Telementoring: The future of surgical training

Clinical Case

Today, experts estimate that all human medical knowledge doubles every 18 months. The pace of progress in surgical innovation is so fast that some surgeons have expressed serious concern about patient safety as technology diffuses throughout keeping hospital organization up with surgical innovation is imperative for growth, but surgical programs can be slow to adopt because new technology may result in poor patient outcomes early in the adoption cycle. Because of these fears, the idea of telementoring is born, so that one surgeon can guide another in the distance, using telecommunications, through audio and video telestration. This valuable tool can help your surgeons and clinical teams feel comfortable adopting the latest procedures

But before continuing talking, we should know… What is the difference between the different concepts of telemedicine?

• Telemedicine: The use of medical information exchanged from one site to another via electronic communications to improve a patient’s clinical health status.
• Teleconferencing: Interactive electronic communication among multiple users at two or more sites that facilitates voice, video and/or data transmission systems: audio, graphics, computer and video systems.
• Telemonitoring: The process of using audio, video and other telecommunications and electronic information processing technologies to monitor the health status of a patient from a distance.
• Telepresence: The use of a set of technologies that allows individuals to feel as if they were present, to give the appearance of being present, or to have an effect at a place other than their true location.
• Teleconsultation: Consultation between a provider and specialist at distance using either store and forward telemedicine or realtime videoconferencing.
• Telementoring: telementoring is a relationship, facilitated by telecommunication technology, in which an expert (Mentor) provides guidance to a less experienced learner (Mentee) from a remote location.
• Telestration: a technique for drawing freehand annotations over a still image or video.

The Mentor/telementor is an expert surgeon who undertakes to impart his/her clinical knowledge and skills in a defined setting to a mentee. The mentor must be appropriately privileged, skilled, and experienced in the procedure and or technique in question. The telementor, by definition, does not have the ability to physically intervene onsite in the primary activity without the telecommunications interface.

The Mentee/trainee is a surgeon with appropriate basic knowledge and experience seeking individual training in skills and/or procedures not previously learned in prior formal residency or fellowship training. The mentee must have appropriate background knowledge, basic skills, and clinical experience relevant to the proposed curriculum.

Telementoring differs from teleconsultation in three precise ways:

1. Telementoring requires an established relationship between the mentor and mentee in which the skills and knowledge of both are understood through a relationship developed prior to the telementoring event.
2. Telementoring is performed with a competent mentee who is capable of managing the patient’s disease, as if the mentor were not telepresent, although likely using a different technique or technology.
3. Telementoring occurs within an educational framework through which both the mentor and mentee have worked to prepare for the mentoring experience.

Modern technology has allowed for numerous advances in the utilization of telementoring. Early telementoring systems were limited by low transmission rates, raising concerns of the deleterious effects that a time delay may have on surgical performance. Current telecommunication systems allow for dramatically increased transmission speeds, permitting a considerably decreased time delay. In addition, the high resolution associated with modern high definition cameras has enhanced the remote surgeon’s ability to zoom and visualize small anatomic details. Wearable technology, such as Virtual Reality Glasses, and methods of augmented reality telementoring have also been implemented and have had some success. Specially designed telemedical robotic platforms have been developed also and may play a role in further increasing the remote surgeon’s presence in the operating room. But one of the most important advances in telementoring systems was the application interactive additions such as laser pointing capabilities, telestration, or increased remote control of the visual field playing a role in enriching the teaching capabilities of the remote surgeon. These different strategies for realizing telementoring have numerous advantages that have been increasing to the present. Telestration enables a trainer to point or draw freehand sketches over a video for the trainees to see. This method can improve the trainees performance, in terms of economy of movement, after the initial mastery has been attained. The improved use of laparoscopic video results in more direct instrument movement. The telestration systemns benefits the trainees in the adoption of professional vision, which would further enhance the trainees technical skills and understanding of the procedure.

Telestration reduces travel and time away from work for both surgeons involved in training a major rate limiting factor in surgeon upskilling. In addition, the hospital benefits from performing more cases at their facility and ensuring that the surgeon has the expert support needed to deliver high quality care early in their post-training learning curve. The patient, meanwhile, gets the comfort of knowing that their surgeon will be supported by additional experts.

As the technology required to implement surgical telestration is currently readily available to many physicians, the advancement of tit is now dependent on several other hurdles limiting its expansion.

Additionally, despite numerous studies demonstrating the utility and safety of telementoring and telestration, the literature is limited by small sample sizes, variation in telementoring platforms, procedure, and the experience of the onsite surgeon. These limitations provide some confusion regarding the optimal use of this technology. Future studies evaluating clinical and educational outcomes with large sample sizes that span numerous procedures may be necessary to validate its utility and appropriate indications for use. The skill set and experience of the onsite surgeon likely has a large impact on the success the telementored procedure. However, some studies have began investigating its potential to be used in “worst-case scenarios”, in which the mentored onsite healthcare professionals have very limited experience or training in the procedure they are required to perform.

Future studies are needed in order to determine the feasibility of telementoring in guiding inexperienced healthcare professionals. Determining a minimum set of qualifications and skillsets is another factor that may better define the best application of telementoring and its future success.

The main benefit is that it has to potential to distribute specialized surgical knowledge and guidance through a relatively convenient and low cost method as compared to traditional mentoring. The development of platforms that optimize patient outcomes and the educational value of that training, while maintaining appropriate cost effectiveness, carry great potential to mitigate the shortage of surgeons around the world. The Hospital Clinic of Barcelona, a reference center in laparoscopic and minimally invasive surgery, will now have this innovative tool, thus breaking the barriers of surgical training, and can bring new knowledge to all types of hospitals around the world, thus improving the development of the surgeons surgical skills and consequently, favoring the treatment of patients and their results.