Remote telementoring: A gateway to global expertise

Mr Graham Watson has been a consultant urological surgeon for 32 years, and developed the first laser to fragment renal stones in 1984. He has been a consultant urologist at Eastbourne General Hospital since 1994, and in 2002 set up Medi Tech Trust — a charity to raise money for equipment in hospitals in the South of England. Over time, Medi Tech Trust expanded and has been providing equipment and training in Sri Lanka and Africa for the last 8 years. Last year, Mr Watson used Proximie for the first time to ‘virtually scrub in’ and guide a surgeon performing a kidney stone operation in Benin, West Africa.

The lack of basic surgical facilities in low-income countries is responsible for more deaths than TB, HIV and malaria combined, which I think is an extraordinary statistic. In the world, at any one time, 30 million people are facing death or financial ruin because surgery is either unavailable or prohibitively expensive. So what I’ve been doing is travelling all over the world and training people, and trying at the same time to reduce the expenses of surgery.

It started when I saw one of my past trainees at an British Association of Urological Surgeons meeting in 2008, and he asked if I’d come to his home country of Sri Lanka to demonstrate stone surgery. Kidney stones are one of the biggest urological problems in Sri Lanka — it’s incredibly common — and they were removing them 99% of the time using open surgery; endoscopic procedures were really very rare and not very successful. So we went out there, and we operated on patient after patient in an incredibly efficient manner, and converted the entire country to carrying out almost all stone work using minimally invasive endoscopic surgery.

“And the experience was such a positive one, because it’s so rewarding to have a good student and to see them benefit from your training — it’s a real buzz.”

But something else happened while I was out there which I wasn’t expecting; while I was working with them I found that my techniques and abilities were improving as well. That was partly because we had the idea to put on training courses in Sri Lanka for UK trainees to attend as well. We could take over three operating theatres in the hospital for a week, fill them up with stone removal procedures and have three teams working with a trainee and a trainer in each theatre.

So up to nine UK trainees would be getting an incredible experience in stone surgery alongside the Sri Lankan trainees, and because I was carrying out so many operations I was honing my own skills as well. On top of that, I would be interacting with other trainers — not just English trainers, but Chinese and Indian trainers — and from seeing them I could learn totally different techniques that improved my own practice tremendously.

From that point on I was hooked, and as well as returning to Sri Lanka a number of times, I travelled extensively in Africa too, carrying out training in Senegal, Gambia, Ghana, Rwanda, Benin, Ethiopia, Zambia, Zimbabwe, and also in a few more advanced training centres in South Africa, Egypt and Cameroon. This went on for eight years and then Covid-19 happened — making it at best inadvisable and at worst impossible to travel. I’d heard about Proximie in conversation with another surgeon who’d mentioned that they’d come across it as a way of maintaining contact, surgically speaking, with trainees in low-income countries, so I looked it up online and was impressed with the stories of how it could help in this regard.

I was due to assist with a endoscopic kidney stone removal in Benin, so we arranged for the delivery of a Proximie system to the National University Hospital Centre in Cotonou. This involved a fair bit of equipment including cameras and various bits of hardware, and one of the difficulties of the Covid era was the inability of having an engineer to put it all together, but the Proximie team were able to remotely guide them on how to set it up. One thing I was worried about was the reliability of the WiFi signal and bandwidth working, but I was amazed at how well the Proximie platform functioned with what I had assumed would be a poor internet connection.

Once everything is set up, it was simply a case of logging on and communicating — and during the operation I could access a whole wealth of audio and visual information. We’re getting the audio and visual feeds from multiple systems, so I’m looking at a live feed of the operation, an image from the ultrasound and so on — my screen was divided into various compartments in which I can watch various things that are going on simultaneously. At the same time, they can hear my voice providing them with audio guidance, and we share a screen on which I’m able to draw and annotate with visual guidance.

“Given that I’m now in my seventies and learning to use this telementoring technology for the first time, I found Proximie remarkably easy and intuitive to control. The operation lasted five hours and was a success, with the patient now recovering well.”

What’s particularly wonderful, however, is what the National University Hospital Centre’s Proximie system enables now it’s in place. Not only can they contact me again if they have another stone case they’re worried about, but they are now able to connect to other experts who could in theory help them with operations in any medical field. Since the operation I assisted in, they’ve connected with a surgeon in Norfolk, Virginia in the US who assisted them in successfully carrying out a complex urethroplasty to repair a stricture of the urethra which would otherwise have been devastating to the patient.

We’ve had sessions where I’ve been on at the same time as a surgeon from China or California, and I can disappear off to do a case as part of my 9 to 5 job, and another trainer that I know well and trust can take the reins until I rejoin the session, and as long as we’re using a similar type of technique it works brilliantly.

“Essentially, Proximie serves as a gateway to an entire planet of surgical expertise, enabling you to link up with any team, anywhere in the world.”

Proximie is more than a tool for coping with pandemic restrictions. In terms of the Medi Tech Trust’s training work in Sri Lanka and Africa, it will no longer be a case of having to travel all over the world to be ‘present’ for our trainees. Up until now we have been visiting each location for a week of intensive training and then leaving them to it, with little idea of how they’re doing after I’ve left. Now, I can stay in touch remotely and continue advising them using Proximie, joining them to advise on procedures as and when is necessary. This is a major benefit that has the potential to revolutionise the scale and the quality of our training. I believe the process of mentoring remotely actually makes you a better teacher — because it removes the possibility of physically intervening, picking up the tools and saying ‘do it like this’; it forces you to slowly and carefully explain what has to be done, and that thought process and communication makes you a more effective instructor.

Technology moves at such a speed that to predict the future of surgery is becoming very difficult, but every so often some new technology comes along and you think ‘wow’, and things move on enormously. Our global connectivity has increased hugely because of Covid-19, and suddenly more people than ever before are becoming aware of what can be accomplished with remote communication and its potential impact on the future.

We’re entering an era of much greater surgical connectivity that will enable surgeons to connect with any department anywhere on the planet, and obtain the expertise needed to virtually guide them through almost any procedure. We no longer have to feel that we’re all isolated from one another.

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