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Television technics in graduate surgical education
Television Technics in Graduate Surgical Education VICTOR RICHARDS, MD, San Francisco, California HENRY JACOBS,MA, San FranCiscolCalifornia
"History." said H. G. Wells in a broad sweeping prophetic sentence. "is a race between education arid catastrophe." Little did he realize, however, that knowlcd,,e was to t~row and accumulate at such a tremendous rate that education was soon to be overwhelmed by the information explosion. M~ln has now reached the stage :~ which he is in danger of losing in understanding what be is g;tining in information. Education itself faces c:~tastrophe unless technics evolve to control the ext~k~skm of information by the acquisiiion of understanding. Our danger in education, to paraphrase John (k:rdner. "is the creeping disaster that overtakes a ~ocietv which little by little loses a commanding grip ,~n its problems and its future." We are dreadfully behind the times in dealing with modern modes o f information transfer and in applying modern technology :~ssociatcd with learning to the educational process. Education is a lifelong process. The information c~plosion not only challenges the undergraduate student in medicine but also threatens the graduate physician with a progressive information gap and accelerating incompetence. Our teaching practices and our professional medical practices have not yet been soundly !~.ookcd into available methods for the retrieval of ini,.~rmation and the transmission of knowledge. There is ,~ crying need. in making education simple, continuous, .~nd lifelong, to turn the uses of technology to the con•.enience and benefit of the individual in the retrieval, .,.cquisition, stimulation, and transfer of knowledge. Technology can be made to serve both the educator :~nd his d!sciple. For the superb educator and teacher '~e audience for the dissemination of distilledinforma:,on becomes, through film, tape, and sound, the world ~l~dnot the isolated individual or classroom. Moreover, ~f technology could make education more convenieni :~:ad economical, the student and physician, particularly the gradhate, could select his own teacher, his own~SUbjcct. and his own rate o f learning in the setting most conducive to his goal which is the better care of patients in health and sickness. To make technology the servant, not the master, of the educational process, clearcut goals must first be From tl~e Electronic Learning Research Laboratory of the Children's Hospital. San Francisco, California, This work was supported by a grant from the California Division of the American Cancer Society. Presented at the Forty-First Annual'Meeting of the Pacific Coast SUrgical Association. San Francisco, California, February 15-18. 1970. Volume 120, August 1970
defined. The goal in medicine, broadly speaking, is to improve the quality of medical Care. The objectives, employing television technics,, would be to bring current information, skill, and knowledge to the student (undergraduate or graduate) in a simple, convenient, economical, stimulating, and continuous flow. The !mpact of continuing education would effect a change in !he physician's approach to the prevention of illness, the preservation of health, and the imposition of specific diagnostic and therapeutic skills (such as drugs and surgical procedures) in fulfilling the health care needs of Society. Our purpose in this pi'esentation is t o r e l a t e our experiences in the use of television in graduate surgical education, recognizing that the problems in cOmmunication, acquisition of skills, and education are universal to all disciplines. Background and Initial Development In 1967 we were awarded a small grant of $20,000
over a two year period tO explore the uses of television. videotape, and related media to continuing medical education in cancer. A small television :studio a n d r e cordingsystem w e r e designed in a n a r e a of less than 500 sqaui'e: feet within the Children's Hospital which" we called the Electronic Learning Research Laboratory. With one Cohu-Kintel 3200 vidieon televisi0n camera witha,q0 to I Zoom lens and one Ampex 7500 C video~ tape recorder, a 1 inch helical scan With .Iwo : audio tracks at a cost of about $12,500, we began/making black ~ d white television tapes; We recorded chalk talks, medical eonferences,grand rouhds,l-and surgical procedures, a n d m a d e for display (o regi0nal.h0spitals a series of talks on cancer, covering- teal Subjects~ineluding the head and neck; breast,, lung, gastrointestinal tract, rectum and co!on, etiol0gy, virology, immunology; isotopes, and chemotherapy of cancer~ These ~tapes were evaluated by:written questiopnaires and by record. ing interviews with physicians on :a' Portable tape"re, corder. Each tape lasted approXlmately- "twent)minrutesl The results o f the eValuati0h were imeresting: Mo~t hysicians filled out the questionnaires as rapidly as ossible, praised the approach tremendouslyas ~ha(~ing the potential. of copingWith the information explCsion, but rarely took the twenty mifiutes to :cotnplete.the tape for'it was not in their particular fieid oflinterest~ EW:
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Richards and Jacobs thusiasm ran high, but tile message was far from reaching its expressed goat. Our initial premises were simple: (1) the tapes should be short and concise, not over twenty minutes; (2) the presentation should be real, lifelike, and ill a familiar setting (cinema vdrit6); (3) the tapes should be so convenient as to be inescapable, that is, in the doctors' lounge, office, or hospital cottee room: (4) the tapes shoukt be inexpensive to produce, thus essentially disposable: and (5) the density of information transmitted per unit of time should be high to maintain interest a n d c o n s e r v e t i m e . The response to the questionnaires praised the concept and the presentations, aside from some technical shortcomings, in g,lowing terms: however, we rcalizetl that we had begun to fill an information gap but had not broken the communication barrier. The main problems in the commu,aication barrier seemed to bc: ( I ) the visual images on our modest equipnmnt were of low resolution on copying, that is, tile images were seen at tile physican's convenience, but were of n'todest quality; (2) our images were black and white ~mly, hardly adequate to at'ract the eye of the ph}sician in the present era of electronic sophistication with color. and furthernaore, color presentation is required to present the tone, depth, and gradations ill visual field required to demonstrate su,'gical tcchrics: f3) our visual display lacked something to stinmlate nnd restimulate the interest and eye of the observer, that is. t h e visual imagery was too monotonous and nol up to the inherent capabilities of the media. These shortcomings were purely technical and sohmte with better equipment. Of greater concern to us, however. were basic problems in communication centering around the motivation and behavior of the graduate physician viewing the tapes. The graduate physician is primarily interested not in general knowledge but in specific information related to a particular problem of interest at the moment. The motivation to learn comes from a specific need, and the physician would like to use the learning media as he does a book, a journal, or library. We clearly needed a library of television tapes so that the individual physician could view the tape at the desired time. Furthermore, the transmission of gcneral knowledge in a group setting is greatly enhanced by participation of the student, learner, or audience in the learning process. "-l'he tapes should be available in a given hospital to serve as a leader of group discussion, and the audience should not be permitted to remain a passive spectator in the learning process. Group interaction can m a k e the audience active participators in the educational process. Of equal importance, but harder to achieve, is tile direct feedback relationship between teacher and pupil in the communication of knowledge wherein they share common interests and work as more 154
or less equal partners in the discussion and acquisition ~I" inft)rmation.
Cur initial premises were simple and sound, but they had now tO be expanded with additional postulates: ( 1 ) colur wus essenti-fl to many presentations, particularly surgery; (2) rnultinwdkt display would sthnulntc, caplure. and hohl tile attention el_the learner; (3) nlt~tivation for spceilic learning required a videotape librilry; (4) audience participution of an active m~lure enhanced the le:u'ning process; and (5) direct lWt~+way communication arid fce,.!bnck t~etween teacher and pupil were diflicuh t~ ublain but desirable, l:Educafion IL~ be ati~e and real is an uctivc, motivated, coh)rful, d.,,nanfic, and conmlt,nieativc
"vent tire.
The Multirnedia Educational Display System Consequent to uur initial experiences we soug,ht a system which would give us good coh>r, g~xl ,,isu:d resolution, high-fidelity .yotlnd. , ;.tlld ccoll~.~nly' '..vhich '~,C could utilize to build a tape library. The ~,>.stem would ha~c to stimulate, restimula~e, and hold the c>e of tll~." viewer, a sy,~tcm w i t h a b u i l t - i n rcfrc,dting, principle.
Yet the display had to bc convenient, at the physici~m's beck and call, and have the vitalilv and dynamism of television with the reportorial excellence nf color+stidc photography. To paraphra:,e Nicfd'luha,n, the n~cdium must bc "'the message" and be "hot." A critical survey of existing mcdi:, was made. Buoks and periodicals, unquestionably essential to the communication process and uhimutety irreph~ceabte, were the cau:,e of the infornmtion explosion, the prubtem we were trying to sMve. Movie film,+ (8. 16. 35, and 70 ram) tire ct~stly to produce, lack the spontaneity c,f television, are time-consuming, do not naturally emerge from the day's work. h a r t no possibility of inexpensive animation, and require extra wo,k and expense for a good sound track. Live radio broadcasts arc often a t an inconvenient time. are still limited to verbal presentation. permit two-way communication between teacher and pupil, but seem to be most valuable when converted to audiotapes which can be heard at the learner's convenience, that is, the Audio-Digest. Live television is not always broadcast at a convenient time. is expensive, and is often unsuitable for public broadcast. Broadcast videotapes are too costly in tape stock+ video equipment. and technical staff for most hospitals and individuals to utilize. 35 m m color slides are inexpensive and have high quality visual resolution, T h e y can be triggered from an audiotape, but this technic does not provide for leading tile eye to specific details within tile slides, and tile vitality of the presentation is not c o m petitive with television. The use of 35 mm color slides would provide reportorial excellence and. if combined with television, might provide a promising m e d i u m which would fulfill our total postulates. We, therefore, settled on a trial of a multimedia display system in The American Journal of Surgery
Television in Graduate Surgical Education which the r e p o r t o r i a l excellence (ff 35 m m color slides would be linked and activated by the a u d i o c h a n n e l of Ihc live telcvision tape, providing the a d v a n t a g e s of television tapes, g o o d resolution, color, eye-refreshing imagery, high-fidelity sound, e c o n o m y , and case of production.
The m u l t i m e d i a d i s p l a y syslem h:ls the following ~:omponents: ( I ) a v i d c o t a p e r e c o r d i n g system. ( 2 ) 2 ~r more 35 m m slide projeclors. ( 3 ) a stereo a u d i o recorder, and t"4) ~l custom designed slide p r o g r a m m e r . , t q g u r c s I and 2.) Program m a t e r i a l s are a m o n o : t - l ' o m e vidcot,~pc, a stereo a u d i o t a p e , a n d t w o o r m o r e .:ar~uscls of 35 m m color slides. T h e videot:~pe gencrutc~ a bhtck ;white television picture with high-fidelity ~ur~d. On the sccc~nd :tudioehannel of the v i d e o t a p e we l~rt~gr~m~ b c c p sigmds to a d v a n c e the two carousels in ~.mdem l ' h c ultimate viewer .',ces three screens which intermittently di,,pluy lwo cc, lor im~.gcs and one tele•,~si~n m~nocltrt~me mlagc, This on-off characteristic ~- the t]i,,pl;~y seems to gcner;~te a Pavlovia~ response ~,~ the ~icwcr in the f()rm ()f :mticip~lting the rm,.ppear,u~cc of the impact, l h e disph~y c o n s t a n t l y rewards, then dcprt~c,; the %,iewer'~ anticip:~tion, kindling, and reki)~dlmg ])i,, interest, b()th visual und auditory. T h e c(~mponelltS :lntl :~rrangcmcnt of the system arc illus'~r.~tcd in the following di:tgrzm~, and the details of the equipment :~rc described in a n o t h e r publication. T h e s,.slcm requires 1.330 ~.~,:I_lllSof power, and is portable. ~ a r~obilc cart f~3r use l h r o u g h o u t lhe hospital. P r o d u c t i o n o~ C u r r e n t P r o g r a m s l h ¢ p r o d u c t i o n of :t progr;m~ r e m a i n s simple, brief. i~¢x[.~nsivc, und purely a' the c o n v e n i e n c e and dis~rcuon of the individual teacher. ( F i g u r e 2.) T h e ~cchncdogy serves the teacher and stimulates the viewer. Fhe setting ix familiar to teacher and student alike; the
p r o d u c t i o n is real, s p o n t a n e o u s , a u t o m a t i c , and can include actual o p e r a t i n g r o o m scenes, footage from existing movies, existing books, charts, and diverse displays within the m u l t i m e d i a a p p r o a c h . T h e finished p r o d u c t can be diversified but requires only t h e ' ingenuity and talent of the individual .teacher and one television o p e r a t o r with an interest in c o m m u n i c a t i o n . T h e r e is n o direction, no script, no p r o g r a m m i n g , for it is true to life, real, u n r e h e a r s e d , and s p o n t a n e o u s . T h e setting also is real for the student, the old c l a s s r o o m w h e r e he !earned best. o r the o p e r a t i n g r o o m w h e r e he a c q u i r e d w d u a b l c skills and j u d g m e n t . T h e e d u c a t o r a s s e m b l e s his g r a p h i c material, such as 35 m m color slides, r o e n t g e n o g r a m s , p h o t o g r a p h s , p a tients, drawings, films, charts, and b l a c k b 5 a r d s . By a s p a r i n g use of c o l o r e d c o n s t r u c t i o n paper, acetate, and m a r k i n g pens we can inject c o l o r into a slide, frame. group, encircle, and underline. S o u r c e credits, including references to journals, books, a n d articles, can be given easily. T h e slides a r e distributed b y the s p e a k e r into the two e m p t y carousels, alternating left a n d ' r i g h t carousels but also interjecting b l a n k slides at irregular intervals to p r o d u c e the on-off stimulating r e s p o n s e in the viewer. T h e s p e a k e r can preview all of his slides and rcvicw the entire s u b j e c t m a t t e r to adjust the scope and lime of the p r e s e n t a t i o n . H e is then r e a d y to p r o d u c e the television p r o g r a m . T h e television c a m e r a then focuses on the teacher. T h e t e a c h e r can use the m e d i a which suits him best at the m o m e n t , such us the b l a c k b o a r d , x-rays, slides, o r cuts from movies. T h e c a m e r a focuses on the t e a c h e r when he is talking, but z o o m s to the slides, b l a c k b o a r d , o r o t h e r m e d i a as he utilizes them. A m o v i n g pointer, still o r electronic, leads the eye to the d e s i r e d detail on the c o l o r slide. T h e triple screen permits one screen to present one slide, the s e c o n d screen a n o t h e r , a n d the
Figure 1. The portable m u l t i m e d i a viewmg device (below). Figure 2. Preparation and production of vtsual material for m u l t i m e d i a display.
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zoom of the camera to focus on the detail of the slide trader immediate discussion. The slides serve as notes and guides for the talk; however, since the teacher is off camera when the slides are being shown, he can utilize notes, books, or script for his narration without marring the presentation. The pointer focuses attention and is 0isplayed on the television monitor. The uhimate viewer can easily switch back and forth between the original slide, in full and sharp color, and the pointer highlighting the detail on the television image. The zooming quality of the television lense permits excellent highl)ghting of details of any slide. When two blank slides appear side by side. a transition point is indicated from one subtopic to another. The television can]era moves back to the teacher when the slides arc not being shown. When the tape is finishcd, it is rewound and the slides are recycled. The program can be studied, altered, or modified easily at any stage by merely redoing that portion. This particular system combines inexpensive black and white television with quality color resolution of 35 m m photograph),'. The use of a color television camera would permit the entire program to be shown in color, and as color cameras become less expensive, the entire master tape can be made in color. The cost of a twenty minute multimedia videotape with our present black and white television system and color slides, exclusive of the two people involved in the production, is approximately S30 to S35. that is. t h e I inch videotape is S 16.66, 100 color slides $13.50. and the audiotape $1.00. totaling $30.16. (A one hour tape with slides would cost approximately $.100.) This is an interesting figure to compare with costs of other media. For example, a twenty minute 16 mm sound fiim can cost from $800 to $8000 depending on film stock, editing, and laboratory costs. A twenty minute broadcast color videotape: costs $160 for the tape plus $50 to $5000 per hour for studio and crew. These remain single media and have but one form; they can neither contract nor expand, be easily changed, nor are they modular.
The Communication Package The multimedia approach has for the moment another potential advantage. The educational demonstration can easily be converted to other existing media of communication. For example, the 35 mm slides need only be'reduplicated and the system can be used from a stereotape recorder with the first channel of the tape recorder delivering t h e ' s o u n d and the second channel of the tape recorder triggering the synchronized slide sequences. This of course loses the ability of the television zoom lens to follow with a pointer the section of the slide under discussion. Similarly the Slides can be converted to a film strip and the film strip can be utilized on one of the new 156
desk-type sound-film viewers, such as the Audiscan viewer and 3M disc viewers. These special sound-film viewers arc becoming less expensive and have the advantage of being available in the physician's home or ofl!.cc. The entire program can be converted to 16 mm or super 8 mm tilm by simple ph3m::~graplaic technics under ideal simple lighting. This converts the multimedia television tape to a cartridge super 8 mm lilm. The multimedia cycling and viewer-holding devices can be incorporated by split-image photography. q'he sound call be converted tc~ a written syllabti~,; and the syllabus and slides can be studied and rc~aincd by the viewer at his convenience. This approach may be required if television display is not pos.,ihtc, but scorns far less desirable as at technic of conllr|unicalion.
Current Uses of the Multimedia System in our Hospital With the goal of improved patient care we ; u c current[y exploring the uses of our multimcdi,t tele~i,,ion tape approach to gradualc yttrgicat education in the following areas: I. ~he creation of a library of surgical tclevb, um tapes o n - a great diversity ~ff subjects. l'hc gradua,tc surgeon would thel~ use these television tapes and slides as he currently uses the books and j,:)urnals t~f the library. This will ;permit us to stud) and evaluate the television tape when the student is moliv.'~ted to tearn a particular subject. 2. Electronic journalism. The graduate surgeon is currently engaged in journal club reviews or in ,.~ystematic reviews of surgical topics in current literature. To become an active participant in the ed~cational process and to stimulate him to c,ptimal performance, we will begin having the ~raduate surgeons make multimedia television tapes for our television library. This also permits the individual m review and improve his performance as an active teacher of his confreres. Surprisingly g o ~ visual material and television tapes have been produced by residents who then become anxious to perform, display, and record their knowledge. 3. Detailed case studies and complete presentations. One of our best teaching exercises is a careful review of patients currently undergoing treatment. The graduate surgeon is stimulated by these educational technics to perform, participate, and communicate, all of which enhance the educational process. The material can easily be stored and is available for review, again in library form. The hospita ! begins to evaluate itself and its work by this new educational technic. 4. Instant replay. The learning experience, particularly in the operating room and less effectively in the emergency room, can be strengthened by instant surgical replay, an inexpensive playback technic only possible with-television tapes. By this technic the experiTh~Amertcan Journal of Surgery
Television in Graduate Surgical Education cnccd surgeon ¢+an actually d e m o n s t r a t e desirable operalivc skills, the graduate student can a,'tempt to : m u l a t c them. and the perform:race can be critically analyzed by student and teacher at their convenience. Moniloring in tile recovery room setting is more diMcull. The o p e r a t i n g .room, e m e r g e n c y r o o m . and in;cn~vc care rooms, however, lend themselves to critical ,qaalvsi~ of urgent problems for which instant decisions :~ltl~! be i n a d e ;.lnd wherein subsequent :malysis of the ~rc and result in critical situations unfold for review w teacher and student. A t t e n t i o n . motivation, and :~.~rlicip;~l~on art: incscapnble as recorded by the tele.~,lon lapc. and ev,duation of oneself, tile learning . , p c r i c n c c . and behavioral patterns emerging from con:muine education i.', inexpensive, feasible, and rewarding ',, l e a c h e r al'ld student alike. The ~hort. c o n c l ~ , c , prat}matic tape. T h e material , t h c c d ;dmo~t :mtomalicallv in the daily care of p:~lcm,, can bc tram, f,~l'mcd into short, concise, practical ".,p~,~ which clearly th.'monstratc the solution to cofllnlon ~ : c n t problems, f h c s c tapes arc particularly useful for ~hc pr;;cncing phy.-ician and ancillary heahh personnel :~,r~kin~ in :u'c:l~ of ~pccial c;,re within the hospital. ~pccific new information is casiiv c o n v e r t e d into useful z ~,~wlcd,_,c m pr':gmalic packmgcs of five to ten minutes
The Ultimate Technologic Achievement ('tur,entlv the production of these diIIerent types of ~cic~i~ion t:tpc~ with varying educational and psycho,~'_'ic cnhanccn;cnts is beconfing simple, automatic, pontanetms, and iqcxpcr,~ivc. T h e display of recorded '~,~.crhd i~ stitl troublesome and s o m e w h t expensive. ~)ur system, for example, requires a p l a y b a c k recorder ~:~d two carousel projectors. O t h e r systems invariably ,,:quirc a p l a y b a c k recorder, which for color television •sts currcnth, $ 7 0 0 0 to $ I 0 . 0 0 0 . T h e b l a c k and white ,htyback r e c o r d e r only is far Icvs expensive but still ,.~1~couraging to the hospital and particulnrly to the ',dividual for home use. Black and white p l a y b a c k re,,rders range between $700 and $1500. At the present time it would appear that three ~mpanies will soon have small cartridges tlmt~ can be :rached to home television units for playback of pecial y processed color television tapes. The Sony .vstem is still undisclosed but will be demonstrated ,hortly, T h e C o l u m b i a B r o a d c a s t i n g System is currently displaying all Electronic Video R e c o r d e r f E V R ) which will cost u n d e r $ 1 0 0 0 and which will be available for i~ome use. Radio Corporation of America is developing :~ holographic teclmic for m a k i n g home television tapes which will permit inexpensive home display in color. In all of these commercial systems the current tele-
vision tapes will have to be converted to a particular home d i s p l a y system. This will be rather expensive
initially, but the price will drop shortly. The ultimate in Volume 120, August 1970
convenience and motivation will be achieved by the development of these home color systems. Excellent color quality at low cost will be available, but the graduate physician will remain passive in this environment and education will be strictly content-oriented. Advances in educational psychology can make the student an active participant in the educational process. These new educational technics are particularly applicable to television and the use of television tapes. The physician need only be aware of his deficiencies. With proper motivation he will select the educational tape of his need and interest. Gaming speculation technics can be applied to the learning process at home so that the student actively participates in the learning process and his education can be controlled and programmed. matching his response to correct responses indicated by starting and stopping the tape at appropriate questions by the teacher. Tapes of this type can be specially prepared and used individually or in group learning experiences, Continuing education of the physician in his home environment or hospital setting will make cducation a daily rewarding experience rather than a struggle with the information explosion. Tile physician will not have to be relieved of the problem of the management of llis day to day practice to' continue his education, and the financial costs of re-learning and continuing education will be meaningful, pleasant, and tolerable. His pattern of medical practice will not have to be reorganized to permit new information to flow into usable knowledge. Ultimately, many organizations and our good hospitals will be engaged in daily lifelong continuing convenient education, and with the new uses of tcchnology, particularly television and developing participatory technics, active learning by the physician will enfible him to cope with the information explosion in his home environment. The universities will with private industry develop the educational concepts and technology, but will share the enormous responsibility of supporting a e w emerging programs for a lifetime of learning. The goal of better and improved patient care will be progressively achieved as new educational objectives and technologic advances alter the behavior of ihe practicing physician in his daily work. Summary Television technics have tremendous major application in graduate surgical education. We have devised a multimedia display technic which has the adwmtages of being simple, economical, corivenient, and stimulating. By combining the reportorial excellence of 35 mm color slides with the dynamic qualities of television, we have developed a unit which holds the individual's attention and communicates to him forceably. The rapid, inexpensive production of tapes permits building of a multimedia tape library. We arc looking for future methods of securing two-way communication between 157
Richards and Jacobs t h e t e a c h e r on the television s c r e e n a n d the student in the television a u d i e n c e . Discussion
DONAI.D Bn~,YTON (Los Angeles, C a l i f ) ; Doctor Victor Richards' innovative combiuation of several audiovisual technics into one system undoubtedly is most effective in his hands. T h e development of audiovisual productions capable of standing alone as leaching devices has been a significant challenge to many of us attempting to use the,~e modalities for wide distribution. Those of us who are nlernhers of the Council on Medical Television an'd of the Association of Medical Television Broadcasters ( A M T v B ) have discovered that the proper use of the media ha.,. to be learned slowly and painfully as indicated by D r Richards. Television is more than just radio with pictures. The professional knowledge and artistry capable of producing programs that both attract and teach the viewer are rare. As hard'.~are required for the production of intramural program.,, is b e c o m i n g cheaper. the professionals needed to produce a superior product are b e c o m i n g dearer. The dillicuhy of the task is evidenced by the decrease in producers of medical educational programs. When the A M T v B was organized in 1965. ten medical teaching institutions were producing programs. some for intramural and others for mass distribution. As of this year, only four are still producing. Of t h e ~ . tt~'b largest is the Medical Television N e t w o r k ( M T N ) located here in California. T h e producers of M T N ha;,e found that for their progrants to be effective as learning devices, they must not be merely passive viewing episodes. Each program now produced by the Network is accompanied by d study guide which converts the program to an active learning experience for the viewer. The audiovisual media are destined to become an intrinsic part o f o u r teaching a r m a m e n t a r i u m . T h e y will g r o w in importance as the student-teacher ratio increases and as more students reared on television come of medical school age. Unlike the physicians of today, they are entirely accustomed to learning from the " t u b e " and are most capable of benefiiting f r o m the special educational advantages television has to offer, such as magnification, storage and retrieval o f data, and electronic integr:~tion o f materials related to a subject in context but not in time or place. F. WILLIAM BLAISDELL (San Francisco, C a l i f ) : I would like to raise a negative note Concerning these fascinating and apparently magical teaching aids. Althotxgh they otter a very praclical means of presenting educational material. they are still second best to similar material presented live. W c h a v e had experience with the rebroadcast of surgical lectures a m o n g the teaching inslitutions at the University of California. W e have polled our students r e g a r d i n g their assessment of these lectures and presentations. T h e r e is no question that the students who see these live lectures and presentations consistently rate the lectures above those who see the re-broadcast. Television has to be used with great skill and imagination if it is to c o m p a r e with live material, for one dimension is lost. A ~ood lecture becomes a m e d i o c r e lecture, and a mediocre lecture becomes impossible. W h a t television does do is to obtain a degree of 158
consistency in the presentat=on of material, One could consistently use an outstanding teacller, such as D r Richards, and therefore ohlain quality control. It may provide tile answer to mass education, hut [ do not think it x~ill ever replace a meeting, such as that of the Pacific Coast Surgical, where conviviality exists and the interchange of ideas can he carried out. JollN A. (.flUS (Iowa City, l.owa): l'hi~ cerlainly is a slimu!ating atnd provocative area of education which v, ill receive increasing attention. However, I me h:wc certain reservat}ons about how el[eclp,e television and other types of electronic communication are iu fulfilling the teaching nllssion at tile undergraduate and l)OSlgradu;ite level. \\'e have had experience with tclevixmn at tl~e University of Iowa t.hlrlng tile pi~M left .years, and I have h,cerl involved to some degree ,,ince the beginning. Actually, ;re reached a peak two to three years after tclcvi'~ion was fir,,| used after which inlercM fell off sharply. Now there is very little elfeclive teaching done wilh it. T h e r e :ire many objections ,~o the u',e of televi,,ion in ,,urgicatl instruction, such a,: it,, impcrsonahty, lack of patient contact, and poor c a m e r a technic, | was impressed with the impair|ante of these criticisnv, when I attempted t o teach the etcmentals of ph3sical diagrto,is to ,,cooled year student,L I thought that certain physical ~,ign':,. which I considered to he important but ',~htch are nol always available for demonstration, could he prcscnled through the mediun~ of films, television, slides, and the hkc. However. nearly all students rejected this approach and demanded the real thing. T h e y decried the use of television and wanted exposure to patients. I learned IlK~t one could suPrdement instruct|on hy nleans Ot television, hut it could not be used in licit of patient material. This of COl_ll~C i~ not surprising. The use o | black and white television, which Dr Richard~, uses and which we too have used. leaves much to be desired. Currently the cost of color equipment is such as to limit the use of color to oqly at few. of the more aitluent centers. Ultimately, however, we will use lelevision as well as other electronic means for storing, processing, and reproducing information nluch mort', in tile fur|ire than we do now. Recently I was impressed with the application of computer-assisted instruction which remain', to be d,zveloped to its full effectiveness. Also. cassette type motion pictures for special purposes or the short single-concept films have ranch to offer. As 1 listened to D r Stephens" talk and watched his old m o v i e . I thought h o w wonderful it would be if the great surgeons and teachers with ,~shon't we worked and w h o m wc loved over the years could be recorded and preserved in living color. Perhaps our new president m a y elect to pursue this project. THOMAS 1". WHITE {Seattle, W a s h ) : 1 would like to discuss how to make a television o r movie film o f an operation. The problem we have had is that the c a m e r a operator does not have any idea what we are going to do even if we discuss the problem with him in advance. I w o n d e r how you are going to get good pictures of operations using nonmedically trained personnel. Are you going to put one of your health officers behind the camera'? I take a preliminary The American Journa! of Surgery
Television in Graduate Surgical Education ,~,per 8 film m y s e l f of s o m e o n e else o p e r a t i n g to s h o w the ~:aJnera o p e r a t o r wh:tt we w a n t . E a c h eight to ten m i n u t e ~caching film w h i c h I h a v e m a d e has t a k e n m e a full two ~ e e k s to p r o d u c e . As part o f the cost o f Ibis you h a v e ~ include t h e salary of the c a m e r a o p e r a t o r a n d the e d i t o r :each $ 1 2 , 0 0 0 per y e a r ) us welt as the p h y s i c i a n s a n d :heir time. W o u l d it not be b e t t e r to d e v e l o p a library o f : : c h n i c s f r o m all o v e r lhe c o t m t r y b e c a u s e we as in~x,iduals c a r m o t afford to s p e n d that m u c h time o n this? VJc'rOR RICIIAROS ( c l o s i n g ) : I w a n t to t h a n k all the :~.,cus.scrs o f lhis paper. D o c t o r B r a y t o n , o f course, is the i.ading expert in the field, a n d ! t h o u g h l his discussion of ~W p a p e r was "~uperb. I agree with e v e r y ! h i n g he said. The soflw:~re is really i m p o r t a n t , a n d is the r e a s o n we ;;;e partictflarly interested in m e t h o d s o f presentfi'tion o f :,.tcvised m~tClial at low cost. D o c t o r White, to n l a k e a ~ o v i e e<~sts abotlt $1(L0tX) an hour. Y o u c a n n o t see w h a t ,,,,t~ are doi~g while you are d o i n g it. Y o u h a v e to wait ~hrce m o n t h ~ ttntil the film r e t u r n s a n d then you h a v e ~,, ~'di: il. I~ty then you ;are fed u p a n d have lost y o u r y,~rpo~e, W i t h the system we have d e v e l o p e d you c a n t:~..c the [~est movies a v a i l a b l e today, excerpt exactly the ~iuh: bit you want. and s u r r o u n d it with slides to e n h a n c e .~,,~ di,~play. \Ve ha're lhe w o r l d of books, literature, fihns, :~I-~tt q i d c s available to us by this technic. All p r o b l e m s of il;~lial CO~,t a n d of not utilizing the c r e a t i v e k n o w l e d g e ~hat ha,, gone b e f o r e are e l i m i n a t e d . Y o u do not h a v e to :.~r~ f r o m scrat.zh, w h i c h is o n e of the big advanttiges o f !he syMenl.
1"o m a k e o u r television tapes in black a n d white costs
VQlurne 120, August 1970
$100 an h o u r total. W e c a n m a k e it in color, w h e n we c a n afford the c o l o r c a m e r a , for m a y b e $125 a n h o u r , the o n l y diit'erence b e i n g the cost o f the tape. O n e t a p e costs $ 4 0 an h o u r w h e r e a s the o t h e r is $ 6 0 an h o u r . So a g a i n it will be inexpensive. N o w , the q u e s t i o n is, w h o is y o u r m a r k e H T o m e the m a r k e t is the o r d i n a r y physician w h o has to c o p e with the i n f o r m a t i o n explosion. A t the present t i m e he h a s to lake t h r e e days off f r o m work, has to find an associate f o r his practice, a n d then h a s to go a w a y for g r a d u a t e e d u c a tion. If you look at e v a l u a t i o n s o f all the c u r r e n t m e t h o d s , you find o n e of t h e big p r o b l e m s is the cost, w h i c h is t r e m e n d o u s fox" a t r u l y c o n t i n u i n g e d u c a t i o n . I t ' w o u l d be f a r b e t t e r for the p h y s i c i a n to be e d u c a t e d d u r i n g his d a y ' s w o r k , s p o n t a n e o u s l y , a u t o m a t i c a l l y . T e l e v i s i o n tapes c o u l d be readily available, even disposable. W e n o w h a v e an a p p r o a c h to l o w e r i n g the cost. W e h a v e the "-world of k n o w l e d g e o p e n to us, a n d the soft w a r e c a n tbe m a d e inexpensively a n d o n l y r e q u i r e s creativity a n d i m a g i n a t i o n if y o u are to use the m e d i a properly. i w o u l d agree with D o c t o r Blaisdell t h a t the worst t h i n g you c a n d o is just to r e c o r d a m a n talking. T h i s is n o t using the m e d i a properly. O n the o t h e r h a n d , s u p p o s e y o u h a v e for y o u r residents readily a v a i l a b l e television t a p e s o f a n o p e r a t i o n . T h e best s u r g e o n in the w o r l d c o u l d be p e r f o r m i n g the o p e r a t i o n , a little e x c e r p t c o u l d b e made, a n d the television c o u l d be viewed f o r ten m i n u t e s b e f o r e a n o p e r a t i o n . H e would talk to y o u a b o u t it. In this w a y the l e a r n e r w o u l d h a v e a u n i q u e e x p e r i e n c e w h i c h h e c o u l d not h a v e a n y o t h e r way.
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"History." said H. G. Wells in a broad sweeping prophetic sentence. "is a race between education arid catastrophe." Little did he realize, however, that knowlcd,,e was to t~row and accumulate at such a tremendous rate that education was soon to be overwhelmed by the information explosion. M~ln has now reached the stage :~ which he is in danger of losing in understanding what be is g;tining in information. Education itself faces c:~tastrophe unless technics evolve to control the ext~k~skm of information by the acquisiiion of understanding. Our danger in education, to paraphrase John (k:rdner. "is the creeping disaster that overtakes a ~ocietv which little by little loses a commanding grip ,~n its problems and its future." We are dreadfully behind the times in dealing with modern modes o f information transfer and in applying modern technology :~ssociatcd with learning to the educational process. Education is a lifelong process. The information c~plosion not only challenges the undergraduate student in medicine but also threatens the graduate physician with a progressive information gap and accelerating incompetence. Our teaching practices and our professional medical practices have not yet been soundly !~.ookcd into available methods for the retrieval of ini,.~rmation and the transmission of knowledge. There is ,~ crying need. in making education simple, continuous, .~nd lifelong, to turn the uses of technology to the con•.enience and benefit of the individual in the retrieval, .,.cquisition, stimulation, and transfer of knowledge. Technology can be made to serve both the educator :~nd his d!sciple. For the superb educator and teacher '~e audience for the dissemination of distilledinforma:,on becomes, through film, tape, and sound, the world ~l~dnot the isolated individual or classroom. Moreover, ~f technology could make education more convenieni :~:ad economical, the student and physician, particularly the gradhate, could select his own teacher, his own~SUbjcct. and his own rate o f learning in the setting most conducive to his goal which is the better care of patients in health and sickness. To make technology the servant, not the master, of the educational process, clearcut goals must first be From tl~e Electronic Learning Research Laboratory of the Children's Hospital. San Francisco, California, This work was supported by a grant from the California Division of the American Cancer Society. Presented at the Forty-First Annual'Meeting of the Pacific Coast SUrgical Association. San Francisco, California, February 15-18. 1970. Volume 120, August 1970
defined. The goal in medicine, broadly speaking, is to improve the quality of medical Care. The objectives, employing television technics,, would be to bring current information, skill, and knowledge to the student (undergraduate or graduate) in a simple, convenient, economical, stimulating, and continuous flow. The !mpact of continuing education would effect a change in !he physician's approach to the prevention of illness, the preservation of health, and the imposition of specific diagnostic and therapeutic skills (such as drugs and surgical procedures) in fulfilling the health care needs of Society. Our purpose in this pi'esentation is t o r e l a t e our experiences in the use of television in graduate surgical education, recognizing that the problems in cOmmunication, acquisition of skills, and education are universal to all disciplines. Background and Initial Development In 1967 we were awarded a small grant of $20,000
over a two year period tO explore the uses of television. videotape, and related media to continuing medical education in cancer. A small television :studio a n d r e cordingsystem w e r e designed in a n a r e a of less than 500 sqaui'e: feet within the Children's Hospital which" we called the Electronic Learning Research Laboratory. With one Cohu-Kintel 3200 vidieon televisi0n camera witha,q0 to I Zoom lens and one Ampex 7500 C video~ tape recorder, a 1 inch helical scan With .Iwo : audio tracks at a cost of about $12,500, we began/making black ~ d white television tapes; We recorded chalk talks, medical eonferences,grand rouhds,l-and surgical procedures, a n d m a d e for display (o regi0nal.h0spitals a series of talks on cancer, covering- teal Subjects~ineluding the head and neck; breast,, lung, gastrointestinal tract, rectum and co!on, etiol0gy, virology, immunology; isotopes, and chemotherapy of cancer~ These ~tapes were evaluated by:written questiopnaires and by record. ing interviews with physicians on :a' Portable tape"re, corder. Each tape lasted approXlmately- "twent)minrutesl The results o f the eValuati0h were imeresting: Mo~t hysicians filled out the questionnaires as rapidly as ossible, praised the approach tremendouslyas ~ha(~ing the potential. of copingWith the information explCsion, but rarely took the twenty mifiutes to :cotnplete.the tape for'it was not in their particular fieid oflinterest~ EW:
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Richards and Jacobs thusiasm ran high, but tile message was far from reaching its expressed goat. Our initial premises were simple: (1) the tapes should be short and concise, not over twenty minutes; (2) the presentation should be real, lifelike, and ill a familiar setting (cinema vdrit6); (3) the tapes should be so convenient as to be inescapable, that is, in the doctors' lounge, office, or hospital cottee room: (4) the tapes shoukt be inexpensive to produce, thus essentially disposable: and (5) the density of information transmitted per unit of time should be high to maintain interest a n d c o n s e r v e t i m e . The response to the questionnaires praised the concept and the presentations, aside from some technical shortcomings, in g,lowing terms: however, we rcalizetl that we had begun to fill an information gap but had not broken the communication barrier. The main problems in the commu,aication barrier seemed to bc: ( I ) the visual images on our modest equipnmnt were of low resolution on copying, that is, tile images were seen at tile physican's convenience, but were of n'todest quality; (2) our images were black and white ~mly, hardly adequate to at'ract the eye of the ph}sician in the present era of electronic sophistication with color. and furthernaore, color presentation is required to present the tone, depth, and gradations ill visual field required to demonstrate su,'gical tcchrics: f3) our visual display lacked something to stinmlate nnd restimulate the interest and eye of the observer, that is. t h e visual imagery was too monotonous and nol up to the inherent capabilities of the media. These shortcomings were purely technical and sohmte with better equipment. Of greater concern to us, however. were basic problems in communication centering around the motivation and behavior of the graduate physician viewing the tapes. The graduate physician is primarily interested not in general knowledge but in specific information related to a particular problem of interest at the moment. The motivation to learn comes from a specific need, and the physician would like to use the learning media as he does a book, a journal, or library. We clearly needed a library of television tapes so that the individual physician could view the tape at the desired time. Furthermore, the transmission of gcneral knowledge in a group setting is greatly enhanced by participation of the student, learner, or audience in the learning process. "-l'he tapes should be available in a given hospital to serve as a leader of group discussion, and the audience should not be permitted to remain a passive spectator in the learning process. Group interaction can m a k e the audience active participators in the educational process. Of equal importance, but harder to achieve, is tile direct feedback relationship between teacher and pupil in the communication of knowledge wherein they share common interests and work as more 154
or less equal partners in the discussion and acquisition ~I" inft)rmation.
Cur initial premises were simple and sound, but they had now tO be expanded with additional postulates: ( 1 ) colur wus essenti-fl to many presentations, particularly surgery; (2) rnultinwdkt display would sthnulntc, caplure. and hohl tile attention el_the learner; (3) nlt~tivation for spceilic learning required a videotape librilry; (4) audience participution of an active m~lure enhanced the le:u'ning process; and (5) direct lWt~+way communication arid fce,.!bnck t~etween teacher and pupil were diflicuh t~ ublain but desirable, l:Educafion IL~ be ati~e and real is an uctivc, motivated, coh)rful, d.,,nanfic, and conmlt,nieativc
"vent tire.
The Multirnedia Educational Display System Consequent to uur initial experiences we soug,ht a system which would give us good coh>r, g~xl ,,isu:d resolution, high-fidelity .yotlnd. , ;.tlld ccoll~.~nly' '..vhich '~,C could utilize to build a tape library. The ~,>.stem would ha~c to stimulate, restimula~e, and hold the c>e of tll~." viewer, a sy,~tcm w i t h a b u i l t - i n rcfrc,dting, principle.
Yet the display had to bc convenient, at the physici~m's beck and call, and have the vitalilv and dynamism of television with the reportorial excellence nf color+stidc photography. To paraphra:,e Nicfd'luha,n, the n~cdium must bc "'the message" and be "hot." A critical survey of existing mcdi:, was made. Buoks and periodicals, unquestionably essential to the communication process and uhimutety irreph~ceabte, were the cau:,e of the infornmtion explosion, the prubtem we were trying to sMve. Movie film,+ (8. 16. 35, and 70 ram) tire ct~stly to produce, lack the spontaneity c,f television, are time-consuming, do not naturally emerge from the day's work. h a r t no possibility of inexpensive animation, and require extra wo,k and expense for a good sound track. Live radio broadcasts arc often a t an inconvenient time. are still limited to verbal presentation. permit two-way communication between teacher and pupil, but seem to be most valuable when converted to audiotapes which can be heard at the learner's convenience, that is, the Audio-Digest. Live television is not always broadcast at a convenient time. is expensive, and is often unsuitable for public broadcast. Broadcast videotapes are too costly in tape stock+ video equipment. and technical staff for most hospitals and individuals to utilize. 35 m m color slides are inexpensive and have high quality visual resolution, T h e y can be triggered from an audiotape, but this technic does not provide for leading tile eye to specific details within tile slides, and tile vitality of the presentation is not c o m petitive with television. The use of 35 mm color slides would provide reportorial excellence and. if combined with television, might provide a promising m e d i u m which would fulfill our total postulates. We, therefore, settled on a trial of a multimedia display system in The American Journal of Surgery
Television in Graduate Surgical Education which the r e p o r t o r i a l excellence (ff 35 m m color slides would be linked and activated by the a u d i o c h a n n e l of Ihc live telcvision tape, providing the a d v a n t a g e s of television tapes, g o o d resolution, color, eye-refreshing imagery, high-fidelity sound, e c o n o m y , and case of production.
The m u l t i m e d i a d i s p l a y syslem h:ls the following ~:omponents: ( I ) a v i d c o t a p e r e c o r d i n g system. ( 2 ) 2 ~r more 35 m m slide projeclors. ( 3 ) a stereo a u d i o recorder, and t"4) ~l custom designed slide p r o g r a m m e r . , t q g u r c s I and 2.) Program m a t e r i a l s are a m o n o : t - l ' o m e vidcot,~pc, a stereo a u d i o t a p e , a n d t w o o r m o r e .:ar~uscls of 35 m m color slides. T h e videot:~pe gencrutc~ a bhtck ;white television picture with high-fidelity ~ur~d. On the sccc~nd :tudioehannel of the v i d e o t a p e we l~rt~gr~m~ b c c p sigmds to a d v a n c e the two carousels in ~.mdem l ' h c ultimate viewer .',ces three screens which intermittently di,,pluy lwo cc, lor im~.gcs and one tele•,~si~n m~nocltrt~me mlagc, This on-off characteristic ~- the t]i,,pl;~y seems to gcner;~te a Pavlovia~ response ~,~ the ~icwcr in the f()rm ()f :mticip~lting the rm,.ppear,u~cc of the impact, l h e disph~y c o n s t a n t l y rewards, then dcprt~c,; the %,iewer'~ anticip:~tion, kindling, and reki)~dlmg ])i,, interest, b()th visual und auditory. T h e c(~mponelltS :lntl :~rrangcmcnt of the system arc illus'~r.~tcd in the following di:tgrzm~, and the details of the equipment :~rc described in a n o t h e r publication. T h e s,.slcm requires 1.330 ~.~,:I_lllSof power, and is portable. ~ a r~obilc cart f~3r use l h r o u g h o u t lhe hospital. P r o d u c t i o n o~ C u r r e n t P r o g r a m s l h ¢ p r o d u c t i o n of :t progr;m~ r e m a i n s simple, brief. i~¢x[.~nsivc, und purely a' the c o n v e n i e n c e and dis~rcuon of the individual teacher. ( F i g u r e 2.) T h e ~cchncdogy serves the teacher and stimulates the viewer. Fhe setting ix familiar to teacher and student alike; the
p r o d u c t i o n is real, s p o n t a n e o u s , a u t o m a t i c , and can include actual o p e r a t i n g r o o m scenes, footage from existing movies, existing books, charts, and diverse displays within the m u l t i m e d i a a p p r o a c h . T h e finished p r o d u c t can be diversified but requires only t h e ' ingenuity and talent of the individual .teacher and one television o p e r a t o r with an interest in c o m m u n i c a t i o n . T h e r e is n o direction, no script, no p r o g r a m m i n g , for it is true to life, real, u n r e h e a r s e d , and s p o n t a n e o u s . T h e setting also is real for the student, the old c l a s s r o o m w h e r e he !earned best. o r the o p e r a t i n g r o o m w h e r e he a c q u i r e d w d u a b l c skills and j u d g m e n t . T h e e d u c a t o r a s s e m b l e s his g r a p h i c material, such as 35 m m color slides, r o e n t g e n o g r a m s , p h o t o g r a p h s , p a tients, drawings, films, charts, and b l a c k b 5 a r d s . By a s p a r i n g use of c o l o r e d c o n s t r u c t i o n paper, acetate, and m a r k i n g pens we can inject c o l o r into a slide, frame. group, encircle, and underline. S o u r c e credits, including references to journals, books, a n d articles, can be given easily. T h e slides a r e distributed b y the s p e a k e r into the two e m p t y carousels, alternating left a n d ' r i g h t carousels but also interjecting b l a n k slides at irregular intervals to p r o d u c e the on-off stimulating r e s p o n s e in the viewer. T h e s p e a k e r can preview all of his slides and rcvicw the entire s u b j e c t m a t t e r to adjust the scope and lime of the p r e s e n t a t i o n . H e is then r e a d y to p r o d u c e the television p r o g r a m . T h e television c a m e r a then focuses on the teacher. T h e t e a c h e r can use the m e d i a which suits him best at the m o m e n t , such us the b l a c k b o a r d , x-rays, slides, o r cuts from movies. T h e c a m e r a focuses on the t e a c h e r when he is talking, but z o o m s to the slides, b l a c k b o a r d , o r o t h e r m e d i a as he utilizes them. A m o v i n g pointer, still o r electronic, leads the eye to the d e s i r e d detail on the c o l o r slide. T h e triple screen permits one screen to present one slide, the s e c o n d screen a n o t h e r , a n d the
Figure 1. The portable m u l t i m e d i a viewmg device (below). Figure 2. Preparation and production of vtsual material for m u l t i m e d i a display.
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Richards and Jacobs
zoom of the camera to focus on the detail of the slide trader immediate discussion. The slides serve as notes and guides for the talk; however, since the teacher is off camera when the slides are being shown, he can utilize notes, books, or script for his narration without marring the presentation. The pointer focuses attention and is 0isplayed on the television monitor. The uhimate viewer can easily switch back and forth between the original slide, in full and sharp color, and the pointer highlighting the detail on the television image. The zooming quality of the television lense permits excellent highl)ghting of details of any slide. When two blank slides appear side by side. a transition point is indicated from one subtopic to another. The television can]era moves back to the teacher when the slides arc not being shown. When the tape is finishcd, it is rewound and the slides are recycled. The program can be studied, altered, or modified easily at any stage by merely redoing that portion. This particular system combines inexpensive black and white television with quality color resolution of 35 m m photograph),'. The use of a color television camera would permit the entire program to be shown in color, and as color cameras become less expensive, the entire master tape can be made in color. The cost of a twenty minute multimedia videotape with our present black and white television system and color slides, exclusive of the two people involved in the production, is approximately S30 to S35. that is. t h e I inch videotape is S 16.66, 100 color slides $13.50. and the audiotape $1.00. totaling $30.16. (A one hour tape with slides would cost approximately $.100.) This is an interesting figure to compare with costs of other media. For example, a twenty minute 16 mm sound fiim can cost from $800 to $8000 depending on film stock, editing, and laboratory costs. A twenty minute broadcast color videotape: costs $160 for the tape plus $50 to $5000 per hour for studio and crew. These remain single media and have but one form; they can neither contract nor expand, be easily changed, nor are they modular.
The Communication Package The multimedia approach has for the moment another potential advantage. The educational demonstration can easily be converted to other existing media of communication. For example, the 35 mm slides need only be'reduplicated and the system can be used from a stereotape recorder with the first channel of the tape recorder delivering t h e ' s o u n d and the second channel of the tape recorder triggering the synchronized slide sequences. This of course loses the ability of the television zoom lens to follow with a pointer the section of the slide under discussion. Similarly the Slides can be converted to a film strip and the film strip can be utilized on one of the new 156
desk-type sound-film viewers, such as the Audiscan viewer and 3M disc viewers. These special sound-film viewers arc becoming less expensive and have the advantage of being available in the physician's home or ofl!.cc. The entire program can be converted to 16 mm or super 8 mm tilm by simple ph3m::~graplaic technics under ideal simple lighting. This converts the multimedia television tape to a cartridge super 8 mm lilm. The multimedia cycling and viewer-holding devices can be incorporated by split-image photography. q'he sound call be converted tc~ a written syllabti~,; and the syllabus and slides can be studied and rc~aincd by the viewer at his convenience. This approach may be required if television display is not pos.,ihtc, but scorns far less desirable as at technic of conllr|unicalion.
Current Uses of the Multimedia System in our Hospital With the goal of improved patient care we ; u c current[y exploring the uses of our multimcdi,t tele~i,,ion tape approach to gradualc yttrgicat education in the following areas: I. ~he creation of a library of surgical tclevb, um tapes o n - a great diversity ~ff subjects. l'hc gradua,tc surgeon would thel~ use these television tapes and slides as he currently uses the books and j,:)urnals t~f the library. This will ;permit us to stud) and evaluate the television tape when the student is moliv.'~ted to tearn a particular subject. 2. Electronic journalism. The graduate surgeon is currently engaged in journal club reviews or in ,.~ystematic reviews of surgical topics in current literature. To become an active participant in the ed~cational process and to stimulate him to c,ptimal performance, we will begin having the ~raduate surgeons make multimedia television tapes for our television library. This also permits the individual m review and improve his performance as an active teacher of his confreres. Surprisingly g o ~ visual material and television tapes have been produced by residents who then become anxious to perform, display, and record their knowledge. 3. Detailed case studies and complete presentations. One of our best teaching exercises is a careful review of patients currently undergoing treatment. The graduate surgeon is stimulated by these educational technics to perform, participate, and communicate, all of which enhance the educational process. The material can easily be stored and is available for review, again in library form. The hospita ! begins to evaluate itself and its work by this new educational technic. 4. Instant replay. The learning experience, particularly in the operating room and less effectively in the emergency room, can be strengthened by instant surgical replay, an inexpensive playback technic only possible with-television tapes. By this technic the experiTh~Amertcan Journal of Surgery
Television in Graduate Surgical Education cnccd surgeon ¢+an actually d e m o n s t r a t e desirable operalivc skills, the graduate student can a,'tempt to : m u l a t c them. and the perform:race can be critically analyzed by student and teacher at their convenience. Moniloring in tile recovery room setting is more diMcull. The o p e r a t i n g .room, e m e r g e n c y r o o m . and in;cn~vc care rooms, however, lend themselves to critical ,qaalvsi~ of urgent problems for which instant decisions :~ltl~! be i n a d e ;.lnd wherein subsequent :malysis of the ~rc and result in critical situations unfold for review w teacher and student. A t t e n t i o n . motivation, and :~.~rlicip;~l~on art: incscapnble as recorded by the tele.~,lon lapc. and ev,duation of oneself, tile learning . , p c r i c n c c . and behavioral patterns emerging from con:muine education i.', inexpensive, feasible, and rewarding ',, l e a c h e r al'ld student alike. The ~hort. c o n c l ~ , c , prat}matic tape. T h e material , t h c c d ;dmo~t :mtomalicallv in the daily care of p:~lcm,, can bc tram, f,~l'mcd into short, concise, practical ".,p~,~ which clearly th.'monstratc the solution to cofllnlon ~ : c n t problems, f h c s c tapes arc particularly useful for ~hc pr;;cncing phy.-ician and ancillary heahh personnel :~,r~kin~ in :u'c:l~ of ~pccial c;,re within the hospital. ~pccific new information is casiiv c o n v e r t e d into useful z ~,~wlcd,_,c m pr':gmalic packmgcs of five to ten minutes
The Ultimate Technologic Achievement ('tur,entlv the production of these diIIerent types of ~cic~i~ion t:tpc~ with varying educational and psycho,~'_'ic cnhanccn;cnts is beconfing simple, automatic, pontanetms, and iqcxpcr,~ivc. T h e display of recorded '~,~.crhd i~ stitl troublesome and s o m e w h t expensive. ~)ur system, for example, requires a p l a y b a c k recorder ~:~d two carousel projectors. O t h e r systems invariably ,,:quirc a p l a y b a c k recorder, which for color television •sts currcnth, $ 7 0 0 0 to $ I 0 . 0 0 0 . T h e b l a c k and white ,htyback r e c o r d e r only is far Icvs expensive but still ,.~1~couraging to the hospital and particulnrly to the ',dividual for home use. Black and white p l a y b a c k re,,rders range between $700 and $1500. At the present time it would appear that three ~mpanies will soon have small cartridges tlmt~ can be :rached to home television units for playback of pecial y processed color television tapes. The Sony .vstem is still undisclosed but will be demonstrated ,hortly, T h e C o l u m b i a B r o a d c a s t i n g System is currently displaying all Electronic Video R e c o r d e r f E V R ) which will cost u n d e r $ 1 0 0 0 and which will be available for i~ome use. Radio Corporation of America is developing :~ holographic teclmic for m a k i n g home television tapes which will permit inexpensive home display in color. In all of these commercial systems the current tele-
vision tapes will have to be converted to a particular home d i s p l a y system. This will be rather expensive
initially, but the price will drop shortly. The ultimate in Volume 120, August 1970
convenience and motivation will be achieved by the development of these home color systems. Excellent color quality at low cost will be available, but the graduate physician will remain passive in this environment and education will be strictly content-oriented. Advances in educational psychology can make the student an active participant in the educational process. These new educational technics are particularly applicable to television and the use of television tapes. The physician need only be aware of his deficiencies. With proper motivation he will select the educational tape of his need and interest. Gaming speculation technics can be applied to the learning process at home so that the student actively participates in the learning process and his education can be controlled and programmed. matching his response to correct responses indicated by starting and stopping the tape at appropriate questions by the teacher. Tapes of this type can be specially prepared and used individually or in group learning experiences, Continuing education of the physician in his home environment or hospital setting will make cducation a daily rewarding experience rather than a struggle with the information explosion. Tile physician will not have to be relieved of the problem of the management of llis day to day practice to' continue his education, and the financial costs of re-learning and continuing education will be meaningful, pleasant, and tolerable. His pattern of medical practice will not have to be reorganized to permit new information to flow into usable knowledge. Ultimately, many organizations and our good hospitals will be engaged in daily lifelong continuing convenient education, and with the new uses of tcchnology, particularly television and developing participatory technics, active learning by the physician will enfible him to cope with the information explosion in his home environment. The universities will with private industry develop the educational concepts and technology, but will share the enormous responsibility of supporting a e w emerging programs for a lifetime of learning. The goal of better and improved patient care will be progressively achieved as new educational objectives and technologic advances alter the behavior of ihe practicing physician in his daily work. Summary Television technics have tremendous major application in graduate surgical education. We have devised a multimedia display technic which has the adwmtages of being simple, economical, corivenient, and stimulating. By combining the reportorial excellence of 35 mm color slides with the dynamic qualities of television, we have developed a unit which holds the individual's attention and communicates to him forceably. The rapid, inexpensive production of tapes permits building of a multimedia tape library. We arc looking for future methods of securing two-way communication between 157
Richards and Jacobs t h e t e a c h e r on the television s c r e e n a n d the student in the television a u d i e n c e . Discussion
DONAI.D Bn~,YTON (Los Angeles, C a l i f ) ; Doctor Victor Richards' innovative combiuation of several audiovisual technics into one system undoubtedly is most effective in his hands. T h e development of audiovisual productions capable of standing alone as leaching devices has been a significant challenge to many of us attempting to use the,~e modalities for wide distribution. Those of us who are nlernhers of the Council on Medical Television an'd of the Association of Medical Television Broadcasters ( A M T v B ) have discovered that the proper use of the media ha.,. to be learned slowly and painfully as indicated by D r Richards. Television is more than just radio with pictures. The professional knowledge and artistry capable of producing programs that both attract and teach the viewer are rare. As hard'.~are required for the production of intramural program.,, is b e c o m i n g cheaper. the professionals needed to produce a superior product are b e c o m i n g dearer. The dillicuhy of the task is evidenced by the decrease in producers of medical educational programs. When the A M T v B was organized in 1965. ten medical teaching institutions were producing programs. some for intramural and others for mass distribution. As of this year, only four are still producing. Of t h e ~ . tt~'b largest is the Medical Television N e t w o r k ( M T N ) located here in California. T h e producers of M T N ha;,e found that for their progrants to be effective as learning devices, they must not be merely passive viewing episodes. Each program now produced by the Network is accompanied by d study guide which converts the program to an active learning experience for the viewer. The audiovisual media are destined to become an intrinsic part o f o u r teaching a r m a m e n t a r i u m . T h e y will g r o w in importance as the student-teacher ratio increases and as more students reared on television come of medical school age. Unlike the physicians of today, they are entirely accustomed to learning from the " t u b e " and are most capable of benefiiting f r o m the special educational advantages television has to offer, such as magnification, storage and retrieval o f data, and electronic integr:~tion o f materials related to a subject in context but not in time or place. F. WILLIAM BLAISDELL (San Francisco, C a l i f ) : I would like to raise a negative note Concerning these fascinating and apparently magical teaching aids. Althotxgh they otter a very praclical means of presenting educational material. they are still second best to similar material presented live. W c h a v e had experience with the rebroadcast of surgical lectures a m o n g the teaching inslitutions at the University of California. W e have polled our students r e g a r d i n g their assessment of these lectures and presentations. T h e r e is no question that the students who see these live lectures and presentations consistently rate the lectures above those who see the re-broadcast. Television has to be used with great skill and imagination if it is to c o m p a r e with live material, for one dimension is lost. A ~ood lecture becomes a m e d i o c r e lecture, and a mediocre lecture becomes impossible. W h a t television does do is to obtain a degree of 158
consistency in the presentat=on of material, One could consistently use an outstanding teacller, such as D r Richards, and therefore ohlain quality control. It may provide tile answer to mass education, hut [ do not think it x~ill ever replace a meeting, such as that of the Pacific Coast Surgical, where conviviality exists and the interchange of ideas can he carried out. JollN A. (.flUS (Iowa City, l.owa): l'hi~ cerlainly is a slimu!ating atnd provocative area of education which v, ill receive increasing attention. However, I me h:wc certain reservat}ons about how el[eclp,e television and other types of electronic communication are iu fulfilling the teaching nllssion at tile undergraduate and l)OSlgradu;ite level. \\'e have had experience with tclevixmn at tl~e University of Iowa t.hlrlng tile pi~M left .years, and I have h,cerl involved to some degree ,,ince the beginning. Actually, ;re reached a peak two to three years after tclcvi'~ion was fir,,| used after which inlercM fell off sharply. Now there is very little elfeclive teaching done wilh it. T h e r e :ire many objections ,~o the u',e of televi,,ion in ,,urgicatl instruction, such a,: it,, impcrsonahty, lack of patient contact, and poor c a m e r a technic, | was impressed with the impair|ante of these criticisnv, when I attempted t o teach the etcmentals of ph3sical diagrto,is to ,,cooled year student,L I thought that certain physical ~,ign':,. which I considered to he important but ',~htch are nol always available for demonstration, could he prcscnled through the mediun~ of films, television, slides, and the hkc. However. nearly all students rejected this approach and demanded the real thing. T h e y decried the use of television and wanted exposure to patients. I learned IlK~t one could suPrdement instruct|on hy nleans Ot television, hut it could not be used in licit of patient material. This of COl_ll~C i~ not surprising. The use o | black and white television, which Dr Richard~, uses and which we too have used. leaves much to be desired. Currently the cost of color equipment is such as to limit the use of color to oqly at few. of the more aitluent centers. Ultimately, however, we will use lelevision as well as other electronic means for storing, processing, and reproducing information nluch mort', in tile fur|ire than we do now. Recently I was impressed with the application of computer-assisted instruction which remain', to be d,zveloped to its full effectiveness. Also. cassette type motion pictures for special purposes or the short single-concept films have ranch to offer. As 1 listened to D r Stephens" talk and watched his old m o v i e . I thought h o w wonderful it would be if the great surgeons and teachers with ,~shon't we worked and w h o m wc loved over the years could be recorded and preserved in living color. Perhaps our new president m a y elect to pursue this project. THOMAS 1". WHITE {Seattle, W a s h ) : 1 would like to discuss how to make a television o r movie film o f an operation. The problem we have had is that the c a m e r a operator does not have any idea what we are going to do even if we discuss the problem with him in advance. I w o n d e r how you are going to get good pictures of operations using nonmedically trained personnel. Are you going to put one of your health officers behind the camera'? I take a preliminary The American Journa! of Surgery
Television in Graduate Surgical Education ,~,per 8 film m y s e l f of s o m e o n e else o p e r a t i n g to s h o w the ~:aJnera o p e r a t o r wh:tt we w a n t . E a c h eight to ten m i n u t e ~caching film w h i c h I h a v e m a d e has t a k e n m e a full two ~ e e k s to p r o d u c e . As part o f the cost o f Ibis you h a v e ~ include t h e salary of the c a m e r a o p e r a t o r a n d the e d i t o r :each $ 1 2 , 0 0 0 per y e a r ) us welt as the p h y s i c i a n s a n d :heir time. W o u l d it not be b e t t e r to d e v e l o p a library o f : : c h n i c s f r o m all o v e r lhe c o t m t r y b e c a u s e we as in~x,iduals c a r m o t afford to s p e n d that m u c h time o n this? VJc'rOR RICIIAROS ( c l o s i n g ) : I w a n t to t h a n k all the :~.,cus.scrs o f lhis paper. D o c t o r B r a y t o n , o f course, is the i.ading expert in the field, a n d ! t h o u g h l his discussion of ~W p a p e r was "~uperb. I agree with e v e r y ! h i n g he said. The soflw:~re is really i m p o r t a n t , a n d is the r e a s o n we ;;;e partictflarly interested in m e t h o d s o f presentfi'tion o f :,.tcvised m~tClial at low cost. D o c t o r White, to n l a k e a ~ o v i e e<~sts abotlt $1(L0tX) an hour. Y o u c a n n o t see w h a t ,,,,t~ are doi~g while you are d o i n g it. Y o u h a v e to wait ~hrce m o n t h ~ ttntil the film r e t u r n s a n d then you h a v e ~,, ~'di: il. I~ty then you ;are fed u p a n d have lost y o u r y,~rpo~e, W i t h the system we have d e v e l o p e d you c a n t:~..c the [~est movies a v a i l a b l e today, excerpt exactly the ~iuh: bit you want. and s u r r o u n d it with slides to e n h a n c e .~,,~ di,~play. \Ve ha're lhe w o r l d of books, literature, fihns, :~I-~tt q i d c s available to us by this technic. All p r o b l e m s of il;~lial CO~,t a n d of not utilizing the c r e a t i v e k n o w l e d g e ~hat ha,, gone b e f o r e are e l i m i n a t e d . Y o u do not h a v e to :.~r~ f r o m scrat.zh, w h i c h is o n e of the big advanttiges o f !he syMenl.
1"o m a k e o u r television tapes in black a n d white costs
VQlurne 120, August 1970
$100 an h o u r total. W e c a n m a k e it in color, w h e n we c a n afford the c o l o r c a m e r a , for m a y b e $125 a n h o u r , the o n l y diit'erence b e i n g the cost o f the tape. O n e t a p e costs $ 4 0 an h o u r w h e r e a s the o t h e r is $ 6 0 an h o u r . So a g a i n it will be inexpensive. N o w , the q u e s t i o n is, w h o is y o u r m a r k e H T o m e the m a r k e t is the o r d i n a r y physician w h o has to c o p e with the i n f o r m a t i o n explosion. A t the present t i m e he h a s to lake t h r e e days off f r o m work, has to find an associate f o r his practice, a n d then h a s to go a w a y for g r a d u a t e e d u c a tion. If you look at e v a l u a t i o n s o f all the c u r r e n t m e t h o d s , you find o n e of t h e big p r o b l e m s is the cost, w h i c h is t r e m e n d o u s fox" a t r u l y c o n t i n u i n g e d u c a t i o n . I t ' w o u l d be f a r b e t t e r for the p h y s i c i a n to be e d u c a t e d d u r i n g his d a y ' s w o r k , s p o n t a n e o u s l y , a u t o m a t i c a l l y . T e l e v i s i o n tapes c o u l d be readily available, even disposable. W e n o w h a v e an a p p r o a c h to l o w e r i n g the cost. W e h a v e the "-world of k n o w l e d g e o p e n to us, a n d the soft w a r e c a n tbe m a d e inexpensively a n d o n l y r e q u i r e s creativity a n d i m a g i n a t i o n if y o u are to use the m e d i a properly. i w o u l d agree with D o c t o r Blaisdell t h a t the worst t h i n g you c a n d o is just to r e c o r d a m a n talking. T h i s is n o t using the m e d i a properly. O n the o t h e r h a n d , s u p p o s e y o u h a v e for y o u r residents readily a v a i l a b l e television t a p e s o f a n o p e r a t i o n . T h e best s u r g e o n in the w o r l d c o u l d be p e r f o r m i n g the o p e r a t i o n , a little e x c e r p t c o u l d b e made, a n d the television c o u l d be viewed f o r ten m i n u t e s b e f o r e a n o p e r a t i o n . H e would talk to y o u a b o u t it. In this w a y the l e a r n e r w o u l d h a v e a u n i q u e e x p e r i e n c e w h i c h h e c o u l d not h a v e a n y o t h e r way.
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