Surgical Skill Acquisition in the Modern Era: Comparative Technology in...

Do we specifically incorporate this into practice? It's very similar to what Brian talked about. This is how we used to teach medicine. Medicine was in an auditorium. We would all sit there and we would, we would watch one person give a lecture, and that was how we were taught. That was how surgery was taught. And I don't know if any of you recognize this gentleman. Uh, this is Sir William Osler. Sir William Osler said, you know what, enough of this lecture nonsense. Lectures are good for maybe medical understanding, but not surgical. Uh, and actually, actually, he wasn't even a surgeon at this. He was, he's the one who decided that in medical training, we need to do residency. We need to bring the doctors to the patient. And then Dr. William Halstead, who was a surgeon, said, Yeah, I like that idea. Let's make a surgical residency. So now they say this is how we're going to learn. Surgery. This is how we're going to learn medicine. It's not lectures, it's hands-on experience. This is a residency. This is surgical residency. You've got the expert on the right and you have a trainee on the left, and the expert first does the operation and the trainee watches. And then the next step is that the trainee. does the operation with the expert watching very carefully and eventually the trainee really does the operation almost completely autonomously with very little oversight. It's a stepwise process of learning and this is how we all have trained. This is how surgeons have trained. The problem, as Brian alluded to earlier, is that what is it, 18 months, Brian, that that our knowledge doubles? OK, so all of these techniques, every second, I mean, from when I trained, I finished 10 years ago, probably everything I learned, especially since it was from Rothenberg, everything is obsolete, and we've got to start learning new things. So now you have people maybe going in and watching someone, seeing how they do it. Uh, that's, that's the way that that we learn, but really, that's not enough. And so, how can busy surgeons learn new techniques? Once I'm in practice, uh, I want to learn. We know that residency works, but the problem is new techniques developed and we want to replicate that model. We know that this apprenticeship model works, where you watch someone, then you work with someone, then you're on your own with them watching you. We know that works. So, how can we apply that to practicing surgeons? Well, right now, we go to simulation, we go to courses, uh, and these courses that are maybe one-day courses would have Halstead turning in his grave, saying, wait a second, this is everything against what I told you. You need much more than just a one day thing. This is an intensive process of watching an expert and the expert watching you, not something that you can learn in one day. So again, once we're in practice, how do we learn? We've defined something called the skill acquisition model. The skill acquisition model is 5 steps. Step 1 is a course, just like we go to, we go travel to a course. Step 2 is that the trainee observes the expert. Then the trainee performs the case with the expert watching them. So now you've reversed it. Then, once this relationship has been established, now you're talking about telementoring. Only now should we be introducing this concept of virtual education of virtual training. Step 4 is where telementoring comes in, not step 1. Last is teleprompter and the idea that once we think that the person has learned how to do it, the expert just watches, just watches and says, I like what you're doing, and they evaluate, not actually helping. So, step one is the course. The idea of a course is that we are used to traveling around the world to courses, but we now have virtual courses and virtual courses just like this one, is a great way for people to learn without having to travel. So again, we're using the internet in ways that makes sense. So that was step one. So step one is attend the court. Now, how do we teach the technique? The trainee has to watch, then the trainee has to do. That's step 2 and 3, and then telementoring. So let's talk about telementoring. So, this is a a brief experiential report of how Steve and I got started on this. So, this is the first case we did. This is a baby that needed a lung resection. And we didn't know anything about technology. We hadn't met Knut and Etai and these people from Norway. So we said, well, let's use Skype. We know Skype. So we did Skype and uh and this was Steve uh helping me here. Yeah, all that stuff there is probably should be safe. Oh, you would divide all this in here. Let me see if we can, yeah, yeah. That'll free up the the. The sound is playing it. So the point was for that case, we had no telestration. So Steve was guiding me through the operation just using verbal pointing. He was saying, you know, go there to the left and find that red dot and buzz there and do that. And it was really difficult without him actually showing me where to go. So then we moved on to a much more robust system. This is the visitor one solution that has been mentioned, and this has, this has the telestration worked in and hopefully the video will play here. You're going to want to put the, it looks like the videos aren't going to play for me today. simulator. You're going to want to put it, but not when I'm sharing my screen, and that's OK. Uh, so I guess we're not going to see any. So this is a visitor and this is me mentoring an adult surgeon to make an incision, laparoscopic hernia. If I were to make an incision, I would make it I can draw using visitor one. With the laser, the green dot is the laser. I'm telling the surgeons where to go and tell them where to go. So what you might want to do after you're done laparoscopic hernia repair. And then we did the same thing to France. We did telementoring to France. Normally, I would put it right I'm pointing with the laser across the ocean here. So, so, so maybe telling them where to go and then you'll see where we go lapat want to put it on this side and you want to actually point on the laparoscopic down to find the appendix. And this is Steve. He already showed his video. So this is the technology that the group in Norway, Etai Bogen came up with and Knut introduced me to as well. And this is using an off the shelf solution. And I know that there was a question from the audience about can we use Androids and iPads for telestration. The answer is absolutely, because of what these guys invented, stuff off the shelf that they came up with, and maybe one interface lower. Now watch this. This is, oh, you know what you're going to get to be able to do. You're gonna get to do a superior segment. Now here you see the issue that Brian was talking about where the lines move when Steve draws, the lines move when I start moving the camera. The scope is in the perfect place. Go where my circle is. This is how we illustration. Here's minor Fisher. All right. Here's the front of Major Fisher. Steve is drawing on an iPad. So what I would do is I'd come right here. And unroof the top of the cyst and carry it all the way back so we can see how it really separates from the vessels in the upper lobe. This plane right here. Yeah. Yeah, it looks like the plane is Right here. The superior segment artery is going to be in there somewhere. What does this feel like right here? And then you've got these nodes that you're going to have to get out of the way. I think once you take this artery, Then you're going to have a plane that comes along like that. Why not, Yeah, I would. That's what I would do. Why even bother? I would, I would end a lupus. Yeah, I would end the loop. You can end a little bit or put a clip on it, whichever one you want. Yeah, that, yeah, that's all right, yeah. Slide it down and yep. So it's just absolutely incredible. There's the lump coming out. You know, having someone who's done hundreds of these over my shoulder made it great. Now, what if the technology shut off? What if I lost internet connection? Well, that's why the person doing the operation has to be able to do the operation. The mentor is only there for a little bit of extra boost of tips and tricks, but really not to be the crutch of the surgeon. The surgeon has to be able to do the operation on their own. So we debate. Brian and I have debated about the two different interpretations of what's going to happen with telementoring. About 2 weeks ago, there was a patient that went to an outside hospital with a bad trauma. They were not a pediatric trauma center, but the patient was too unstable to transfer. So I was trying to talk them through what to do. I eventually drove down to their hospital, but wouldn't it be great if they could, if they had a little thing like that they could break the glass and say emergency, and then a mentor would come in and help them through the case. A lot of people debate about this because remember, this, this solution would not have prior relationship. This is someone getting guidance from someone they've never met before. Some people call this the co-pilot method, the virtual first assistant. It's becoming more accepted that Brian has really been the leader in defining how we incorporate this into the educational training model, a lecture, a course, followed by a staged stepwise process, a skill acquisition model where the expert does the case. Here we are with a simulator. Then I'm doing the case with the trainee watching, and then we do tele mentoring at the end. This is probably what's becoming the more accepted model. hurdles. We've talked about medical, legal, licensing, credentialing, who's paying for all of this? How are we affording the technology? How are we affording the time of the experts? Is this all going to be, are the experts going to do this just out of their own goodwill, or is that going to not take us to where we need to go? I think if you want it on a global scale. We're going to need a way for them to justify not spending time in their own operating room. We have to figure out the technology and the logistics, has been mentioned enough before. Project 6 is really pushing this, and now at the American College of Surgeons, the Education Committee, David Hoyt and Sadiva are really pushing telementoring as well. Really, the demand has come from rural surgeons, surgeons by themselves who want some help, don't want to have to send all their patients to the main tertiary centers. Uh, so we know we polled the rural surgeons and they want telementoring. The second time, I'm going to skip through these slides. So can this work in real life? And this is an example of what we did. We wanted to test this model. Can we do this? So we decided to go to the Trumsa, Norway, and we decided to do a what we call the Akron Trumsa project. was led by Knut, uh, who's here on the screen, Etai Bogan, Ralph Ole, uh, and we decided to see if we could test this model. So the idea was that can I teach them the laparoscopic non-mesh hernia repair using the skill acquisition model that we talked about. So, step one is the course. We did a virtual course and the surgeons over there watched the virtual course. Then I flew to Norway. This is the team you see Knut there in the middle, and Etai Bogan on the right. And then we, we started here. And this is Peter Gessing, who is the general surgeon there, very talented general surgeon who also does pediatrics. There's me doing the first case. Then I showed him on a training model. Then he did the case and I'm instructing him as he's doing it. Now we're on step 3. And we go to step 4, which is telementoring. So we decided to test it step by step. So the first telementoring case we did, I was actually there, but we wanted to test the model, make sure everyone knew, felt comfortable with this concept of telementoring before I actually went back overseas. So I'm in Norway in the operating room while he's doing this technique, and I'm drawing on an iPad. And he's 4 ft away from me doing the operation, listening to my mentorship. Then I said, OK, let's get courageous. I went to the 4th floor of the hospital and, and, and did the telementoring from there. So he was really by himself, but I could come down there if he needed me. And lastly, this is the logistics problem. 33 o'clock in the morning, they had a full day of cases, and I mentored them through a full day of cases using the iPad drawing system. Here's a video of that. I mean, sometimes you can go like even much deeper, but yeah, try that. That's good. I mean, and Peter, as you said before, do your like, make sure you're on the inside so that the stitch doesn't pull through the dead tissue. Yeah. That's great. You can see how I can draw. I think so. I think that's really good because you have nice healthy tissue. So in conclusion, a true skill acquisition of new techniques requires more than a simulation course or a lecture. Virtual presence may facilitate this skill acquisition model, but it has to be an element of a much more robust model where a relationship is identified and the two become comfortable with each other. And new advanced multimedia technology may allow for improved learning in medicine virtually.