Technology for teaching: New tools for 21st century surgeons

Since William S. Halsted, MD, FACS, first developed his principles for the training of surgical residents, young surgeons have faced the challenge of acquiring surgical skills and clinical experience in the pressure cooker of residency.¹ With limited time, increased patient volume, administrative responsibilities, and the overarching objective to keep pace with the wealth of new research, hospitals and house staff alike are using technology-based tools as clinical and educational aids. Advances in electronic health record technology combined with the vast amount of health care data available on the Internet give users quick access to reference and self-assessment tools at the touch of a button on a smartphone or tablet. At the same time, innovative techniques in the operating room (OR) have led to the creation of laparoscopic and endoscopic instruments, robotic consoles, stapling and cautery devices, and advanced audio-visual aids. Surgeons can remotely consult one another through telementoring and share ideas or discuss clinical decisions and strategies internationally via teleconferencing. Now more than ever, technology-based media and the virtual world have become essential components of surgical education.

Technology advances in surgical education

As the surgical community develops new treatment modalities and the procedure repertoire extends to include technology-assisted and minimally invasive approaches, the education of surgical trainees must continue to adapt and evolve.² The days of operating theaters and “see one, do one, teach one” are waning in favor of safer, more efficient, and measurably effective means of acquiring surgical skills. Implementation of the 80-hour workweek has limited the time residents spend in the hospital and the OR, while the understanding of the pathophysiology of disease and options for treatment continue to advance and expand.³ Such a dichotomy in surgical education necessitates alternative methods of active training.⁴

Seasoned surgeons and clinicians are challenged to develop new forums away from the bedside and the OR to develop basic knowledge in an effort to optimize the limited clinical time for building and honing more complex surgical skills. Textbooks, scientific articles, and didactics can be consolidated into smartphone applications for enhanced accessibility, allowing residents to learn while on the go in the midst of hectic rotations. Simulated trainers for practice in laparoscopy, endoscopy, and robotics have been developed to supplement intraoperative hands-on experience and to act as surrogates for the patient-as-teacher relationship. Using simulated training in a variety of clinical settings with associated complications reinforces surgical skills without compromising patient safety.⁵ These simulations also provide a controlled teaching environment in which trainees can be objectively evaluated via structured courses. In the wake of today’s information overload, the current generation of practicing surgeons and surgical trainees must take a modernized approach to the challenges of medicine encountered by their predecessors and embrace the shift toward education through technology and simulation.

However, each generation of surgeons has its own learning style, which may influence each group’s affinity for technology as an educational instrument.Millennials, defined as those individuals born between 1982 and 2001, are digital natives who are accustomed to multitasking and the continuous use of digital devices, whereas older generations may be less comfortable with the diffusion of technology.^6,7 At the same time, each generation is heterogeneous and diverse, and the increasing prominence of technology in surgical education and its potential for individualized learning may be a unifying intergenerational factor.⁸

Gadgets and devices

Advances in computer technology, video cameras, and smartphones play a vital role in clinical medicine and have revolutionized how surgeons care for patients both inside and outside of the OR.⁹ Today, trainees of all levels not only participate in the traditional study of textbooks, attend didactic lectures, and learn directly from attending surgeons, they also regularly use handheld devices and computers to access information and engage with colleagues at any time.¹⁰

The advent of video-assisted procedures, including laparoscopy, endoscopy, and robotics, has expanded the armamentarium of the general surgeon and magnified the number of skills a surgical trainee must master in addition to traditional open techniques.^1,5 In turn, video recordings of training and intraoperative sessions give residents further exposure to the steps and skills employed in specific operations, augmenting their preparation for the OR and compensating for the decreased amount of time spent therein.¹¹ Video sessions at national meetings organized by the Society of American Gastrointestinal and Endoscopic Surgeons and the American College of Surgeons attract many trainees and practicing surgeons who are interested in watching and learning new techniques. Online video libraries with content from national conferences and other contributors have also proliferated for easy access to both trainees and advanced surgeons.

Smartphone applications (“apps”) have permeated surgical training, enhancing traditional methods of teaching.¹² A plethora of apps are available on topics ranging from anatomy review to self-assessment question banks. In fact, preparation for the annual resident in-service exam has evolved, as information via apps can be accessed anytime with a smartphone. Trainees can better budget their time by spending a few minutes of free time answering practice questions, studying anatomy, or even logging duty hours—all through smartphone apps.¹³ Apps such as Epocrates, UpToDate, Medscape, and others are tools for disseminating current health care information, while TouchSurgery, Truelearn, and SurgQuest allow surgical residents to practice the steps for common procedures or review high-yield facts. A user can browse the latest journal articles, listen to a surgical podcast, consult updated staging guidelines for cancer patients, and even calculate the risk of infection after a hernia repair—all by tapping the screen of a smartphone.

The genre of wearable technology also has found an application in surgical education. Devices developed for assessment include those with physiologic sensor capabilities to monitor and evaluate the impact of stressors on performance during training sessions.^{13, 14} Intraoperative teaching via wearable devices such as video cameras allows not only the surgeon and first assistant to view an operation from the primary perspective, but residents and students as well. Wearable gadgets such as Google Glass have shown promise in education by providing real-time teaching from the wearer’s point of view as well as a heads-up display for reference to imaging or other useful data.¹⁵ Furthermore, virtual interactive presence (VIP) enables skilled surgeons to interact with a trainee in the operative field and give real-time coaching or assistance from a remote location.

Simulation

Since minimally invasive surgery gained traction in the 1980s, surgeons have known that acquiring new surgical skills involves training beyond the traditional Halstedian apprenticeship model of supervised intraoperative learning. The combination of shorter duty hours, along with the need to balance patient safety with resident learning, increases the need for education both inside and outside the OR.

While simulation training cannot replace the traditional apprenticeship model of intraoperative training, simulation experiences allow trainees to learn at their individual pace, and to have the freedom to make mistakes and to learn from those mistakes in a safe environment. Many educators advocate for mandatory simulation training to enhance proficiency before trainees are allowed to perform procedures on patients. A range of simulators have been created and studied, from box simulators and tasks to advanced simulators that mimic a complete surgical procedure. Surgeons, gynecologists, and urologists use the Fundamentals of Laparoscopic Skills (FLS) education modules to acquire and test basic laparoscopic dexterity, while other health care professionals use the Fundamentals of Endoscopic Skills (FES) course to hone upper and lower endoscopic skills.^16,17 The fields of laparoscopy and endoscopy are continuously evolving with the introduction of single-incision laparoscopic surgery and natural orifice transluminal endoscopic surgery, which also require a dynamic platform of learning and skills practice. The latest simulators include the robotic training console, and formal robotic training courses may soon become standard components of a surgical residency curriculum.¹⁷

A vast amount of literature describing the efficacy of stimulation training modalities is available. Research has shown that early exposure to simulation is critical in surgical training. Incorporation of trauma patient simulators into an intensive trauma boot camp in 2016 was found to significantly increase the overall confidence level of 15 interns with respect to delegation, leadership, crisis resource management principles, and performance of trauma primary and secondary surveys.¹⁸

Virtual reality is another validated form of simulation training. A systematic review of 31 randomized controlled trials examining simulation training for abdominal laparoscopy found virtual reality training to be superior to video trainers and equal to box trainers in the teaching of laparoscopic skills.¹⁹ In randomized controlled studies, virtual reality simulation has been demonstrated to be effective in other surgical procedures, such as robotic cardiac surgery and urology.^20,21 In addition, a 2015 randomized controlled trial (n=16) found that four hours of virtual reality simulator training was significantly more efficient than a half day of supervised training on patients using the traditional apprenticeship model.^22,23 However, virtual reality training is more likely to be successful when it occurs as part of an organized education program with validated performance measures and when practiced at regular intervals rather than consolidated into a single extensive period.²⁴

Three-dimensional (3-D) printed models are the next frontier of simulation training. With the advent of 3-D printing, surgical teams can now train with high-fidelity simulation on personalized 3-D models to enable preoperative preparation, optimize operative performance, and teach postoperative care. In neurosurgery, patient-specific 3-D brain models were found to be valuable for preoperative patient illustration, teaching, learning, surgical training. and preoperative planning.²⁵ Simulation training on patient-derived 3-D models is particularly important for procedures with decreasing volume, which has led to fewer opportunities for OR training.²⁶

In addition, 3-D models can be valuable for simulation of postoperative care. Following congenital cardiac surgery, patient-specific 3-D models have been used to train intensive care unit (ICU) teams in postoperative care.²⁷ In particular, nurses and ancillary staff found 3-D models helpful for successful postoperative critical care handoffs. They also reported a greater understanding of the patient’s operation.

The cost associated with newer forms of simulation training, such as virtual reality simulators and 3-D models, may be burdensome for some training programs. However, a number of training programs have developed low-cost, easy-to-assemble simulation models. For example, inexpensive endoscopy simulators have been developed to facilitate FES skills training. Some cost less than $100 to build using easily obtainable materials and were rated by endoscopy experts as both easy to assemble as well as realistic.^17,28

Simulation as a training modality is an inter-generational tool. It can be valuable for independently practicing surgeons as a component of continuing medical education (CME) and as an educational home to acquire new techniques, further refine skills, and maintain proficiency in a safe setting without endangering patients.^29-31 Postgraduate training courses and surgical simulation centers can provide a valuable venue for practicing surgeons after residency and fellowship training to gain simulation experience. A systematic review of 17 studies found that simulation-based training for practicing physicians demonstrated both immediate and sustained improvements.³²

Telemedicine

Telemedicine is defined as the use of electronic communication systems to exchange medical information and improve patient health outcomes.³³ Telemedicine has been available for several decades; in fact, Evans and Schenarts report that the late Michael DeBakey, MD, FACS, used telemedicine in 1965 to guide European surgeons in the performance of open heart surgery.³⁴ The technology boom of the last two decades has made telemedicine significantly more available and its use more widespread in the health care system. Indeed, the American Telemedicine Association reports that more than half of all hospitals in the U.S. use some form of telemedicine.³³

Telemedicine has transformed the way we learn about surgery. In Dr. Halsted’s time, a surgeon might travel overseas to learn state-of-the-art procedures from the innovators of those techniques. With telementoring—the practice of having an experienced, senior surgeon remotely guide a less experienced, junior surgeon through a procedure—surgeons no longer need to travel to learn about a new operation. As a result, telementoring has gained popularity, especially among physicians in rural or austere environments, as a means to learn new techniques and seek advice from more experienced surgeons.

The clear advantage of telementoring is its natural integration with minimally invasive surgical techniques. For example, Treter and colleagues have described the use of telementoring to instruct surgeons in remote locations how to perform posterior retroperitoneoscopic adrenalectomy, concluding that “cyberspace consultation is safe.”³⁵ Telementoring has been used in various subspecialties as well, including colorectal, pediatric, head and neck, and urologic surgery.

Interestingly, the benefits of surgical telementoring are not limited to surgeons. Kirkpatrick and colleagues found that the telepresence of a surgeon significantly improved the confidence of nonsurgeons when they were performing a procedure.³⁶ This underscores the utility and versatility of telementoring as an effective educational tool for a range of health care professionals.

Teleconferencing also has had a profound effect on surgical education. In trauma surgery, for example, the American Association for the Surgery of Trauma (AAST) hosts monthly grand rounds transmitted via teleconferencing to its many member institutions. These grand rounds cover a multitude of topics pertinent to the care of trauma patients and connect trauma surgeons from across the country to the nation’s leading experts in the field. The University of Miami, FL, Ryder Trauma Center, along with other partners, established International Trauma Tele-Grand Rounds, connecting more than 40 participating institutions around the globe to discuss difficult cases or new management strategies.³⁷

At the Ryder Trauma Center, telemedicine is routinely used for morning rounds in the trauma intensive care unit (TICU). A mobile teleconferencing system is controlled from a conference room where the entire TICU team is located. The conference room is equipped with three large screens that simultaneously show the patient and bedside monitor (via the mobile teleconferencing system) as well as the details of the patient chart. Aside from minimizing the risk of nosocomial infection by limiting the traffic in the ICU during rounds, telemedicine improves the quality of education by combining several tools in real time and allowing more time for teaching.

These innovative strategies have revolutionized the way both senior and younger surgeons deliver and receive information; this approach is especially true for health care professionals who practice in non-academic centers with limited access to educational resources.

Looking forward

The future holds an incredible opportunity to harness technology for the education and evaluation of surgeons in an increasingly complex world. Devices, simulators, and telemedicine allow for increased access to surgical information, novel surgical applications, and real-time teaching of surgical techniques. The innovations described in this article have permeated surgical instruction to differing degrees; some, such as smartphones, are widespread, while others, such as 3-D printing and telemedicine, are more nascent. Nonetheless, these advances are changing the way we think and teach. We are on the brink of transforming surgical education from a one-size-fits-all training paradigm to a system that builds on the strengths of the individual surgeon while helping to address any individual weaknesses. As new technologies are created, surgical training will continue to adapt and change. To encourage innovation in surgical education is to open new portals for communication, assessment, and progress.

However, the wisdom of the past should continue to inform the present. As certain procedures become less common due to changing disease etiologies and management, young surgeons have much to learn from their older colleagues.^38,39 As we train the next generation of surgeons, we must continue to impart these skills and lessons to practicing surgeons to ensure that all members of the profession are prepared to meet today’s patient care challenges.

The rich history and tradition of surgery transcends intergenerational differences in learning styles. While virtual platforms have revolutionized surgical education, we should consider the benefits of in-person coaching and relationship-building. In a changing world, we must safeguard the lessons passed down from every generation and embrace technologies that facilitate the exchange of ideas.

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