No Surgeon Should Operate Alone: How Telementoring Could Change Operations

Introduction

As part of the ever-present evolution in surgical techniques, technology has allowed surgeons to perform complex procedures using minimally invasive methods. However, learning the ins and outs of laparoscopic and robotic operations takes practice and is best not ventured into alone. But the logistics associated with shadowing an experienced surgeon, performing the procedure under his or her tutelage, and then progressing to independent, skilled practice are problematic. Telementoring, a process during which an experienced surgeon remotely guides another surgeon through a procedure using a telecommunication system, offers a viable option for facilitating the transfer of knowledge and skills, as it cost-effectively expands the mentor pool and increases experienced surgeons' availability to assist in educating other surgeons. However, concerns about privileges, licensing, equipment, and connecting novices with experts remain.

“Telementoring has widespread use, and not just in surgery but anywhere there are procedures or clinicians or nurses that need oversight,” said James “Butch” Rosser Jr., M.D., FACS, a professor of clinical surgery at Morehouse School of Medicine and chief of minimally invasive surgery at Beth Israel Medical Center and director of the hospital's Advanced Medical Technology Institute in New York.

Telementoring is not new. Rosser participated in a telementoring procedure in 1993 for the military, using a television production mobile unit normally employed to broadcast football games to transmit the audio and video. Rosser is now working on a plan to establish a global telementoring support network, with the mantra “no surgeon should operate alone.”

“(Telementoring) is still not mainstream,” Rosser said. “To really be able to help the public, we have to have a more organized effort. The scientific validation and investigation phase is over; now we need global application.”

Tackling the Learning Curve

Even among experienced surgeons, learning a new procedure takes time. In 1995, J.D. Wishner, at the Eastern Virginia Medical School in Norfolk, published in the journal Surgical Endoscopy that “the learning curve for laparoscopic-assisted colectomies was as many as 35–50 procedures.” ¹ More recently, Prasanna Sooriakumaran, M.D., Ph.D., a fellow in the Department of Urology at Weill Cornell Medical College in New York, reported at the 2011 Genitourinary Conference in Orlando that the learning curve for robotic-assisted laparoscopic radical prostatectomy was as steep as 1,600 cases to obtain a positive surgical margin rate of less than 10%. ²

Cognizant of the risks and skilled at open procedures, surgeons may resist changing their well-honed practices and surgical strategies.

“One of the reasons new technologies are not embraced as fast is that the technology's or procedure's learning curve is very steep,” said Alex Gandsas, M.D., M.B.A., FACS, professor and chair of the Department of Surgery at the University of Medicine and Dentistry, Newark, NJ.

Experienced surgeons, in community practice, may take weekend seminars to learn a new procedure. They return to their home facilities with knowledge about the new technique but, likely, little experience in performing it on a human patient. The senior surgeon then needs to travel to the less-experienced surgeon's hospital to coach him through a few procedures.

“With our workloads, it is very hard for (surgeons) to take time away, unless you are in an academic practice,” Gandsas said. “You cannot afford to take a month off or two weeks off to learn a procedure.”

Evelyn Baram-Clothier, Ph.G., J.D., executive director of the American Medical Foundation for Peer Review and Education in Philadelphia, added that the organization's grant-funded preceptor program to create a template for teaching new procedures and devices experienced difficulties with patient and doctor cancellations and transportation issues.

“That grant, given to six specialty societies, showed that the training that a physician needed to be proficient required traveling a number of times, and that was not doable,” said Baram-Clothier. “Telementoring could change that.”

Even more concerning, Rosser reports that some physicians may read a book about a procedure and then operate on someone using that technique.

“That's what we call worst-case scenarios,” Rosser said.

Outside the United States, surgeons will often travel to the host country to learn a new procedure.

Alternately, surgeons have watched new operations from remote locations. For instance, Gandsas allowed two surgeons in Argentina to observe him perform bariatric operations during a 3-month period to learn his technique. He then used a remote-presence robot to watch them operate and offer guidance.

“These are trained surgeons, who need to learn strategy,” Gandsas said. “They know how to cut and sew.”

Time differences often help. A doctor half a world away may be able to watch a procedure at home after hours.

Telementoring Proves Successful

Many studies have shown that telementoring can successfully help physicians in mastering the learning curve in a variety of specialties.

In 2003, Nelson Rodrigues Netto, M.D., and colleagues, including Louis R. Kavoussi, M.D., formerly at Johns Hopkins Hospital in Baltimore, reported in the Journal of Endourology that several techniques such as laparoscopic bilateral varicocelectomy and a percutaneous renal access for a percutaneous nephrolithotomy can be mentored safely and effectively with telemedicine technology. ³

“The idea was to bring a novel surgical technique and oversight to a remote area,” said Kavoussi, now the chairman of urology for the North Shore-LIJ Health System in New Hyde Park, NY, and a clinical professor of urology at the New York University School of Medicine. “Telementoring is viable. We demonstrated the feasibility. You can do it, and it's cheaper now because telecommunication with the Internet has gotten a lot less expensive. Early on with the T1 lines, bandwidth was expensive.”

Ivar Mendez, M.D., Ph.D., at the Queen Elizabeth II Health Sciences Centre in Nova Scotia, Canada, and colleagues concluded in the journal Neurosurgery, after telementoring six long-distance neurosurgery cases, that telementoring is “feasible, reliable, and safe.” ⁴

Steven S. Rothenberg, M.D., chief of pediatric surgery and medical director of the Minimally Invasive Surgery Center at the Rocky Mountain Hospital for Children in Denver, reported in 2008 in the Journal of Laparoendoscopic and Advanced Surgical Techniques that remote presence technology in the operating room may be useful in adding to pediatric surgeons' expertise in minimally invasive surgery. ⁵ He used the technology to successfully mentor junior partners in his practice, when he could not be present at the hospital. He is also mentoring young colleagues at Morgan Stanley Children's Hospital at Columbia University Medical Center in New York, where he is also licensed and has privileges.

“In pediatric surgery, there are things you only see every couple of years, so you can be in practice a long time and come across things you are not familiar with,” Rothenberg said. “Our concept is the surgeon will have taken some advanced training in minimally invasive surgery. But it's a lot different to do a case when I am next to you in the OR to where you are doing it by yourself. The hope is this technology will bridge the gap.”

Telementoring has been also shown to be successful in training residents. A 2010 study in the Journal of the American College of Surgeons reported that eight general surgery residents operating on animal cadavers while telementored achieved higher overall mean performance scores when compared with completing the same operations without the telerobotic proctoring. ⁶ The residents also said they felt more competent when they were telementored.

Equipment Requirements

Telementoring requires equipment that allows remote surgeons to watch what is taking place in the operating room and communicate back and forth in real time with the physician performing the surgery.

“You have to have real-time interaction in the operating room,” Kavoussi said. “There are a lot of things you need on both ends to make it run.”

Kavoussi's study of telementoring surgeons in Brazil used a personal computer fitted with a video coder/decoder and a communication board. A surgical robot was added and allowed the remote surgeon to assist with some manipulation.

Florida Hospital's Nicholson Center for Surgical Advancement in Celebration received a $4.2 million Congressional Directed Department of Defense Grant in 2009 to focus on increasing telesurgery and telementoring capabilities. Roger Smith, Ph.D., M.B.A., chief technology officer at the center, said that a slight lag in data exchange will necessitate some changes in technique to make remote operations safe. The center will research what changes are needed in surgeon's hand movements or equipment.

Overcoming Licensure and Liability Challenges

Licensure and hospital credentialing can present barriers to broader telementoring within the United States.

Gandsas said most states do not require licensure to mentor someone in that state if one is not touching the patient and not practicing medicine, such as consulting about a patient. Baram-Clothier added she believes 30 states have visiting professor statutes that allow expert physicians to proctor and mentor local surgeons.

“I don't think state-line issues were meant to stop telementoring or telesurgery; those rules came up before there was such a thing,” Smith said.

The telementor also must obtain credentials at the hospital where the surgery is performed. Hospitals may offer temporary privileges.

“That's not a bad thing, because you need to have quality control in the hospital,” Kavoussi said. “But there needs to be some way to facilitate that.”

The surgeon coaching the mentee could be liable if something goes wrong, Gandsas said. Medical liability policies, typically, will not cover telementoring. A rider may be possible. However, he said, the surgical device manufacturers may provide proctors with malpractice coverage.

“There is a lot of medical expertise that would benefit the patient if we could figure out a way around the legal and liability issue,” Rothenberg said.

An additional concern, raised by Rothenberg, is the amount of time telementoring may consume of the expert surgeon's time. He said a financial model will need to be developed to provide compensation.

“Part of it might be going to industry to support it,” said Rothenberg, suggesting as an example that the company from which a hospital buys the robotic equipment could offer a subscription to available mentors for a period of time, or the health system may see the value and offer a subscription-based service.

A Possible Network of Mentors

That sort of subscription service does not currently exist.

“I'd like to see a network of surgeons available in a pool to provide backup support if something does not go the way you want it,” Gandsas said. That might include contacting a mentor online if the surgeon finds the patient's anatomy to be different from that expected or if some other problem arises. Those mentors might include retired surgeons skilled in that procedure.

“The potential of providing knowledge through this platform is enormous,” Gandsas said.

Before its widespread use can improve surgeons' skills, telementoring must overcome the challenge of matching surgeons needing mentoring with experts in that procedure.

“Telementoring is doable, but the issue is setting people up with each other,” Kavoussi said.

Many of the existing telementoring projects have taken place as research projects, as a result of preexisting informal relationships, or a physician wanting more training after hearing an expert present at a conference or after reading a journal article. Kavoussi expects that resolving the matching issue will require assistance from an organized medical body or a company to facilitate connecting doctors wanting to learn with experienced surgeons.

Rosser aims to create a global network of mentors to resolve the matching quandary.

“The surgeons we are targeting are the ones most difficult subjects, meaning they have little experience in the operation you are mentoring them in, and they have little skill level,” Rosser said.

Kavoussi also suggests that additional research is needed, including identification of criteria for success in helping surgeons perform the procedures on their own.

Next Steps

The American Medical Foundation for Peer Review and Education aims to provide some of that structure and research. The foundation has brought together several specialty medical societies to determine whether telementoring is an effective way for physicians to learn new skills and improve old ones. The Society of American Gastrointestinal and Endoscopic Surgeons, in collaboration with the American Society for Metabolic and Bariatric Surgery, will oversee design and implementation of the project, targeting skill development associated with complex laparoscopic bariatric procedures in existing centers of excellence. The Society of Thoracic Surgery and the American Association of Thoracic Surgery will focus on teaching mitral valve repair. Baram-Clothier said this is the first time organized medicine will use telementoring to improve skills, which should lead to improved patient care (Fig. 1).

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Fig. 1.

InTouch Health and Karl Storz, developers of VisitOR1, are lending the remote presence devices to surgeons participating in the American Medical Foundation for Peer Review and Education telementoring study. Photo credit: InTouch Health.

Participants will follow a three-stage process developed by the Foundation for Advanced Medical Education, a division of American Medical Foundation: didactic education and videos to increase surgeons' knowledge, simulation until competent, and then telementoring.

“Physicians want to learn to perform with proficiency, and this gives them the opportunity,” Baram-Clothier said.

Baram-Clothier is seeking $200 million to expand the program, so that all specialty societies could participate simultaneously.

“If we had enough money, we could give physicians a real way to get post-residency education,” Baram-Clothier said. “That is what will change outcomes.”