595322
research-article2015
SRIXXX10.1177/1553350615595322Surgical InnovationPaiz et al
Letter to the Editor
Surgical Learning Application (app) for Smartphones and Tablets: A Potential Tool for Laparoscopic Surgery Teaching Courses
Surgical Innovation 1–2 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1553350615595322 sri.sagepub.com
Fabio Paiz, MD, MSc1, Eduardo A. Bonin, MD, MSc2, Leandro Totti Cavazzola, MD, MSc, PhD3, Antônio Moris Cury, MD, MSc2, Christiano M. P. Claus, MD, MSc2, Danielson Dimbarre, MD, MS2, and Marcelo de Paula Loureiro, MD, MSc, PhD1,2 Dear Editor: We present herein our experience in developing a medical application software for smartphone and tablets to be used in laparoscopic surgery teaching courses, such as the one at Jacques Perissat Institute, Brazil. The use of software programs, called medical applications (apps), has increased over recent years among medical students, residents, and surgeons.1 Although medical apps have become popular as reference for disease diagnosis and medical calculators,2 many of such programs have been devoted to medical education. In fact, medical apps for medical learning purposes took a step forward regarding app software use, as they rank second in number in 2014 with an estimated 800 apps.3 In the field of surgery, the number of available apps is relatively small compared with other medical areas, such as anesthesiology and radiology. For instance, for hernia surgery, one of the most common surgical procedures performed worldwide, a review in 2014 mentioned only 6 apps related to learning of anatomy and surgical techniques. Two of them were produced by pharmaceutical and devices companies, concerning their products.4 As software-learning platforms became part of medical curriculum over the years, the use of apps for medical learning seems natural, since smartphones and tablets are portable and facilitate on-demand access to medical contents. However, doctors’ general perception of medical app quality is low, and most of them agree that there is a need for quality assessment. In a survey of 115 urologists, data showed that they believe peer review (78%) and validation (78%) would be beneficial, and 48% supported regulatory oversight for medical app quality.5 Despite medical apps seen as a promising surgical learning tool, they lack quality assessment, and there are doubts if they are an effective educational tool. Content quality of medical education is always a concern, especially when electronic information is delivered.
Governance and legal framework have been proposed for apps designed to have a direct impact on clinical decisionmaking, including medication dose calculation, adjustment of therapy, and for diagnostic purposes.6 Despite these efforts, currently there are no formal requirements for quality control for surgical learning apps contents. Boulos et al7 have listed some requirements for online medical/healthrelated information resources, such as providing authorship information, list of all references or sources of contents, full disclosure of any app sponsorship or potential conflicts of interest, and finally ensuring a balanced and nonbiased coverage of facts. Accuracy of information can be evaluated through peer review, a process in which a panel of experts elaborate a critical analysis of content in which it can be either approved or not. Although it has been considered a “gold standard” method for evaluating scientific merit, one limitation of peer review is low interrater reliability. The number and allocation of reviewers is not well established; a minimum of 3 to 5 reviewers randomly selected from a pool of reviewers seems appropriate.8 Reviewer analysis may be obtained by a survey, with participants answering a Likert-type questionnaire based on accuracy, quality, and relevance of information. In October 2014, we at the Jacques Perissat Institute, Brazil, conceived a surgical learning app for tablet computer concerning abdominal wall (hernia) surgery (iPad, Apple, Cupertino, CA) including 3 basic elements—text, illustrations, and videos (available at https://itunes.apple. 1
Positivo University, Curitiba, Paraná, Brazil Jacques Perissat Institute, Curitiba, Paraná, Brazil 3 Universidade Federal do Rio Grande do Sul, Rio Grande do Sul, Brazil 2
Corresponding Author: Fabio Paiz, Rua Itália, 878/202, Erechim, Rio Grande do Sul, CEP 99700-000 Brazil. Email: [email protected]
Downloaded from sri.sagepub.com at UNIV OF PITTSBURGH on November 13, 2015
2
Surgical Innovation
com/br/app/laparoscopia-avancada-hernias/ id921621010?mt=8). Such elements were conceived for dynamic interaction and navigation of text as for illustrations, high-definition videos, and text references. Software evaluation was performed using a Likert-type questionnaire survey among surgeons and software users. Navigation and image quality were the main criteria for software analysis. We identified high-definition videos as a limitation for apps due to large-size files; as they need to be compressed, quality was somehow at risk. For content assessment, we selected 6 expert laparoscopic surgeons and recognized educators in Brazil. After a 1-month evaluation period, all surgeons responded, and 5 experts approved the text as for quality and relevance. Although we had a 100% response rate, responders were not blinded to authors. It seems reasonable that such a method could follow the same pathway adopted for peer-review manuscripts. The use of surgical learning apps can improve education of medical students, residents, and surgeons. They may learn, for example, several aspects in technique and anatomy, ultimately reflecting on how procedures are performed in the operating room. For a surgical learning app, one may also expect changes within the clinical routine, that is, surgical decision-making. Our next step is to implement our surgical learning app in our laparoscopic surgery postgraduate course, in which our apprentices will be exposed and evaluated on retention of basic concepts with regard to laparoscopic hernia surgery. The research agenda is open for prospective randomized trials comparing traditional paper or electronic learning methods versus surgical learning apps. Surgical learning apps have the potential of becoming part of modern surgical curriculum. For this, the introduction of such multimedia technologies in the surgical educational process should be encouraged and evaluated, always with the ultimate aim of patient care. Author Contributions Study concept and design: Fabio Paiz, Marcelo de Paula Loureiro Acquisition of data: Fabio Paiz, Eduardo A. Bonin, Antônio Moris Cury, Christiano M. P. Claus Analysis and interpretation: Fabio Paiz, Eduardo A. Bonin, Danielson Dimbarre, Leandro Totti Cavazzola Study supervision: Marcelo de Paula Loureiro
Authors’ Note This article was presented by Fabio Paiz, Oncologic Surgeon, MD, and approved in a scientific committee for obtaining a master’s degree in biotechnology from Positivo University (Curitiba, Paraná, Brazil), February 28, 2014.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Wallace S, Clark M, White J. “It’s on my iPhone”: attitudes to the use of mobile computing devices in medical education, a mixed-methods study. BMJ Open. 2012;2(4). doi:10.1136/bmjopen-2012-001099. 2. Payne KF, Wharrad H, Watts K. Smartphone and medical related App use among medical students and junior doctors in the United Kingdom (UK): a regional survey. BMC Med Inform Decis Mak. 2012;12:121. 3. Seabrook HJ, Stromer JN, Shevkenek C, Bharwani A, de Grood J, Ghali WA. Medical applications: a database and characterization of apps in Apple iOS and Android platforms. BMC Res Notes. 2014;27:573. 4. Connor K, Brady RR, de Beaux A, Tulloh B. Contemporary hernia smartphone applications (apps). Hernia. 2014;18: 557-561. 5. Dempster NJ, Risk R, Clark R, Meddings R. Urologists’ usage and perceptions of urological apps. J Telemed Telecare. 2014;20:450-453. 6. Charani E, Castro-Sánchez E, Moore LS, Holmes A. Do smartphone applications in healthcare require a governance and legal framework? It depends on the application! BMC Med. 2014;12:29. 7. Boulos MN, Brewer AC, Karimkhani C, Buller DB, Dellavalle RP. Mobile medical and health apps: state of the art, concerns, regulatory control and certification. Online J Public Health Inform. 2014;5:229. 8. Snell RR. Menage a quoi? Optimal number of peer reviewers. PLoS One. 2015;10:e0120838.
Downloaded from sri.sagepub.com at UNIV OF PITTSBURGH on November 13, 2015
research-article2015
SRIXXX10.1177/1553350615595322Surgical InnovationPaiz et al
Letter to the Editor
Surgical Learning Application (app) for Smartphones and Tablets: A Potential Tool for Laparoscopic Surgery Teaching Courses
Surgical Innovation 1–2 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1553350615595322 sri.sagepub.com
Fabio Paiz, MD, MSc1, Eduardo A. Bonin, MD, MSc2, Leandro Totti Cavazzola, MD, MSc, PhD3, Antônio Moris Cury, MD, MSc2, Christiano M. P. Claus, MD, MSc2, Danielson Dimbarre, MD, MS2, and Marcelo de Paula Loureiro, MD, MSc, PhD1,2 Dear Editor: We present herein our experience in developing a medical application software for smartphone and tablets to be used in laparoscopic surgery teaching courses, such as the one at Jacques Perissat Institute, Brazil. The use of software programs, called medical applications (apps), has increased over recent years among medical students, residents, and surgeons.1 Although medical apps have become popular as reference for disease diagnosis and medical calculators,2 many of such programs have been devoted to medical education. In fact, medical apps for medical learning purposes took a step forward regarding app software use, as they rank second in number in 2014 with an estimated 800 apps.3 In the field of surgery, the number of available apps is relatively small compared with other medical areas, such as anesthesiology and radiology. For instance, for hernia surgery, one of the most common surgical procedures performed worldwide, a review in 2014 mentioned only 6 apps related to learning of anatomy and surgical techniques. Two of them were produced by pharmaceutical and devices companies, concerning their products.4 As software-learning platforms became part of medical curriculum over the years, the use of apps for medical learning seems natural, since smartphones and tablets are portable and facilitate on-demand access to medical contents. However, doctors’ general perception of medical app quality is low, and most of them agree that there is a need for quality assessment. In a survey of 115 urologists, data showed that they believe peer review (78%) and validation (78%) would be beneficial, and 48% supported regulatory oversight for medical app quality.5 Despite medical apps seen as a promising surgical learning tool, they lack quality assessment, and there are doubts if they are an effective educational tool. Content quality of medical education is always a concern, especially when electronic information is delivered.
Governance and legal framework have been proposed for apps designed to have a direct impact on clinical decisionmaking, including medication dose calculation, adjustment of therapy, and for diagnostic purposes.6 Despite these efforts, currently there are no formal requirements for quality control for surgical learning apps contents. Boulos et al7 have listed some requirements for online medical/healthrelated information resources, such as providing authorship information, list of all references or sources of contents, full disclosure of any app sponsorship or potential conflicts of interest, and finally ensuring a balanced and nonbiased coverage of facts. Accuracy of information can be evaluated through peer review, a process in which a panel of experts elaborate a critical analysis of content in which it can be either approved or not. Although it has been considered a “gold standard” method for evaluating scientific merit, one limitation of peer review is low interrater reliability. The number and allocation of reviewers is not well established; a minimum of 3 to 5 reviewers randomly selected from a pool of reviewers seems appropriate.8 Reviewer analysis may be obtained by a survey, with participants answering a Likert-type questionnaire based on accuracy, quality, and relevance of information. In October 2014, we at the Jacques Perissat Institute, Brazil, conceived a surgical learning app for tablet computer concerning abdominal wall (hernia) surgery (iPad, Apple, Cupertino, CA) including 3 basic elements—text, illustrations, and videos (available at https://itunes.apple. 1
Positivo University, Curitiba, Paraná, Brazil Jacques Perissat Institute, Curitiba, Paraná, Brazil 3 Universidade Federal do Rio Grande do Sul, Rio Grande do Sul, Brazil 2
Corresponding Author: Fabio Paiz, Rua Itália, 878/202, Erechim, Rio Grande do Sul, CEP 99700-000 Brazil. Email: [email protected]
Downloaded from sri.sagepub.com at UNIV OF PITTSBURGH on November 13, 2015
2
Surgical Innovation
com/br/app/laparoscopia-avancada-hernias/ id921621010?mt=8). Such elements were conceived for dynamic interaction and navigation of text as for illustrations, high-definition videos, and text references. Software evaluation was performed using a Likert-type questionnaire survey among surgeons and software users. Navigation and image quality were the main criteria for software analysis. We identified high-definition videos as a limitation for apps due to large-size files; as they need to be compressed, quality was somehow at risk. For content assessment, we selected 6 expert laparoscopic surgeons and recognized educators in Brazil. After a 1-month evaluation period, all surgeons responded, and 5 experts approved the text as for quality and relevance. Although we had a 100% response rate, responders were not blinded to authors. It seems reasonable that such a method could follow the same pathway adopted for peer-review manuscripts. The use of surgical learning apps can improve education of medical students, residents, and surgeons. They may learn, for example, several aspects in technique and anatomy, ultimately reflecting on how procedures are performed in the operating room. For a surgical learning app, one may also expect changes within the clinical routine, that is, surgical decision-making. Our next step is to implement our surgical learning app in our laparoscopic surgery postgraduate course, in which our apprentices will be exposed and evaluated on retention of basic concepts with regard to laparoscopic hernia surgery. The research agenda is open for prospective randomized trials comparing traditional paper or electronic learning methods versus surgical learning apps. Surgical learning apps have the potential of becoming part of modern surgical curriculum. For this, the introduction of such multimedia technologies in the surgical educational process should be encouraged and evaluated, always with the ultimate aim of patient care. Author Contributions Study concept and design: Fabio Paiz, Marcelo de Paula Loureiro Acquisition of data: Fabio Paiz, Eduardo A. Bonin, Antônio Moris Cury, Christiano M. P. Claus Analysis and interpretation: Fabio Paiz, Eduardo A. Bonin, Danielson Dimbarre, Leandro Totti Cavazzola Study supervision: Marcelo de Paula Loureiro
Authors’ Note This article was presented by Fabio Paiz, Oncologic Surgeon, MD, and approved in a scientific committee for obtaining a master’s degree in biotechnology from Positivo University (Curitiba, Paraná, Brazil), February 28, 2014.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Wallace S, Clark M, White J. “It’s on my iPhone”: attitudes to the use of mobile computing devices in medical education, a mixed-methods study. BMJ Open. 2012;2(4). doi:10.1136/bmjopen-2012-001099. 2. Payne KF, Wharrad H, Watts K. Smartphone and medical related App use among medical students and junior doctors in the United Kingdom (UK): a regional survey. BMC Med Inform Decis Mak. 2012;12:121. 3. Seabrook HJ, Stromer JN, Shevkenek C, Bharwani A, de Grood J, Ghali WA. Medical applications: a database and characterization of apps in Apple iOS and Android platforms. BMC Res Notes. 2014;27:573. 4. Connor K, Brady RR, de Beaux A, Tulloh B. Contemporary hernia smartphone applications (apps). Hernia. 2014;18: 557-561. 5. Dempster NJ, Risk R, Clark R, Meddings R. Urologists’ usage and perceptions of urological apps. J Telemed Telecare. 2014;20:450-453. 6. Charani E, Castro-Sánchez E, Moore LS, Holmes A. Do smartphone applications in healthcare require a governance and legal framework? It depends on the application! BMC Med. 2014;12:29. 7. Boulos MN, Brewer AC, Karimkhani C, Buller DB, Dellavalle RP. Mobile medical and health apps: state of the art, concerns, regulatory control and certification. Online J Public Health Inform. 2014;5:229. 8. Snell RR. Menage a quoi? Optimal number of peer reviewers. PLoS One. 2015;10:e0120838.
Downloaded from sri.sagepub.com at UNIV OF PITTSBURGH on November 13, 2015
