Would You Want to Be the Patient? “Live Surgical Broadcast” or “As-Live Unedited Surgical Broadcast”

Introduction

Live surgical demonstration has been the cornerstone of surgical education for centuries. Halstead's educational philosophy of “see one, do one, teach one” are familiar words to surgeons. The scope of surgical demonstrations has increased significantly in recent times with advances in audiovisual technology and minimally invasive surgery.

Live surgical broadcast (LSB) enables high-definition images to be streamed directly to audiences from around the globe. Some argue that the real-life nature of LSB provides an educational perspective and intrigue not gained through edited recordings or textbooks. It has been suggested that LSB can improve the procedure and surgical quality through immediate observer feedback. ¹ Nevertheless, increasing concern for patient safety, educational value, and financial/professional conflicts of interest has called into question its ongoing practice. ² The majority of respondents of a recent American surgical survey felt LSB should not continue indefinitely in its current format. ³ Recently, due to high-profile complications with LSB, several international medical societies have chosen to abandon the practice, ⁴ while others have published a policy and framework within which LSB can continue. ²

As-live surgical broadcast (ALB) enables an unedited demonstration of a surgical case. The ability to have the surgeon hosting, commenting on, and debating their case as-live, without the distraction of having to operate simultaneously, may provide the necessary useful education from LSB without the suggested disadvantages.

In this study, we evaluate patient safety, educational value, and ethical issues surrounding LSB and ALB using data obtained from urologic delegates attending two recent UK endourology meetings.

Subjects and Methods

Questionnaire-based studies were delivered to delegates attending the Société Internationale d'Urologie (SIU) U K section meeting in December 2013 and the British Association of Urological Surgeons (BAUS) Endourology Section meeting in March 2014. The two questionnaires asked questions relating to many important aspects of surgical broadcast, including educational, patient safety, and ethical issues. The two questionnaires are shown in full in Appendix 1 and 2.

Delegates at the SIU UK section meeting watched ALB of ultramini percutaneous nephrolithotomy (PCNL), diagnostic flexible ureteroscopy, and combined supine PCNL with retrograde intrarenal surgery. An electronic link to this survey was subsequently emailed out to 212 delegates using the online survey software SurveyMonkey^® in December 2013. Delegates were asked to compare their previous perception of LSB and ALB and to compare their current experience of ALB to previous experience of LSB.

Delegates at the BAUS Endourology meeting watched both the LSB and ALB of PCNL and laparoscopic nephrectomy on the same day. Live voting keypads were used at the meeting to compare 103 delegates' perception of LSB and ALB simultaneously, as well as comparing their current experience of ALB to previous experience of LSB.

No plenary or educational sessions debating LSB and ALB were provided at the two meetings. Both survey formats were anonymous and contained questions with fixed answer choices. No remuneration was offered for survey completion. The survey queried several nonidentifying demographic points, including the extent of previous experience of LSB/ALB and level of training. The delegates' answers were recorded using Likert scales. A 10-point Likert scale with “1” representing “totally disagree” and “10” representing “totally agree” was used in addition to a 5-point Likert scale with “1” representing “strongly disagree,” “3” representing “neutral,” and “5” representing “strongly agree.” A further 5-point Likert scale was used with “1” representing “significantly less,” “3” representing “equal,” and “5” representing “significantly more” and all Likert scales were subsequently converted to 5-point scales for comparison. The Likert scale was used to enable the numerical standardization of a subjective variable. The Likert data were treated in this study as the ordinal data. Statistical comparison of the data was made using a Mann–Whitney U-test.

Results

Demographics

Sixty-two responses were analyzed from the SIU meeting representing a survey response rate of 35%. One hundred three responses were analyzed from the live voting report generated at the BAUS meeting, with a survey response rate of 62%. Most delegates were aged 30 to 39 years (49.2%). Most delegates were in specialist practice either as a consultant urologist (67.1%) or trainee Urologist (22%).

LSB had been previously witnessed by delegates, significantly, more frequently than ALB (87.1% vs 66.6%, p=0.049). Most delegates had seen LSB greater than 10 times (48.6%), whereas most delegates had only seen ALB 1–3 times (42.8%) (Fig. 1.)

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FIG. 1.

Previous exposure to surgical broadcasts.

Previous experiences and educational value

The educational value that the delegates had derived from previous experiences of LSB and ALB is shown in Figure 2. Delegates reported no differences in the ability to learn new tips, manage complications, or question the surgeon/panel. Overall, based on their previous experience, the delegates felt the education value of the two formats was similar.

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FIG. 2.

Previous experiences and educational value.

Previous experiences and patient safety

The delegates' experience of patient safety from previous experiences of LSB and ALB is shown in Figure 3. They felt that there were significant patient safety benefits with ALB over LSB, including a less pressurized surgeon, less concern over patients' well-being, and the patient's eventual outcome. All parameters assessed reached a statistical significance (p<0.05) in favor of ALB.

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FIG. 3.

Previous experiences and patient safety.

Previous experiences—friends and family test

Delegates were asked a “friends and family” test style question based on their previous experiences of LSB and ALB (Fig. 4). They were significantly less likely to recommend a friend or family member to be a patient in an LSB setting, and were also significantly less likely to volunteer to be a patient themselves (p<0.05) in an LSB format.

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FIG. 4.

Previous experiences—friends and family test.

On-the-day comparison of LSB and ALB

Based on delegates simultaneous experience of LSB and ALB at the BAUS Endourology meeting (Fig. 5), the delegates felt the educational value of the two formats was similar. There was no perceived difference in the ability to learn how to manage a complication between the two formats. They felt that learning new tips/tricks from the surgeon was significantly more likely to happen with ALB. The delegates also perceived the surgeon to be less pressurized/anxious during an ALB (Fig. 6). Overall, there was significantly less concern with ALB that the patient's outcome may have been compromised. Both these last safety parameters assessed, reached statistical significance (p<0.05) in favor of ALB.

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FIG. 5.

On-the-day comparison and educational value.

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FIG. 6.

On-the-day comparison and patient safety.

On-the-day comparison of LSB and ALB—friends and family test

Delegates were also asked a “friends and family” test style question based on their current experience of LSB and ALB (Fig. 7).They were significantly less likely to recommend a friend or family member to be a patient in an LSB format, and were significantly less likely to be a patient themselves (p<0.05) in an LSB setting.

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FIG. 7.

On-the-day comparison—friends and family test.

Experience of ALB

Delegates were asked a further set of questions to clarify their current experience and perception of ALB (Fig. 8). There was significantly less concern for both the surgeon and the patient with ALB. From an educational perspective, the ability to see intraoperative complications managed was felt to be similar to LSB, however, the ability to demonstrate a complex surgery and visualize different surgical views/radiological images/fluoroscopy images was felt to be significantly better with ALB. The delegates also favored ALB as a format for questioning the operating surgeon. Overall, they felt that the educational benefits of ALB were equal to those of LSB, and that LSB was not significantly superior in the educational benefit it provides.

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FIG. 8.

As-live surgical broadcast—current experience.

Discussion

Instruction of trainees by surgeons while operating is still the cornerstone of surgical training throughout the world. As technology advances, this practice continues to adapt and we are now in an era where broadcasting surgical procedures live, as-live, or in edited forms to audiences is common. ^5,6 LSB sessions are often popular sessions, but it is unclear from an objective perspective what draws delegates. Several benefits have previously been suggested, including the knowledge gained from closely observing an experienced surgeon handling unexpected intraoperative issues as well as examining and peer reviewing cases in a manner that is not possible with an edited video. ⁷ It has been previously reported in a survey of delegates at an interventional vascular meeting that 82% felt live cases had a greater educational value than a recorded video. ⁸

Concerns have been leveled at LSB with regard to patient safety. During a live broadcast of a percutaneous coronary intervention at a meeting in Europe in 2013, an intraoperative complication requiring defibrillation was identified first by members of a panel and an audience who were watching the procedure remotely with the surgeons explaining live; “…we did a mistake while talking during the live broadcast…”. ⁹ Other high-profile complications with LSB have been published in the nonpeer-reviewed press. ⁴ As a consequence, the American College of Obstetricians and Gynecologists, American College of Surgeons, Japanese Society for Cardiovascular Surgery, and the Japanese Urological Association have chosen to abandon the practice of LSB. ³ Recently, while recognizing LSB's potential unique educational merits, the European Association of Urology (EAU) has acknowledged the concerns of the wider community and published a policy and framework to facilitate the safe delivery of EAU-endorsed LSBs. ²

There are several aspects to consider with regard to the debate over LSB. Some have reported that outcomes of live broadcast procedures are equivalent to those found in cases performed without observers. An article on live transmitted carotid artery stenting showed that technical success was achieved in 99.5% of cases with complication rates similar to those reported in the literature. ¹⁰ A further article published in the cardiovascular literature this year, looking at transcatheter aortic valve intervention live transmission, when performed by experienced operators, can be done safely with similar outcomes when compared with nontransmitted cases. ¹¹ Within the urological literature, an article looking at the outcomes of 39 live broadcast robotic partial nephrectomies reported that the outcomes were not significantly different to those of 847 standard procedures. ¹² Not all the literature is in agreement though. Endoscopic retrograde cholangiopancreatography cases performed live over a 5-year period were matched to control cases and were found to have a significantly inferior complete success rate, although the complication rate did not differ. ¹³ Interestingly, subgroup analysis also showed a trend toward lower success rate with visiting faculty compared with local faculty.

Operating in a live forum brings with it specific challenges for the surgeon. Ninety members of the American Association of Genitourinary Surgeons (AAGUS) responded to a survey in 2012. ³ 93% had performed LSB as visiting professors, and 73% of them had rated their anxiety levels as moderate, high, or very high when doing these procedures. Approximately, 40% reported that excessive conversation in theatre was a major distraction. Most telling from this survey was the “friends and family” test that showed only 28.2% of AAGUS would let a visiting faculty member operate on them or a family member.” A recent survey of urologists attending two major international meetings in 2012 reported that a slim majority (58%) of urologists would allow themselves or a family member to be operated on. Our data add further to this debate, with a clear consensus based on previous and contemporary experiences of UK surgeons. There is significantly more concern over the patient and surgeon welfare in the LSB setting, and thus, delegates are significantly less likely to recommend a friend or family member, or be willing to be a patient themselves in the LSB setting.

If most surgeons, or even a substantial minority at 40%, would not allow live broadcast surgery on themselves, should patients continue to be subjected to it? A commentary on the role of LSB highlights a patient's perspective of this form of broadcast—namely that of pride in facilitating the education of surgeons. ¹⁴ Patient cooperation is paramount in providing all surgical education, and is firmly based on a trusting doctor–patient working relationship. If as surgeons we wish to see LSB continue as an education tool, having a surgeon operate on his own patient, with his own theatre team, in his own hospital, may be the model that is required to ensure this trusting doctor–patient working is maintained.

The specifics of educational benefit derived from LSB and ALB has received considerable attention in the recent literature. An American study looked at delegates' perception of educational benefit with live case demonstration and both edited and unedited taped case demonstrations. ¹⁵ The perceived benefit was significantly more with LSB, but few respondents selected “not helpful” or “minimally helpful” for any of the taped case formats. Having the opportunity to ask questions and access to the full unedited tape of the case afterward was felt to improve the educational benefit of edited videos. Our study highlighted that some delegates found the ability to demonstrate complex surgery and visualize different surgical views/radiological images/fluoroscopy images to be significantly better with ALB. This may be because the surgeon has more time to present this information in the ALB setting. This enables the audience to make better sense of complex information relating to the case and, perhaps, draw more educational benefit from the case as a consequence.

This study is unique as it directly compares and contrasts delegates' previous and contemporary experiences of LSB and ALB. Based on previous experiences at conferences, they did not perceive a difference in their ability to question the surgeon and panel, to learn new tips/tricks, or manage complications between the two broadcast modalities.

These perceptions were broadly replicated when delegates compared broadcast modalities after observation at two UK conferences. Moreover, delegates felt that with ALB they were significantly more likely to learn a new tip/trick. Overall, our study delivers a clear educational message from UK surgical conference delegates that there is no significant difference in the ability of ALB to deliver good quality education when compared with LSB.

The differing case-mix presented at the two conferences could suggest that the complexity or invasiveness of the procedure affects delegates' attitudes to LSB and ALB. We feel that the strength of this study is the concurrent evaluation of more invasive and less invasive procedures, with similar outcomes from delegates reported.

This study does have limitations. By its nature of being a survey, it is subject to a number of biases. Despite our expert panel consensus in constructing the survey, it remains still a subjective measure of validity. Selection bias is always a concern when presenting survey data. We do not believe that delegates supporting ALB are more likely to complete these surveys than delegates supporting LSB. Canvassing delegates' opinion at two endourology-based meetings held in the United Kingdom does introduce a potential multiple response bias. There was a higher proportion of international delegates at the SIU meeting and hence, we feel the effect of this on our results is small. Asking delegates to recall their experiences of LSB and ALB does introduce a recall bias. A study comparing LSB and ALB witnessed during the same session would minimize this bias. However, having a live voting and follow-up survey that are supportive of each other should be regarded as another strength of the study, with different data collection methods producing results that correlate. Another limitation is a nonresponse bias. Our response rate from delegates attending the SIU UK section meeting was 35%. This may have introduced error into our results, however, the live voting of the majority of delegates in the BAUS Endourology meeting, with similar findings to the SIU UK meeting, validates our results and suggests that the nonresponse bias is minimal. Finally, all our findings with regard to an educational benefit are purely based on the perception of benefit and not an actual measured educational benefit.

Conclusions

ALB offers similar educational opportunities to delegates when compared with LSB, while appearing to offer significant welfare benefits to both surgeon and patient. Further studies are required to objectively quantify these subjective observations.