Undergraduate surgical teaching utilizing telemedicine

Y A Gul, A C T Wan & A Darzi

Objectives To evaluate the concept of a new telemedi-

cine orientated educational application by exposing

junior medical students to surgical teaching via video-

conferencing from the operating theatre and comparing

this to the traditional method currently employed,

which requires the presence of students in the operating

room. To determine student satisfaction with this novel

method and identify de®ciencies associated with tradi-

tional surgical teaching.

Design Students were connected by video-conferencing

equipment 2 Mbit/s permanent virtual circuits that

provided two-way picture and voice communication.

Traditional tutoring involved students attending the

operating theatre in set numbers. Video recordings

were made during the telemedicine transmission for

highlighting important factors relevant to the operative

procedure. A questionnaire was used to assess the

quality of time spent and information obtained by the

students.

Setting Telemedicine centre and operating theatre, St

Mary's Hospital, London.

Subjects Junior clinical students.

Results The median score for surgical teaching utilizing

videoconferencing was 9 (scale 0±10) compared to 5 for

traditional operating theatre surgical teaching. All 46

(100%) subjects indicated a willingness to return for

the telemedicine in¯uenced method of tutoring com-

pared to 65% of students exposed to the conventional

method.

Conclusions Our early experience with telemedicine as-

sisted surgical teaching indicate high acceptance and

satisfaction rates by clinical students. Further studies to

evaluate the objective gain in knowledge associated with

this method is required prior to its implementation in

any future medical curriculum.

Keywords Consumer satisfaction; education, medical,

undergraduate, *methods; students, medicical, psy-

chology; surgery, *education.

Medical Education 1999;33:596±599

Introduction

Medical teaching has recently undergone changes, with

continuing reforms looming on the horizon in recog-

nition of the need for a new and modern structured

educational programme. A signi®cant drive related to

this phenomenon is largely attributable to develop-

ments in information technology, which is capable of

improving upon the antiquated methods that are still

being employed in certain academic institutions.

Telemedicine encompasses a whole spectrum of

medical activities and has great potential for improving

health care delivery, including medical education.1

There has already been a number of established projects

in distance education for doctors at undergraduate and

postgraduate level. Novel teaching techniques are,

however, required to overcome the `passive viewer'

syndrome that may be associated with this system.2 We

assessed telemedicine as a teaching method for under-

graduate medical students undergoing their surgical at-

tachment by utilizing this alternative process. The main

purpose of the study was to evaluate student satisfaction

with telemedicine teaching via surgical video-

conferencing from the operating theatre and comparing

it to the established method of operating theatre surgical

teaching. An attempt was also made to identify

de®ciencies in the traditional method employed.

Subjects and methods

Undergraduate medical students in their ®rst clinical

year with no previous exposure to hospital medicine

Minimal Access Surgical Unit, Imperial College School of Medicine

and St Mary's Hospital, London, UK

Correspondence: Professor Ara Darzi, Minimal Access Surgical Unit,

4th Floor, Stanford Wing, St Mary's Hospital, Paddington, London

W2 1NY, UK

Clinical skills

596 Ó Blackwell Science Ltd MEDICAL EDUCATION 1999;33:596±599

were selected randomly to participate in the study over

a 10-week period from October to December 1997. All

46 students were attached to a general surgical ®rm at a

teaching hospital in London. Teaching venues were at

the general surgical operating theatres and the tele-

medicine centre. Conventional teaching consisted of

students (up to six at any theatre session), attending the

operating theatre during surgical procedures. Teaching

utilizing telemedicine involved up to 12 students at-

tending the telemedicine centre and viewing surgical

procedures transmitted from the operating theatre

using compressed digital video signals which are con-

verted by a codec. The video network is based on 2

Mbit/s permanent virtual circuits which allows for two-

way visual transmission (625 picture lines at 25 frames

per second) and audio interaction (Fig. 1). Views ob-

tained from the operating theatre were either from an

external wall-mounted or hand-held camera which was

balanced on a tripod. Endoscopic images were trans-

mitted in the case of laparoscopic and other minimally

invasive procedures. An endoscopic camera was used to

provide a view of the internal body cavity during open

surgery whenever necessary.

The surgical procedures demonstrated included

laparoscopic cholecystectomies, inguinal hernia re-

pairs, haemorrhoidectomies and breast surgery (mas-

tectomy and axillary clearance). Operative procedures

were performed by either a consultant or senior

specialist registrar. A moderator of the grade of a

specialist registrar was present at the telemedicine

centre, conducting a short lecture prior to each op-

erative procedure. This also ensured a reduction of

unnecessary interruptions involving the operating

team, as the moderator attempted to answer some of

the questions raised by the students during the tele-

conferencing sessions.

The students participating in the study were given a

self-administered questionnaire after each teaching

session. Questions pertaining to their satisfaction and

the perceived educational value of the time spent in

theatre and the telemedicine centre were evaluated.

Items on the questionnaire were rated on a four-point

scale: 1 (poor) to 4 (excellent). Informed consent was

obtained from all the patients who were briefed fully on

the teaching methods employed.

Results

All 46 students returned the questionnaire. Students'

interpretation of telemedicine and traditional operative

surgery teaching is summarized in Tables 1 and 2. More

than 90% of students who attended the telemedicine

teaching found the audiovisual cues to be exceptional,

with all procedures clearly seen and demonstrated. Views

obtained of the surgical procedure by those who attended

the operating theatre session was considered to be poor

by 41%. Quality of tutoring was graded excellent by 96%

of the students attending the telemedicine sessions

compared with only 50% of those exposed to traditional

operating theatre teaching. Over 30% of students felt

that they were either in the way of the theatre staff or not

welcomed during their time spent in theatre.

Sixty-three per cent of students felt that valuable time

was wasted during their presence in the operating the-

atre and that 38% of time spent in theatre was squan-

dered from the learning perspective. All 46 students

Figure 1 Diagrammatic representation of telemedicine teaching from the operating theatre

Ó Blackwell Science Ltd MEDICAL EDUCATION 1999;33:596±599

Undergraduate surgical teaching · Y A Gul et al. 597

who completed the evaluation forms indicated that they

would return for similar teaching experience with tele-

medicine in¯uenced methods compared with 65% of

those who attended the operating theatre venue. Ad-

ditional positive feedback regarding the video-

conferencing method was obtained from 27 students,

who commented favourably on the interaction they had

with the operating surgeon. On a scale of 0 (worst) to

10 (best), the students surveyed gave a median score of

5 for operating theatre teaching and a rating of 9 for the

newly implemented surgical teaching. The mean period

of tutoring was 138 min (range: 120±146 min) for

telemedicine sessions and 216 min (range: 126±

326 min) for attendance at the operating theatre.

Discussion

Constraints with time and resources may have a signi®-

cant impact on the availability of clinical staff for teach-

ing. The resulting reduction in the quality and quantity of

tutoring may have a detrimental effect on our healthcare

system. The use of telecommunications in the provision

of educational services is well established and telemedi-

cine assisted teaching has been found to generate a high

level of interest from students.3

Teaching of surgery commonly relies on the use of

several media including the use of videos. The routine

attendance of medical students at the operating theatre

during their surgical attachments can be of variable ed-

ucational value. Low or infrequent levels of interaction

between medical students and the operating team is

commonplace and the random nature of this important

exercise in the undergraduate medical training pro-

gramme may have a signi®cant impact in their under-

standing of basic surgery. The frequent comment made

by clinical students of `too much time spent in theatre

with too many people around' and `not being able to see

anything' has been observed in an earlier study.4

Even though previous studies have questioned the ef-

fectiveness of teleconferencing in conducting tasks such

as information exchange and problem-solving, this form

of media is beginning to show signs of replacing routine

`face-to-face' meetings.5 We assessed videoconferencing

from the operating theatre as a complementary method

of tutoring in the discipline of surgery to determine if this

would improve the quality of surgical teaching. The

successful implementation of surgical videoconferencing

during courses held for postgraduate surgical teaching

was a driving force in conducting the study.

Our results indicate students' preference for surgical

teaching at the telemedicine centre, which involved

demonstration of live surgery rather than traditional

attendance at the theatre venue. The students' ques-

tionnaire used in this study did not measure actual gain

in knowledge, but rather their impressions of the ben-

e®t obtained and how much they had learnt. We do not

envisage this mode of teaching as a barrier to students

Table 1 Student evaluation of teaching utilizing surgical videoconferencing and traditional operating theatre attendance

Videoconferencing Operating theatre

*4 3 2 1 4 3 2 1

Clarity of procedure 42 (91) 3 (7) 1 (2) ± 17 (37) 5 (11) 5 (11) 19 (41)

Ability to ask questions freely 40 (87) 4 (9) 2 (4) ± 25 (54) 4 (9) 4 (9) 13 (28)

Quality of time spent learning 44 (96) 2 (4) ± ± 23 (50) 5 (11) 12(26) 6 (13)

Sound quality 44 (96) 2 (4) ± ± ± ± ± ±

Willingness to return for similar 100 65

teaching experience (%)

Mean overall time (%) 0 38

deemed wasted

Median score (0±10) 9 5

*Rating (4 excellent, 3 good, 2 satisfactory, 1 poor) Value in parantheses are percentages.

Table 2 Medical students' perception of operating theatre

teaching environment

Yes No Occasionally

Impression of obstructing

theatre staff

19 (41%) 11 (24%) 16 (35%)

Made to feel unwelcome

during time spent in theatre

15 (33%) 25 (54%) 6 (13%)

Time squandered while in

theatre

29 (63%) 11 (24%) 6 (13%)

Undergraduate surgical teaching · Y A Gul et al.598

Ó Blackwell Science Ltd MEDICAL EDUCATION 1999;33:596±599

attending the operating rooms. In fact, we emphasize

the importance of exposing medical students to the

operating theatre environment, especially when they are

allowed to assist and, therefore, participate closely in

the operative procedure. This is, however, only feasible

when operating during emergency hours or when there

is a low ratio or number of students attached to a sur-

gical ®rm. The latter is unfortunately not frequently

observed, especially in a teaching hospital. From the

students' perspective, a greater degree of interactive

discussion is possible with the telemedicine method

employed in our study. A possible explanation for this

®nding is probably related to the fact that the students

exhibit a lesser degree of inhibition when tutored in this

less hostile environment.

The costs of providing such a service in our institution

was limited by the already available video technology

network in place, which we utilize to conduct postgrad-

uate courses on a regular basis. Data are transmitted at

2 Mbit/s using this technology, which is ®ve times higher

than that used in standard commercial 384 kbit/s vid-

eoconferencing systems. This, however, could have

considerable implications for institutions that do not

provide such a service. Costs related to the requirements

for additional manpower in the form of audiovisual

technicians will also need to be considered if telemedi-

cine teaching sessions are held regularly. We found the

presence of a moderator necessary in minimizing com-

munications between the telemedicine centre and the

operating theatre. The moderator was also involved in

conducting a short lecture, discussing the relevant

pathophysiology and clinical aspects associated with the

operative procedure. This could be viewed as one of the

major differences in the methods compared. The pres-

ence of a similar lecturer in the operating theatre was

explored prior to commencing the study, but this was

dismissed by the operating surgeons due to the perceived

interruptions and disturbance caused by the increased

number of people in the operating room. There is no

doubt that teaching via live surgical videoconferencing

enables a greater number of students to be tutored which

could, theoretically, balance the need for separate lec-

tures on the relevant topics that are being demonstrated

and therefore sustain the manpower required to provide

such an educational service. Patient turnover time be-

tween cases probably accounts for the longer mean pe-

riod of tutoring in the operating theatre in this study.

Even though the operating surgeon or his assistant may

utilize this time to teach students, this may not always be

feasible.

It may be argued that video playback can be as ef-

fective as surgical videoconferencing to demonstrate

similar surgical procedures. The need for extensive

video editing, which can be time-consuming, may be an

essential prerequisite in utilizing this media as a

teaching aid. We feel that demonstrating surgical pro-

cedures utilizing video playback are best performed by

the operating surgeon, as the content is frequently de-

pendent on interpreting edited footage of the proce-

dure, which may be dif®cult. A comparative study is

required to con®rm the effectiveness of this media vs.

videoconferencing as a surgical teaching aid.

Students' opinions of their studies at medical school

could be used to modify educational structures and

improve upon the traditional curriculum. The students'

perception of the proportion of time they spent learning

while in theatre was low in this pilot study. We feel that

surgical teaching via videoconferencing from the oper-

ating theatre can be employed as a useful adjunct to

conventional teaching for medical students on their

surgical rotation. Acceptability of this method of tu-

toring was encouragingly high among the undergradu-

ate students, who also found it preferable to traditional

operating theatre attendance. The medical undergrad-

uates particularly enjoyed the communication they had

with the operative surgeon and the interactive nature of

the discussion that took place during the video-

conferencing teaching sessions. It would require a

greater number of subjects and objective methods of

assessment before a ®rm conclusion can be made about

the bene®t of this new method of undergraduate

teaching. Other forms of telemedicine orientated

teaching techniques, such as in the outpatient setting,

could be implemented selectively in other clinical

specialities allowing for useful dispersion of medical

information to the bene®t of undergraduate and post-

graduate students.

References

1 Wootton R. Telemedicine: the current state of the art. Minim

Invasive Ther Allied Tech 1997;5:393±403.

2 Jameson DG, O'Hanlon P, Buckton S, Hobsley M. Broadband

telemedicine: teaching on the information superhighway.

J Telemed Telecare 1995;1:111±16.

3 Gschwendtner A, Netzer T, Mairinger B, Mairinger T. What

do students think about telemedicine? J Telemed Telecare

1997;3:169±71.

4 Lockwood DNJ, Goldman LH, McManus IC. Surgical dress-

ers: the theatre experience of junior clinical students. Med Educ

1986;20:216±21.

5 Williams E. Face to face and mediated communication. Psychol

Bull 1977;84:963±76.

Received 26 June 1998; editorial comments to authors 6 August 1998;

accepted for publication 17 September 1998

Undergraduate surgical teaching · Y A Gul et al. 599

Ó Blackwell Science Ltd MEDICAL EDUCATION 1999;33:596±599