Role of Telemedicine Technology in Endocrine Surgery Knowledge Sharing

Introduction

Telemedicine is a well-established technology that is increasingly utilized for knowledge and skill sharing in a collaborative environment across geographically dispersed learners. With the advancement of health sciences, in terms of both knowledge and technology, further specialization has taken place in medical and surgical disciplines around the world. It has also posed a challenge in developing knowledgeable and technically skillful health professionals across the globe, particularly in low-resource countries.

Endocrine surgery is relatively a newer surgical subspecialty, with only a few academic centers offering training opportunities. Most of these centers are in the developed world. Although two-thirds of the global population resides in the developing world, the available academic centers offering such training opportunities are very few, leading to a wide gap in demand and supply. The Department of Endocrine Surgery at Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, India, was established in the year 1989. It had been engaged in training and offering fellowships of different kinds since its inception (e.g., 3-year hospital services residency, 1-year postgraduate diploma, 3-year MCh [Master Chirurgiae]) besides hosting professional skill development courses biennially since the year 1993 and continuous medical education programs.

As information science and communication technology were making waves around the world, the Department quickly adopted the technology in the year 1999 and mastered the technical skills to incorporate the new collaborative environment with the existing training program offered by the Department. The experience and outcome of such collaborative learning practice and its potential role in bridging the knowledge and skill gap, based on the data acquired over a decade and sharing our story with the distance-learning practitioners in the surgical field, are the main objective of this body of work.

Materials and Methods

After its initiation in 1999, the telemedicine program was soon incorporated in the academic program of the Department of Endocrine Surgery at SGPGIMS. This retrospective study was based on the endocrine surgery tele-education (EST) activities carried out between October 1999 and December 2012. These EST activities were divided into various modules: case/problem-based learning, clinical grand rounds, and postgraduate courses/continuing medical educations/symposia/live surgical workshops.

SGPGIMS is involved in these activities regularly with different remote partners in India having specialized departments/units practicing endocrine surgery: Shrirama Chandra Bhanj Medical College, Cuttack (distance, 870 km); Maharaja Krishna Chandra Gajapati Medical College, Berhampur (distance, 931 km); Christian Medical College, Vellore (distance, 1,562 km); and Amrita Institute of Medical Sciences, Kochi (distance, 1,945 km). Surgeons actively participating in these EST activities were divided into two groups: faculty (holding a regular academic position) and residents (trainees in endocrine surgery).

There was no available validated questionnaire to assess the role of telemedicine technology in distance education and skill sharing in surgical education. Hence, we constructed a multidomain questionnaire to test various aspects of EST activities. As we intended to include all the surgeons actively participating in EST activities, we constructed this questionnaire based on the Likert scale system. Replies were graded for all questions. The domains tested were level of involvement, assessment of familiarity, role in knowledge exchange and skill development, quality of transmissions, level of satisfaction, and future role of the technology. The participants were supplied this questionnaire in 2012 (i.e., the last year of the study) to gather their collective knowledge and information regarding these EST activities.

Analysis was performed using SPSS statistical software (version 15.0; SPSS, Inc., Chicago, IL). ¹ Proportions were calculated for overall response, and the chi-squared test was used to find the association between the study groups and outcome measures. Significance level was calculated at ≤0.05.

Results

The questionnaire was sent to 38 specialist surgeons, of whom 36 replied back (response rate, 94.74%); 14 were faculty, and 22 were residents.

Most participants had moderate to extensive exposure to EST activities (86%) and were regular in attending these sessions (78%). Four residents (18%) had stopped attending these sessions because of lack of access to EST after completion of their residency (Table 1). Participants were usually aware of telemedicine technology and research publications in relation to endocrine surgery (Table 2).

When knowledge exchange was assessed, >90% of participants responded that EST activities have helped in knowledge exchange. Most participants also were of the opinion that these EST activities helped them to learn new things and strengthened networking with peers (Table 3). However, response rates were less for development of skill and telementoring when compared with knowledge exchange. The majority of participants (>70%) felt that telemedicine helped them in clinical decision-making support (Table 4).

Quality of transmissions was excellent to good for 56–81% of participants, and >72% felt that telemedicine has a beneficial important role in conference transmissions (Table 5). More than half of the participants (>60%) had a change in attitude and perception toward telemedicine, and >85% enjoyed the technology. Overall satisfaction was high (excellent to good, >90%); however, only a few participants felt that telemedicine is better compared with live classroom teaching. Also, learning with the technology was easy for only 45–64% of participants (Table 6).

Although there were variable opinions on the use of telemedicine technology for knowledge sharing, all expressed a desire to continue participating in EST activities. The vast majority (>95%) wished that the technology should be developed in other institutes and that it should be incorporated with other specialties. Furthermore, >90% were of the opinion that the technology has a very important role in the future (Table 7).

There was no significant difference between responses of the faculty and residents for any of the domains tested.

Discussion

We are actively using telemedicine as a distance education tool as we have a resource crunch for endocrine surgery expertise in our country. Previously we published our experience with telemedicine technology and endocrine surgery and showed that telemedicine technology helped the trainees regarding reinforcement of knowledge and skills after a few years of completion of a short-term training in endocrine surgery. ²

In a recent randomized controlled study by Haney et al. ³ from Florida, tele-education was used for skill development among paramedics, and they found no significant difference between videoconferencing and live didactic lectures when used for wound closure by the study population. Bertsch et al. ⁴ concluded that interactive videoconferencing was an effective tool to teach clinical examination objectives, but when they compared it with in-person teaching of third-year internal medicine clerkship students, they found there were no significant difference in responses for both methods. Satisfaction surveys were also performed by other authors and found a high user ratings for tele-education sessions with no significant differences between online teaching and live classroom teaching. ^{5 –8} However, results of our study showed that surgeons prefer live classroom teaching over tele-education sessions. Similar results were also described by Kidd and Stamatakis, ⁹ who found that live classroom teaching was significantly more effective than interactive videoconferencing for teaching clinical pharmacokinetics to students.

Chipps et al. ¹⁰ systematically reviewed the effectiveness of videoconference-based education and found five studies were eligible out of 312 studies selected for review. They found sufficient evidence to provide a grade B evidence-based recommendation ¹¹ of moderate support that nursing and medical education should consider videoconference-based teaching, which is at least as effective as face-to-face teaching in terms of knowledge gains. Similar to our results, Aas ¹² found that 83% of participants learned new things by taking part in tele-education sessions. Fahey et al. ¹³ reported, when they surveyed individuals involved in child and family services, that 80% of sessions were highly informative, 68% reported gain in knowledge, 86% confirmed that the content of these sessions was very useful, and 80% of participants reported they changed their practice because of knowledge gained from these sessions. Similarly, increase in knowledge and skill level among nurses for neonatal resuscitation was found after attending tele-education sessions. ¹⁴

Western Australia has a large telemedicine network, and in a recent survey of its activities, education was found to be the most important purpose for videoconferencing in country hospitals and nursing posts. ¹⁵ We have also found similar results, with education being the most common telemedicine application.

Another large study from the European Union project, HELLODOC^®, done mainly for neurological patients, yielded high satisfaction rates among therapists. ¹⁶ Demartines et al. ¹⁷ tested the acceptance of telemedicine among surgeons and reported that surgeons are interested in telemedicine and open to its development. A simple method was devised by Azuh et al. ¹⁸ to study telementoring among surgical residents and found favorable results. Previously we too had demonstrated the beneficial role of telementoring for a patient with residual primary hyperparathyroidism. ¹⁹ Schlachta et al. ²⁰ described their experience with telementoring for laparoscopic colon surgery and found this method very useful.

Our results were also comparable with those of Moser et al., ²¹ who in their survey of medical students reported that telemedicine has a very important future role (79%) and that students wish to attend lectures in telemedicine (77%) and got personally benefited from telemedicine (75%). Gschwendtner et al.²³ surveyed medical students and found similar recommendations regarding the future role of telemedicine: 93% thought it will play a very important role, 75% wished to attend telesessions, and 84% had benefitted by telelearning.

Conclusions

Knowledge sharing for development of new subspecialties using telemedicine technology as a tool has been found to be successful. These research findings could satisfy policy makers to integrate the module for various other subspecialties to meet the capacity gap in a low-resource setting.

However, there are certain shortcomings in our study. As it is a retrospective study, problems inherent to such kind of research are inevitable. Also, the study has used a custom-made questionnaire, which may have inherent deficiencies. Hence, there is a need to develop a standard validated questionnaire for evaluation of tele-educational practices.