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Inspired by a visit to Botswana, a Canadian surgeon has found an inexpensive and effective way to train doctors in complex surgical techniques over the Internet.
A Toronto doctor is using the popular Internet telephone service Skype to train surgeons in remote parts of the world — both in Canada and overseas.
Dr. Allan Okrainec, assistant professor of surgery at the University of Toronto, came up with the idea of using the Internet for distance teaching on a return trip from Botswana, where he had been training physicians on minimally invasive surgical techniques with his colleague, Dr. Georges Azzie, of the Hospital for Sick Children.
Specifically, he was teaching local physicians how to perform abdominal surgery using laparoscopy, a technique that involves inserting a long camera and tiny instruments into the abdominal cavity.
Dr. Allan Okrainec uses the Internet to teach physicians overseas how to perform minimally invasive abdominal surgery.
With the near 30-hour flight each way, plus the days teaching the course and testing trainees, the time spent was close to two weeks. But Dr. Okrainec found the trip to Botswana unsatisfactory. When the physicians who had taken the course underwent testing for the credentials to practice laparoscopy, only 10 percent of them passed. Dr. Okrainec felt that the poor success rate was due to the fact that the experts teaching the course were there for such a short period of time.
"This was a highly inefficient way of teaching,” says Dr. Okrainec. “We were trying to teach these complex skills in short bursts.” On the way home, he figured there had to be a more effective way.
A Eureka moment
Part of the training was done using a laparoscopy simulator developed by researchers at McGill University to mimic the skills needed to perform intestinal or abdominal surgery. (The device is used in the widely adopted Fundamentals of Laparoscopic Surgery (FLS) certification program.) As in real laparoscopy, the procedures performed in the simulator are shown on a large monitor so doctors can see what is happening in the virtual abdomen.
That meant the information was all digital. And digital information can be transmitted over the Internet. This is where the idea of using the Internet came to Dr. Okrainec in a “Eureka!” moment.
"I thought, why can't we just set up webcams and teach from here the same way we were doing over there?” says Dr. Okrainec. “We could create a sort of virtual learning environment over the Internet." This was the birth of the concept that Dr. Okrainec called telesimulation.
As a scientist, Dr. Okrainec knew that the idea had to be tested. He did a study in which one group of surgeons in Botswana communicated with the Toronto-based instructors for 15 minutes each week for a total of eight teaching sessions. A second group of surgeons was told to practice using the simulator on their own.
"Our skills certification rate in the telesimulation group was 100 percent, and only 38 percent in the other group," says Dr. Okrainec. The study was published in 2009.
Training that costs less
Since then, more than 130 surgeons in 12 different countries have been trained using telesimulation.
"It's a great way to get training to doctors in resource-restricted countries," says Dr. Okrainec. Plus, computer-to-computer communication through the Internet is free, saving costs in poorer regions.
The teaching approach is now being expanded to medical skills beyond laparoscopic surgery. The Internet is now being used as the communication and visual medium to help teach anaesthesia, nursing skills and trauma skills. Neurosurgery is potentially on the list too.
“The next application we're using it for is to teach live surgery,” says Dr. Okrainec. “In Peru we've done this three times now, where the image from the laparoscope inside the abdomen is sent over the Internet. We do that to supervise and teach surgeons overseas.”
Teaching physicians in Canada
The approach is also helping to bring additional skills to physicians who practice in remote parts of Canada. When it comes to getting FLS certification, doctors have had to travel to one of three places in Canada where FLS courses and testing are offered: Toronto, Montreal and Vancouver.
Pilot projects in Ontario have shown that Canadian doctors can also get the skills through the FLS program set-up on the Internet. To date, 30 surgeons in remote parts of Northern Ontario have undergone the telesimulation training in FLS and received certification.
Funding for Dr. Okrainec’s work has been provided by an Ontario Ministry of Health Innovation Grant, in order to train 100 surgeons throughout Ontario using the telesimulation teaching approach. It’s an approach that can’t help but catch on considering the sparse population distribution in Canada. One of the next projects will likely involved teaching neurosurgery via the Internet, using a neurosimulator called “Neurotouch” developed by NRC.
“We're hoping to partner with various organizations, either in Canada or internationally, to use our telesimulation program with the NRC simulator,” Dr. Okrainec says.
“The response we've had throughout the various medical communities has been amazing. It’s such a simple idea — it’s not rocket science but it makes sense.”