An anonymous survey was distributed via email inviting the participants of the ... link. Keywords surgical education, live-surgical broadcast, training, mentoring, ..... Companies marketing new devices or sponsoring conferences could also ...
Surgical Education
Live surgical education: a perspective from the surgeons who perform it Shahid A.A. Khan, Richard T.M. Chang*, Kamran Ahmed*, Thomas Knoll†, Roland van Velthoven‡, Ben Challacombe*, Prokar Dasgupta* and Abhay Rane East Surrey Hospital, Surrey, *MRC Centre for Transplantation, NIHR Biomedical Research Centre, King's Health Partners, King's College London and Department of Urology, Guy's Hospital, London, UK, †Klinikum Sindelfingen-Boeblingen, University of Tuebingen, Tuebingen, Germany, and ‡Institut Jules Bordet, Brussels, Belgium
Objective • To evaluate the experience and views regarding live surgical broadcasts (LSB) among European urologists attending the European Association of Urology Robotic Urology Society (ERUS) congress in September 2012.
Materials and Methods • An anonymous survey was distributed via email inviting the participants of the ERUS congress with experience of LSB to share their opinions about LSB. • The outcomes measured included; personal experience of LSB, levels of anxiety faced and the perceived surgical quality. • The impact of factors, such as communication/teamworking, travel fatigue and lack of specific equipment were also evaluated.
Results • In all, 106 surgeons responded with 98 (92.5%) reporting personal experience of LSB; 6.5% respondents noted ‘significant anxiety’ increasing to 19.4% when performing surgery away from home (P < 0.001). • Surgical quality was perceived as ‘slightly worse’ and ‘significantly worse’ by 16.1% and 2.2%, which deteriorated further to 23.9% and 3.3% respectively in a ‘foreign’ environment (P = 0.005). • In all, 10.9% of surgeons ‘always’ brought their own surgical team compared with 37% relying on their host institution;
Introduction Surgeons have an obligation to transfer their skills, knowledge and experience to others. Workplace and simulation-based training in surgical specialties is supported by various additional teaching activities, which include specialist courses, professional meetings and seminars for continuing professional development [1]. Advances in technology, increasing demand for quality and safety improvement has resulted in the introduction of new © 2013 The Authors BJU International © 2013 BJU International | doi:10.1111/bju.12283 Published by John Wiley & Sons Ltd. www.bjui.org
2.4% raised significant concerns with their team and 18.8% encountered significantly more technical difficulties. • Lack of specific equipment (10.3%), language difficulties (6.2%) and jet lag (7.3%) were other significant factors reported. • In all, 75% of surgeons perceived the audience wanted a slick demonstration; however, 52.2% and 42.4% respectively also reported the audience wished the surgeon to struggle or manage a complication during a LSB.
Conclusions • A small proportion of surgeons had significantly heightened anxiety levels and lower perceived performance during LSB, which in a ‘foreign’ environment seemed to affect a greater proportion of surgeons. • Various factors appear to impact surgical performance raising concerns about the appropriateness of unregulated LSB as a teaching method. • To mitigate these concerns, surgeons’ performing live surgery feel that the operation needs to be well planned using appropriate equipment; with many considering bringing their own team or operating from home on a video link.
Keywords surgical education, live-surgical broadcast, training, mentoring, live case demonstration
training methods and courses that involve live surgical demonstrations [2]. These courses are considered to be useful not only for trainees but also for the independently practicing surgeons as an effective source of continuing medical education. Exhibitions demonstrating surgical procedures have been staged since the beginning of surgery itself and lie at the heart of surgical training; with surgeons teaching and actively interacting with their apprentices or trainees as they conduct
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live operations. As such, many urologists and trainees will be familiar with this form of mentoring. These demonstrations were previously confined to a much smaller locality than is possible today; restricted to ‘theatre’ or a ‘viewing gallery’ sized venues that limited efficiency to disseminate knowledge to a larger and wider audience [2]. ‘Live surgery observation’ refers to an interactive small group-teaching between a surgeon and his trainees/observers within the vicinity of the operating theatre. The term ‘live surgery broadcasts’ (LSB) has been used to describe live surgical demonstrations when viewed remotely via relayed ‘real-time’ audiovisual feeds [3]. The uptake of LSB by various medical and surgical disciplines has been consolidated by the development and expansion of endoscopic, laparoscopic and robot-assisted techniques that fundamentally incorporate a video-optic element. Urology, being particularly technologically driven, has also benefited from these advancements. This is represented in the last decade by a surge in the uptake of LSB from regional urological meetings to international conferences, with many of these broadcasts now commonly at the heart of many surgical conferences [AUA, European Association of Urology (EAU), EAU Robotic Urology Society (ERUS) and the World Congress of Endourology]. Following the death of a patient in Japan in 2006, after an aortic aneurysm repair performed as part of a live cardiothoracic surgical broadcast, a number of institutions and associations were forced to evaluate their practice [4]. Subsequently, the Society of Thoracic Surgeons Standards and Ethics Committee recommended termination of LSB to the public at their annual meetings [3]. The American College of Obstetricians and Gynecologists and the American College of Surgeons have also ceased LSB at their major meetings and some meetings have even imposed outright bans. Although the BAUS currently permits LSB during its meetings, unlike the AUA, EAU, Société Internationale d’Urologie and various other leading organisations, it currently lacks guidelines to regulate this practice although they are in development. This quantitative survey evaluates the experience, opinions and views regarding LSB among European urologists attending the ERUS congress and examines the impact various non-technical variables have on surgical performance.
recipients to the survey posted on the SurveyMonkey website. Respondents with no experience of LSB were excluded from the final analyses. All responses were anonymous. Development of Survey and Outcomes of Interest The survey was composed of 17 questions; 14 questions were multiple-choice, two were free text answers and one question had a single response. Participants were asked to provide demographic data, state their level of experience, record the frequency and number of LSBs over the previous 12 months and 5 years (Table 1). Outcomes of interest included; personal experience of LSB, levels of anxiety endured during the live case and the perceived quality of surgical performance/ outcomes. The impact of various confounding factors, i.e. communication/team-working in a new environment, fatigue (due to travelling) and the use of unfamiliar equipment or devices on surgical performance, were also evaluated (Table 2). A 5-point Likert scale assessed responses to the question about anxiety faced during LSB (1, ‘significantly anxious’; 2, ‘somewhat anxious’; 3, ‘no change’; 4, ‘no anxiety’; and 5, ‘less anxious’). Responses to perceived surgical quality were assessed by a 6-point Likert scale (1, ‘much better’; 2, ‘better’; 3, ‘no change’; 4, ‘slightly worse’; 5, ‘worse’; and 6, ‘unsure’). The impact of other correlating factors was assessed using a
Table 1 Demographics, experience and perceptions of LSB. Variable Age (years) of the participants, n (%) 30–44 45–54 55–64 >64 Mean (range): Number of LSB in the last 5 years Number of LSB in the last 12 months Type of audience, n (%) Local National International Expectations of the audience, n (%) Demonstration of a safe and slick procedure To struggle during a LSB, but to deliver in the end To endure a complication and witness it being dealt with safely
Value
41 (41.8) 39 (39.7) 16 (16.3) 2 (2) 13.35 (1–150) 4.81 (1–50) 52 (53) 55 (56.1) 71 (72.4) 69 (75) 48 (52.2) 39 (42.4)
Materials and Methods Participants European urologists who attended the ERUS Congress in London in September 2012 were invited via email to complete an online survey (Appendix 1) outlining their experience and views on LSB. Predominately those urologists performing robotic or laparoscopic surgery or known to have been involved in LSB were preferentially targeted for this survey. A link was embedded within e-mails directing the selected
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Table 2 Components of the survey. • Opinions about anxiety levels during LSB vs when not demonstrating. • Opinions about the quality of surgical performance during LSB from a foreign vs home institution. • Opinion about team work, communication, equipment and technical issues faced during LSB from a ‘foreign’ environment (other institution). • Opinions about the complications encountered when operating outside of their home institutions. • Opinions about the perceived expectations of the audience from a LSB.
Surgeons' perspective on live surgical broadcasts
4-point Likert scale (1, ‘never’; 2, ‘sometimes’; 3, ‘mostly’; and 4, ‘always’). Statistical Analysis Wilcoxon signed-rank analysis and unpaired Student’s t-test were used to compare the 5-point Likert scale responses of anxiety levels from demonstrators during LSB vs not during an LSB. The same statistical method was also used to compare the responses about the perceived quality of surgical performance from a home vs ‘foreign’ institution. Categorical data of the various correlating factors affecting surgical performance are presented as numbers and percentages. A two-sided P < 0.05 was considered to indicate statistical significance.
Results In all, 106 of 220 (48.1%) invited delegates who attended the London ERUS congress completed the survey. In all, 98 (92.5%) surgeons had personal experience of LSB having performed at least one LSB within the last 5 years. Surgeons with no previous experience of LSB were excluded from the final analysis. In all, 52 (53%), 55 (56.1%) and 71 (72.4%) responders had either presented to a local, national or an international audience, respectively. Demographic data (Table 1) shows that 41.8% (41 surgeons) and 39.7% (39 surgeons) respondents were aged 30–44 and 45–55 years performing a mean (range) LSBs of 3 (1–25) and 6 (1–50) respectively, over a 12-month period (Figs 1,2). Opinions about Anxiety Levels during LSB (Table 3) Table 3 lists the responses of participants about anxiety levels faced during LSB. Most (62.4%) replied that they were somewhat anxious/apprehensive with 6.5% feeling significant levels of anxiety. In all, 18.3% respondents noted ‘no change’, while 8.6% and 4.3% respectively reported either ‘no anxiety’ or ‘less anxiety’.
Whilst performing at a ‘foreign’ institution; 19.4% surgeons reported a ‘significant increase’ in their stress levels (P < 0.001). In all, 63.4% felt ‘somewhat anxious’, 14% noted ‘no change’ and 3.2% reported ‘no anxiety’ compared with demonstrating from their home institution. Figure 3 stratifies the anxiety levels faced by demonstrators based on their age. Further analysis reveals that the surgeons aged 45–54 years had significantly more stress than other age groups, which was further substantially increased (three surgeons vs 11 surgeons) when the LSB was being conducted in a ‘foreign’ institution. Opinions about the Quality of Surgical Performance during LSB (Table 4) The first part of the question assessed the perceived impact LSB had on surgical performance compared with when the responder was not demonstrating live surgery. None of the responders felt that the surgical performance during LSB were excellent; however, 11.8% did report a ‘better’ performance on the day. The vast majority (69.9%) reported replicating the same quality of operation as when they were not broadcasting. While, 16.1% and 2.2% of the responders recorded a ‘slightly worse’ and ‘significantly worse’ surgical performance, respectively. Most (67.4%) felt their performance in a ‘foreign’ institution vs presenting at home was the same. While, 4.3% responders reported a ‘better’ performance and 23.9% described a ‘slightly worse’ performance (P = 0.005). In all, 3.3% of the surgeons felt their performance being ‘significantly worse’ when presenting from a ‘foreign’ institution. Surgeons aged 45–54 years when compared with other age groups reported a significantly inferior surgical performance during LSB. Eight surgeons (20.5%) in this group noted a ‘worse’ or ‘slightly worse’ surgical performance. However, 25 Fig. 2 Experience of LSB stratified according to surgeon's age.
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Fig. 1 Demographic data of the surgeons involved in LSB.
35
140
30
120 100
25
80 20 N
Local National
15
International
60 40
10
20
5
0
0
30-44 years 30-44
45-54 55-64 Age, years
>64
45-54 years
No of procedures/5 years Age, years
>55 years
No of Procedures/1 years
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Table 3 Opinions about anxiety levels faced during LSB. Question
Responses, n (%) Significantly anxious
Somewhat anxious
No change
No anxiety
Less anxiety
6 (6.5) 18 (19.4)
