Surgical Skill Acquisition In The Modern Era Todd Ponsky MD Associate Professor of Surgery and Pediatrics Northeast Ohio Medical College Akron Children’s Hospital
Current Surgical Training Model Residency
Simulation and Courses
“Apprenticeship”The Gold Standard
Skill Acquisition Model•Step 1: Course or Didactic Instruction•Step 2: Trainee observes the Expert (+/- Simulation Model)•Step 3: Expert Mentors the Trainee on-site•Step 4: Distant Mentoring (Telementoring)•Step 5: Teleproctoring (+/- reverse mentoring)
The Akron-Tromsø ProjectStep 1: Virtual Course on New Hernia Technique
How to Educate Through The Internet?Must be designed like a television showHigh Energy, Highly ProducedInteractivityDebates, Discussions, Polling, etcHigh Fidelity Audio and Video
The Boston Massacre
The Akron-Tromsø Project•Step 1: Course or Didactic Instruction •Step 2: Trainee observes the Mentor (+/- Simulation Model)•Step 3: Mentor performs case with the Trainee on-site•Step 4: Telementoring•Step 5: Teleproctoring (+/- reverse mentoring)
Step 1: Virtual Course
Fly To Norway
Meet The Team
Training on a Simulator
Expert performs the first caseTrainee 1st Assists
Trainee Performs Second Case Expert 1st Assists(And Mentors)
Expert telementorsin the OR So both can get comfortable with telementoring
Telementoring From another location in the hospital
“Closet Surgeon” in Akron at 3am
Te l e m e n t o r i n gTelementoring: an expert assists another, usually less experienced person, from a remote location through real-time, live interactions. (Sereno, S., Mutter, D., Dallemagne, B., Smith, C.D., Marescaux, J., 2007)
Six Cases of Transcontinental Telementoring1.VATS left lower lobectomy2.Temporary gastric stimulator placement3.(2 cases) Laparoscopic gastric stimulator placement4.(2 cases) Laparoscopic inguinal hernia repair IPEG Conference, Edinburgh, Scotland, 2014
METHODS:Multiple different tele-presence technologies were utilized
Case 1 -VATS Lobectomy•Mentee: Peds Surgeon, 8 previous cases•Mentor: Peds Surgeon, over 300 cases•Skype connected to Lap tower and external webcam
Skype or Vidyo Challenges•No HIPAA compliance•Lack of interactivity (pointing or telestration)
Storz VisitOR1 Solution•High Fidelity External Video in addition to Laparoscopic Tower Feed•Laser pointing capability•HIPAA Compliant (Encrypted)•FDA Approved
Cases 3-4- Laparoscopic Permanent Gastric Stimulator Placement•Mentee: Peds surgeon, zero previous cases•Mentor: 8 previous cases•FDA approved virtual presence device
Cases 5-6 Cross Specialty Lap Hernia Repairs•Mentor: Peds Surgeon, over 300 cases•Mentee: General Surgeons, zero•FDA approved virtual presence device
Trans-Atlantic Telementoring to France
VisitOR1: Challenges•Proprietary Equipment•Higher cost of entry•Learning curve with client laptop•Both endpoints need compatible equipment
Alternative Solution
Alternative Solution•Macbook Pro retina core i7 (fast!!)•Epiphan Frame Grabber DVI to USB•DVI Splitter•Stryker Polycom bridge built in to tower (not really needed, Skype would suffice)•remote iPad w/Splashtop whiteboard•local laptop with Splashtop client•a lot of flexibility with OR staff and nurses!
Conclusion:•True Skill Acquisition of new techniques requires more than a simulation course or a lecture•Virtual Presence may facilitate Skill Acquisition•The use of Telementoring for skill acquisition may allow for: •Reduced cost•Transfer of skills remotely avoiding travel•Shortened time for implementation of new techniques into practice•Improved patient outcome•Rapid dissemination of novel skills