Telehealth and teaching in a post-pandemic world

Dr Matt Albert is one of Florida’s premier colorectal surgeons specialising in laparoscopic and robotic colorectal surgery. He founded the Centre for Colon and Rectal Surgery in 2004 at AdventHealth Hospital and is the founder of the revolutionary TAMIS technique — TransAnal Minimally Invasive Surgery to remove polyps and some cancers from the rectum. What follows is an interview that has been edited for length and clarity.

The pandemic has dramatically changed the way surgical education is delivered. Previously, I would have been attending speaking engagements and forums, and that has changed in an instant. No one wants to jump on a plane at the moment, and that has inevitably led to disruption of resident education, particularly in specialties that involve acquisition of procedural skills.

Something is going to have to change to allow that to continue, and clearly digital technology is playing a central role in how we adapt.

Medicine in general will look at this in a positive way — speed of processes has shown we’re capable of quickly working on vaccines and microbiology, and any innovation that enables us to create improved responses should be a good thing.

But equally, it has exposed our shortcomings in the way we do things. Why haven’t we been utilising telehealth more widely before now? Why should travel be necessary for me when I already have the perfect opportunity to learn online or via Zoom?

Other than the social contact and camaraderie, there’s no reason that I shouldn’t transition to remote learning, and that includes learning surgical procedures long distance. People can be taught effectively this way.

In surgery, there aren’t going to be crowds in operating rooms anymore, from the medical device industry in particular. Obviously we sometimes need some of the technical people in there, but as we plan for our future, I think we’ve had a taste of what the operating room is going to look like — fewer people, with dialled-in support.

From a medical device point of view, as a surgeon I need those devices — whether a rep is there or not. That won’t change. The one universal reaction is that they have to have increased virtual presence, the ability to communicate more effectively and easily than we were doing before, streamlining the ability to do video chats and operate as a virtual rep. I think device companies relied heavily on major national meetings — sometimes costing millions to get the necessary personnel there and to build a booth — and they were getting very little return on investment. They aimed to increase and maintain a surgical educational forum, but value-wise, it’s a zero for a lot of the companies. It can all be done at a fraction of the cost online.

Another major question is how do you get surgeons and people to train on your system?

Simulation has been trying to make a breakthrough for years, but we’ve never been able to crack the paradigm shift of getting trainees to simulate things that are accurate, that are reproducible, that are similar to the real task as possible with some objective measurement. Yet things like telemedicine are working harder on this now, to bring to us real products that will replace how we did surgical training and mentoring before.

It all revolves around companies clearly recognising the huge need to shift to some virtual presence and have augmented areas of remote and computer-based learning, which in the past have had difficulty gaining traction.

I’ve run a course every single month for the last five years, performing live surgical cases where I’ve had to bring 12 to 20 surgeons into the operating room and coordinate this with the patient. We had to fly these people in; some were concerned about being away from their offices, some of them showed up late. There’s huge inefficiencies and concerns over all these logistics, yet now I’m sitting here thinking ‘I can do any live surgery and just bring anyone right into my operating room?’ Under those circumstances, who in a million years would travel to see surgery? With the systems today, the ability to annotate and communicate on screen with extra imaging overlays will really make it easier to broadcast these procedures.

Proctor shifts and proctoring surgeons in the United States have always been massively troubling because of reimbursement issues, because of the legal issues of being in somebody else’s operating room, and because of time issues for the surgeon and the proctor. Even showing up in the operating theatre, if you can’t scrub in or be a part of the operation, then you’re just a voice in the room. You end up with an ineffective system of having to physically point to the monitor and show people with your finger; you can’t jump on their shoulders and look inside the patient, you can’t get on the robot with them.

So from that standpoint proctors will now have the added advantage of being in their computer screen with some of the newer software like Proximie, using augmented reality that actually enables you to demonstrate better virtually than you possibly could even being in the room.

Some of these things are so obvious, but they take the right amount of momentum to get going; they need the right surgeons or company to demonstrate that they actually work, and they need to make that really obvious to the industry. But I think it’s telementoring and having a real virtual presence that will have the biggest impact on the medical device industry.

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