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Telemedicine is a rapidly growing sector within medicine. It has the ability, through audio and video technology, to connect remote healthcare providers with patients or other providers without direct contact. Telementoring, a concept within telemedicine, is when an expert physician guides another physician at a different geographic location. Access to expertise using this technology-based approach has been shown to save lives, reduce hospital stay, and reduce cost in trauma and elective surgical settings. Recently, a new interactive technology has been introduced that takes a dual reality-based approach to surgical training.
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The Evolution of Surgical Training
The increase in arthroscopy, endoscopy, microscopy, and robotics in surgery has challenged the traditional side-by-side surgical training paradigm. Minimally invasive surgery techniques have steep learning curves which frequently place surgeons-in-training in passive learning roles.
Knowledge and skill acquisition theories emphasize the need for active participation of the student in the learning process and focus on immediate implementation of the newly acquired knowledge. Post-graduate training centers are facing the need to evolve and utilize technical advances to educate.
The benefits of surgical simulators are well documented. Virtual reality (VR) training shortens the learning curve of surgical trainees in addition to the benefits of not injuring patients or extending the length of operations. There are, however, a number of challenges with VR training. Building realistic models of the human body and creating interface tools to view, hear, and manipulate these human body models remain significant hurdles to overcome.
Telemedicine is a rapidly growing sector within medicine. It has the ability, through audio and video technology, to connect
remote healthcare providers with patients or other providers without direct contact. Telementoring, a concept within
telemedicine, is when an expert physician guides another physician at a different geographic location. Access to
expertise using this technology-based approach has been shown to save lives, reduce hospital stay, and reduce cost in
trauma and elective surgical settings. Recently, a new interactive technology has been introduced that takes a dual reality-
based approach to surgical training.
Augmented Reality
Virtual and augmented reality technologies are well-known outside of resident education. While virtual reality can be thought as creating an entirely digital world in which a user interacts in, augmented reality can be defined as enhancing
an individual’s experience in the real world through the addition of digital elements.
Popular augmented reality mobile applications superimpose useful data on top of the real world, in real-time. As an example, certain applications allow a user to view interesting or relevant historical information as he or she walks down a street in a new city. Additionally, many augmented reality applications allow interactivity with the superimposed data. Rotating, resizing, and dynamic user input is often allowed, further enhancing the experience.
Aside from popular mobile applications, field staff are using augmented reality software to view data regarding a mechanical repair in real-time. A staff member, wearing a head-mounted display (HMD) can have the particular points at which he or she should manipulate a mechanical device be digitally highlighted for an added layer of assurance the task is being completed correctly.
While these technologies are continually increasing in pervasiveness outside of resident education, this pilot study examined the viability of augmented reality technology being applied in the educational arena. We utilized a Virtual
Interactive Presence (VIP) (VIPAAR, Birmingham, AL) system that allows superimposition of an instructor’s hand over
imaging of the surgical field in real-time. The objectives of this study were to evaluate the performance of a VIP system implemented in an operating room setting with respect to efficiency, safety, and teaching.
Telementoring: Augmented Reality in Orthopaedic Education
Ponce BA, Jennings JK, Sheppard ED, Clay TB, May MB, Huisingh C, Siegel HJ.
University of Alabama at Birmingham (UAB)Research or other financial support has been received from the same company as the products discussed.
Study Design
• Following VA and University IRB approval, a consecutive cohort of 15 patients scheduled for arthroscopic shoulder
surgery at the Birmingham Veterans Affairs (VA) Medical Center were enrolled from April -August 2012
• Six orthopaedic residents, three PGY-3s and three PGY-5s, and one attending surgeon participated
• For each case, the attending surgeon used the VIP system to remotely proctor one or more resident surgeons as portions
of the surgical case were performed.
• When the attending surgeon felt his presence was necessary in the operating room, he physically entered the case.
• Following each case, the attending, resident surgeons ,anesthetist, circulator and surgical tech completed a Likert-scale
questionnaire (1-5 with 1 = strongly disagree, 5 = strongly agree) that assessed their opinions on the VIP station's effect
on education, safety, and efficiency. A subjective feedback section was also included on the survey.
• Set up times and operative times were recorded. Operative times were historically matched to comparable prior cases by
the same attending surgeon prior to the initiation of this study
Examples of Augmented Reality in Current Use
Google Glass: allows viewing weather, sending text messages, taking pictures & video, performing Internet searches.
Word Lens: superimposes translated text on top of the real world.
Google Sky Map: displays spatially-registered constellation details on smartphone or tablet.
Wikitude: superimposes relevant information on users’ surroundings.
Telementoring: Augmented Reality in Orthopaedic Education
Ponce BA, Jennings JK, Sheppard ED, Clay TB, May MB, Huisingh C, Siegel HJ.
University of Alabama at Birmingham (UAB)Research or other financial support has been received from the same company as the products discussed.
Virtual Interactive Presence (VIP) Setup
• Two Virtual Interactive Presence (VIP) stations (VIPAAR, Birmingham, AL, USA) with an Internet Protocol (IP)-based
connection
• One positioned in the operating room
• One positioned in surgical dictation room outside the operating room suite
• Attending surgeon (proctor) was positioned at a station located in the physician’s dictation area to simulate geographic
remoteness
• The proctor’s hands and other surgical tools were merged directly with the arthroscopic image
• The station positioned in the surgical dictation room additionally had a telestration feature that allowed the attending
surgeon to draw on the image with a two-dimensional pen tool
Virtual Interactive Presence (VIP) Platform
• A virtual interactive presence (VIP) platform (VIPAAR, Birmingham, AL, USA) has been developed that allows a remote surgeon to deliver real-time virtual assistance to a local surgeon over a standard Internet connection
• VIP stations use software that enables the proctor to virtually “reach into” the surgical field in real-time
• This creates an experience of dual reality for the local surgeon that may enhance knowledge transfer and skill acquisition
• While virtual reality can be defined as immersing a user in a virtual world, dual reality merges physical realities to provide a shared first-person environment for learning
• In other words, in a dual reality environment a remote surgeon can see what the operating surgeon sees and virtually identify anatomy or direct the surgical technique
Telementoring: Augmented Reality in Orthopaedic Education
Ponce BA, Jennings JK, Sheppard ED, Clay TB, May MB, Huisingh C, Siegel HJ.
University of Alabama at Birmingham (UAB)Research or other financial support has been received from the same company as the products discussed.
Setup Schematic: Operating Room and Dictation Room
Telementoring: Augmented Reality in Orthopaedic Education
Ponce BA, Jennings JK, Sheppard ED, Clay TB, May MB, Huisingh C, Siegel HJ.
University of Alabama at Birmingham (UAB)Research or other financial support has been received from the same company as the products discussed.
Attending surgeon’s hand superimposed on
arthroscopic image
Resident & attending survey results
Category Statement N
Attending
Mean
(SD)
Attending Median
(IQR)N
Resident
Mean
(SD)
Resident Median
(IQR)P-value*
Efficiency Ease of use 15 4.53 (0.52) 5 (4-5) 19 4.74 (0.45) 5 (4-5) 0.23
Efficiency Reliability 15 4.60 (0.51) 5 (4-5) 20 4.60 (0.60) 5 (4-5) 0.87
Efficiency Lag in motion 15 4.60 (0.51) 5 (4-5) 19 4.00 (0.82) 4 (4-5) 0.01
Safety Sufficient image resolution
15 4.67 (0.49) 5 (4-5) 20 4.65 (0.75) 5 (4.5-5) 0.69
Safety No safety concerns 15 4.60 (0.51) 5 (4-5) 20 4.75 (0.72) 5 (5-5) 0.14
Safety No interference with surgery
15 4.60 (0.51) 5 (4-5) 20 3.85 (1.31) 4 (4-5) 0.05
Teaching Highlighting anatomy 15 4.73 (0.46) 5 (4-5) 20 4.85 (0.37) 5 (5-5) 0.41
Teaching Feedback to resident 15 4.73 (0.46) 5 (4-5) 19 4.84 (0.37) 5 (5-5) 0.46
Teaching Communication 15 4.67 (0.49) 5 (4-5) 20 4.75 (0.44) 5 (4.5-5) 0.61
SD: standard deviation; IQR: interquartile range*p-value to compare median scores obtained via the Wilcoxon rank-sum test
Category Statement N Staff Mean (SD)Staff Median
(IQR)
Efficiency No Increase in Workload 31 4.35 (0.91) 5 (4-5)
Efficiency Unobtrusive to Workflow 35 4.17 (0.92) 4 (4-5)
Efficiency Awareness of Progress of Procedure 35 4.11 (0.90) 4 (4-5)
Safety Reliability 35 4.63 (0.49) 5 (4-5)
Safety Sufficient Image Resolution 35 4.57 (0.50) 5 (4-5)
Safety No Safety Concerns 34 4.47 (0.56) 4.5 (4-5)
Safety Remote Presence Had No Adverse Effect 34 4.44 (0.70) 5 (4-5)
Safety Quality of Patient Care 34 4.35 (0.73) 4 (4-5)
Safety Visualization 34 4.62 (0.55) 5 (4-5)
Teaching Effectiveness as Guidance Tool 35 4.23 (0.73) 4 (4-5)
Teaching Feedback to Resident 35 4.43 (0.61) 4 (4-5)
Teaching Communication 35 4.23 (0.73) 4 (4-5)
OR Staff survey results
Telementoring: Augmented Reality in Orthopaedic Education
Ponce BA, Jennings JK, Sheppard ED, Clay TB, May MB, Huisingh C, Siegel HJ.
University of Alabama at Birmingham (UAB)Research or other financial support has been received from the same company as the products discussed.
Result Summary
• No differences between attending and resident surgeons’
scores on the utility of the VIP to highlight anatomy and
provide feedback to the resident (p>.05).
• No differences were noted between groups in the ease of
use and safety during the procedure (p>.05).
• Majority of resident and attending surgeons reported no
perceptible lag between motions (95% and 100%,
respectively) (p>0.99) and no interference of the VIP with
the surgical procedure (85% and 100%, respectively)
(p=0.24).
• The mean surgical times for rotator cuff and instability
procedures were not significantly different with and without
use of VIP (p=0.57, p=0.61, respectively).
• VIP technology effectively allowed the attending surgeon to
remotely proctor resident surgeons.
• Residents felt training was improved
• Able to do more with greater supervision
• Attending surgeon believed teaching effectiveness as a
proctor was improved through this technology.
• Despite being remote, attending felt had greater control
through this technology
• No difference in surgical time and no observed
complications encountered
• Both residents and faculty believed residents were able to
participate to a greater degree.
Telementoring: Augmented Reality in Orthopaedic Education
Ponce BA, Jennings JK, Sheppard ED, Clay TB, May MB, Huisingh C, Siegel HJ.
University of Alabama at Birmingham (UAB)Research or other financial support has been received from the same company as the products discussed.
•Resident comments
• Communication between staff and resident was
precise; it allowed us to know exactly where to
debride tissue, place anchors and pass sutures
• Attending able to give instruction without taking over
case
• I felt well supervised and yet I had an increased
sense of autonomy being in the room by myself
• Highlighted anatomy great
• Enhanced my understanding
• It allowed for resident autonomy but did not sacrifice
staff oversight and patient safety
• Better than computer or cadaveric models
•Attending comments
• First time in my six years on staff that a resident did an
entire arthroscopic stabilization and the repair was
excellent
• Third year resident did entire subacromial
decompression
• Improved safety – I am able to better monitor the case
and give necessary instruction until my presence for the
more complex portions is required.
• Improved instruction/communication – normally I say ‘go
up, down, etc.’ , now can say and show what to do which
gives resident greater involvement AND me greater
supervision/control
• Only time not comfortable with being remote was when
resident did not have a good view in the subacromial
space and I was unable to help as the outside camera
view was not sufficient
Free Form Feedback
Conclusion
References and Contact
VIP technology may effectively allow attending surgeons to remotely proctor resident surgeons. Both the attending and residents agreed that training was enhanced without sacrificing operative times. Furthermore, the attending surgeon felt this technology improved teaching effectiveness. These results are promising and support further objective quantification.
Aggarwal R, et al. Effectiveness of VR simulation for training in laparoscopic surgery. Ann Surg. 2007;246(5):771-779.Burgess L, et al. Overview of Telemedicine Applications for Otolaryngology. The Laryngoscope. 1999; 109.9:
1433-437.Edelman DA, et al. Laparoscopic training in a 4th-year medical school surgical skills elective. J Surg Res. 2012.
Web published.Farnworth LR, et al. Op. times in arthroscopic ACL reconst. btw. faculty and residents.Iowa Orthop J. 2001;21: 31–35.
Grantcharov TP, et al. Performance of VR simulator to test laparoscopic skills. Am J Surg. 2003;185(2):146-149.
Grantcharov TP, et al. Randomized clinical trial of VR simulation for laparoscopic skills training. Br J Surg. 2004;91(2):146-150.Harrington D, et al. Time-Cost Analysis of Teaching Laparoscopic Entero-Enterostomy. J of Surg Edu.
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2011;119.1: 95-98.
Brent A. Ponce, MDAssociate ProfessorUAB Division of Orthopaedic [email protected]
Stan McDuffieDirector, Clinical [email protected]
Telementoring: Augmented Reality in Orthopaedic Education
Ponce BA, Jennings JK, Sheppard ED, Clay TB, May MB, Huisingh C, Siegel HJ.
University of Alabama at Birmingham (UAB)Research or other financial support has been received from the same company as the products discussed.
Discussion
• Telemedicine is a rapidly growing field due to
technological advancements, clinical need, governmental
incentivisation, and increased investment capital.
• Clinical need
�US experiencing a shortage of up to 200,000 physicians
�Specialized care lacking in rural areas for 80 million Americans
• Government incentivization
�Medicare covers certain telemedicine services
�VA Office of Telehealth Services in 2012 hired 1000 telehealth
professionals
• Increased investment capital
�Telehealth sector grew from $3 to $7.7 billion in the last 5 years
• Telementoring is a proven and validated means to
transmit skill and expertise to a site of need.
• VIP technology provides a shared first person learning
environment idea for telementoring anywhere an internet
connection is available
• Consistent with educational theories of active
participation and immediate implementation of newly
acquired knowledge
• Study Limitations:• Limited number of surgical cases• One attending surveyed• Small number of residents surveyed• No patient outcomes collected• Inclusion of only arthroscopic procedures. • Was done over a local internet network
• Potential Benefits
• Possible shortening of surgical skill learning curve
�Potential to offset decreased resident operating exposure due to
work hour restrictions
• Possible cost savings
• With potential condensed learning curve, VIP technology may
allow shorter operative times in cases involving residents without
compromising safety
• Training augmentation
• VIP offers the ability to train residents with a basic orthopaedic
surgical skill set, i.e. upper level residents, with in vivo training as
opposed to traditional cadaveric or virtual reality training
• Potential applications with VIP technology
• Preceptoring of practicing physicians to gain new
surgical skills in real time
• Virtual presence of an industry rep in OR
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/index.htmlhttps://www.aamc.org/download/286592/data/physicianshortage.pdfLange T, et al. VR in surgical training. Surg Oncol Clin N Am. 2000; 9(1): 61-79, vii.
Larsen CR, et al. Effect of VR training on laparoscopic surgery: randomized controlled trial. Br Med J. 2009;338:b1802.Latifi R, et al. Stud Health Technol Inform. 2004;104: 200-6.
Mendez I, et al. Robotic Long-distance Telementoring in Neurosurgery. Neurosurgery. 2005; 56.3: 434-40.Panait LA, et al. Telementoring vs On-site Mentoring in VR-Based Surgical Training. Surgical Endoscopy. 2006; 20.1: 113-18.Schlachta C, et al. Mentoring & Telementoring Leads to Incorporation of Lap. Colon Surgery. Surg Endosc. 2010;24.4: 841-44.
Seymour NE, et al. Virtual reality training improves operating room performance. Ann Surg. 2002;236(4):458-464.Shenai MB, et al. VIPAR for Remote Surgical Assistance. Neurosurgery. 2011;68(1 Suppl Operative):200-7; discussion 207.
Shortage Desig.: Health Prof. Shortage Areas & Med. Underserved Areas. Web. 31 July 2012. <http://bhpr.hrsa.gov/shortage/>. Wilson MS, et al. MIST VR: VR trainer for laparoscopic surgery assesses performance. Ann R Coll Surg Engl. 1997;79(6):404-404.