Role of Telemedicine Technology in Endocrine Surgery Knowledge Sharing
Ritesh Agrawal, MS, MCh, Saroj Kanta Mishra, MS, Anjali Mishra, MS, Gyan Chand, MS, Gaurav Agarwal, MS, Amit Agarwal, MS, and Ashok Kumar Verma, MS Department of Endocrine Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.
Abstract Introduction: This retrospective study was designed to assess the outcome of telemedicine technology supportive of educational collaboration among endocrine surgery peers and its impact on knowledge and skill development. Materials and Methods: The study was carried out in the Department of Endocrine Surgery in collaboration with School of Telemedicine and Biomedical Informatics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India, during October 1999–December 2012. Telemedicine activities were divided into various modules (e.g., case/problembased learning, clinical grand rounds, postgraduate course/continuing medical education/conference). Endocrine surgeons participating in such sessions were divided into two groups (faculty and residents). A multimodule questionnaire was constructed based on a Likert scale (2–7 points) to test various aspects (e.g., technical performance, role in knowledge exchange, skill development, level of satisfaction, and future recommendations). Responses were expressed in proportions, and the chi-squared test was used to find the differences in opinions of the study groups. Results: The questionnaire was sent to 38 surgeons, of whom 36 replied (response rate, 94.74%); of these respondents, 14 were faculty and 22 were residents. More than 80% of participants felt that the technology helped in learning new things and strengthening relations with peers, whereas >90% were of the view that it helped in knowledge exchange and development of skills as well as was helpful in supporting clinical decisions. More than 90% of participants were satisfied and enjoyed using this technology and also were of the opinion that the technology should be integrated into other specialties. Satisfaction with the technology was excellent to good for 94.44% of participants. Both faculty and residents were of the same opinion, and there was no significant difference in their replies. Conclusions: Knowledge sharing in a collaborative environment using telemedicine technology has been found successful in a lowresource setting and is now adopted in the departmental educational program. Key words: telemedicine, telesurgery, e-health, distance learning, telecommunications
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Introduction
T
elemedicine is a well-established technology that is increasingly utilized for knowledge and skill sharing in a collaborative environment across geographically dispersed learners. With the advancement of health sciences, in terms of both knowledge and technology, further specialization has taken place in medical and surgical disciplines around the world. It has also posed a challenge in developing knowledgeable and technically skillful health professionals across the globe, particularly in lowresource countries. Endocrine surgery is relatively a newer surgical subspecialty, with only a few academic centers offering training opportunities. Most of these centers are in the developed world. Although two-thirds of the global population resides in the developing world, the available academic centers offering such training opportunities are very few, leading to a wide gap in demand and supply. The Department of Endocrine Surgery at Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, India, was established in the year 1989. It had been engaged in training and offering fellowships of different kinds since its inception (e.g., 3-year hospital services residency, 1-year postgraduate diploma, 3-year MCh [Master Chirurgiae]) besides hosting professional skill development courses biennially since the year 1993 and continuous medical education programs. As information science and communication technology were making waves around the world, the Department quickly adopted the technology in the year 1999 and mastered the technical skills to incorporate the new collaborative environment with the existing training program offered by the Department. The experience and outcome of such collaborative learning practice and its potential role in bridging the knowledge and skill gap, based on the data acquired over a decade and sharing our story with the distance-learning practitioners in the surgical field, are the main objective of this body of work.
Materials and Methods After its initiation in 1999, the telemedicine program was soon incorporated in the academic program of the Department of Endocrine Surgery at SGPGIMS. This retrospective study was based on the endocrine surgery tele-education (EST) activities carried out between October 1999 and December 2012. These EST activities were divided into various modules: case/problem-based learning, clinical grand rounds, and postgraduate courses/continuing medical educations/ symposia/live surgical workshops. SGPGIMS is involved in these activities regularly with different remote partners in India having specialized departments/units practicing
DOI: 10.1089/tmj.2013.0164
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endocrine surgery: Shrirama Chandra Bhanj Medical College, Cuttack (distance, 870 km); Maharaja Krishna Chandra Gajapati Medical College, Berhampur (distance, 931 km); Christian Medical College, Vellore (distance, 1,562 km); and Amrita Institute of Medical Sciences, Kochi (distance, 1,945 km). Surgeons actively participating in these EST activities were divided into two groups: faculty (holding a regular academic position) and residents (trainees in endocrine surgery). There was no available validated questionnaire to assess the role of telemedicine technology in distance education and skill sharing in surgical education. Hence, we constructed a multidomain questionnaire to test various aspects of EST activities. As we intended to include all the surgeons actively participating in EST activities, we constructed this questionnaire based on the Likert scale system. Replies were graded for all questions. The domains tested were level of involvement, assessment of familiarity, role in knowledge exchange and skill development, quality of transmissions, level of satisfaction, and future role of the technology. The participants were supplied this questionnaire in 2012 (i.e., the last year of the study) to gather their collective knowledge and information regarding these EST activities. Analysis was performed using SPSS statistical software (version 15.0; SPSS, Inc., Chicago, IL).1 Proportions were calculated for overall response, and the chi-squared test was used to find the association between the study groups and outcome measures. Significance level was calculated at £ 0.05.
Results The questionnaire was sent to 38 specialist surgeons, of whom 36 replied back (response rate, 94.74%); 14 were faculty, and 22 were residents. Most participants had moderate to extensive exposure to EST activities (86%) and were regular in attending these sessions (78%). Four residents (18%) had stopped attending these sessions because of lack of access to EST after completion of their residency (Table 1). Participants were usually aware of telemedicine technology and research publications in relation to endocrine surgery (Table 2). When knowledge exchange was assessed, > 90% of participants responded that EST activities have helped in knowledge exchange. Most participants also were of the opinion that these EST activities helped them to learn new things and strengthened networking with peers (Table 3). However, response rates were less for development of skill and telementoring when compared with knowledge exchange. The majority of participants ( > 70%) felt that telemedicine helped them in clinical decision-making support (Table 4). Quality of transmissions was excellent to good for 56–81% of participants, and > 72% felt that telemedicine has a beneficial important role in conference transmissions (Table 5). More than half of the participants ( > 60%) had a change in attitude and perception toward telemedicine, and > 85% enjoyed the technology. Overall satisfaction was high (excellent to good, > 90%); however, only a few participants felt that telemedicine is better compared with live classroom teaching. Also, learning with the technology was easy for only 45–64% of participants (Table 6).
Table 1. Level of Involvement of Participants FACULTY
RESIDENTS
TOTAL
Exposure to telemedicine (in years) £1
0 (0.00)
5 (22.73)
5 (13.89)
> 1 to £ 3
2 (14.29)
10 (45.45)
12 (33.33)
> 3 to £ 6
3 (21.43)
5 (22.73)
8 (22.22)
>6
9 (64.29)
2 (9.09)
11 (30.56)
Monthly attendance for EST (in hrs) £1
4 (28.57)
10 (45.45)
14 (38.89)
> 1 to £ 3
9 (64.29)
8 (36.36)
17 (47.22)
>3
1 (7.14)
0 (0.00)
1 (2.78)
Stopped
0 (0.00)
4 (18.18)
4 (11.11)
Current status of attending sessions Regular
14 (100.00)
14 (63.64)
28 (77.78)
Irregular
0 (0.00)
2 (9.09)
2 (5.56)
Rare
0 (0.00)
2 (9.09)
2 (5.56)
Stopped
0 (0.00)
4 (18.18)
4 (11.11)
Reason behind lack of participation Busy with patients
2 (14.29)
13 (59.09)
15 (41.67)
Timings of these sessions not suitable
2 (14.29)
0 (0.00)
2 (5.56)
No facility of telemedicine currently
0 (0.00)
2 (9.09)
2 (5.56)
10 (71.43)
7 (31.82)
17 (47.22)
No answer
Numbers in parentheses indicate percentages. EST, endocrine surgery tele-education activities.
Although there were variable opinions on the use of telemedicine technology for knowledge sharing, all expressed a desire to continue participating in EST activities. The vast majority ( > 95%) wished that the technology should be developed in other institutes and that it should be incorporated with other specialties. Furthermore, > 90% were of the opinion that the technology has a very important role in the future (Table 7). There was no significant difference between responses of the faculty and residents for any of the domains tested.
Discussion We are actively using telemedicine as a distance education tool as we have a resource crunch for endocrine surgery expertise in our
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Table 2. Assessment of Familiarity with the Technology QUESTION
OVERALL RESPONSE
FACULTY
RESIDENTS
Aware with scope and limitations of telemedicine
P VALUE 0.387
Yes
31 (86.11)
12 (85.71)
19 (86.36)
No
4 (11.11)
1 (7.14)
3 (13.64)
No answer
1 (2.78)
1 (7.14)
0 (0.00)
Read literature on telemedicine 21 (58.33)
8 (57.14)
13 (59.09)
No
15 (41.67)
6 (42.86)
9 (40.91)
Aware of research article on role of telemedicine in endocrine surgery 27 (75.00)
10 (71.43)
17 (77.27)
No
7 (19.44)
3 (21.43)
4 (18.18)
No answer
2 (5.56)
1 (7.14)
1 (4.55)
FACULTY
RESIDENTS
P VALUE 1.000
Yes
34 (94.44)
14 (100.00)
20 (90.91)
No
1 (2.78)
0 (0.00)
1 (4.55)
No answer
1 (2.78)
0 (0.00)
1 (4.55) 0.315
Yes
29 (80.56)
13 (92.86)
16 (72.73)
No
6 (16.67)
1 (7.14)
5 (22.73)
No answer
1 (2.78)
0 (0.00)
1 (4.55)
Networking with peers strengthened by attending EST
0.181
Written any research article on role of telemedicine in endocrine surgery
OVERALL RESPONSE
Learned new things by attending EST
0.910
Yes
QUESTION EST have helped in knowledge exchange
1.000
Yes
Table 3. Assessment of the Role of Telemedicine in Endocrine Surgery Knowledge Exchange
1.000
Yes
30 (83.33)
12 (85.71)
18 (81.82)
No
6 (16.67)
2 (14.29)
4 (18.18)
Numbers in parentheses indicate percentages. EST, endocrine surgery tele-education activities.
Yes
6 (16.67)
4 (28.57)
2 (9.09)
No
30 (83.33)
10 (71.43)
20 (90.91)
Knowledge regarding telemedicine
0.340
Very knowledgeable
1 (2.78)
1 (7.14)
0 (0.00)
Knowledgeable
9 (25.00)
5 (35.71)
4 (18.18)
Somewhat knowledgeable
23 (63.89)
7 (50.00)
16 (72.73)
Not at all knowledgeable
3 (8.33)
1 (7.14)
2 (9.09)
Numbers in parentheses indicate percentages.
country. Previously we published our experience with telemedicine technology and endocrine surgery and showed that telemedicine technology helped the trainees regarding reinforcement of knowledge and skills after a few years of completion of a short-term training in endocrine surgery.2
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In a recent randomized controlled study by Haney et al.3 from Florida, tele-education was used for skill development among paramedics, and they found no significant difference between videoconferencing and live didactic lectures when used for wound closure by the study population. Bertsch et al.4 concluded that interactive videoconferencing was an effective tool to teach clinical examination objectives, but when they compared it with in-person teaching of third-year internal medicine clerkship students, they found there were no significant difference in responses for both methods. Satisfaction surveys were also performed by other authors and found a high user ratings for tele-education sessions with no significant differences between online teaching and live classroom teaching.5–8 However, results of our study showed that surgeons prefer live classroom teaching over tele-education sessions. Similar results were also described by Kidd and Stamatakis,9 who found that live classroom teaching was significantly more effective than interactive videoconferencing for teaching clinical pharmacokinetics to students. Chipps et al.10 systematically reviewed the effectiveness of videoconference-based education and found five studies were eligible out of 312 studies selected for review. They found sufficient evidence to provide a grade B evidence-based recommendation11 of
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Table 4. Assessment of Role of Telemedicine in Endocrine Surgery Skill Development QUESTION
OVERALL RESPONSE
QUESTION FACULTY
RESIDENTS
Skill improved after participation in EST
P VALUE 0.473
Yes
20 (55.56)
6 (42.86)
14 (63.64)
No
6 (16.67)
3 (21.43)
3 (13.64)
10 (27.78)
5 (35.71)
5 (22.73)
No answer
Table 5. Assessment of Quality of Transmissions
Role of telemedicine in skill development in endocrine surgery
0.705
25 (69.44)
10 (71.43)
15 (68.18)
Somewhat beneficial
9 (25.00)
4 (28.57)
5 (22.73)
Not at all beneficial
1 (2.78)
0 (0.00)
1 (4.55)
No answer
1 (2.78)
0 (0.00)
Role of telementoring
0.740
RESIDENTS
10 (27.78)
4 (28.57)
6 (27.27)
Good
14 (38.89)
4 (28.57)
10 (45.45)
Fair
12 (33.33)
6 (42.86)
6 (27.27)
Poor
0 (0.00)
0 (0.00)
0 (0.00)
Quality of transmission of conferences
0.517
8 (22.22)
2 (14.29)
6 (27.27)
20 (55.56)
8 (57.14)
12 (54.55)
Fair
7 (19.44)
4 (28.57)
3 (13.64)
Poor
0 (0.00)
0 (0.00)
0 (0.00)
No answer
1 (2.78)
0 (0.00)
1 (4.55)
Role of telemedicine in conference transmissions
0.711
Beneficial
22 (61.11)
8 (57.14)
14 (63.64)
Beneficial
27 (75.00)
11 (78.57)
16 (72.73)
Somewhat beneficial
10 (27.78)
5 (35.71)
5 (22.73)
Somewhat beneficial
8 (22.22)
3 (21.43)
5 (22.73)
Not at all beneficial
1 (2.78)
0 (0.00)
1 (4.55)
Not at all beneficial
0 (0.00)
0 (0.00)
0 (0.00)
No answer
3 (8.33)
1 (7.14)
2 (9.09)
No answer
1 (2.78)
0 (0.00)
1 (4.55)
0.639
Role of telemedicine in clinical decisionmaking support Beneficial
26 (72.22)
10 (71.43)
16 (72.73)
Somewhat beneficial
8 (22.22)
4 (28.57)
4 (18.18)
Not at all beneficial
1 (2.78)
0 (0.00)
1 (4.55)
No answer
1 (2.78)
0 (0.00)
1 (4.55)
Numbers in parentheses indicate percentages. EST, endocrine surgery tele-education activities.
P VALUE 0.534
Excellent
Good
1 (4.55)
FACULTY
Quality of transmission of presentations
Excellent
Beneficial
OVERALL RESPONSE
Numbers in parentheses indicate percentages.
moderate support that nursing and medical education should consider videoconference-based teaching, which is at least as effective as face-to-face teaching in terms of knowledge gains. Similar to our results, Aas12 found that 83% of participants learned new things by taking part in tele-education sessions. Fahey et al.13 reported, when they surveyed individuals involved in child and family services, that 80% of sessions were highly informative, 68% reported gain in knowledge, 86% confirmed that the content of these sessions was very useful, and 80% of participants reported they changed their practice because of knowledge gained from these sessions. Similarly, increase in knowledge and skill level among nurses for neonatal resuscitation was found after attending tele-education sessions.14 Western Australia has a large telemedicine network, and in a recent survey of its activities, education was found to be the most important purpose for videoconferencing in country hospitals and
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Table 6. Assessment of Telemedicine Technology by Users QUESTION
OVERALL RESPONSE
FACULTY
RESIDENTS
Change in attitude while gaining experience with telemedicine technology
0.300
Yes
25 (69.44)
11 (78.57)
14 (63.64)
No
7 (19.44)
1 (7.14)
6 (27.27)
Somewhat
1 (2.78)
1 (7.14)
0 (0.00)
No answer
3 (8.33)
1 (7.14)
2 (9.09)
Enjoyed using telemedicine technology
0.890
Yes
32 (88.89)
12 (85.71)
20 (90.91)
No
2 (5.56)
1 (7.14)
1 (4.55)
No answer
2 (5.56)
1 (7.14)
1 (4.55)
Found learning with the use of telemedicine technology Very easy
0.678 7 (19.44)
4 (28.57)
3 (13.64)
12 (33.33)
5 (35.71)
7 (31.82)
Neither difficult nor easy
8 (22.22)
2 (14.29)
6 (27.27)
Moderately difficult
8 (22.22)
3 (21.43)
5 (22.73)
Very difficult
1 (2.78)
0 (0.00)
1 (4.55)
Moderately easy
Overall satisfaction with telemedicine technology
0.705
Excellent
10 (27.78)
4 (28.57)
6 (27.27)
Very good
15 (41.67)
6 (42.86)
9 (40.91)
Good
9 (25.00)
4 (28.57)
5 (22.73)
Fair
2 (5.56)
0 (0.00)
2 (9.09)
Poor
0 (0.00)
0 (0.00)
0 (0.00)
More beneficial for knowledge exchange Live classroom teaching EST Both equally good
P VALUE
0.318 18 (50.00)
5 (35.71)
13 (59.09)
3 (8.33)
1 (7.14)
2 (9.09)
15 (41.67)
8 (57.14)
7 (31.2)
Numbers in parentheses indicate percentages. EST, endocrine surgery tele-education activities.
nursing posts.15 We have also found similar results, with education being the most common telemedicine application. Another large study from the European Union project, HELLO DOC, done mainly for neurological patients, yielded high satisfaction rates among therapists.16 Demartines et al.17 tested the acceptance of telemedicine among surgeons and reported that surgeons are interested in telemedicine and open to its development. A simple method was devised by Azuh et al.18 to study telementoring among surgical residents and found favorable results. Previously we too had demonstrated the beneficial role of telementoring for a patient with residual primary hyperparathyroidism.19 Schlachta et al.20 described
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their experience with telementoring for laparoscopic colon surgery and found this method very useful. Our results were also comparable with those of Moser et al.,21 who in their survey of medical students reported that telemedicine has a very important future role (79%) and that students wish to attend lectures in telemedicine (77%) and got personally benefited from telemedicine (75%). Gschwendtner et al.23 surveyed medical students and found similar recommendations regarding the future role of telemedicine: 93% thought it will play a very important role, 75% wished to attend telesessions, and 84% had benefitted by telelearning.
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Table 7. Recommendations Regarding Future Role of Telemedicine Technology QUESTION
OVERALL RESPONSE
FACULTY
RESIDENTS
Would like to attend EST in future if provided an opportunity
NA
Yes
36 (100.00)
14 (100.00)
22 (100.00)
No
0 (0.00)
0 (0.00)
0 (0.00)
Institutes should create infrastructure for telemedicine to facilitate service and education.
1.000
Yes
35 (97.22)
14 (100.00)
21 (95.45)
No
1 (2.78)
0 (0.00)
1 (4.55)
Telemedicine knowledge exchange program should be applied to other medical and surgical subspecialties.
1.000
Yes
35 (97.22)
14 (100.00)
21 (95.45)
No
1 (2.78)
0 (0.00)
1 (4.55)
Future role of telemedicine technology in endocrine surgery Very important
P VALUE
0.689 33 (91.67)
13 (92.86)
20 (90.91)
Little importance
2 (5.56)
1 (7.14)
1 (4.55)
Not at all important
1 (2.78)
0 (0.00)
1 (4.55)
Numbers in parentheses indicate percentages. EST, endocrine surgery tele-education activities.
Conclusions
Disclosure Statement
Knowledge sharing for development of new subspecialties using telemedicine technology as a tool has been found to be successful. These research findings could satisfy policy makers to integrate the module for various other subspecialties to meet the capacity gap in a low-resource setting. However, there are certain shortcomings in our study. As it is a retrospective study, problems inherent to such kind of research are inevitable. Also, the study has used a custom-made questionnaire, which may have inherent deficiencies. Hence, there is a need to develop a standard validated questionnaire for evaluation of teleeducational practices.
Acknowledgments We would like to acknowledge the financial grants received from the following agencies of the Government of India for creation and sustenance of telemedicine infrastructure and activities at the School of Telemedicine & Biomedical Informatics, SGPGIMS, Lucknow: the Department of Electronics & Information Technology, Ministry of Communication & Information Technology; the Indian Space Research Organization; and the Ministry of Health & Family Welfare. We would also like to thank all the participants of this study and the technical staff at the School of Telemedicine and Biomedical Informatics and at the Department of Endocrine Surgery, SGPGIMS.
No competing financial interests exist.
REFERENCES 1. Norman G. Likert scales, levels of measurement and the ‘‘laws’’ of statistics. Adv Health Sci Educ Theory Pract 2010;15:625–632. 2. Pradeep PV, Mishra A, Mohanty BN, Mohapatra KC, Agarwal G, Mishra SK. Reinforcement of endocrine surgery training: Impact of telemedicine technology in a developing country context. World J Surg 2007;31:1665– 1671. 3. Haney M, Silvestri S, Van Dillen C, Ralls G, Cohen E, Papa L. A comparison of tele-education versus conventional lectures in wound care knowledge and skill acquisition. J Telemed Telecare 2012;18:79–81. 4. Bertsch TF, Callas PW, Rubin A, Caputo MP, Ricci MA. Effectiveness of lectures attended via interactive video conferencing versus in-person in preparing thirdyear internal clerkship students for clinical practice examinations (CPX). Teach Learn Med 2007;19:4–8. 5. Joshi A, Novaes MA, Iyengar S, Machivelli JL, Zhang J, Vogler R, Hsu CE. Evaluation of a tele-education programme in Brazil. J Telemed Telecare 2011;17:341–345. 6. Elison-Bowers P, Snelson C, Casa de Calvo M, Thompson H. Health science students and their learning environment: A comparison of perceptions of onsite, remote-site, and traditional classroom students. Perspect Health Inf Manag 2008;5:2. 7. Pereira BM, Calderan TR, Silva MT, Silva AC, Marttos AC Jr, Fraga GP. Initial experience at a university teaching hospital from using telemedicine to promote education through videoconferencing. Sao Paulo Med J 2012;130: 32–36.
ª M A R Y A N N L I E B E R T , I N C . VOL. 20
NO. 9 SEPTEMBER 2014
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AGRAWAL ET AL.
8. Andreazzi DB, Rossi F, Wen CL. Interactive tele-education applied to a distant clinical microbiology specialization university course. Telemed J E Health 2011;17:524–529. 9. Kidd RS, Stamatakis MK. Comparison of students’ performance in and satisfaction with a clinical pharmacokinetics course delivered live and by interactive videoconferencing. Am J Pharmaceut Educ 2006; 70:10.
18. Azuh O, Sen A, Ilan R, Shah N, Parker A, Blyden D, Broasy A, Velanovich V, Falvo A, Patton P. Heralding new ringtones of patient safety: Blackberry based clinical communication and telementoring in laparoscopic surgery. AMIA Annu Symp Proc 2009;23. 19. Pradeep PV, Mishra SK, Vaidyanathan S, Nair CG, Ramalingam K, Basnet R. Telementoring in endocrine surgery: Preliminary Indian experience. Telemed J E Health 2006;12:73–77.
10. Chipps J, Brysiewicz P, Mars M. A systematic review of the effectiveness of videoconference-based tele-education for medical and nursing education. Worldwide Evid Based Nurs 2012;9:78–87.
20. Schlachta CM, Lefebvre KL, Sordahl AK, Jayaraman S. Mentoring and telementoring leads to effective incorporation of laparoscopic colon surgery. Surg Endosc 2010;24:841–844.
11. How to use the evidence: assessment and application of scientific evidence, handbook series on preparing clinical practice guidelines. Canberra: National Health and Medical Research Council, 1999.
21. Moser PL, Hager M, Lorenz IH, Sogner P, Schubert HM, Mikuz G, Kolbitsch C. Acceptance of telemedicine and new media: A survey of Austrian medical students. J Telemed Telecare 2003;9:273–277.
12. Aas IH. Learning in organizations working with telemedicine. J Telemed Telecare 2002;8:107–111.
22. Gschwendtner A, Netzer T, Mairinger B, Mairinger T. What do students think about telemedicine? J Telemed Telecare 1997;3:169–171.
13. Fahey A, Day NA, Gelber H. Tele-education in child mental health for rural allied health workers. J Telemed Telecare 2003;9:84–88. 14. Jain A, Agarwal R, Chawla D, Paul V, Deorari A. Tele-education vs classroom training of neonatal resuscitation: A randomized trial. J Perinatol 2010;30:773–779. 15. Bahaadinbeigy K, Yogesan K, Wootton R. A survey of the state of telemedicine in Western Australia. J Telemed Telecare 2010;16:176–180. 16. Hermens H, Huijgen B, Giacomozzi C, Ilsbroukx S, Macellari V, Prats E, Rogante M, Schifini MF, Spitali MC, Tasies S, Zampolini M, Vollenbroek-Hutten M. Clinical assessment of the HELLODOC tele-rehabilitation service. Ann Ist Super Sanita 2008;44:154–163. 17. Demartines N, Freiermuth O, Mutter D, Heberer M, Harder F. Knowledge and acceptance of telemedicine in surgery: A survey. J Telemed Telecare 2000;6:125–131.
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Address correspondence to: Saroj Kanta Mishra, MS Department of Endocrine Surgery Sanjay Gandhi Postgraduate Institute of Medical Sciences Raibareli Road Lucknow 226014 India E-mail: [email protected] Received: May 4, 2013 Revised: December 4, 2013 Accepted: December 4, 2013
Ritesh Agrawal, MS, MCh, Saroj Kanta Mishra, MS, Anjali Mishra, MS, Gyan Chand, MS, Gaurav Agarwal, MS, Amit Agarwal, MS, and Ashok Kumar Verma, MS Department of Endocrine Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.
Abstract Introduction: This retrospective study was designed to assess the outcome of telemedicine technology supportive of educational collaboration among endocrine surgery peers and its impact on knowledge and skill development. Materials and Methods: The study was carried out in the Department of Endocrine Surgery in collaboration with School of Telemedicine and Biomedical Informatics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India, during October 1999–December 2012. Telemedicine activities were divided into various modules (e.g., case/problembased learning, clinical grand rounds, postgraduate course/continuing medical education/conference). Endocrine surgeons participating in such sessions were divided into two groups (faculty and residents). A multimodule questionnaire was constructed based on a Likert scale (2–7 points) to test various aspects (e.g., technical performance, role in knowledge exchange, skill development, level of satisfaction, and future recommendations). Responses were expressed in proportions, and the chi-squared test was used to find the differences in opinions of the study groups. Results: The questionnaire was sent to 38 surgeons, of whom 36 replied (response rate, 94.74%); of these respondents, 14 were faculty and 22 were residents. More than 80% of participants felt that the technology helped in learning new things and strengthening relations with peers, whereas >90% were of the view that it helped in knowledge exchange and development of skills as well as was helpful in supporting clinical decisions. More than 90% of participants were satisfied and enjoyed using this technology and also were of the opinion that the technology should be integrated into other specialties. Satisfaction with the technology was excellent to good for 94.44% of participants. Both faculty and residents were of the same opinion, and there was no significant difference in their replies. Conclusions: Knowledge sharing in a collaborative environment using telemedicine technology has been found successful in a lowresource setting and is now adopted in the departmental educational program. Key words: telemedicine, telesurgery, e-health, distance learning, telecommunications
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Introduction
T
elemedicine is a well-established technology that is increasingly utilized for knowledge and skill sharing in a collaborative environment across geographically dispersed learners. With the advancement of health sciences, in terms of both knowledge and technology, further specialization has taken place in medical and surgical disciplines around the world. It has also posed a challenge in developing knowledgeable and technically skillful health professionals across the globe, particularly in lowresource countries. Endocrine surgery is relatively a newer surgical subspecialty, with only a few academic centers offering training opportunities. Most of these centers are in the developed world. Although two-thirds of the global population resides in the developing world, the available academic centers offering such training opportunities are very few, leading to a wide gap in demand and supply. The Department of Endocrine Surgery at Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, India, was established in the year 1989. It had been engaged in training and offering fellowships of different kinds since its inception (e.g., 3-year hospital services residency, 1-year postgraduate diploma, 3-year MCh [Master Chirurgiae]) besides hosting professional skill development courses biennially since the year 1993 and continuous medical education programs. As information science and communication technology were making waves around the world, the Department quickly adopted the technology in the year 1999 and mastered the technical skills to incorporate the new collaborative environment with the existing training program offered by the Department. The experience and outcome of such collaborative learning practice and its potential role in bridging the knowledge and skill gap, based on the data acquired over a decade and sharing our story with the distance-learning practitioners in the surgical field, are the main objective of this body of work.
Materials and Methods After its initiation in 1999, the telemedicine program was soon incorporated in the academic program of the Department of Endocrine Surgery at SGPGIMS. This retrospective study was based on the endocrine surgery tele-education (EST) activities carried out between October 1999 and December 2012. These EST activities were divided into various modules: case/problem-based learning, clinical grand rounds, and postgraduate courses/continuing medical educations/ symposia/live surgical workshops. SGPGIMS is involved in these activities regularly with different remote partners in India having specialized departments/units practicing
DOI: 10.1089/tmj.2013.0164
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endocrine surgery: Shrirama Chandra Bhanj Medical College, Cuttack (distance, 870 km); Maharaja Krishna Chandra Gajapati Medical College, Berhampur (distance, 931 km); Christian Medical College, Vellore (distance, 1,562 km); and Amrita Institute of Medical Sciences, Kochi (distance, 1,945 km). Surgeons actively participating in these EST activities were divided into two groups: faculty (holding a regular academic position) and residents (trainees in endocrine surgery). There was no available validated questionnaire to assess the role of telemedicine technology in distance education and skill sharing in surgical education. Hence, we constructed a multidomain questionnaire to test various aspects of EST activities. As we intended to include all the surgeons actively participating in EST activities, we constructed this questionnaire based on the Likert scale system. Replies were graded for all questions. The domains tested were level of involvement, assessment of familiarity, role in knowledge exchange and skill development, quality of transmissions, level of satisfaction, and future role of the technology. The participants were supplied this questionnaire in 2012 (i.e., the last year of the study) to gather their collective knowledge and information regarding these EST activities. Analysis was performed using SPSS statistical software (version 15.0; SPSS, Inc., Chicago, IL).1 Proportions were calculated for overall response, and the chi-squared test was used to find the association between the study groups and outcome measures. Significance level was calculated at £ 0.05.
Results The questionnaire was sent to 38 specialist surgeons, of whom 36 replied back (response rate, 94.74%); 14 were faculty, and 22 were residents. Most participants had moderate to extensive exposure to EST activities (86%) and were regular in attending these sessions (78%). Four residents (18%) had stopped attending these sessions because of lack of access to EST after completion of their residency (Table 1). Participants were usually aware of telemedicine technology and research publications in relation to endocrine surgery (Table 2). When knowledge exchange was assessed, > 90% of participants responded that EST activities have helped in knowledge exchange. Most participants also were of the opinion that these EST activities helped them to learn new things and strengthened networking with peers (Table 3). However, response rates were less for development of skill and telementoring when compared with knowledge exchange. The majority of participants ( > 70%) felt that telemedicine helped them in clinical decision-making support (Table 4). Quality of transmissions was excellent to good for 56–81% of participants, and > 72% felt that telemedicine has a beneficial important role in conference transmissions (Table 5). More than half of the participants ( > 60%) had a change in attitude and perception toward telemedicine, and > 85% enjoyed the technology. Overall satisfaction was high (excellent to good, > 90%); however, only a few participants felt that telemedicine is better compared with live classroom teaching. Also, learning with the technology was easy for only 45–64% of participants (Table 6).
Table 1. Level of Involvement of Participants FACULTY
RESIDENTS
TOTAL
Exposure to telemedicine (in years) £1
0 (0.00)
5 (22.73)
5 (13.89)
> 1 to £ 3
2 (14.29)
10 (45.45)
12 (33.33)
> 3 to £ 6
3 (21.43)
5 (22.73)
8 (22.22)
>6
9 (64.29)
2 (9.09)
11 (30.56)
Monthly attendance for EST (in hrs) £1
4 (28.57)
10 (45.45)
14 (38.89)
> 1 to £ 3
9 (64.29)
8 (36.36)
17 (47.22)
>3
1 (7.14)
0 (0.00)
1 (2.78)
Stopped
0 (0.00)
4 (18.18)
4 (11.11)
Current status of attending sessions Regular
14 (100.00)
14 (63.64)
28 (77.78)
Irregular
0 (0.00)
2 (9.09)
2 (5.56)
Rare
0 (0.00)
2 (9.09)
2 (5.56)
Stopped
0 (0.00)
4 (18.18)
4 (11.11)
Reason behind lack of participation Busy with patients
2 (14.29)
13 (59.09)
15 (41.67)
Timings of these sessions not suitable
2 (14.29)
0 (0.00)
2 (5.56)
No facility of telemedicine currently
0 (0.00)
2 (9.09)
2 (5.56)
10 (71.43)
7 (31.82)
17 (47.22)
No answer
Numbers in parentheses indicate percentages. EST, endocrine surgery tele-education activities.
Although there were variable opinions on the use of telemedicine technology for knowledge sharing, all expressed a desire to continue participating in EST activities. The vast majority ( > 95%) wished that the technology should be developed in other institutes and that it should be incorporated with other specialties. Furthermore, > 90% were of the opinion that the technology has a very important role in the future (Table 7). There was no significant difference between responses of the faculty and residents for any of the domains tested.
Discussion We are actively using telemedicine as a distance education tool as we have a resource crunch for endocrine surgery expertise in our
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Table 2. Assessment of Familiarity with the Technology QUESTION
OVERALL RESPONSE
FACULTY
RESIDENTS
Aware with scope and limitations of telemedicine
P VALUE 0.387
Yes
31 (86.11)
12 (85.71)
19 (86.36)
No
4 (11.11)
1 (7.14)
3 (13.64)
No answer
1 (2.78)
1 (7.14)
0 (0.00)
Read literature on telemedicine 21 (58.33)
8 (57.14)
13 (59.09)
No
15 (41.67)
6 (42.86)
9 (40.91)
Aware of research article on role of telemedicine in endocrine surgery 27 (75.00)
10 (71.43)
17 (77.27)
No
7 (19.44)
3 (21.43)
4 (18.18)
No answer
2 (5.56)
1 (7.14)
1 (4.55)
FACULTY
RESIDENTS
P VALUE 1.000
Yes
34 (94.44)
14 (100.00)
20 (90.91)
No
1 (2.78)
0 (0.00)
1 (4.55)
No answer
1 (2.78)
0 (0.00)
1 (4.55) 0.315
Yes
29 (80.56)
13 (92.86)
16 (72.73)
No
6 (16.67)
1 (7.14)
5 (22.73)
No answer
1 (2.78)
0 (0.00)
1 (4.55)
Networking with peers strengthened by attending EST
0.181
Written any research article on role of telemedicine in endocrine surgery
OVERALL RESPONSE
Learned new things by attending EST
0.910
Yes
QUESTION EST have helped in knowledge exchange
1.000
Yes
Table 3. Assessment of the Role of Telemedicine in Endocrine Surgery Knowledge Exchange
1.000
Yes
30 (83.33)
12 (85.71)
18 (81.82)
No
6 (16.67)
2 (14.29)
4 (18.18)
Numbers in parentheses indicate percentages. EST, endocrine surgery tele-education activities.
Yes
6 (16.67)
4 (28.57)
2 (9.09)
No
30 (83.33)
10 (71.43)
20 (90.91)
Knowledge regarding telemedicine
0.340
Very knowledgeable
1 (2.78)
1 (7.14)
0 (0.00)
Knowledgeable
9 (25.00)
5 (35.71)
4 (18.18)
Somewhat knowledgeable
23 (63.89)
7 (50.00)
16 (72.73)
Not at all knowledgeable
3 (8.33)
1 (7.14)
2 (9.09)
Numbers in parentheses indicate percentages.
country. Previously we published our experience with telemedicine technology and endocrine surgery and showed that telemedicine technology helped the trainees regarding reinforcement of knowledge and skills after a few years of completion of a short-term training in endocrine surgery.2
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In a recent randomized controlled study by Haney et al.3 from Florida, tele-education was used for skill development among paramedics, and they found no significant difference between videoconferencing and live didactic lectures when used for wound closure by the study population. Bertsch et al.4 concluded that interactive videoconferencing was an effective tool to teach clinical examination objectives, but when they compared it with in-person teaching of third-year internal medicine clerkship students, they found there were no significant difference in responses for both methods. Satisfaction surveys were also performed by other authors and found a high user ratings for tele-education sessions with no significant differences between online teaching and live classroom teaching.5–8 However, results of our study showed that surgeons prefer live classroom teaching over tele-education sessions. Similar results were also described by Kidd and Stamatakis,9 who found that live classroom teaching was significantly more effective than interactive videoconferencing for teaching clinical pharmacokinetics to students. Chipps et al.10 systematically reviewed the effectiveness of videoconference-based education and found five studies were eligible out of 312 studies selected for review. They found sufficient evidence to provide a grade B evidence-based recommendation11 of
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Table 4. Assessment of Role of Telemedicine in Endocrine Surgery Skill Development QUESTION
OVERALL RESPONSE
QUESTION FACULTY
RESIDENTS
Skill improved after participation in EST
P VALUE 0.473
Yes
20 (55.56)
6 (42.86)
14 (63.64)
No
6 (16.67)
3 (21.43)
3 (13.64)
10 (27.78)
5 (35.71)
5 (22.73)
No answer
Table 5. Assessment of Quality of Transmissions
Role of telemedicine in skill development in endocrine surgery
0.705
25 (69.44)
10 (71.43)
15 (68.18)
Somewhat beneficial
9 (25.00)
4 (28.57)
5 (22.73)
Not at all beneficial
1 (2.78)
0 (0.00)
1 (4.55)
No answer
1 (2.78)
0 (0.00)
Role of telementoring
0.740
RESIDENTS
10 (27.78)
4 (28.57)
6 (27.27)
Good
14 (38.89)
4 (28.57)
10 (45.45)
Fair
12 (33.33)
6 (42.86)
6 (27.27)
Poor
0 (0.00)
0 (0.00)
0 (0.00)
Quality of transmission of conferences
0.517
8 (22.22)
2 (14.29)
6 (27.27)
20 (55.56)
8 (57.14)
12 (54.55)
Fair
7 (19.44)
4 (28.57)
3 (13.64)
Poor
0 (0.00)
0 (0.00)
0 (0.00)
No answer
1 (2.78)
0 (0.00)
1 (4.55)
Role of telemedicine in conference transmissions
0.711
Beneficial
22 (61.11)
8 (57.14)
14 (63.64)
Beneficial
27 (75.00)
11 (78.57)
16 (72.73)
Somewhat beneficial
10 (27.78)
5 (35.71)
5 (22.73)
Somewhat beneficial
8 (22.22)
3 (21.43)
5 (22.73)
Not at all beneficial
1 (2.78)
0 (0.00)
1 (4.55)
Not at all beneficial
0 (0.00)
0 (0.00)
0 (0.00)
No answer
3 (8.33)
1 (7.14)
2 (9.09)
No answer
1 (2.78)
0 (0.00)
1 (4.55)
0.639
Role of telemedicine in clinical decisionmaking support Beneficial
26 (72.22)
10 (71.43)
16 (72.73)
Somewhat beneficial
8 (22.22)
4 (28.57)
4 (18.18)
Not at all beneficial
1 (2.78)
0 (0.00)
1 (4.55)
No answer
1 (2.78)
0 (0.00)
1 (4.55)
Numbers in parentheses indicate percentages. EST, endocrine surgery tele-education activities.
P VALUE 0.534
Excellent
Good
1 (4.55)
FACULTY
Quality of transmission of presentations
Excellent
Beneficial
OVERALL RESPONSE
Numbers in parentheses indicate percentages.
moderate support that nursing and medical education should consider videoconference-based teaching, which is at least as effective as face-to-face teaching in terms of knowledge gains. Similar to our results, Aas12 found that 83% of participants learned new things by taking part in tele-education sessions. Fahey et al.13 reported, when they surveyed individuals involved in child and family services, that 80% of sessions were highly informative, 68% reported gain in knowledge, 86% confirmed that the content of these sessions was very useful, and 80% of participants reported they changed their practice because of knowledge gained from these sessions. Similarly, increase in knowledge and skill level among nurses for neonatal resuscitation was found after attending tele-education sessions.14 Western Australia has a large telemedicine network, and in a recent survey of its activities, education was found to be the most important purpose for videoconferencing in country hospitals and
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Table 6. Assessment of Telemedicine Technology by Users QUESTION
OVERALL RESPONSE
FACULTY
RESIDENTS
Change in attitude while gaining experience with telemedicine technology
0.300
Yes
25 (69.44)
11 (78.57)
14 (63.64)
No
7 (19.44)
1 (7.14)
6 (27.27)
Somewhat
1 (2.78)
1 (7.14)
0 (0.00)
No answer
3 (8.33)
1 (7.14)
2 (9.09)
Enjoyed using telemedicine technology
0.890
Yes
32 (88.89)
12 (85.71)
20 (90.91)
No
2 (5.56)
1 (7.14)
1 (4.55)
No answer
2 (5.56)
1 (7.14)
1 (4.55)
Found learning with the use of telemedicine technology Very easy
0.678 7 (19.44)
4 (28.57)
3 (13.64)
12 (33.33)
5 (35.71)
7 (31.82)
Neither difficult nor easy
8 (22.22)
2 (14.29)
6 (27.27)
Moderately difficult
8 (22.22)
3 (21.43)
5 (22.73)
Very difficult
1 (2.78)
0 (0.00)
1 (4.55)
Moderately easy
Overall satisfaction with telemedicine technology
0.705
Excellent
10 (27.78)
4 (28.57)
6 (27.27)
Very good
15 (41.67)
6 (42.86)
9 (40.91)
Good
9 (25.00)
4 (28.57)
5 (22.73)
Fair
2 (5.56)
0 (0.00)
2 (9.09)
Poor
0 (0.00)
0 (0.00)
0 (0.00)
More beneficial for knowledge exchange Live classroom teaching EST Both equally good
P VALUE
0.318 18 (50.00)
5 (35.71)
13 (59.09)
3 (8.33)
1 (7.14)
2 (9.09)
15 (41.67)
8 (57.14)
7 (31.2)
Numbers in parentheses indicate percentages. EST, endocrine surgery tele-education activities.
nursing posts.15 We have also found similar results, with education being the most common telemedicine application. Another large study from the European Union project, HELLO DOC, done mainly for neurological patients, yielded high satisfaction rates among therapists.16 Demartines et al.17 tested the acceptance of telemedicine among surgeons and reported that surgeons are interested in telemedicine and open to its development. A simple method was devised by Azuh et al.18 to study telementoring among surgical residents and found favorable results. Previously we too had demonstrated the beneficial role of telementoring for a patient with residual primary hyperparathyroidism.19 Schlachta et al.20 described
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their experience with telementoring for laparoscopic colon surgery and found this method very useful. Our results were also comparable with those of Moser et al.,21 who in their survey of medical students reported that telemedicine has a very important future role (79%) and that students wish to attend lectures in telemedicine (77%) and got personally benefited from telemedicine (75%). Gschwendtner et al.23 surveyed medical students and found similar recommendations regarding the future role of telemedicine: 93% thought it will play a very important role, 75% wished to attend telesessions, and 84% had benefitted by telelearning.
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Table 7. Recommendations Regarding Future Role of Telemedicine Technology QUESTION
OVERALL RESPONSE
FACULTY
RESIDENTS
Would like to attend EST in future if provided an opportunity
NA
Yes
36 (100.00)
14 (100.00)
22 (100.00)
No
0 (0.00)
0 (0.00)
0 (0.00)
Institutes should create infrastructure for telemedicine to facilitate service and education.
1.000
Yes
35 (97.22)
14 (100.00)
21 (95.45)
No
1 (2.78)
0 (0.00)
1 (4.55)
Telemedicine knowledge exchange program should be applied to other medical and surgical subspecialties.
1.000
Yes
35 (97.22)
14 (100.00)
21 (95.45)
No
1 (2.78)
0 (0.00)
1 (4.55)
Future role of telemedicine technology in endocrine surgery Very important
P VALUE
0.689 33 (91.67)
13 (92.86)
20 (90.91)
Little importance
2 (5.56)
1 (7.14)
1 (4.55)
Not at all important
1 (2.78)
0 (0.00)
1 (4.55)
Numbers in parentheses indicate percentages. EST, endocrine surgery tele-education activities.
Conclusions
Disclosure Statement
Knowledge sharing for development of new subspecialties using telemedicine technology as a tool has been found to be successful. These research findings could satisfy policy makers to integrate the module for various other subspecialties to meet the capacity gap in a low-resource setting. However, there are certain shortcomings in our study. As it is a retrospective study, problems inherent to such kind of research are inevitable. Also, the study has used a custom-made questionnaire, which may have inherent deficiencies. Hence, there is a need to develop a standard validated questionnaire for evaluation of teleeducational practices.
Acknowledgments We would like to acknowledge the financial grants received from the following agencies of the Government of India for creation and sustenance of telemedicine infrastructure and activities at the School of Telemedicine & Biomedical Informatics, SGPGIMS, Lucknow: the Department of Electronics & Information Technology, Ministry of Communication & Information Technology; the Indian Space Research Organization; and the Ministry of Health & Family Welfare. We would also like to thank all the participants of this study and the technical staff at the School of Telemedicine and Biomedical Informatics and at the Department of Endocrine Surgery, SGPGIMS.
No competing financial interests exist.
REFERENCES 1. Norman G. Likert scales, levels of measurement and the ‘‘laws’’ of statistics. Adv Health Sci Educ Theory Pract 2010;15:625–632. 2. Pradeep PV, Mishra A, Mohanty BN, Mohapatra KC, Agarwal G, Mishra SK. Reinforcement of endocrine surgery training: Impact of telemedicine technology in a developing country context. World J Surg 2007;31:1665– 1671. 3. Haney M, Silvestri S, Van Dillen C, Ralls G, Cohen E, Papa L. A comparison of tele-education versus conventional lectures in wound care knowledge and skill acquisition. J Telemed Telecare 2012;18:79–81. 4. Bertsch TF, Callas PW, Rubin A, Caputo MP, Ricci MA. Effectiveness of lectures attended via interactive video conferencing versus in-person in preparing thirdyear internal clerkship students for clinical practice examinations (CPX). Teach Learn Med 2007;19:4–8. 5. Joshi A, Novaes MA, Iyengar S, Machivelli JL, Zhang J, Vogler R, Hsu CE. Evaluation of a tele-education programme in Brazil. J Telemed Telecare 2011;17:341–345. 6. Elison-Bowers P, Snelson C, Casa de Calvo M, Thompson H. Health science students and their learning environment: A comparison of perceptions of onsite, remote-site, and traditional classroom students. Perspect Health Inf Manag 2008;5:2. 7. Pereira BM, Calderan TR, Silva MT, Silva AC, Marttos AC Jr, Fraga GP. Initial experience at a university teaching hospital from using telemedicine to promote education through videoconferencing. Sao Paulo Med J 2012;130: 32–36.
ª M A R Y A N N L I E B E R T , I N C . VOL. 20
NO. 9 SEPTEMBER 2014
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AGRAWAL ET AL.
8. Andreazzi DB, Rossi F, Wen CL. Interactive tele-education applied to a distant clinical microbiology specialization university course. Telemed J E Health 2011;17:524–529. 9. Kidd RS, Stamatakis MK. Comparison of students’ performance in and satisfaction with a clinical pharmacokinetics course delivered live and by interactive videoconferencing. Am J Pharmaceut Educ 2006; 70:10.
18. Azuh O, Sen A, Ilan R, Shah N, Parker A, Blyden D, Broasy A, Velanovich V, Falvo A, Patton P. Heralding new ringtones of patient safety: Blackberry based clinical communication and telementoring in laparoscopic surgery. AMIA Annu Symp Proc 2009;23. 19. Pradeep PV, Mishra SK, Vaidyanathan S, Nair CG, Ramalingam K, Basnet R. Telementoring in endocrine surgery: Preliminary Indian experience. Telemed J E Health 2006;12:73–77.
10. Chipps J, Brysiewicz P, Mars M. A systematic review of the effectiveness of videoconference-based tele-education for medical and nursing education. Worldwide Evid Based Nurs 2012;9:78–87.
20. Schlachta CM, Lefebvre KL, Sordahl AK, Jayaraman S. Mentoring and telementoring leads to effective incorporation of laparoscopic colon surgery. Surg Endosc 2010;24:841–844.
11. How to use the evidence: assessment and application of scientific evidence, handbook series on preparing clinical practice guidelines. Canberra: National Health and Medical Research Council, 1999.
21. Moser PL, Hager M, Lorenz IH, Sogner P, Schubert HM, Mikuz G, Kolbitsch C. Acceptance of telemedicine and new media: A survey of Austrian medical students. J Telemed Telecare 2003;9:273–277.
12. Aas IH. Learning in organizations working with telemedicine. J Telemed Telecare 2002;8:107–111.
22. Gschwendtner A, Netzer T, Mairinger B, Mairinger T. What do students think about telemedicine? J Telemed Telecare 1997;3:169–171.
13. Fahey A, Day NA, Gelber H. Tele-education in child mental health for rural allied health workers. J Telemed Telecare 2003;9:84–88. 14. Jain A, Agarwal R, Chawla D, Paul V, Deorari A. Tele-education vs classroom training of neonatal resuscitation: A randomized trial. J Perinatol 2010;30:773–779. 15. Bahaadinbeigy K, Yogesan K, Wootton R. A survey of the state of telemedicine in Western Australia. J Telemed Telecare 2010;16:176–180. 16. Hermens H, Huijgen B, Giacomozzi C, Ilsbroukx S, Macellari V, Prats E, Rogante M, Schifini MF, Spitali MC, Tasies S, Zampolini M, Vollenbroek-Hutten M. Clinical assessment of the HELLODOC tele-rehabilitation service. Ann Ist Super Sanita 2008;44:154–163. 17. Demartines N, Freiermuth O, Mutter D, Heberer M, Harder F. Knowledge and acceptance of telemedicine in surgery: A survey. J Telemed Telecare 2000;6:125–131.
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Address correspondence to: Saroj Kanta Mishra, MS Department of Endocrine Surgery Sanjay Gandhi Postgraduate Institute of Medical Sciences Raibareli Road Lucknow 226014 India E-mail: [email protected] Received: May 4, 2013 Revised: December 4, 2013 Accepted: December 4, 2013
