Remote teaching and learning: A leap into the future

Gustavo Cumbo-Nacheli is a board-certified interventional pulmonologist working with the Spectrum Health Medical Group in western Michigan. A leading innovator in the field of bronchoscopy, he is an early adopter and advocate of robotic-assisted bronchoscopy. In February 2021 he became the first to use Proximie alongside a robotic assisted bronchoscopy platform in order to stream a bronchoscopy procedure.

I am a firm believer that if somebody has been doing something the same way after two or three years, they’re doing it wrong. At Spectrum Health, we perform cases that are unique, develop new techniques and find ways to do things better — so we are often exploring areas and methods that have not been explored before.

As a result, there are multiple physicians who would like to come and observe my work, to see if my approach meshes with what they envision the future of healthcare in my field should be. Geographically speaking, this isn’t always the easiest thing to arrange, and on top of that 2020/2021 has been a very strange period that has required many interpersonal relationships to shift into the virtual world. We had the ambition of finding a platform that would allow us to provide virtual education, but we were finding that very few platforms had the versatility, quality and ease of use that we needed.

Proximie was the exception — having mastered the art of intertwining technology with medical knowledge in order to make breakthrough developments in technique more widely and readily observable — so we embarked on a journey with Proximie to leverage the technological aspects of what I do.

“This culminated in a world-first: Using Proximie to stream the first robotic bronchoscopy internally at Spectrum Health, as a proof of concept.”

Consequently, I am of the strong belief that the highly beneficial aspects of Proximie’s platform will enable us to rattle the cage on many conventional ideas in the medical community — our aim is to be positively disruptive by empowering others with knowledge; to educate, to proctor and perform quality procedures for observation.

The integration of Proximie is cross-platform. Most of the video generating devices that we use in the medical space have fairly standard wires and connectors, so Proximie allows for a wide variety of accepted devices. Not only does it seamlessly broadcast the video image from the robotic platform I’m using, but it can also integrate with the other devices I use; fluoroscopy devices, cone beam, CT, multislice, 3D scanners, or even ultrasound probes. Most importantly for observers in the room, Proximie allows for camera streaming of workflow around the procedure — so it’s multidimensional, making it possible to see not only the equipment I’m using, but also my movements — my technique in the room, patient set-up, allocation of space — providing a full-immersion platform that allows for virtual learning.

The fact that Proximie allows you to stream four screens at once feeds into what I consider to be one of the most beneficial aspects of the platform: it is a fully immersive experience which can be recorded. This allows learners to review procedures retroactively, taking their time to dissect the information provided by each stream, or to concentrate on one particular screen and focus on what was taking place there. Proximie allows for the passing of a fine tooth comb over the critical part of any procedure, to pause and relive any decision made at any point in the procedure, and to compare this against what was going on in the workflow on any or all of the other screens. Compare this to observing a procedure in person, where you might be shifting your focus between the doctor and a camera for example, and in attempting to pay attention to multiple aspects you might miss a critical moment that Proximie would invariably capture.

What is very close to my heart is communicating to learners that robotic bronchoscopy is here to stay, that there’s an optimal way to go about the workflow of cases, and the many benefits of leveraging diverse alternate technologies. It’s important that learners see the safety steps that I take in order to produce good outcomes, and the learning process has three stages. The first stage is watching me do a case. The second stage is I do a case, while explaining how I’m doing it. The third stage is I do a case while the learner tells me what I should be doing. The fourth stage is the learner does the case.

“The “see one, do one, teach one” methodology is an old gestalt from dogmatic teachers; Proximie allows for a greater emphasis on seeing, communication and instant, flexible, on-going proctoring.”

At a national level, Proximie has the ability to be deployed in any hospital that is seeking Centre of Excellence certification and requires experts in the field to see how they perform. As we roll out Centres of Excellence for bronchoscopy, is it very challenging for experts in the field to physically visit different healthcare facilities seeking certification or endorsement, and Proximie allows me to bridge that gap to virtually observe the workflow of their cases. I can see how they’re setting up, how they carry out their procedures and how they navigate potential complications and difficulties. From wherever I am in the world, I can grade or assess proficiency in order to award certification to Centres of Excellence.

The primary function of Proximie is enabling others to see me and me to see others performing procedures; this is the first step in creating a relationship that is beneficial for patients. However, there are also opportunities to make use of the platform in clinical spaces, as well as for teaching and learning in procedural spaces. It would be highly beneficial for learners to see the way that I engage with patients prior to procedures, and to be virtually present for diagnostic visits and the decision-making process that leads to a procedure. The recovery, discharge and follow-ups with patients are equally important, and can also be monitored using remote technology — so there are pre-procedure, intra-procedure and post-procedure benefits of having a virtual platform that can educate others on different ways to do things, and ultimately lead to better outcomes for patients.

Remote teaching and learning provides a series of stepping stones towards being the best versions of ourselves. It allows people to see how procedures are performed properly in Centres of Excellence, and it empowers them with the ability to have Proximie users like myself, for example, go over their cases remotely. Hopefully, as the future delivers lower latency broadband and next generation technology, we will gain the ability to perform entire procedures virtually — making it a full immersion platform that not only allows me to educate and proctor, but also to actually perform surgery remotely as well.

“Proximie’s algorithms, software and technology constitute what I believe to be the holy grail of virtual learning and teaching — and I see it as a technological segue enabling us to leap into the future.”
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