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Live endoscopy demonstrations are great, but…
Editorials
Live endoscopy demonstrations are great, but... When endoscopy entered routine practice about 30 years ago, one trainee at a time could share the endoscopic image through a “teaching side arm.” The first attempts to transmit live images to large audiences were made with expensive broadcastquality video cameras. Smaller video cameras became available in the mid 1970s; they were adequate for short demonstrations, but too bulky and impractical for everyday use. With this equipment we developed one of the first videoconferencing suites, at The Middlesex Hospital in London, which allowed groups of trainees to observe the endoscopic and radiologic images and to communicate from a nearby seminar room. We carried this equipment to do video workshops in many countries. By this means, the excitement and potential of endoscopic diagnosis and therapy were brought home vividly (literally) to thousands of gastroenterologists and Copyright © 2000 by the American Society for Gastrointestinal Endoscopy 0016-5107/2000/$12.00 + 0 37/70/105098 doi:10.1067/mge.2000.105098 VOLUME 51, NO. 5, 2000
P Cotton
related personnel. The arrival of videoendoscopes in the mid 1980s gave this process a tremendous boost. Live demonstration programs are now incorporated in many local, national, and international conferences—because they bring in the crowds. The benefits seem obvious and substantial, but there are some problems which need to be confronted. My biggest concern is for the safety of the patients when being worked on by visiting experts in unfamiliar surroundings. Demonstrations are popular partly because they can be exciting. It is instructive and fun to see how experts deal with difficult situations, but I fear that some exciting situations do not end happily. Are we sure that patients always get optimal care? Are the complication rates the same as they are back home? We have no data, but there are plenty of embarrassing anecdotes. Do all patients know what is going on? Privacy and confidentiality should be easy to safeguard, but can be forgotten in the heat of the moment. Often the “backstage” of a demonstration meeting is a chaotic mixture of bemused patients, relatives, performers, trainees, nurses, instrument company representatives, and heaven knows who else. It would be surprising if patients feel that they are the cenGASTROINTESTINAL ENDOSCOPY
627
P Cotton
ter of attention. Some may have had their treatment delayed to fit the demonstration schedule. Does the demonstrating expert always have enough knowledge of the patients to make good clinical judgements before and during procedures? It can be difficult to grasp the intricacies of an individual patient’s problem, especially if there is a language barrier. Records are often incomplete, and the local physician of record (if identifiable) may be too preoccupied with other arrangements to be the patient’s advocate. Do visiting experts always check on key clinical facts as they would at home (e.g., laboratory studies, prior radiographs, comorbidities, and specific risk factors)? How detailed is the informed consent process? How many experts have declined to do a procedure because they cannot see a good indication when confronted with the patient on the table, and an expectant audience? To do so may be the most telling educational statement of the day, but it is a brave (and rare) decision. How many experts check on key environmental factors that they take for granted at home—such as local practices for disinfection, antibiotic prophylaxis, sedation, and monitoring. If it appears that the local practices are different, should you insist on your own standards or bend them for the benefit of “the show”? If you compromise at all, how does this square with being an expert teacher? The pressure to do what the organizer wants and to “succeed” can be substantial. It takes real courage to “fail” on camera or to desist when the benefit/risk ratio appears inadequate—indeed to behave totally responsibly, especially when jetlagged and well entertained. All true experts acknowledge the importance of their support teams. At home they work with people they trust, with agreed practices and familiar equipment. Performing in a foreign environment can be destabilizing. The local nurses and technicians may be experienced and usually anxious to help, but may not be familiar with your methods or language. The equipment may look different, even if you have taken the trouble to inform the organizer of your specific requirements. Demonstrations are often sponsored generously and honorably by instrument and accessory manufacturers, who presumably hope that their equipment will be shown to full advantage. Although I have never experienced any overt requests to use specific equipment, there are unstated expectations. What to do when faced with equipment that we have never used before or even seen? Are we comfortable having our first experience of a new gizmo on an unsuspecting patient before an audience clamoring for action? Doctor, would you like to use this new expandable stent with a double retracting superslip delivery device? What dia628
GASTROINTESTINAL ENDOSCOPY
Editorials
thermy settings do you like? How do I answer that question when I have never seen the diathermy machine before, and in fact only entered medicine because I could not understand electricity? The endoscopist has important duties after the procedure is completed. At home, we make sure that the patient and any accompanying persons understand what has happened, and the future plans, and we record our findings, actions and recommendations. It may be reasonable to leave these tasks to the local physician of record, but I suspect that time pressures may interfere with their completion. Do you check? Demonstrators should not forget the risk of personal injury. Some patients have curious diseases. Protection equipment (gowns, gloves, masks, etc.) are not always available, and it is wise to carry appropriate supplies. And there are legal pitfalls. In the early years of demonstrations, most countries seemed to ignore the licensing issue; now it can be a serious hassle. In one I was obligated recently to provide swabs from my “moist bodily parts” as part of this process. And what about medical liability insurance? Is this covered by the conference organizer and his institution, or is the visiting expert personally “at risk”? Medico-legal action for endoscopy accidents is no longer solely an American sport. Does it constitute “abandonment” to fly out on the next plane after doing a complex procedure? The visiting expert may be seen as a convenient “big pocket” when the results are not optimal. Live demonstrations carry some hazards for people other than the immediate patients and performers. Organizers of large multi-performer meetings carry a tremendous load of anxiety on numerous fronts. They must worry about the care of the patients, particularly those who have been referred in by their friends in other institutions when their own supply of “suitable cases” dries up suddenly. This last minute panic often results in too many patients (some not really suitable) who must be dealt with responsibly, often late into the night. One of the most difficult tasks of a local organizer is to rein in a visiting expert who appears to have left his expertise on the plane. Prying the scope away with dignity can be a challenge. It is wise to have two procedure rooms active during demonstration meetings, so that it is possible to switch politely to “something interesting happening in the other room,” and do the necessary arm wrestling off camera. There are also some risks for the audience, and their future patients. Not surprisingly, delegates may feel empowered to try out things which they have seen demonstrated. How many ERCPists have done their first precuts after simply seeing some live VOLUME 51, NO. 5, 2000
Editorials
demonstrations? The needle knife is a useful tool in expert hands; it can also be lethal. No matter how carefully the caveats are presented, some delegates leave only with stimulating imagery. Again, it is the patients who may suffer. And if they do, are the demonstrators accessories after the fact? Do we check that the demonstrations are relevant to the expertise of the audience? For example, how many “mother and baby” endoscopy procedures have been educationally (or clinically) useful? It may seem curious that I am making negative comments about a teaching system which has been rather successful, and which I had some part in creating. However, circumstances change and we must change with them. What was useful 20 years ago may not be appropriate now. There are outstanding live demonstration conferences now in all continents. I am sure that many of them deal with these issues sensitively and well, but some do not. Some distinguished travelers will be irritated if not enraged by these comments, arguing that the local patients should be grateful for their expert touch. This may have been the case 10 or 20 years ago when the specific procedures were not available locally. In some of my first ERCP demonstrations overseas, many of the patients were doctors for that same reason. Teaching is important, but it is different from entertainment; our overriding responsibility is toward our individual patients. So, how do we move forward responsibly? This is not a plea to abandon a popular teaching system. We should not discard the baby with the bath water. However, it is appropriate to consider how to ensure that patients get good care during demonstrations. One could argue that experts should do demonstrations only on their own patients in their own clinical environment with familiar teams and equipment. Indeed this is common practice, as in our own unit. The experience can be transmitted to wider audi-
VOLUME 51, NO. 5, 2000
P Cotton
ences by video conferencing, locally or at a distance. Visiting experts are invited in to comment on the performances and bring videotapes showing their own methods of approaching specific technical and clinical problems. Soon such videoconferencing will be possible directly on the WorldWide Web, so that interested parties can choose from a menu of experts working from their own medical centers. The crucial issue is whether and under what circumstances it is appropriate for endoscopists to perform demonstrations in other centers. Each will make their individual decisions, but I suggest that they should examine and define their own limits. Perhaps the professional organizations (such as the ASGE) should develop appropriate guidelines. The Master Class concept is also worth considering for those experts who like to travel (and there are few who don’t). Under this system, the visiting expert helps the local endoscopists working on their own cases, usually only with a small audience (say within the procedure room). The local endoscopist takes overall responsibility for the patient care and the procedure. The role of the expert is to make useful suggestions. With appropriate licensing, discussion, and insurance, the expert can go “hands on” at times, with the understanding that the local endoscopist is still responsible both medically and legally. Live demonstration conferences have had an enormous impact around the world. I have contributed to many and enjoyed most. Perhaps it’s a sign of advancing age that I feel increasingly uncomfortable about participating when not in complete control of the patient’s welfare. However, I believe that open discussion of the issues will result in a better system. Teaching is so important that we must do it right. Peter B. Cotton, MD Charleston, South Carolina
GASTROINTESTINAL ENDOSCOPY
629
Live endoscopy demonstrations are great, but... When endoscopy entered routine practice about 30 years ago, one trainee at a time could share the endoscopic image through a “teaching side arm.” The first attempts to transmit live images to large audiences were made with expensive broadcastquality video cameras. Smaller video cameras became available in the mid 1970s; they were adequate for short demonstrations, but too bulky and impractical for everyday use. With this equipment we developed one of the first videoconferencing suites, at The Middlesex Hospital in London, which allowed groups of trainees to observe the endoscopic and radiologic images and to communicate from a nearby seminar room. We carried this equipment to do video workshops in many countries. By this means, the excitement and potential of endoscopic diagnosis and therapy were brought home vividly (literally) to thousands of gastroenterologists and Copyright © 2000 by the American Society for Gastrointestinal Endoscopy 0016-5107/2000/$12.00 + 0 37/70/105098 doi:10.1067/mge.2000.105098 VOLUME 51, NO. 5, 2000
P Cotton
related personnel. The arrival of videoendoscopes in the mid 1980s gave this process a tremendous boost. Live demonstration programs are now incorporated in many local, national, and international conferences—because they bring in the crowds. The benefits seem obvious and substantial, but there are some problems which need to be confronted. My biggest concern is for the safety of the patients when being worked on by visiting experts in unfamiliar surroundings. Demonstrations are popular partly because they can be exciting. It is instructive and fun to see how experts deal with difficult situations, but I fear that some exciting situations do not end happily. Are we sure that patients always get optimal care? Are the complication rates the same as they are back home? We have no data, but there are plenty of embarrassing anecdotes. Do all patients know what is going on? Privacy and confidentiality should be easy to safeguard, but can be forgotten in the heat of the moment. Often the “backstage” of a demonstration meeting is a chaotic mixture of bemused patients, relatives, performers, trainees, nurses, instrument company representatives, and heaven knows who else. It would be surprising if patients feel that they are the cenGASTROINTESTINAL ENDOSCOPY
627
P Cotton
ter of attention. Some may have had their treatment delayed to fit the demonstration schedule. Does the demonstrating expert always have enough knowledge of the patients to make good clinical judgements before and during procedures? It can be difficult to grasp the intricacies of an individual patient’s problem, especially if there is a language barrier. Records are often incomplete, and the local physician of record (if identifiable) may be too preoccupied with other arrangements to be the patient’s advocate. Do visiting experts always check on key clinical facts as they would at home (e.g., laboratory studies, prior radiographs, comorbidities, and specific risk factors)? How detailed is the informed consent process? How many experts have declined to do a procedure because they cannot see a good indication when confronted with the patient on the table, and an expectant audience? To do so may be the most telling educational statement of the day, but it is a brave (and rare) decision. How many experts check on key environmental factors that they take for granted at home—such as local practices for disinfection, antibiotic prophylaxis, sedation, and monitoring. If it appears that the local practices are different, should you insist on your own standards or bend them for the benefit of “the show”? If you compromise at all, how does this square with being an expert teacher? The pressure to do what the organizer wants and to “succeed” can be substantial. It takes real courage to “fail” on camera or to desist when the benefit/risk ratio appears inadequate—indeed to behave totally responsibly, especially when jetlagged and well entertained. All true experts acknowledge the importance of their support teams. At home they work with people they trust, with agreed practices and familiar equipment. Performing in a foreign environment can be destabilizing. The local nurses and technicians may be experienced and usually anxious to help, but may not be familiar with your methods or language. The equipment may look different, even if you have taken the trouble to inform the organizer of your specific requirements. Demonstrations are often sponsored generously and honorably by instrument and accessory manufacturers, who presumably hope that their equipment will be shown to full advantage. Although I have never experienced any overt requests to use specific equipment, there are unstated expectations. What to do when faced with equipment that we have never used before or even seen? Are we comfortable having our first experience of a new gizmo on an unsuspecting patient before an audience clamoring for action? Doctor, would you like to use this new expandable stent with a double retracting superslip delivery device? What dia628
GASTROINTESTINAL ENDOSCOPY
Editorials
thermy settings do you like? How do I answer that question when I have never seen the diathermy machine before, and in fact only entered medicine because I could not understand electricity? The endoscopist has important duties after the procedure is completed. At home, we make sure that the patient and any accompanying persons understand what has happened, and the future plans, and we record our findings, actions and recommendations. It may be reasonable to leave these tasks to the local physician of record, but I suspect that time pressures may interfere with their completion. Do you check? Demonstrators should not forget the risk of personal injury. Some patients have curious diseases. Protection equipment (gowns, gloves, masks, etc.) are not always available, and it is wise to carry appropriate supplies. And there are legal pitfalls. In the early years of demonstrations, most countries seemed to ignore the licensing issue; now it can be a serious hassle. In one I was obligated recently to provide swabs from my “moist bodily parts” as part of this process. And what about medical liability insurance? Is this covered by the conference organizer and his institution, or is the visiting expert personally “at risk”? Medico-legal action for endoscopy accidents is no longer solely an American sport. Does it constitute “abandonment” to fly out on the next plane after doing a complex procedure? The visiting expert may be seen as a convenient “big pocket” when the results are not optimal. Live demonstrations carry some hazards for people other than the immediate patients and performers. Organizers of large multi-performer meetings carry a tremendous load of anxiety on numerous fronts. They must worry about the care of the patients, particularly those who have been referred in by their friends in other institutions when their own supply of “suitable cases” dries up suddenly. This last minute panic often results in too many patients (some not really suitable) who must be dealt with responsibly, often late into the night. One of the most difficult tasks of a local organizer is to rein in a visiting expert who appears to have left his expertise on the plane. Prying the scope away with dignity can be a challenge. It is wise to have two procedure rooms active during demonstration meetings, so that it is possible to switch politely to “something interesting happening in the other room,” and do the necessary arm wrestling off camera. There are also some risks for the audience, and their future patients. Not surprisingly, delegates may feel empowered to try out things which they have seen demonstrated. How many ERCPists have done their first precuts after simply seeing some live VOLUME 51, NO. 5, 2000
Editorials
demonstrations? The needle knife is a useful tool in expert hands; it can also be lethal. No matter how carefully the caveats are presented, some delegates leave only with stimulating imagery. Again, it is the patients who may suffer. And if they do, are the demonstrators accessories after the fact? Do we check that the demonstrations are relevant to the expertise of the audience? For example, how many “mother and baby” endoscopy procedures have been educationally (or clinically) useful? It may seem curious that I am making negative comments about a teaching system which has been rather successful, and which I had some part in creating. However, circumstances change and we must change with them. What was useful 20 years ago may not be appropriate now. There are outstanding live demonstration conferences now in all continents. I am sure that many of them deal with these issues sensitively and well, but some do not. Some distinguished travelers will be irritated if not enraged by these comments, arguing that the local patients should be grateful for their expert touch. This may have been the case 10 or 20 years ago when the specific procedures were not available locally. In some of my first ERCP demonstrations overseas, many of the patients were doctors for that same reason. Teaching is important, but it is different from entertainment; our overriding responsibility is toward our individual patients. So, how do we move forward responsibly? This is not a plea to abandon a popular teaching system. We should not discard the baby with the bath water. However, it is appropriate to consider how to ensure that patients get good care during demonstrations. One could argue that experts should do demonstrations only on their own patients in their own clinical environment with familiar teams and equipment. Indeed this is common practice, as in our own unit. The experience can be transmitted to wider audi-
VOLUME 51, NO. 5, 2000
P Cotton
ences by video conferencing, locally or at a distance. Visiting experts are invited in to comment on the performances and bring videotapes showing their own methods of approaching specific technical and clinical problems. Soon such videoconferencing will be possible directly on the WorldWide Web, so that interested parties can choose from a menu of experts working from their own medical centers. The crucial issue is whether and under what circumstances it is appropriate for endoscopists to perform demonstrations in other centers. Each will make their individual decisions, but I suggest that they should examine and define their own limits. Perhaps the professional organizations (such as the ASGE) should develop appropriate guidelines. The Master Class concept is also worth considering for those experts who like to travel (and there are few who don’t). Under this system, the visiting expert helps the local endoscopists working on their own cases, usually only with a small audience (say within the procedure room). The local endoscopist takes overall responsibility for the patient care and the procedure. The role of the expert is to make useful suggestions. With appropriate licensing, discussion, and insurance, the expert can go “hands on” at times, with the understanding that the local endoscopist is still responsible both medically and legally. Live demonstration conferences have had an enormous impact around the world. I have contributed to many and enjoyed most. Perhaps it’s a sign of advancing age that I feel increasingly uncomfortable about participating when not in complete control of the patient’s welfare. However, I believe that open discussion of the issues will result in a better system. Teaching is so important that we must do it right. Peter B. Cotton, MD Charleston, South Carolina
GASTROINTESTINAL ENDOSCOPY
629