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Streaming Video in Surgical Training: Facilitates Standardization, Acquisition of Experience and Knowledge

Article 4 in the “Reimagining Telemedicine” series
by Mark Mariotti
(President and CEO, TIMS Medical) 

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Training Surgical Residents and Fellows (Source: feinberg.northwestern.edu)

In a prior Telemedicine Reimagined article I wrote titled Reinventing ‘See One, Do One, Teach One’ for the 21st Century,” I examined how new technologies and associated procedures are now being used to continue the well-established SODOTO medical education approach, introduced by W.S. Halstead, MD in the 1890s. As I observed, while See One, Do One, Teach One (SODOTO) has served medical schools, clinicians and patients well for more than a century, the world has changed, and medicine with it.

When Halstead first mentored surgical residents more than a century ago, radiology and video were in their infancy, clinicians of that time could scarcely conceive imaging innovations (e.g., Ultrasound, MRI, PET) that are now commonplace.

In this article, I will share ‘best practices’ examples of innovative live video and audio currently in use by surgeons and professors to better train future clinicians, as well as to keep already certified medical professionals up to date on new techniques.

Additionally, I’ll make the case (with support from educators) that real-time video streaming with concurrent audio interactions, coupled with the ability to telestrate and annotate over the Iive surgical video (to highlight points of emphasis) can demonstrably accelerate and standardize medical training. While I’ve seen many deployments of medical video across a broad swath of fields (e.g., interventional radiology, pathology, and dysphagia diagnosis and treatment), as it is arguably the most “hand-on” of practice areas, this article focuses principally on surgery.

The Standardization of Medical Education: Yesterday, Today, and Tomorrow

During the 18th century and for several decades into the 19th century, most physicians in North America received their training as apprentices to practicing physicians, despite the fact that the first American medical school was established at the University of Pennsylvania in 1765, with additional medical schools founded at Kings College (now Columbia University) in 1768, and at Harvard in 1783. In 1910, the Flexner Report reformed American medical training and established the first national standards for medical education and curricula, but still did not codify medical school accreditation.

Founded in 1982, the Accreditation Council for Graduate Medical Education (ACGME), in 2002 ACGME codified what it deems are six core competencies for all medical residents across 135 specialties and subspecialties:
    1. Patient care
    2. Medical Knowledge
    3. Practice-Based Learning and Improvement
    4. Interpersonal and Communication Skills
    5. Professionalism
    6. Systems-Based Practice
While this listing of ‘competencies’ is laudable, given that there are approaching 10,000 residents completing their training at any given time, variations between different competencies, should ideally require more detail on what should be mastered on a specialty-by-specialty basis.

Let us examine considerations and factors of mastering the art and science of surgery...

Education and Criteria for Surgical Proficiency

In order to excel as surgeons, surgical residents must experience more hours of observation, simulations, and hands-on participation than that necessary for proficiency in other practice areas.

Given possible risks from errors during any given operation, the importance of surgical training is paramount in order to lessen complications, failures, and deaths related to surgery. Additionally, even before issues caused by COVID-19, concerns about fatigue and burnout among surgeons and surgeons in training have led to restrictions in the number of hours worked, with residents' hours limited to 80 per week since 2003.

Ironically, “Education and Training” specified by the American Board of Surgery (ABS) is surprisingly minimal in detail. The Board’s website lists these just three criteria (for surgeons seeking board certification by the ABS):
1. Medical School: Graduation from an accredited medical school in the U.S. or Canada
2. Residency Training: Following med school, surgeons must complete at least five years of training in a residency program approved by the Accreditation Council for Graduate Medical Education (ACGME).
3. Experience: “During their training, residents must acquire extensive operative experience and a broad knowledge of disease management.”

In my view, Criterion #3 (Experience) is particularly interesting, and is much more vague than established requirements for the completion of med school and a residency.
   What do “extensive operative experience” and “a broad knowledge of disease management” actually mean?
   • What experience and knowledge are considered essential (vs. ‘nice to have’)?
   • How does a surgeon-in-training acquire requisite experience and knowledge?

Fortunately, for the advancement of science, and patient outcomes -- there is a growing movement in support for standardization in surgical training amongst medical educators, clinicians, and administrators.

Standardizing and Accelerating Training of Surgical Residents

This clarion call was well expressed in “Finally...Standardization in Residency Training”, an August 2020 paper in Orthospine News (OSN) by Elizabeth Hofheinz, M.P.H., M.Ed.. Citing a broad range of sources, Hofheinz’s article describes calls for a “uniform residency training curriculum for the entire United States,” from diverse influencers including the American Academy of Orthopaedic Surgeons (AAOS), the American Board of Orthopedic Surgery (ABOS), and the American Orthopedic Association/Council of Orthopedic Residency Directors (AOA/CORD).
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Paul Tornetta, III. M.D. (Source: Boston University)

A very informative “read,” that article includes insights from senior leaders from both the AAOS and the ABOS (respectively: Dr. Paul Tornetta III, MD - AAOS Chair of the Council on Education, and Chair, Professor, and Residency Program Director in the Dept. of Orthopedic Surgery at Boston University School of Medicine; as well as Ann Van Heest, M.D, chair of the GME committee at the ABOS, and Vice Chair of Education, University of Minnesota Medical School).

As shown in their clinical and academic backgrounds, these two educators have prescribed what residents need to experience in the way of practice-based learning and improvement, as well as systems-based practice. Both are strong advocates for allowing residents to watch, engage, and participate in as many procedures as possible, in order to acquire the knowledge, skills, and behavior to succeed as surgeons.

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 Surgical Training in a Crowded OR (Source: Orthospine News)

In the recent OSN article, Van Heest expressed her valid concern that “the pandemic has highlighted the issue of resident competency, with the fundamental question being: ‘How many cases does a resident need in order to be proficient with a given procedure?’”
Extrapolating on her ‘fundamental question,’ I believe hospitals and medical schools should also be asking these three additional questions:
    1. Given limitations of physical space in an OR and COVID-associated social distancing requirements, is there a way that residents (who are not in the room) can watch operations remotely?
    2. How can residents observe live surgical procedures while also being able to unobtrusively interact with surgeons in real-time?
    3. With the availability of experienced surgeons limited, how can residents participate in simulations, and acquire necessary hands-on operative experience in order to become proficient (while ensuring patient safety).

How Live Video Streaming/Telemedicine Aids In Surgical Education

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 Live video and Telestration via TIMS Consultant (Source: TIMS Medical)

In the experience of our clients, an effective way to address these three issues is through the sharing of live video streams from the point of operative care to remotely located surgical residents who are physically based anywhere a stable, secure connection may be assured. Systems such as our TIMS Consultant solution meet the experience-delivery requirements of teaching hospitals by directly resolving the trio of aforementioned, asked-for capabilities:
I) Is there a way that residents (who are not in the room) can watch operations remotely? Through its patented hardware/software, TIMS Consultant captures any medical imaging modality (retaining high resolution video at the lowest possible bit rates and ultra-low latency), and then transmits live video and audio via a secure HTML5 internet connection to residents and fellows who observe via a standard web browser in real time.
II) How can residents observe live surgical procedures while also being able to unobtrusively interact with surgeons in real-time? TIMS Consultant provides multi-party interactivity and collaboration through integrated audio conferencing, chat, and live telestrations.
III) How can residents participate in simulations and acquire necessary hands-on operative experience? Systems such as TIMS Consultant fulfill the promise for telesurgery in medical education described by Drs. Sajeesh Kumar and Jacques Marecaux in their eponymous Telesurgery
textbook (Springer, 2008): “Just as military and commercial pilots, who perform a considerable amount of their training in simulated environments, the surgeons of the future may be trained with the aid of realistic surgical simulators and their skills assessed repeatedly and objectively.”

Kumar and Marecaux expounded further on telesurgery as a ‘new approach’ to surgical training suggesting that it “may shorten residency training programs, lower educational expenses, and possibly avoid the detrimental consequences of the early phases of the learning curve. Surgical education can also benefit from the possibility of obtaining expert assistance from distance in the form of teleproctoring, telementoring, and tele consultation.”

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“Telesurgery” by Kumar & Marecaux (Source: Springerpub.com)

As hands-on participation by residents in surgical procedures present significant risks (e.g., negative patient outcomes, and legal consequences for the healthcare facility) expounded further on telesurgery as a ‘new approach’ to surgical training Kumar and Marecaux also praise telesurgery as a safe training environment “where errors can be made without consequence to the patient, and the learning process is based on learning the cause of failure.”

Video Facilitates Sharing and Acquisition of Surgical Experience

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Real Time Remote Surgical Proctoring (Source: Retina Today)

Because of its uniquely broad reach, video is the ideal medium to facilitate the acquisition of what residents and fellows, as well as board-certified surgeons need most:


While neither Albert Einstein nor Julius Caesar were medical professionals, as thoughtful leaders in their respective fields, their perspectives on the importance of observation and practice for learning were quoted in a 2010 paper in the Journal of the Society of Laparoscopic and Robotic Surgeons (JSLS):

“The only source of knowledge is experience.” Albert Einstein
“Experience is the teacher of all things.” Julius Caesar

Written by the then president of the SLS (Gustavo Stringel, MD, MBA) and titled How to make the most of the hours we have left, this article focuses on what every physician knows: that “experience is the one proven way to gain knowledge.” In the conclusion to his paper,
Stringel wrote:

“Everyone knows that experience matters. And when a person's life or health is on the line, then experience matters most. Throughout history, the sheer number of hours worked has been the benchmark of experience. As our profession's hours dwindlefor both residents and practicing physicianswe must take action to ensure that the hours we have left count, more than ever before. This task is imperative: If we fail, then our performance and our
patients will suffer.”

In a recent interview with Scott E. Burgess of Healthcare360podcast.com, Dr. Joseph Lamelas (Chief of Cardiac Surgery/University of Miami Health System) addressed the topic of experience directly, challenging the widely-held belief that 50 is the number of cases surgeons need to
have in order to become proficient.

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Cardiothoracic Surgeon Joseph Lamelas (Source UMiamiHealth.org)

Having performed more than 16,000 cardiac operations and taught minimally invasive techniques to surgeons across the globe via live case demonstrations, Dr. Lamelas not only believes that first rate surgeons need many more than fifty cases to excel, but also believes in the importance of observation and lifelong learning in order to “see things you’ve never seen before.”

See Many, Do Many, Teach Many (SM/DM/TM)

As I suggested previously in a September 2020 Paper, live video “lets students observe and 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.”

On further reflection, new technologies for web-powered streaming video and related capabilities are actually now redefining the classic See One, Do One, Teach One approach to surgical education for a much broader impact:
“See Many, Do Many, Teach Many”
Here are six results delivered through video-enabled SM/DM/TM surgical education:
    1. Expand the number and quality of hours residents and fellows can have as observers, before they ever pick up a scalpel.
    2. Accelerate the cognitive rate at which surgeons-in-training learn by letting them watch expert surgeons even before they enter the OR.
    3. Facilitate interactive, real-time interaction between and students and surgeons in the midst of procedures.
    4. Make medical education more immersive and inclusive.
    5. Allow hospitals to become their own broadcast TV networks, with onsite, low-cost, high-quality video equipment replacing the need to hire expensive external video production companies.
    6. Lower Total-Cost-of-Operations and learning cost per student, while also creating new monetization opportunities (e.g., recording & selling surgeons’ proprietary video footage).

For those of you out there who are using streaming video for surgical training:
What benefits are you seeing?
We’d love to hear your success stories!


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About This Article and its Author
This original article “Streaming Video in Surgical Training: Facilitates Standardization, Acquisition of Experience and Knowledge is the fourth in a series of educational “Telemedicine Reimagined” articles published by TIMS Medical, Inc. 

Mark Mariotti, President/CEO, TIMS Medical & Foresight Imaging
E: mmariotti@tims.com  W: www.tims.com 

LI: https://www.linkedin.com/in/markdmariotti/  

#Tags: #Telesurgery #Telemedicine #TelemedicineReimagined #Telehealth #LiveRemoteMedicalVideo #MedicalEducation #ResidentsTraining #FellowsTraining #MedicalSchool #MedicalStudents #RemotePreceptors #RemoteMentoring #RemoteCollaboration #Telementoring #Teleproctoring #Telestration #TIMSConsultant #TIMSMedical

1 LinkedIn ‘Telemedicine Reimagined’ Article Mark Mariotti/TIMS Medical.
Telemedicine: Much More than Doctor-Patient Video Visits. July 2020.
Source: http://bit.ly/MoreThanZoom
2 Forbes.com Robert Pearl, MD.
Why Telemedicine Is Much More Than A Digital Doctor’s Office. February 1, 2021.
Source: bit.ly/2O2wv3v
3 New York Times Ella Koeze, Jugal K. Patel, Anjali Singhvi.
Where American Live Far From The ER. April 26, 2020.
Source: https://www.nytimes.com/interactive/2020/04/26/us/us-hospital-access-coronavirus.html
4 ICD-10 Monitor Stanley Nachimson, MS.
Federal Authorities Adjusting Regulatory Requirements Ahead of 2021. December 7, 2020.
Source: https://www.icd10monitor.com/federal-authorities-adjusting-regulatory-requirements-ahead-of-2021

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To learn more, see these four case studies of the use of video streaming for surgical education:

University of Kansas Medical Center (Neurosurgery) In July 2020, members of the Department of Neurosurgery at the University of Kansas Medical Center (Kansas City, KS) published a paper in The Journal of Surgical Education titled Live-Streaming Surgery for Medical Student Education - Educational Solutions in Neurosurgery During the COVID-19 Pandemic.’ This timely article acknowledges how COVID-19 has significantly altered medical education, by restricting students’ ability to be present in an OR, and details the use of live-streaming with real-time communication between surgeon and students.

National University of Malaysia (General Surgery) In July 2020, three doctors affiliated with the National University of Malaysia authored a paper for the ANZ Journal of Surgery titled ‘Use of contemporary live tele-video conferencing for continuing surgical training at the time of COVID-19 pandemic.’ As a Malaysian government order currently precludes surgical trainers and trainees from gathering for any form of education activities, these surgeons (affiliated with Kebangsaan Malaysia Medical Centre) developed a clinical pedagogic curriculum based on real- time video and online education for 40+ trainees in the university’s Masters of Surgery program.

Tokyo Women’s Medical University (Neurosurgery) As a  outlines, “While nothing can replace the hands-on experience of operating
theatre training, Tokyo Women’s Medical University (TWMU) is providing the next best thing.” Through an overhead camera in TWMU’s Smart Cyber Operating Theater, students can remotely observe surgeries in virtual reality, while minimizing infection risks.

Excelsior Surgical Society (Trauma Surgery) Founded in the bar of Rome’s Excelsior Hotel at the end of World War II, the Excelsior Surgical Society brought together U.S. military surgeons who shared their experience in treating battlefield wounds they had seen during the war. More recently during its 2017 annual meeting, the Society joined with
the American College of Surgeons (ACS) for a day-long event focused surgical readiness, care for troops injured in combat, as well as victims of mass causality events. Given its global roster of attendees, videos from sessions at the meeting were live-streamed from three US locations, as well as to military surgeons stationed in Afghanistan, Iraq, Kuwait and elsewhere. Live streaming at that historic event, helped to reinforce the mission of the ESS: “to improve military medicine through education, research, and fellowship.