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Mr Amyn Haji was appointed as a Consultant in Colorectal and Laparoscopic Surgery at King’s College Hospital NHS Foundation Trust in 2011. He is an expert in minimally invasive surgery and natural orifice surgery, and in 2019 helped develop the Pentax Forward program, giving promising clinicians new to the field of endoscopic therapeutic procedures the chance to work one-to-one with experts in Endoscopic Submucosal Dissection (ESD).

Endoscopic Submucosal Dissection is a complex procedure that requires dedicated training and mentorship. Unfortunately, there aren’t any formalised training programmes around the world that are available for endoscopists to attend. The Pentax Forward program was designed to fill that gap by supporting trained endoscopists to learn the technique over the course of a year.

Each compartment of the program was intended to be face-to-face — whether that be in the lab, the live animal lab, during the mentorship with patients in hospitals, or as part of an ongoing mentorship programme providing support through feedback as trainees were doing their cases. Then the Covid pandemic happened, and we adapted the programme using the Proximie platform to deliver virtual teaching and mentoring.

For example, on a Wednesday I would have people sign into my list at King’s and we would teach and mentor them through the technique. Equally, the mentees have the same software within their institutions, so we could also dial in and support them while they were doing their procedures if they felt confident to do it.

“The virtual mentoring programme was accelerated by COVID because we didn’t really have a need to do that before, but going forward there is definitely a need to do more virtual mentoring.”

It’s too onerous for mentors to travel around the world like we used to; it’s a much more efficient use of our time to support those who require more in-depth assistance face-to-face, and others that are more advanced in their training can be supported virtually.

Proximie is very well suited to endoscopic and laparoscopic surgery, because both procedures require the surgeon to look at a screen anyway, so it is extremely easy to integrate that with Proximie. With open surgery, you need a more mobile camera that requires the presence of a more technical team, so while you’re doing those procedures the setup is a little bit more complex. For any sort of surgery that involves a screen, however, it’s literally just plug and play; it takes a few minutes to set up a stable internet connection and then you’re ready to go — and I don’t need a technical team to assist me with that at all.

Additionally, Proximie’s multiple camera functionality is very well suited to endoscopic and laparoscopic surgery. You can have one camera that provides an overview shot of the room, or focuses on the surgeon’s hands, and then another camera that is focused on the actual endoscopy image. You can have as many sources as possible, but generally we just use two: an overview shot, and the actual image on the endoscopy camera itself.

The feedback we’ve had from mentees on the Pentax Forward programme has been excellent; without them being able to come to us or us not travelling to them, their training was going to stop completely as a result of Covid — we’ve not had any practical or laboratory workshops at all because of social distancing. Adapting the programme to work virtually has been a lifeline, with participants having had the opportunity to sign in at their convenience — and the great thing is they can also record their ESD procedures themselves, after which we can schedule a mentoring session at a time that’s convenient for both the mentee and the mentor to go through that particular case. Equally, mentors can record a procedure and then schedule a session with their groups at a later date — it doesn’t necessarily have to be at the exact time that we’re doing our procedure live, and people find it very useful to be able to sign in and make comments at their convenience. Having that sort of flexibility is really useful.

Face-to-face and hands-on training are such important parts of surgery and interventional endoscopy, so we’re not looking at leaving that behind. Where Proximie is going to be really useful, however — and where we should build towards using it in future — is for monitoring an ongoing mentorship process that centres on the video review of cases. Once endoscopists are signed off and go and do their independent work for the first time, they can have a bank of their first ten cases which we can use to review and support their ongoing development.

“This is an invaluable tool, and once things return to normality we should be incorporating it into the training process.”

Similarly, mentors can record all their cases to build up a library of educational data, and as trainees reach different skill levels they can access a basic library, an intermediate library or an advanced library; specific libraries can then be useful not just for trainees but for advanced practitioners and established consultants as well.

Looking further into the future, it would be very useful to integrate Proximie completely with operating systems and operating rooms, so that it’s fully enmeshed with any training that goes on — even when you’re face-to-face with trainees in the room. I think that’s going to be a big change, and it’s something we’re hoping to try and do at King’s going forward.

There’s a real need to be able to work collaboratively across the globe to support institutions that want to start doing this type of procedure, because expertise in these advanced techniques is fairly thinly spread, with maybe a handful of experts in Europe and the rest in Japan.

The other aspect that we’re very keen to set up is the use of Proximie as a referral tool. We receive approximately 450 referrals a year on complex polyps for this type of procedure, so the idea would be to provide all our referring hospitals with the software in order that we can set up a network of expertise that would allow virtual multidisciplinary meetings and reviews of cases. This would save patients coming to us for an assessment prior to treatment, and going forward this network could be set up all over the country as a UK-wide working group for a particular procedure. We would have an ESD working group within the UK, where we’re all within a network on Proximie; we would have all our procedures added to the library, alongside mentoring and feedback to support surgeons’ professional development.

There are huge opportunities to take this sort of working group to the next level; obviously it would require considerable funding, but the advantage to patients in terms of referrals is immense.

At the moment some patients are having to travel three hours to come for assessment; we could save that entirely by using Proximie to power a vast diagnostic network of expertise that spans the country.