The emotional and educational power of remote surgical assistance

Dr Miriam Redleaf is a Professor of Otology/Neurology and heads up the Otology/Neurotology Program at the University of Illinois Department of Otolaryngology-Head and Neck Surgery, and is extensively published, having authored more than 80 scholarly articles. Since 2012 she has been traveling to Ethiopia and teaching ENT residents and doctors how to manage ear disease and operate on ears. She was University of Illinois’ ENT education director for five years until her work in Ethiopia needed more attention.

I think sometimes people look at telemedicine and platforms like Proximie through the wrong lens. They focus their attention on the technological elements of how it works and what it can facilitate. But in my experience, having used it in Ethiopia and in the US during the pandemic, the main role of this technology is to bring people closer together emotionally.

I have been using telemedicine in the US since 2013, initially for cochlear implant patients. I was interviewing people who lived in small towns in Illinois, people who were scared to come to the big city and didn’t want to drive. We found that by interviewing them in advance, when they came for their operations in Chicago and I met them face-to-face for the first time, they’d all say, “I feel like I already know you, I feel like I have already been in the room with you.” I felt the same way too — I’d often ask if we had met in person already because it felt like we had already had that human connection.

In Ethiopia, it was very difficult to get telemedicine started because we had to really fight to get good internet connections — the hospitals originally didn’t have the bandwidth. One of the major obstacles we had to overcome was getting the internet speed up and making all the necessary connections; a lead might not be compatible with a certain device, for example. The surgeons in Ethiopia were really expecting this not to work out and were baffled that I kept trying. When we began working with Proximie in Addis Ababa — and then again up in Mekelle — I had them pick cases that they felt they could certainly do, but where they’d benefit from somebody in the room guiding them.

Now, we have to be clear: Surgeons have to be trained to do these operations before I would ever supervise them with Proximie. So initially, and for the safety of the patient, an experienced surgeon has to be in the room when they’re learning how to do the operations. But then, once I know they can do the operation safely, and just need more confidence — that’s when Proximie comes in.

Every single surgeon who I remotely assisted in such an operation would say, “I wasn’t scared at all. I felt like you were there in the room with me.” That, for me, is the role of this technology.

There’s also another tier of operations that can benefit from remote surgical assistance — where surgeons are capable of performing the operation, but are still concerned they might hurt the patient. What most surgeons do in that situation is avoid performing the operation, and then they very quickly lose the skills, and they’ll avoid that procedure for the rest of their career. But if you have the surgeon use Proximie and you observe them, it gives them the confidence that they’re able to carry it out. All I do is watch them and ask questions: ‘What’s that suture? What are you doing there? Why don’t you do this instead?’

Just being with them during the session or the operation gives them the confidence and the belief they need to be able to complete the operation successfully, and they gain the experience. This is the essence of Proximie; it’s expert hand holding, and it works very well.

I have also used Proximie in the US during the pandemic because medical students that were supposedly to be rotating on ENT couldn’t gain as much exposure to patients due to operating theatre restrictions. I started to dial-in live procedures to their houses via Proximie, so they could watch operations and get a much better view. The clarity of the screen is fantastic; students can precisely point out something they’re unclear on, they can stop and ask questions during the procedure, and their understanding of the operation is much better than it would be in the OR, where they don’t want to interrupt and they’re in the corner with an obstructed view. The students universally found this to be an excellent learning tool.

I have very close relations with all our trainees in Ethiopia, too. The first three doctors graduated approximately two years ago, and we gave them certificates of completion. The next two graduated last November, and another two are currently in training — which of course has been interrupted due to COVID. We have developed trained professionals in Ethiopia, that includes people in different capacities; surgeons, audiologists, educators, audiology trainees. Each of these professionals would work for free, since they love their fields, but we give them a minimal stipend, in order for them to know they are not forgotten, especially during COVID. Ethiopia has some political problems now, and their internet is shut down frequently for weeks on end. Once it opens up again, I’m going to invite them all to view my surgeries; I want them to know that they haven’t been forgotten.

“With platforms like Proximie I’m able to carry on mentoring these surgeons from the other side of the world. It’s important to say that these guys are top notch — they know their stuff. They don’t need more lectures, they need to be able to operate and have someone watch them.”

I think COVID-19 has certainly accelerated conversations about whether face-to-face physical meetings are absolutely necessary. Here in the US, we academic otolaryngologists go through the same ritual every fall, where 100 to 150 medical students come through our department in Illinois for interviews for residency. For years I’ve been saying we need to do this remotely; there’s absolutely no reason for these guys to pay for plane tickets, stay in town, for people to take the day off work — all of these interactions could be done virtually.

Similarly, we used to run an ENT clinic where all of us were physically present and in the room. But there really wasn’t any need for this, so we started to use telemedicine to host the ENT clinic virtually. The nurse would hold a speculum, and hold the otoscope in the ear, and clinicians could dial-in for a viewpoint of the kids’ ear without having to be there in person.

Now, people are starting to realise you can actually do all these things remotely, through a screen and an internet connection, and it can be just as intimate as a face-to-face encounter.

To read more from Dr. Redleaf:

Kerolus J, Korra B, Ali Ahmad T, Moukhtafi A, Redleaf M. Real-time interactive telementoring between Ethiopia and the United States. Online J Otolaryngol Rhinol June 2020. ISSN: 2688–8238. DOI: 10.33552/OJOR.2020.02.000546

Redleaf MI, Welling DB, Wackym PA. Expanded use of tele-services in otology-neurotology in response to the COVID-19 (SARS-Cov-2) pandemic. Laryngoscope Invest Otolaryngol. Article ID: LIO42466. Internal article ID: 16898251. DOI: 10.1002/lio2.466.

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