As I foreshadowed in my earlier article (“Telemedicine: Much More than Doctor-Patient Video Visits”), the range of applications for real-time, high quality video in the hospital setting is growing rapidly.    

In this third article in the "Reimagining Telemedicine" series, I will focus on recent applications of live video and multi-party audio for medical education, and how it is being used to train medical students, residents, fellows, surgeons in training, Speech Language Pathologists, and other medical practitioners...  

Is “See One, Do One, Teach One” (SODOTO) Passé for Medical Education?

Since the 1890s, when W.S. Halstead of Johns Hopkins Hospital first introduced it – the practice of “See One, Do One, Teach One” (SODOTO) has long been embraced as an effective method to train medical students, and surgical residents in particular.  

While the SODOTO approach to medical education served medical schools, clinicians, and patients well for more than a century-- the world has changed, and medicine with it.  

Without medical progress we’ve seen since Halstead’s time, doctors might still be practicing barbaric treatments (washing hair with gasoline to remove head lice, forcing patients to swallow mercury syphilis, or prescribing starvation diets to prevent aneurysms).   

Amidst medical advances brought by new technologies, devices, and drugs -- today’s healthcare is also influenced by new factors including insurance coverage, reducing the cost of care, heightened concern for patient safety, HIPAA compliance, and a growing volume of malpractice lawsuits from overzealous lawyers.   

Given this, as Kotsis and Chung wrote in an 2013 article published in Plastic and Reconstructive Surgery, some critics have argued that the SODOTO method of surgical training is passé, contending that “patient safety is at risk with this type of teaching because students are unable to safely perform a medical procedure after only seeing it once.”  

That same article also suggested it has been reported that inadequate knowledge, experience, and/or supervision are the causes of medical mistakes, and that “the high rate of preventable medical errors supports patients’ fear of being ‘practiced’ on.”  

SODOTO: More Valuable Than Ever in Medical Learning  

Despite these concerns, Kotsis and Chung concluded (rightly I think), that the “See One, Do One, Teach One” method of medical learning is still applicable, and “can be built upon and greatly enhanced with various learning principles, committed mentors, and advanced technology.”  

The value of mentored practice is supported by the thesis Malcolm Gladwell made in his 2008 book Outliers: The Story of Success: that it takes many hours of concerted effort and practice to become a true expert in any field. As Gladwell wrote in Outliers: “Practice isn't the thing you do once you're good. It's the thing you do that makes you good.” Importantly, Gladwell also noted that those who are most successful also have great teachers and coaches.

SODOTO 2.0: Redefining Medical Education 

As I’ll explain through real-world examples, the introduction of live medical video and multi-party audio communications into medical training, has redefined the SEE/DO/TEACH paradigm – expanding from “ONE” to “MANY MORE.” 

Now, today’s students can: 

• SEE MANY MORE (procedures and simulations) because they can watch via live and archived video.
• DO MANY MORE (procedures) while under the watchful eye of remote expert mentors in real time. 

Also…

• Educators can TEACH MANY MORE (students and junior practitioners), who can interact with teachers and other students during procedures (regardless of their location).

Experience, Observation, and Action are Critical Components of Medical Education  

Made possible by new technologies – the sharing of real-time, high quality video and interactive audio with medical trainees (throughout and beyond their formal education and certifications) is the embodiment of two widely heralded models for higher education:  

Kolb’s Cycle of “Learning by Doing”   

Through which experience, observation, learning and action are blended together for lifelong hands-on experiential learning.  

 The ‘New’ Bloom’s Taxonomy   

Through which Lorin Anderson and David Krathwohl updated Benjamin Bloom’s classic 1956 cognitive taxonomy on the importance of how “Creating, Evaluating, Analyzing, Applying, Understanding, and Remembering” are essential elements of knowledge. Beyond acquiring typical factual and conceptual learning, current medical students at Eastern Virginia Medical School (and elsewhere) benefit from special focus on “Applying” lessons learned through hands-on procedural experience (including how to do something, methods of inquiry, and criteria for using skills, algorithms, techniques, and methods.)

 

Telemedicine in Medical Education 

To figuratively and literally illustrate how these learning models are being used today, here are examples of how forward-looking hospitals and medical education leaders are using live video with multi-party audio and advanced imaging to improve students’ ability to evaluate, analyze, understand, and remember. 

 

Telestration in Medical Education: 

Montefiore Medical Center and Albert Einstein College of Medicine   

Montefiore Medical Center presents a notable example of the use of live medical video for both clinical care and medical education. Rated one of New York City’s “best” care facilities, Montefiore Medical Center is also the primary teaching hospital of the Albert Einstein College of Medicine. One of the largest medical residency programs in the country, Montefiore provides post graduate clinical training to more than 1,400 residents across 150 accredited resident/and fellowship programs.  

Amongst Montefiore’s wide range of specialties, its expertise in clinical radiology is one that stands out as particularly innovative. As Einstein ECM Professor and Director of the Division of Vascular and Interventional Radiology at Montefiore Medical Center, Jacob Cynamon, MD is a pioneer in the use of live medical video as both an educational tool, and as a clinical adjunct for anatomical diagnosis, assessment, and access.  

In an article co-authored with Kevin “Chaim” Herman, MD for EV Today, titled “Telestrator Uses in the Cath Lab,” Dr. Cynamon detailed use of real-time fluoroscopic video imaging (specifically a telestrator) as “both an educational and adjunctive procedural tool” in a catheterization lab or an operating room. While many of us may not have used a telestrator, it is a device that allows its operator to draw a freehand sketch over a moving or still video image,  which should be very familiar to anyone who ever watched the immortal TV sports commentator John Madden draw lines and squiggles over video to show what just happened in an NFL football game. 

When used by experienced radiologists, a telestrator can be used to highlight anatomical details and precisely convey crucial information to a healthcare team that might be located far from the patient and their in-process procedure. 

Using the TIMS Consultant video system, Dr. Cynamon can conduct and securely live stream procedures to students (medical fellows) who watch remotely and ask questions of him. Telestrating directly from the procedure theater, he can point out areas of interest (e.g. problematic blood vessels) to students in real time. 

Telementoring and Teleproctoring in Medical Education:  Training Speech Language Pathologists at Northwestern University 

Through its Swallowing Cross-Systems Collaborative, Northwestern Memorial Hospital, and Feinberg School of Medicine, Northwestern University is a longtime innovator in the treatment of “communications disorders” (language and speech problems) impacting 40 million Americans. 

Medical pros who diagnose and treat communications disorders are known as “Speech Language Pathologists.” SLPs undergo a rigorous training program (combining a 2-year master’s degree, supervised clinical experiences, passing a national certification exam, and completion of a year-long fellowship), before they are qualified.   

Surveys of certified SLPs show that having sufficient time to observe studies and procedures with actual patients is crucial to their education and success as practitioners. 

As typical radiological suites (where videofluoroscopic imaging of patients is captured) are very cramped, there is little physical room for SLPs-in-training watch or participate in procedures. 

To address this issue, Northwestern has deployed a TIMS Consultant system which securely transmits live video and audio from the hospital to remote locations and participants. 

This Provides Quadruple Benefits: 

1. Means for interprofessional remote collaboration on complex cases. 
2. Frequent opportunities for students to observe simulations & patient procedures, and 
3. Unique telementoring and teleproctoring platform that jointly connects Northwestern’s experts/professors to students via interactive video and audio in real-time. 
4. Superior procedural outcomes and improved patient quality of care. 

Northwestern Prof. Bonnie Martin-Harris, PhD described this innovation as a major step forward in the education of speech pathologists in a 2020 commencement address saying:  “You are the FIRST to experience the introduction of novel clinical experiences through remote, interactive technologies...FIRST to be involved in fast tracking the approval and implementation of telepractice methods for patients.” 

Speech pathology is not the only medical specialty that is seeing tangible benefits from these new technologies

A 2016 Current Trauma paper “Telementoring and Teleproctoring in Trauma and Emergency Care” favorably describes telemedicine capabilities as “new tools for expanding the reach of surgeon as skilled provider and proctor or mentor.” 

The authors of that article (Doarn & Latifi) go even further, projecting that:  “Advances in technology, including telemedicine and telepresence applications for trauma, emergency management, and intensive critical care, may be the solution that can reduce, eliminate, or ameliorate the gap in trauma care between rural and urban areas.” 

Simulations and Hands-On Experiences are Integral to Modern Medical Education: The New Kaiser Permanente School of Medicine  

As shown by these examples from hospitals in New York and Chicago, advanced imaging and collaboration through real-time medical video is increasingly important for teaching and practicing medicine. 

In August 2020, the nation’s newest medical school (the Kaiser Permanente Bernard J. Tyson School of Medicine ) opened its doors, both physically and virtually. 

Backed by Kaiser Permanente (largest managed care organization in the United States), the @KPMedSchool sees reimagining medical education as part of its charter. KP’s Tyson School stands out from older institutions through a modern integrated curriculum and a thoughtful hands-on learning environment furnished by its state-of-the-art Simulation Center. 

Kaiser sees this as a major differentiator for prospective med school enrollees, with its website exhorting “you won’t have to wait until your third year for hands-on experience: You’ll join a clinical care team almost as soon as you arrive.” 

Long before the opening of its medical school, Kaiser Permanente has been using TIMS Consultant for teleconsultations since 2015. Currently, TIMS Consultant systems are used by KP urologists, in live pathology slide reviews (to gain consensus between pathologists in different hospitals); for the mentoring of fellows during procedures; as well as to assist in educating clinicians in the conduct of new procedures at Kaiser facilities nationwide. Given the growing adoption of teleproctoring and telementoring in multiple Kaiser Permanente medical centers this new way of seeing and collaborating is catching the attention of the faculty of its new medical school. 

As Edward M. Ellison, MD (executive sponsor and board member for the school) said in an interview with Healthcare IT News: "Teaching physicians new and collaborative ways to practice medicine is critical to ensuring high-quality care in the future."  

Telemedicine: Taking “See One, Do One Teach One” Medical Education Forward in the 21st Century 

From the nation’s newest medical school (the @KPMedSchool) to its oldest (The Perelman School of Medicine at the University of Pennsylvania), it’s certain that live medical video and other forms of telemedicine are here to stay.  

While its long-term effects remain to be seen, the COVID-19 pandemic has had a significant impact on how everyone from kindergarten kids to post-doctoral scholars will learn.  

Quoted in a May 2020 Harvard Gazette article (titled “Harvard Medical School uses telemedicine as a way forward”), John Dalyrmple, associate dean at Harvard Medical School declared the reality that telemedicine “will be an important curricular element from now on.”   

Much as On-Screen, On-Demand, On-Time telemedicine is delivering improved diagnoses and better outcomes for patients -- remote observation and collaboration through live medical video and multi-party audio is helping to redefine the “See One, Do One, Teach One” method for enhanced medical education in the twenty-first century. 

Both trainees and medical educators are bullish about the possibilities, as students’ capability for live interactions with physicians/clinicians (while they are performing a procedure) provide and invaluable learning platform. 

Furthermore, given the current reality of healthcare restrictions in the age of COVID-19, this innovative form of remote learning lets students observe & engage from a distance, while being able to see and comment on what’s going on, as if they were physically present in the operating room.