ORIGINAL ARTICLE
Surgical Education Through Video Broadcasting Eric S. Nagengast,*†‡ Margarita S. Ramos, MD, MPH,§|| Hiteswar Sarma, MCh,# Gaurav Deshpande, MDS,# Kristin Hatcher, MPH,¶ William P. Magee, Jr, DDS, MD,¶ and Alex Campbell, MD¶ Abstract: Surgical training is facing new obstacles. As advancements in medicine are made, surgeons are expected to know more and to be able to perform more procedures. In the western world, increasing restrictions on residency work hours are adding a new hurdle to surgical training. In low-resource settings, a low attendingto-resident ratio results in limited operative experience for residents. Advances in telemedicine may offer new methods for surgical training. In this article, the authors share their unique experience using live video broadcasting of surgery for educational purposes at a comprehensive cleft care center in Guwahati, India. Key Words: Telesurgery, cleft lip and palate, telemedicine, surgical education
of the global burden of disease but only 3% of the world’s health care workers.3 To combat this problem, 76% of existing subSaharan medical schools are increasing enrollment even though most are short faculty and do not have the finances or infrastructure to support the medical schools.4–6 In these locations, it is not uncommon to see five or more residents attempting to observe one surgery. As many of us know from our own training, it is very hard to see or learn surgical technique with two residents in one case, let alone eight or nine. Video broadcasting surgery is one innovative way residents in both low-resource and high-resource environments could gain more surgical experience. We would like to share our experiences with broadcasting live surgeries at the Operation Smile Guwahati Comprehensive Cleft Care Center (GCCCC) in Guwahati, India.
METHODS
(J Craniofac Surg 2014;25: 1619–1621)
A
s clinical practice becomes increasingly complex, and resident duty hours are further restricted, more and more surgeons claim to be insufficiently prepared for operating independently after residency. In fact, in a survey conducted by Coleman et al in 2013, 23% of chief residents in general surgery in the United States responded "no" or "unsure" when asked if a 5-year general surgery residency fully prepares you to practice general surgery.1 Similarly, 21% of fellowship directors felt that new fellows arrive unprepared for the operating room.2 These statistics are alarming, and surgical residencies must adapt their training to keep up with the rapidly evolving field of surgery. Indeed, the United States is not the only place where surgical resident training needs improvement. Sub-Saharan Africa has 24% What Is This Box? A QR Code is a matrix barcode readable by QR scanners, mobile phones with cameras, and smartphones. The QR Code links to the online version of the article.
From the *Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts; †Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts; ‡University of Nebraska College of Medicine, Omaha, Nebraska; §Center for Surgery and Public Health, Brigham and Women´s Hospital, Boston, Massachusetts; ||Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts; #Guwahati Comprehensive Cleft Care Center, Guwahati, India; and ¶Operation Smile, Virginia Beach, Virginia. Received March 28, 2014. Accepted for publication June 13, 2014. Address correspondence and reprint requests to Alex Campbell, MD, Operation Smile, 3641 Faculty Boulevard, Virginia Beach, VA 23453; E-mail: [email protected] The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001143
Inaugurated in February 2011, the GCCCC was built to be a state-of-the-art facility set in an area of intense need. This modern surgical center was designed to include an integrated operating suite with an open layout to facilitate communication, efficiency, and safety. Though the chief mission of the center is to bring comprehensive cleft care to the people of northeast India, education is also a top priority. The operating theater was designed to transcend hands on education and includes internet technology in the operating room to transmit surgery to any place in the world. Every operating table has a light with a high-definition camera in the light handle. Additionally, stationary cameras may be set up and portable handheld cameras can be used simultaneously. This way, all operations are able to be recorded from multiple angles. Above the foot of each operating table is a high-definition screen offering the surgical team the view of the overhead camera. The operating room is also equipped with speakers and wireless headsets allowing someone out of the room to talk with the surgeon during the operation.
Experience During the GCCCC Cleft Conference 2013 In November 2013, Operation Smile hosted a cleft conference in Guwahati, India. As part of this conference, live operations were held at the GCCCC, some of which were performed by visiting expert surgeons. During the surgeries, three angles of the operation were recorded: one from the foot of the bed, one from a mobile handheld camera, and one from over head in the light handle (Figs. 1 and 2). The operations were broadcasted live on highdefinition screens in a nearby conference room. The surgeons wore a headset microphone, and the observers in the conference room had a microphone allowing live conversation during the operation. Video broadcasting was used during a variety of facial reconstructive operations including cleft lip and palate repairs and revisions, rhinoplasties, and other more complex craniofacial operations. This setup created a fertile learning environment. The overhead camera gave the observers the surgeon’s vantage point. The camera at the foot of the bed allowed the viewers to see room setup, and the mobile camera was moved to supplement the overhead
The Journal of Craniofacial Surgery • Volume 25, Number 5, September 2014
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
1619
The Journal of Craniofacial Surgery • Volume 25, Number 5, September 2014
Nagengast et al
FIGURE 3. The interaction room during the live surgery broadcast. Note two simultaneous cases and different camera views. Also, note the moderator at the front leading the discussion.
FIGURE 1. An ongoing operation while video broadcasting. Note the camera in the overhead light handle and the handheld supplementary camera.
camera. Before the operation, the surgeon was able to explain the operation plan and interact with the audience regarding alternative considerations. Any interesting or complex part of the operation was coupled with a detailed explanation in real time. A surgeon moderator in the viewing area stimulated discussion and facilitated questions from the audience to the surgeon throughout the case. Audience members also interacted with each other as various aspects of the procedure were discussed. Two procedures were broadcast simultaneously so that the audience could switch back and forth to maximize efficiency and stimulation (Figs. 3 and 4).
DISCUSSION The GCCCC’s interactive live surgery model offers a number of advantages over the traditional operating theater learning. First, this model can accommodate a large number of observers without increasing the number of people in the operating room. Clinical flow is not disrupted, and audiovisual specialists are tasked with all of the broadcast logistics. During the GCCCC conference in
FIGURE 2. An ongoing operation while video broadcasting. The high-definition monitor above the foot of the bed demonstrates an excellent view of the surgical field. A third camera is at the foot of the bed to show the operating room setup.
1620
November 2013, over 30 people were observing and interacting with a surgeon at one time. Another advantage of high-definition cameras and the option of multiple cameras is that the observers can see much better than if they were crowded around the table, and the case does not have to pause as different observers take their turn looking at what just took place. The live conversation with the surgeon is extremely advantageous as the surgeon can narrate exactly what he or she is doing and how he or she is doing it. The group learning that this educational model offers is also advantageous. Students learn well from others’ questions or from listening to interactions between their superiors. Accomplished surgeons also have a unique forum to discuss the fine points of techniques and experience with one another to determine best practices. The different advantages to this form of surgical education are applicable to surgical training in both the developed and the developing world. If there is a rare or complicated case that all residents would benefit from seeing, then the whole team could observe together, either live or via a recording. In areas with a high ratio of residents to attendings, this model could give a better operative view to the residents than crowding around a table. Receiving broadcasts from around the world, trainees in low-resource settings could learn from a wide range of operations and specialties. Additionally, specialized centers such as the GCCCC have appeal to students in high-resource settings due to the volume of cases and experience of providers. Interactive video surgery, though it has a great deal to offer, does have drawbacks. The live video streaming also requires a great deal of technology, which is expensive and requires technicians for upkeep. In areas that already are constrained by lack of financial resources, these requirements may be an issue. Along with these
FIGURE 4. The audience partaking in group learning during the live surgical broadcasting during GCCCC.
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 25, Number 5, September 2014
problems, the technology is not always reliable. Internet connection may not be readily available in remote areas and, when available, it is often not adequate. But, as the technology advances, these problems will lessen. Another potential challenge to this model is patient privacy. Patients must consent to having their operation recorded or broadcasted for educational purposes, and protection of sensitive data is also a requirement. At GCCCC, the patient consent form has a section for consent to video recording of surgery and the use of the video for educational purposes. And, as is the case at GCCCC, the patient’s choice to consent should not affect their ability to receive medical care. Certainly, there are challenges to implementation of the interactive surgical broadcasting, but potential benefits seem well worth the investment. Telesurgery, or telemedicine in the surgical field, has been used for education, proctoring, robotic surgery, conferencing, and consultation.7–11 Broadcasting surgery for educational purposes is not a new idea.8,9 However, our experience at GCCCC shows this technology can be used successfully during facial reconstruction and that this can be done in a middle-income country.
CONCLUSIONS Observing surgery cannot replace live hands-on surgical training. Residents will still need to learn in the operating room. But, if we become complacent with our current training strategies, then the shortage of adequately trained surgeons will only get worse. The live-stream interactive surgery from the Guwahati Comprehensive Cleft Care Center gives access to precious intraoperative learning. Use of this technology will be advantageous to surgical training in high-, middle-, and low-income environments. ACKNOWLEDGMENTS This manuscript was composed with data provided by the Guwahati Comprehensive Cleft Care Center (Assam, India), located at the Mahendra Mohan Choudhury Hospital, Guwahati.
Surgical Education Through Video Broadcasting
The authors acknowledge the support of the Government of Assam, the National Rural Health Mission, the Sir Dorabji Tata Trust and Allied Trusts, Operation Smile International, and Operation Smile India for providing infrastructure and funding to ensure that all patients at this center are treated free of costs with no commercial or financial gains to any member of the team.
REFERENCES 1. Coleman JJ, Esposito TJ, Rozycki GS, et al. Early subspecialization and perceived competence in surgical training: are residents ready?. J Am Coll Surg 2013;216:764–771 2. Mattar SG, Alseidi AA, Jones DB, et al. General surgery residency inadequately prepares trainees for fellowship: results of a survey of fellowship program directors. Ann Surg 2013;258:440–449 3. World Health Organization. The World Health Report 2006: working together for health 2006. Available: http://www.who.int/entity/whr/ 2006/en. Accessed February 22, 2009 4. Mullan F, Frehywot S, Omaswa F, et al. Medical schools in sub-Saharan Africa. Lancet 2011;377:1113–1121 5. Frenk J, Chen L, Bhutta ZA, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet 2010;376:1923–1958 6. Celletti F, Reynolds TA, Wright A, et al. Educating a new generation of doctors to improve the health of populations in low- and middle-income countries. PLoS Med 2011;8:e1001108 7. Gambadauro P, Torrejon R. The “tele” factor in surgery today and tomorrow: implications for surgical training and education. Surg Today 2013;43:115–122 8. Dekastle R. Telesurgery: providing remote surgical observations for students. AORN J 2009;90:93–101 9. McCarthy PM. Going live: implementing a telesurgery program. AORN J 2010;92:544–552 10. Joseph B, Hadeed G, Sadoun M, et al. Video consultation for trauma and emergency surgical patients. Crit Care Nurs Q 2012;35:341–345 11. Augestad KM, Lindsetmo RO. Overcoming distance: video-conferencing as a clinical and educational tool among surgeons. World J Surg 2009;33:1356–1365
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
1621
Surgical Education Through Video Broadcasting Eric S. Nagengast,*†‡ Margarita S. Ramos, MD, MPH,§|| Hiteswar Sarma, MCh,# Gaurav Deshpande, MDS,# Kristin Hatcher, MPH,¶ William P. Magee, Jr, DDS, MD,¶ and Alex Campbell, MD¶ Abstract: Surgical training is facing new obstacles. As advancements in medicine are made, surgeons are expected to know more and to be able to perform more procedures. In the western world, increasing restrictions on residency work hours are adding a new hurdle to surgical training. In low-resource settings, a low attendingto-resident ratio results in limited operative experience for residents. Advances in telemedicine may offer new methods for surgical training. In this article, the authors share their unique experience using live video broadcasting of surgery for educational purposes at a comprehensive cleft care center in Guwahati, India. Key Words: Telesurgery, cleft lip and palate, telemedicine, surgical education
of the global burden of disease but only 3% of the world’s health care workers.3 To combat this problem, 76% of existing subSaharan medical schools are increasing enrollment even though most are short faculty and do not have the finances or infrastructure to support the medical schools.4–6 In these locations, it is not uncommon to see five or more residents attempting to observe one surgery. As many of us know from our own training, it is very hard to see or learn surgical technique with two residents in one case, let alone eight or nine. Video broadcasting surgery is one innovative way residents in both low-resource and high-resource environments could gain more surgical experience. We would like to share our experiences with broadcasting live surgeries at the Operation Smile Guwahati Comprehensive Cleft Care Center (GCCCC) in Guwahati, India.
METHODS
(J Craniofac Surg 2014;25: 1619–1621)
A
s clinical practice becomes increasingly complex, and resident duty hours are further restricted, more and more surgeons claim to be insufficiently prepared for operating independently after residency. In fact, in a survey conducted by Coleman et al in 2013, 23% of chief residents in general surgery in the United States responded "no" or "unsure" when asked if a 5-year general surgery residency fully prepares you to practice general surgery.1 Similarly, 21% of fellowship directors felt that new fellows arrive unprepared for the operating room.2 These statistics are alarming, and surgical residencies must adapt their training to keep up with the rapidly evolving field of surgery. Indeed, the United States is not the only place where surgical resident training needs improvement. Sub-Saharan Africa has 24% What Is This Box? A QR Code is a matrix barcode readable by QR scanners, mobile phones with cameras, and smartphones. The QR Code links to the online version of the article.
From the *Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts; †Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts; ‡University of Nebraska College of Medicine, Omaha, Nebraska; §Center for Surgery and Public Health, Brigham and Women´s Hospital, Boston, Massachusetts; ||Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts; #Guwahati Comprehensive Cleft Care Center, Guwahati, India; and ¶Operation Smile, Virginia Beach, Virginia. Received March 28, 2014. Accepted for publication June 13, 2014. Address correspondence and reprint requests to Alex Campbell, MD, Operation Smile, 3641 Faculty Boulevard, Virginia Beach, VA 23453; E-mail: [email protected] The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001143
Inaugurated in February 2011, the GCCCC was built to be a state-of-the-art facility set in an area of intense need. This modern surgical center was designed to include an integrated operating suite with an open layout to facilitate communication, efficiency, and safety. Though the chief mission of the center is to bring comprehensive cleft care to the people of northeast India, education is also a top priority. The operating theater was designed to transcend hands on education and includes internet technology in the operating room to transmit surgery to any place in the world. Every operating table has a light with a high-definition camera in the light handle. Additionally, stationary cameras may be set up and portable handheld cameras can be used simultaneously. This way, all operations are able to be recorded from multiple angles. Above the foot of each operating table is a high-definition screen offering the surgical team the view of the overhead camera. The operating room is also equipped with speakers and wireless headsets allowing someone out of the room to talk with the surgeon during the operation.
Experience During the GCCCC Cleft Conference 2013 In November 2013, Operation Smile hosted a cleft conference in Guwahati, India. As part of this conference, live operations were held at the GCCCC, some of which were performed by visiting expert surgeons. During the surgeries, three angles of the operation were recorded: one from the foot of the bed, one from a mobile handheld camera, and one from over head in the light handle (Figs. 1 and 2). The operations were broadcasted live on highdefinition screens in a nearby conference room. The surgeons wore a headset microphone, and the observers in the conference room had a microphone allowing live conversation during the operation. Video broadcasting was used during a variety of facial reconstructive operations including cleft lip and palate repairs and revisions, rhinoplasties, and other more complex craniofacial operations. This setup created a fertile learning environment. The overhead camera gave the observers the surgeon’s vantage point. The camera at the foot of the bed allowed the viewers to see room setup, and the mobile camera was moved to supplement the overhead
The Journal of Craniofacial Surgery • Volume 25, Number 5, September 2014
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
1619
The Journal of Craniofacial Surgery • Volume 25, Number 5, September 2014
Nagengast et al
FIGURE 3. The interaction room during the live surgery broadcast. Note two simultaneous cases and different camera views. Also, note the moderator at the front leading the discussion.
FIGURE 1. An ongoing operation while video broadcasting. Note the camera in the overhead light handle and the handheld supplementary camera.
camera. Before the operation, the surgeon was able to explain the operation plan and interact with the audience regarding alternative considerations. Any interesting or complex part of the operation was coupled with a detailed explanation in real time. A surgeon moderator in the viewing area stimulated discussion and facilitated questions from the audience to the surgeon throughout the case. Audience members also interacted with each other as various aspects of the procedure were discussed. Two procedures were broadcast simultaneously so that the audience could switch back and forth to maximize efficiency and stimulation (Figs. 3 and 4).
DISCUSSION The GCCCC’s interactive live surgery model offers a number of advantages over the traditional operating theater learning. First, this model can accommodate a large number of observers without increasing the number of people in the operating room. Clinical flow is not disrupted, and audiovisual specialists are tasked with all of the broadcast logistics. During the GCCCC conference in
FIGURE 2. An ongoing operation while video broadcasting. The high-definition monitor above the foot of the bed demonstrates an excellent view of the surgical field. A third camera is at the foot of the bed to show the operating room setup.
1620
November 2013, over 30 people were observing and interacting with a surgeon at one time. Another advantage of high-definition cameras and the option of multiple cameras is that the observers can see much better than if they were crowded around the table, and the case does not have to pause as different observers take their turn looking at what just took place. The live conversation with the surgeon is extremely advantageous as the surgeon can narrate exactly what he or she is doing and how he or she is doing it. The group learning that this educational model offers is also advantageous. Students learn well from others’ questions or from listening to interactions between their superiors. Accomplished surgeons also have a unique forum to discuss the fine points of techniques and experience with one another to determine best practices. The different advantages to this form of surgical education are applicable to surgical training in both the developed and the developing world. If there is a rare or complicated case that all residents would benefit from seeing, then the whole team could observe together, either live or via a recording. In areas with a high ratio of residents to attendings, this model could give a better operative view to the residents than crowding around a table. Receiving broadcasts from around the world, trainees in low-resource settings could learn from a wide range of operations and specialties. Additionally, specialized centers such as the GCCCC have appeal to students in high-resource settings due to the volume of cases and experience of providers. Interactive video surgery, though it has a great deal to offer, does have drawbacks. The live video streaming also requires a great deal of technology, which is expensive and requires technicians for upkeep. In areas that already are constrained by lack of financial resources, these requirements may be an issue. Along with these
FIGURE 4. The audience partaking in group learning during the live surgical broadcasting during GCCCC.
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 25, Number 5, September 2014
problems, the technology is not always reliable. Internet connection may not be readily available in remote areas and, when available, it is often not adequate. But, as the technology advances, these problems will lessen. Another potential challenge to this model is patient privacy. Patients must consent to having their operation recorded or broadcasted for educational purposes, and protection of sensitive data is also a requirement. At GCCCC, the patient consent form has a section for consent to video recording of surgery and the use of the video for educational purposes. And, as is the case at GCCCC, the patient’s choice to consent should not affect their ability to receive medical care. Certainly, there are challenges to implementation of the interactive surgical broadcasting, but potential benefits seem well worth the investment. Telesurgery, or telemedicine in the surgical field, has been used for education, proctoring, robotic surgery, conferencing, and consultation.7–11 Broadcasting surgery for educational purposes is not a new idea.8,9 However, our experience at GCCCC shows this technology can be used successfully during facial reconstruction and that this can be done in a middle-income country.
CONCLUSIONS Observing surgery cannot replace live hands-on surgical training. Residents will still need to learn in the operating room. But, if we become complacent with our current training strategies, then the shortage of adequately trained surgeons will only get worse. The live-stream interactive surgery from the Guwahati Comprehensive Cleft Care Center gives access to precious intraoperative learning. Use of this technology will be advantageous to surgical training in high-, middle-, and low-income environments. ACKNOWLEDGMENTS This manuscript was composed with data provided by the Guwahati Comprehensive Cleft Care Center (Assam, India), located at the Mahendra Mohan Choudhury Hospital, Guwahati.
Surgical Education Through Video Broadcasting
The authors acknowledge the support of the Government of Assam, the National Rural Health Mission, the Sir Dorabji Tata Trust and Allied Trusts, Operation Smile International, and Operation Smile India for providing infrastructure and funding to ensure that all patients at this center are treated free of costs with no commercial or financial gains to any member of the team.
REFERENCES 1. Coleman JJ, Esposito TJ, Rozycki GS, et al. Early subspecialization and perceived competence in surgical training: are residents ready?. J Am Coll Surg 2013;216:764–771 2. Mattar SG, Alseidi AA, Jones DB, et al. General surgery residency inadequately prepares trainees for fellowship: results of a survey of fellowship program directors. Ann Surg 2013;258:440–449 3. World Health Organization. The World Health Report 2006: working together for health 2006. Available: http://www.who.int/entity/whr/ 2006/en. Accessed February 22, 2009 4. Mullan F, Frehywot S, Omaswa F, et al. Medical schools in sub-Saharan Africa. Lancet 2011;377:1113–1121 5. Frenk J, Chen L, Bhutta ZA, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet 2010;376:1923–1958 6. Celletti F, Reynolds TA, Wright A, et al. Educating a new generation of doctors to improve the health of populations in low- and middle-income countries. PLoS Med 2011;8:e1001108 7. Gambadauro P, Torrejon R. The “tele” factor in surgery today and tomorrow: implications for surgical training and education. Surg Today 2013;43:115–122 8. Dekastle R. Telesurgery: providing remote surgical observations for students. AORN J 2009;90:93–101 9. McCarthy PM. Going live: implementing a telesurgery program. AORN J 2010;92:544–552 10. Joseph B, Hadeed G, Sadoun M, et al. Video consultation for trauma and emergency surgical patients. Crit Care Nurs Q 2012;35:341–345 11. Augestad KM, Lindsetmo RO. Overcoming distance: video-conferencing as a clinical and educational tool among surgeons. World J Surg 2009;33:1356–1365
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
1621
