Abstract
It is fundamental that telemedicine can be used to eliminate distance as a barrier to care. From very early times, telemedicine technology has been used not only to deliver care but also for the educational benefit and instruction of caregivers. The technology has also been invaluable to inform patients and incorporate them fully into their care. The technology has been highly effective in videoconference mode and increasingly with mobile health to deliver just-in-time information to patients and caregivers. Here we address the enormous impact our journal has had in the specific area of educating health workers. Precepts of education do not change or compromise just by a shift in technology to telecommunications. Certainly, informing via television has been around for some 60 years in popular culture, and it is clear that advertisers are effective in modifying behavior through video material. Thus, we buy their products, and they support the television enterprise. The same may be said for digital telecommunications and the Internet. The precepts of education are well known and address attention span, need to know, credibility, palatability of the presentation, repetition, and a clear focus on the outcome of changed behavior. The principles in cyberspace are no different from print media or face-to-face contact. Transition of education to the electronic media, just like the rest of telemedicine, tolerated no compromise. Education by telecommunications and information technology still relies on the core reality of curriculum. What do you want to teach, and what is the outcome with the best formula of presentation? Curriculum is generally evaluated by the three Ps: Process, Perception, and Product, with the last being the most important.
However, in any educational endeavor the process of the presentation must be efficient and effective communication. The learner has the right to perception positive or otherwise, and a curriculum will not generally succeed with a noxious presentation. However, the product is the big thing. Did the learner acquire new knowledge or skills via the presentation or curriculum?
The motive for a strong educational component integrated into a telemedicine program is simple. Distance is the problem. Over the last 20 years the problem has actually worsened. For practitioners in remote areas, the cost of medical meetings has become prohibitive. The cost of print media in medical libraries of developing countries has become impossible even as the amount of biomedical information has risen geometrically. Yet, we firmly espouse the use of information over experience in order to practice medicine properly with the best in new evidence. Medical libraries around the world have been contracting despite the excellent program of the World Health Organization with the Health InterNetwork Access to Research Initiative to bring electronic subscriptions to international sites through a massive cooperation with publishers. The health worker must, of course, be expected to access with competence a computer station under the control of the library. The expansion of medical information and the contraction of access through meetings and libraries are ironically in a timeline that more and more calls for health providers to work in interactive teams informed less and less by individual experience but more by the best in shared experience. Lifelong education and collaboration are in the best interest of patients but very difficult without electronic education across borders, geography, and economic disparity. Recognition of the importance of education throughout one's career is evidenced in the growing requirement for continuing medical education (CME). Medicine changes, and new technology can overwhelm the precious skills of practitioners to the point that their work is no longer relevant. Yet, to retrain involves perhaps leaving a practice where there is no redundancy or backup. Retraining may involve expensive travel, loss of income, and family disruption.
Therefore, from the earliest volumes of our journal, articles recorded incorporation within telemedicine programs of measures for the education of doctors and nurses. Canada was a leader in this regard with its enormous territory and sparse population. Cheung et al. 1 in 1998 described the Ottawa Telehealth Project where CME was integral. Jennett et al. 2 in that same issue reported on their tele-education program in Calgary, where greater than half of providers were engaged in learning through the telehealth network and one-third of undergraduate and graduate students in the health professions were involved. It is interesting that at that early date only a few patients were engaged. Certainly that has changed. 2
There is no attempt here to list all the articles in our journal that have influenced distant learning through telemedicine. In fact, more than half the 1,500 or so articles published over these 20 years cross-reference to education. In the same timeline, online general education has progressed with rigid requirements for certification by educational bodies such that not only the courses but full degrees, thus earned, are recognized as equivalent to classroom education. There has been no shortage of critics among educators, and many of the online universities are regularly cited for abuses. This is not entirely different from the critics of telemedicine who believe there is no equivalent for face-to-face doctor–patient encounters. However, in the online world of education, most criticisms are directed at for-profit entities, and no charges have closed a single course. The principles of education are not in the least in conflict with electronic education. Education of caregivers by telemedicine has continued to be studied, refined, and reported with the techniques of videoconferencing 3 and full integration into a general curriculum. In the case of Brazil, great care has been taken by dedicated educators to bring current and unifying materials into the primary care curriculum across vast distances of the Amazon jungle. 4 The efforts of such leaders as Professor Maria do Carmo Barros de Melo have succeeded in an environment of geographical adversity to create and support a well-equipped primary care work force in solid mutual agreement as to practice standards and the need for consistent electronic data. Distance learning has found no clearer application than in capacitation and team building in telemedicine itself as in the case of Pakistan. 5 In that program, given the cooperation among the Higher Education Council of Pakistan, the U.S. Army, the U.S. Agency for International Development, and medical societies with the leadership of the telemedicine director, Zafar et al. 5 established a highly effective curriculum to assure that all personnel involved in the telemedicine program were informed as to their task, empowered as to the possibilities, and made part of a large virtual team with consistent goals and knowledge.
The matter of creating virtual medical staffs dealing with information in a common forum has been demonstrated as a powerful tool in the most common of CME settings, the clinical conference. This was carefully demonstrated in cancer conference work between Darwin and Adelaide in 2000. 6 This shared conference format has received ever-wider application.
As technology moves forward, the applications to education in telemedicine will expand. Chang et al., 7 in a collaboration between the University of Pennsylvania and Botswana, showed that residents in training could make powerful use of mobile learning tools with hand-held devices. It is difficult to find medical trainees in the developed world who are not constantly taking recourse to hand-held smartphones, etc., for just-in-time reference to large and rich databases in the course of daily medical practice. This activity can only serve to reinforce the clinical experience and make for better retention. That assumption really should be tested. In the developing world, smartphone access to patient data, colleagues, and published experience can serve as a leapfrog maneuver when resort to a distant physical classroom is not feasible. This was precisely the experience in Botswana. The Webinar phenomenon is firmly established, and trainees can have the best in educational sources in video format wherever they might be. Tele-education is not confined to the cognitive. As true visionaries, Satava and Jones 8 in 1996 proposed shared virtual reality environments of the physical world to explore from any distance the technical and mechanical solutions to problems previously considered as surgical hands-on. Recently, a panel of experts including Butch Rosser made the radical proposal that surgeons in fact should not be alone in the operating room; their environment and that of their patients should be shared for the purpose of education as well as consultation. 9 The physical environment of the operating room can be richly integrated into a virtual environment with mentoring and even robotic participation from afar. We continue to learn in this area and to benefit from our international readership and authors. In February we published a fine article from Shanghai on videoconference technology to support CME for laparoscopic surgery. 10
It is hard to imagine a successful telemedicine program now that does not have a strong education as well as evaluative component. 11 The pages of this journal have long been open to testing the hypotheses of distance learning education and applicability of successful approaches in face-to-face versus video settings. The principles of the standard electronic classroom are now firmly established, and we look forward to the impact of new technology on the possibilities for education of healthcare providers. We simply cannot accept distance as a barrier to the well-informed caregiver.