship programs. Amidst COVID-19, distance mentorship is particularly important because of decreased face-to-face opportunity. Future studies in the surgical field should investigate distance mentoring as a means of increasing mentorship for professional development.

The evolution of surgical virtual education and telementoring: One surgeon's journey

The first era of the global proliferation of surgical advancements involved surgical infection rate and technique breakthroughs by Lister, Halsted, and others. This was propagated by letters, academic papers, and international visits. While success was achieved, it was at a suboptimal pace. In the current era of minimally invasive surgical approaches, these methods are inadequate. This paper chronicles the development and application of virtual learning and telementoring as force multipliers to speed procedural adoption and proliferation.

Using artificial intelligence to improve medical services in China

Artificial intelligence (AI) is one hotspot of research in the field of modern medical technology. Medical AI has been applied to various areas and has two main branches including virtual and physical. Recently, Chinese State Council issued a guideline on developing AI and indicated that the widespread application of AI will improve the level of precision in medical services and achieve the intelligent medical care. Medical resources, especially the high-quality resources, are deficient across the entire health service system in China. AI technologies, such that virtual AI and telemedical technology, are expected to overcome the current limitations of the distribution of medical resources and relieve the pressure associated with obtaining high-quality health care.

The Potential for Undue Patient Exposure during the Use of Telementoring Technology

Background

Surgical telementoring holds great promise for safe and effective patient care and medical education, but recording and streaming audio and video introduces the potential for exposure of patient information. Physicians maintain an ethical responsibility to protect the privacy of patients, and privacy violations may carry significant legal liability. Despite the legal treatment of violations as discrete, methods for quantifying and characterizing the exposure of patient information during procedural recordings are lacking. This study is the first to quantify the potential risk for violation of privacy when using a wearable, telementoring technology capable of video and audio recording during surgical procedures in various locations including the operating room, interventional radiology suite, and the intensive care unit.

Methods

A head-mounted recording device, Google Glass™, was used to record routine neurosurgical and critical care procedures in a convenience sample of patients. Periods of maximal risk, including the beginning of procedures, were targeted. Recordings were manually coded for discrete instances of exposure of directly identifying information and indirectly identifying information.

Results

Twenty-two procedures were recorded for a total of 12 hours, during which 807 directly identifiable exposures were found. The overall average rate of exposure was 1.13 exposures per minute. Most exposures were full-face images (90%), names (7%), or phone numbers (3%). Indirectly identifying exposures were found to be tattoos, genitals, and caretaker names. The rate of exposures was found to be lower in the operating room (OR) when compared to the intensive care unit (ICU) or interventional radiology (IR) suite (p = 0.0376).

Conclusions

High rates of potential privacy violations were discovered and found to be related the location of the procedure. Sterile draping of the face prior to recording, when appropriate, would mitigate most exposure risk, though patient names and unique tattoos may be an underappreciated source of potential exposure. This study establishes the most conservative baseline to compare techniques for preventing exposure of patient information on telementoring or video/audio recording/streaming platforms.

High Efficiency Video Coding (HEVC)-Based Surgical Telementoring System Using Shallow Convolutional Neural Network

Surgical telementoring systems have gained lots of interest, especially in remote locations. However, bandwidth constraint has been the primary bottleneck for efficient telementoring systems. This study aims to establish an efficient surgical telementoring system, where the qualified surgeon (mentor) provides real-time guidance and technical assistance for surgical procedures to the on-spot physician (surgeon). High Efficiency Video Coding (HEVC/H.265)-based video compression has shown promising results for telementoring applications. However, there is a trade-off between the bandwidth resources required for video transmission and quality of video received by the remote surgeon. In order to efficiently compress and transmit real-time surgical videos, a hybrid lossless-lossy approach is proposed where surgical incision region is coded in high quality whereas the background region is coded in low quality based on distance from the surgical incision region. For surgical incision region extraction, state-of-the-art deep learning (DL) architectures for semantic segmentation can be used. However, the computational complexity of these architectures is high resulting in large training and inference times. For telementoring systems, encoding time is crucial; therefore, very deep architectures are not suitable for surgical incision extraction. In this study, we propose a shallow convolutional neural network (S-CNN)-based segmentation approach that consists of encoder network only for surgical region extraction. The segmentation performance of S-CNN is compared with one of the state-of-the-art image segmentation networks (SegNet), and results demonstrate the effectiveness of the proposed network. The proposed telementoring system is efficient and explicitly considers the physiological nature of the human visual system to encode the video by providing good overall visual impact in the location of surgery. The results of the proposed S-CNN-based segmentation demonstrated a pixel accuracy of 97% and a mean intersection over union accuracy of 79%. Similarly, HEVC experimental results showed that the proposed surgical region-based encoding scheme achieved an average bitrate reduction of 88.8% at high-quality settings in comparison with default full-frame HEVC encoding. The average gain in encoding performance (signal-to-noise) of the proposed algorithm is 11.5 dB in the surgical region. The bitrate saving and visual quality of the proposed optimal bit allocation scheme are compared with the mean shift segmentation-based coding scheme for fair comparison. The results show that the proposed scheme maintains high visual quality in surgical incision region along with achieving good bitrate saving. Based on comparison and results, the proposed encoding algorithm can be considered as an efficient and effective solution for surgical telementoring systems for low-bandwidth networks.

Effectiveness of Telementoring in Surgery Compared With On-site Mentoring: A Systematic Review

BACKGROUND

Mentorship is important but may not be feasible for distance learning. To bridge this gap, telementoring has emerged. The purpose of this systematic review was to evaluate the effectiveness of telementoring compared with on-site mentoring.

METHODS

A search was done up to March 2015. Studies were included if they used telementoring between surgeons during a clinical encounter and if they compared on-site mentoring and telementoring.

RESULTS

A total of 11 studies were included. All reported no difference in complication rates, and 9 (82%) reported similar operative times; 4 (36%) reported technical issues, which was 3% of the total number of cases in the 11 studies. No study reported on higher levels of evidence for effectiveness of telementoring as an educational intervention.

CONCLUSION

Studies reported that telementoring is associated with similar complication rates and operative times compared with on-site mentoring. However, the level of evidence to support the effectiveness of telementoring as a training tool is limited. There is a need for studies that provide evidence for the equivalence of the effectiveness of telementoring as an educational intervention in comparison with on-site mentoring.

Teledebriefing: connecting learners to faculty members

BACKGROUND

Simulation has become widespread among medical educators. Although simulation facilities are available at most teaching institutions, the number of qualified instructors to facilitate post-simulation debriefing is inadequate, resulting in sub-par educational experiences for learners.

CONTEXT

Efforts to broaden medical curricula to include simulation have been successful. An integral component of simulation-based education is the debriefing stage, in which learning and reflection are believed to be greatest. To be maximally effective, debriefing should be performed by faculty members who have both expertise in the subject matter and a strong grasp of debriefing principles. Unfortunately, the debriefing portion of simulation exercises is often performed in a sub-par fashion because many simulation centres do not have access to trained debriefers. As a result, the overall experience of simulation training programmes is reduced, and the exercises have much less educational benefit to the learner.

INNOVATION

This article outlines a novel use of videoconferencing technology for debriefing learners at remote locations, which we term teledebriefing. This can be accomplished in a cost-effective and straightforward manner using basic equipment: a smartphone and a television. Many simulation centres do not have access to trained debriefers

IMPLICATIONS

Teledebriefing can create a mutually beneficial faculty instructor network between institutions. By connecting clinical educators from geographically distant areas or from specialties not available locally, learners are exposed to faculty that can provide content expertise and high-quality debriefing during simulation exercises. Evaluating the effectiveness and feasibility of teledebriefing is warranted.

Telemedical technologies in urological cancer care: past, present and future applications

Since the initial development of telegraphy by Sir Charles Wheatstone in 1837 and the telephone by Alexander Graham Bell in 1875, doctors have been able to convey medical information across great distances. The exchange and sharing of medical information has evolved and adapted to suit the vast array of today's medicine. Early adopters of telemedicine within clinical practice have gained significant health economic benefits. The arrival of wireless connections has further enhanced the possibilities for all clinical work with focus on diagnosis, treatment and management of urological cancers, as highlighted in this article.

Laparoscopic colorectal fellowship training programme : a 6-year experience in a university colorectal unit

BACKGROUND

The aim of this study was to evaluate a structured training programme for laparoscopic colorectal surgery in a university colorectal unit over a 6-year period.

METHODS

Data on patients who underwent laparoscopic colectomy between November 2004 and October 2010 were analyzed. Operations were performed either by the consultant colorectal surgeons or colorectal fellows. The effectiveness and safety of our structured training programme were evaluated.

RESULTS

During the study period, 813 patients (478 men) with a median age 69 years (range 22-93) underwent laparoscopic colectomy. A total of 370 cases (45.5 %) were performed by four colorectal fellows. Overall, 674 patients (82.9 %) were classified as ASA I or II. The conversion rate was 3.7 %. The conversion rate, intra-operative blood loss, number of lymph nodes retrieved and post-operative recovery were similar between the two groups. When comparing with consultant group, the patients operated by fellows were: (1) significantly older; (2) more were operated on as emergency cases; (3) had pathologically less advanced tumours; (4) less patients with low rectal cancers. There were two surgical mortalities in this series. The morbidities between the two groups were similar. At the end of 3 years of training, the fellows had performed more than 85 cases of laparoscopic colectomies. The level of supervision decreased with increased experience. Finally, experienced fellows were able to supervise more junior colleagues on laparoscopic colectomies.

CONCLUSIONS

Our results confirmed a structured training programme for laparoscopic colectomy is safe and effective. Reasonable results were achieved even though a high volume of cases were performed by surgical fellows.

Web-conferenced simulation sessions: a satisfaction survey of clinical simulation encounters via remote supervision

PURPOSE

A critical barrier to expanding simulation-based instruction in medicine is the availability of clinical instructors. Allowing instructors to remotely observe and debrief simulation sessions may make simulation-based instruction more convenient, thus expanding the pool of instructors available. This study compared the impact of simulation sessions facilitated by in-person (IP) faculty versus those supervised remotely using Web-conferencing software (WebEx(®), Cisco [ www.webex.com/ ]).

SUBJECTS AND METHODS

A convenience sample of preclinical medical students volunteered to "care for" patients in a simulation laboratory. Students received either standard IP or Web-conferenced (WC) instruction. WC sessions were facilitated by off-site instructors. A satisfaction survey (5-point Likert scale, where 1=strongly disagree and 5=strongly agree) was completed immediately following the sessions.

RESULTS

Forty-four surveys were analyzed (WC n=25, IP n=19). In response to the question "Was the communication between faculty and students a barrier to understanding the case?," the average student responses were 2.8 (95% confidence interval [CI] 2.4-3.2) for WC and 4.5 (95% CI 4.0-5.0) for IP (p<0.0001). In response to the question "Would you participate again in such a session?," the average student responses were 4.2 (95% CI 4.0-4.5) for WC and 4.9 (95% CI 4.6-5.2) for IP (p=0.0003). Both groups agreed that they acquired new skills (4.2 for WC, 4.5 for IP; p=0.39) and new knowledge (4.6 for WC, 4.7 for IP; p=0.41).

CONCLUSIONS

Telecommunication can successfully enhance access to simulation-based instruction. In this study, a Web interface downgraded the quality of student-faculty communication. Future investigation is needed to better understand the impact of such an effect on the learning process and to reduce barriers that impede implementation of technology-facilitated supervision.

Significance of telemedicine for video image transmission of endoscopic retrograde cholangiopancreatography and endoscopic ultrasonography procedures

BACKGROUND

With the rapid and marked progress in gastrointestinal endoscopy, the education of doctors in many new diagnostic and therapeutic procedures is of increasing importance. Telecommunications (telemedicine) is very useful and cost-effective for doctors' continuing exposure to advanced skills, including those needed for hepato-pancreato-biliary diseases. Nevertheless, telemedicine in endoscopy has not yet gained much popularity. We have successfully established a new system which solves the problems of conventional ones, namely poor streaming images and the need for special expensive teleconferencing equipment.

METHODS

The digital video transport system, free software that transforms digital video signals directly into Internet Protocol without any analog conversion, was installed on a personal computer using a network with as much as 30 Mbps per channel, thereby providing more than 200 times greater information volume than the conventional system. Kyushu University Hospital in Japan was linked internationally to worldwide academic networks, using security software to protect patients' privacy.

RESULTS

Of the 188 telecommunications link-ups involving 108 institutions in 23 countries performed between February 2003 and August 2009, 55 events were endoscopy-related, 19 were live demonstrations, and 36 were gastrointestinal teleconferences with interactive discussions. The frame rate of the transmitted pictures was 30/s, thus preserving smooth high-quality streaming.

CONCLUSIONS

This paper documents the first time that an advanced tele-endoscopy system has been established over such a wide area using academic high-volume networks, funded by the various governments, and which is now available all over the world. The benefits of a network dedicated to research and education have barely been recognized in the medical community. We believe our cutting-edge system will be a milestone in endoscopy and will improve the quality of gastrointestinal education, especially with respect to endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasonography (EUS) procedures.

Surgery in space: the future of robotic telesurgery

BACKGROUND

The origins of telemedicine date back to the early 1970s, and combined with the concept of minimally invasive surgery, the idea of surgical robotics was born in the late 1980s based on the principle of providing active telepresence to surgeons. Many research projects were initiated, creating a set of instruments for endoscopic telesurgery, while visionary surgeons built networks for telesurgical patient care, demonstrated transcontinental surgery, and performed procedures in weightlessness. Long-distance telesurgery became the testbed for new medical support concepts of space missions.

METHODS

This article provides a complete review of the milestone experiments in the field, and describes a feasible concept to extend telemedicine beyond Earth orbit. With a possible foundation of an extraplanetary human outpost either on the Moon or on Mars, space agencies are carefully looking for effective and affordable solutions for life-support and medical care. The major challenges of surgery in weightlessness are also discussed.

RESULTS

Teleoperated surgical robots have the potential to shape the future of extreme health care both in space and on Earth. Besides the apparent advantages, there are some serious challenges, primarily the difficulty of latency with teleoperation over long distances. Advanced virtualization and augmented-reality techniques should help human operators to adapt better to the special conditions. To meet safety standards and requirements in space, a three-layered architecture is recommended to provide the highest quality of telepresence technically achievable for provisional exploration missions.

CONCLUSION

Surgical robotic technology is an emerging interdisciplinary field, with a great potential impact on many areas of health care, including telemedicine. With the proposed three-layered concept-relying only on currently available technology-effective support of long-distance telesurgery and human space missions are both feasible.

What ring tone should be used for patient safety? Early results with a Blackberry-based telementoring safety solution

OBJECTIVE

Technology currently exists for the application of remote guidance in the laparoscopic operating suite. However, these solutions are costly and require extensive preparation and reconfiguration of current hardware. We propose a solution from existing technology, to send video of laparoscopic cholecystectomy to the Blackberry Pearl device (RIM Waterloo, ON, Canada) for remote guidance purposes. This technology is time- and cost-efficient, as well as reliable.

METHODS

After identification of the critical maneuver during a laparoscopic cholecystectomy as the division of the cystic duct, we captured a segment of video before it's transection. Video was captured using the laparoscopic camera input sent via DVI2USB Solo Frame Grabber (Epiphan Ottawa, Canada) to a video recording application on a laptop. Seven- to 40-second video clips were recorded. The video clip was then converted to an .mp4 file and was uploaded to our server and a link was then sent to the consultant via e-mail. The consultant accessed the file via Blackberry for viewing. After reviewing the video, the consultant was able to confidently comment on the operation.

RESULTS

Approximately 7 to 40 seconds of 10 laparoscopic cholecystectomies were recorded and transferred to the consultant using our method. All 10 video clips were reviewed and deemed adequate for decision making.

CONCLUSION

Remote guidance for laparoscopic cholecystectomy with existing technology can be accomplished with relatively low cost and minimal setup. Additional evaluation of our methods will aim to identify reliability, validity, and accuracy. Using our method, other forms of remote guidance may be feasible, such as other laparoscopic procedures, diagnostic ultrasonography, and remote intensive care unit monitoring. In addition, this method of remote guidance may be extended to centers with smaller budgets, allowing ubiquitous use of neighboring consultants and improved safety for our patients.

Overcoming distance: video-conferencing as a clinical and educational tool among surgeons

Background

Since the 1960s, there has been substantial development in the uses of video-conferencing (VC) among medical personnel, including surgeons who have adopted the technology.

Methods

A report on our own experience with VC was combined with a comprehensive PubMed search with the key words telepresence, video-conferencing, video-teleconferencing, telementoring and surgery, trauma, follow-up, education, and multidisciplinary teams. A search through two peer-reviewed telemedicine journals—Journal of Telemedicine and Telecare and Telemedicine and e-Health Journal—and references of all included papers and identified additional reports was conducted.

Results

A total of 517 articles were identified with 51 relevant manuscripts, which included the key phrases. VC is widely used among surgeons for telementoring surgical procedures and in trauma and emergency medicine. Furthermore, VC is widely used by multidisciplinary teams and for the follow-up of patients after surgery.

Conclusions

VC is a common clinical tool for surgeons and provides a great opportunity to alter surgical practice and to offer patients the best expertise in surgical treatment despite long distances, especially in rural areas.