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Video teleconferencing with realistic simulation for medical education
JEPM: Special Article Video Teleconferencing With Realistic Simulation for Medical Education Jeffrey B. Cooper, PhD,* Deborah Barron, MD,† Richard Blum, MD,‡ J. Kenneth Davison, MD,§ David Feinstein, MD,¶ Jordan Halasz,㥋 Daniel Raemer, PhD,* Roger Russell, MD** Center for Medical Simulation, Boston, MA
*Associate Professor of Anaesthesia, Harvard Medical School, Massachusetts General Hospital, Boston, MA Department of Anesthesia, Henrico’s Doctors Hospital, Richmond, VA ‡Instructor in Anaesthesia, HMS, Children’s Hospital Medical Center, Boston, MA §Instructor in Anaesthesia, HMS, Massachusetts General Hospital, Boston, MA ¶Instructor in Anaesthesia, HMS, Beth Israel Deaconess Medical Center, Boston, MA 㛳 Technical Manager, Center for Medical Simulation
**Instructor in Anaesthesia, HMS, Brigham and Women’s Hospital, Boston, MA Address reprint requests to Dr. Schubert at the Department of General Anesthesia, E-31, The Cleveland Clinic Foundation, 9500 Euclid Ave., Cleveland, OH 44195, USA. Supported by the Department of Anesthesia, Beth Israel Deaconess Hospital, Department of Anesthesia and Perioperative Medicine, Brigham and Women’s Hospital, Department of Anesthesia, Children’s Hospital Medical Center, and Department of Anesthesia and Critical Care, Massachusetts General Hospital, Boston, MA. Teleconferencing Equipment provided by GE Marquette Medical Electronics, Inc. Received and accepted for publication March 10, 2000.
This report describes how realistic patient simulation can be used with video teleconferencing to conduct long-distance clinical case discussions with realistic re-enactments of critical events. By observing what appears to be a real procedure unfolding in real time, it is intended that audience members will better learn and appreciate the lessons from conferences. A commercially available mannequin simulator and video teleconferencing technology were used in nine sessions between a free-standing simulation center and different conference sites throughout the U.S. Transmission was via high-speed telephone lines. In each conference, a clinical scenario was simulated on a screen. Audience members asked questions of a live simulated “patient” and family and later advised the care team on routine treatments and management of urgent clinical problems that arose during management of the mannequin simulator in a highly realistic clinical setting. Ninety-eight percent of respondents from one audience of 150 (response rate 60%) judged the quality of the presentation as “very good or excellent.” In response to the statement that “the educational value of the presentation was much greater than that of a standard case conference,” 95% scored 4 or 5 on a five-point Likert scale (where 5 is highest agreement). While all conferences were conducted successfully, there were instances of technical challenge in using teleconferencing technology. Technical information about the teleconferencing system and scenario preparation, contingency planning for failures, and other details of using this new teaching modality are described. Although audiences were enthusiastic in their response to this approach to clinical case conferences, further study is needed to assess the added value of interactive simulation for education compared to standard conference formats. © 2000 by Elsevier Science Inc.
Introduction Realistic simulation is a newly established technology for medical training.1 Its first uses were in anesthesia, but that has since expanded into other medical domains, such as emergency medicine, radiology, critical care, advanced cardiopulmonary life support (ACLS) training, and medical student education. Two educational uses of realistic simulators have been for teaching basic skills and for training in management of critical events (Anesthesia Crisis Resource Management [ACRM]).2 One limitation of this approach is that is does not lend itself to training of large groups. Coincident with the emergence of realistic medical
Journal of Clinical Anesthesia 12:256 –261, 2000 © 2000 Elsevier Science Inc. All rights reserved. 655 Avenue of the Americas, New York, NY 10010
0952-8180/00/$–see front matter PII S0952-8180(00)00148-3
Video teleconferencing: Cooper et al.
Table 1. Simulation Clinical Case Discussion Teleconferences
Type
Date
No. of People (approximate)
Clinical anesthesia conference Clinical anesthesia conference Clinical anesthesia conference Society meeting Society meeting Medical school course Clinical case conference
5/22/97 7/2/97 1/7/98 1/15/98 2/13/98 2/23/98 3/11/98
75 100 75 150 150 100 50
Review course Medical school course
5/22/98 2/22/99
150 100
Location Massachusetts General Hospital (Boston, MA) Brigham and Women’s Hospital (Boston, MA) Children’s Hospital Medical Center Society for Technology in Anesthesia (Tucson, AZ) Society for Pediatric Anesthesia (Phoenix, AZ) Harvard Medical School Pharmacology (Boston, MA) Dartmouth Hitchcock Medical Center Asesthesia Grand Rounds (Lebanon, NH) Harvard Anesthesia Review Course (Boston, MA) Harvard Medical School Pharmacology (Boston, MA)
simulation, the technology for video teleconferencing has evolved to where it is now affordable for routine applications. Its use for meetings conducted at a distance is becoming common, and desktop units are proliferating. We have combined these technologies to conduct longdistance clinical case discussions with realistic re-enactments of anesthesia critical events. We describe how we have applied these technologies and report on subjective evaluations by some participants in the programs.
Description of Teleconferencing Sessions The concept of using teleconferenced, realistic simulations was tested via several two-way, interactive, simulated cases presented to large audiences in different locales (Table 1). Realistic case simulations were enacted at the Center for Medical Simulation (CMS),* which uses a commercially available, life-like mannequin housed in a simulated medical facility (MedSim Advanced Medical Simulation, Ft. Lauderdale, FL). The technology for realistic simulation has been described extensively.1,3,4 In our application, we provide a highly realistic experience as a means to deeply embed concepts relating to critical-event management.5 The simulation environment follows that described by Howard et al.4 by being a recreation of the real medical environment, e.g., operating room (OR), intensive care unit (ICU), or emergency department (ED), and by including actors in the roles of personnel other than those being trained. Figure 1 is a photograph of the simulation environment configured in the OR mode. The first video teleconferencing demonstration was conducted at the Massachusetts General Hospital on May 22, 1997. A scenario was developed based on an actual recent clinical event. An audience of approximately 60 attending staff, residents, and certified registered nurse anesthetists (CRNAs) observed the re-enactment, interacting throughout the procedure with the entire OR team, which included an anesthesiologist, “surgeon,” and “nursing staff” (the latter two were played by other clinical personnel acting in these roles). The two-way video and audio signals *CMS is a nonprofit 501 (c)3 corporation and a collaborative of the anesthesia departments affiliated with Harvard Medical School (www.harvardmedsim.org).
were transmitted over six integrated services digital network (ISDN) phone lines (yielding a transmission rate of 384 kilobaud) via a V-Tel teleconferencing system at both sites. Two images were presented to the audience by projecting the images on a large screen via standard liquid crystal display (LCD) projectors. The video display of the CMS OR was on one screen and the image from a camera trained on a slave physiological monitor was on the other screen. The moderator of the session stood at a lectern at the front of the auditorium, just to the side of the screen. Throughout the conference, participants on both ends could carry on real-time conversations, although the audio characteristics and microphone capabilities limited highfidelity conversations to a subset of about eight individuals while other participants could use a hand-held microphone that was passed between participants. A more detailed explanation of the technology and the steps in conducting a session appear in Appendix 1. The conference began with an interview with a live (simulated) “patient” who was actually at the simulation center, in a simulated patient holding area. The audience was given information about the “patient”’s history and physical examination and then proceeded to question the “patient” (in real life, a retired cardiologist), who had prepared responses appropriate to the situation being simulated. During a short break, a presentation was given about an aspect of the patient’s history, which permitted time to rearrange the setting at the simulation center. The audience then returned to the OR, where the “patient” was now the realistic mannequin simulator on the operating table. The anesthesiologist, with consultation from the audience, proceeded with the induction. There were some minor perturbations in vital signs, which were treated. After another short break and didactic presentation (primarily to simulate the passage of time in the procedure), the audience returned to the procedure in progress. The patient now was experiencing unexplained variations from his previously stable state. The audience asked a broad range of questions, which were answered by the anesthesiologist, who also consulted with the surgeon, interacted with a nurse and technician, and carried out other normal activities. The interactive, rapid-paced dialogue led to discovery of the cause of what was now a J. Clin. Anesth., vol. 12, May 2000
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Figure 1. Center for Medical Simulation configured as an operating room.
deteriorating condition. Treatment was initiated. The scenario ended with the anesthesiologist thanking the audience members for their assistance. A presentation about the technical details of teleconferencing and simulation followed. Eight other conferences have been conducted with variations on the original case and other simulated procedures (Table 1). For example, the scenario for medical students was a simple anesthetic induction with mild hypotension and bradycardia. The audiences have included those in local hospital department rounds and large audiences at three national meetings. At the Society of Pediatric Anesthesia Conference in 1998, each audience participant also was given the opportunity by the anesthesiologist to select from multiple options for actions via a polling system installed at each seat. The results were displayed immediately and used to suggest actions to the clinician who was managing the case. The technical procedures for transmission of the conference varied in each session depending upon the equipment available to us and at the remote sites and as we learned how to optimize the process. For instance, we were able to use as few as three ISDN lines, reducing costs substantially especially for international conferences. In that case, the monitor image is overlaid onto the image of the OR using a digital video mixer. Other details are described in Appendix 1.
assessment of how the methodology imparts learning differently than traditional approaches. But to assess audience opinions regarding our demonstrations of these two technologies, a survey was given to the audience participants in one of our largest teleconferences, which was delivered at the winter meeting of the Pediatric Society of Anesthesia in 1998 (see Appendix 2 for the survey questions). Surveys were distributed to 150 participants; 103 were returned for a 69% response rate. Participants were asked to rate four aspects of the program on a five-point Likert scale (where 1 ⫽ lowest agreement and 5 ⫽ highest agreement). The results are graphed in Figure 2. The overall quality was highly rated (98% of ratings were either “very good” or “excellent”). Ninety-three percent of respondents felt that the goals of the teleconferencing session were met (ratings of 4 or 5). The goals were stated at the outset of the sessions as (1) enhancing value of medical case conferences via use of realistic simulation, (2) demonstrating teleconferencing technology and (3) bringing realistic simulation to a wider audience. The realism of the scenario was rated by 93% of respondents as “very good” or “excellent.” In response to the question “the educational value of the presentation was much greater than that of a standard case conference,” 97% of respondents gave a score of 4 or 5. A representative sample of audience comments about the presentation is listed in Appendix 2.
Evaluation
Discussion
The first several teleconferencing sessions were used to gain some practice in the use of this technology. Anecdotally, the audiences were generally enthusiastic about the value of this approach to teaching, although there have always been some individuals who questioned the benefit versus the cost (see Appendix 2). We have not yet attempted to do a formal experiment or even a large-scale
Our objective in this exercise was to address two specific problems of educating via the traditional case-discussion model used in many medical conferences. First, participants can only imagine what would be the effects of their or others’ actions during an actual event and, second, the presentation and discussion are not acted out in real time, thus losing realism that could enhance learning. Real-time
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Figure 2. Teleconference survey results from the 1998 winter meeting of the Society for Pediatric Anesthesia (n ⫽ 103).
re-enactments could allow testing of alternative hypotheses and explanations for the course of events, thus revealing causes that would otherwise not be identified. By observing what appears to be the real case unfolding in real time, audience members might better learn and appreciate the lessons from conferences. We expect that such teleconferenced training sessions can enhance the traditional mode of case-based clinical education. We subjectively evaluated the concept of doing this through several video-teleconference sessions and collected selected feedback from one of the groups of participants. Each video teleconference presented new technical challenges. This is a new technology to most facilities. New ISDN phone lines usually had to be installed (at a cost of approximately $100 per line; hotel and conference facilities generally add charges beyond the phone company line charge). There are at least five different types of ISDN switches, which are compatible with software adjustments. Video teleconferencing equipment (H.320 standard compatible) must be available at each audience site. Internet connectivity for this application is a likely possibility in the future. The bandwidth of the internet does not yet support this application due to limitations on speed and resolution. We found that considerable planning and practice were required to re-enact the scenarios in a way that could convey the lesson. Just as in our routine ACRM courses, the student or audience can take many paths from the intended lesson. The moderator and the faculty playing the role of patient or anesthesiologist must be sufficiently knowledgeable to respond appropriately when questioned or if the simulation path takes an unexpected turn.
Although there have been some difficulties both technically and with the simulated clinical environment, to date we have not had a failure that disrupted any of our medical conferences. We were, however, prepared to handle failures that could and will someday likely occur given the still fragile nature of the technology used for teleconferencing. The most likely failure is of transmission of the video or audio signal, either of which can happen in several ways, e.g., hardware or software failure in the computer or bad physical connections, human error in setup or use of the software or in making physical connections, mismatched switching systems. All of these have occurred in the preparation process of one or more sessions. In several instances, failures could have caused use of our backup plans were it not for our preparatory process. We believe that the experience of our team in crisis management, gained from the clinical courses that we teach regularly, was also a key factor in our so far failure free performance (we can also credit a bit of luck perhaps as well). The most important preventive measure is to perform a test transmission as far as possible before the actual real session and then to make the actual connection as early as possible on the day of the session. It is also critical to have experienced technical personnel on both ends of the session. Had there been a failure that would prevent conducting a session, we were prepared, instead, to provide a more conventional lecture about simulation and crisis management and/or about teleconferencing, using slides and videotapes from prior sessions. In that event, the audience could not participate interactively, but at least some information would be conveyed about the concept of teleconJ. Clin. Anesth., vol. 12, May 2000
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ferencing, simulation and/or crisis management training, depending upon the objective of the particular session. The integration of realistic simulation with video teleconferencing has the potential for other applications similar in concept to what we have described here. In several conferences, we demonstrated how these technologies can be used for remote monitoring and consultation, i.e., for observing a procedure in progress and providing advice as needed (also called telementoring). The sessions need not be as elaborate or resource-intensive as the above applications. For instance, we have conducted lectures for a pharmacology course for medical students. Here, the clinician conducted a general anesthetic with minor complications (hypotension on induction, bradycardia, etc.) while interacting with the students about the pharmacology of each medication administered. When complications occurred, the clinician asked the students for the appropriate class of medication to ameliorate the problem. This allowed the demonstration of effective and ineffective pharmacology depending on the choices solicited from the audience. If the modality proliferates, the technical challenges wil be mastered and less intensive preparation will be needed to convey the lesson objectives. Given the relatively high ratings of the one conference evaluation and anecdotal feedback from other audiences, we encourage others to employ the video-teleconferencing approach for teaching and learning. In this report, we have demonstrated the feasibility of video teleconferencing for several teaching applications. We have not rigorously evaluated its efficacy; the audience evaluation scores obtained may reflect, in part, the entertainment value of the program. Further study is needed to assess the added value of the interactive simulation for education compared to standard conference formats.
Acknowledgments We gratefully appreciate the efforts of many people who played roles or otherwise participated in creating these educational sessions: Dr. Andre Heuvos, Zachary Raemer, and Noreen Cousins for roles as simulated patients; Dr. Monique Heuvos, Dr. Ronald Minter, and Dr. Ronald Hurley in various acting roles; Dr. James Philip for technical guidance at several critical moments; Jean-Marie Jackson of Global Telemedics Corporation for production management; and all of the CMS faculty and staff who supported these productions.
Appendix 1: Description of Teleconferencing Process Commercial teleconferencing systems are widely available. The system we have used conforms to a standard (H.320) promulgated by the United Nations International Telecommunications Union. For a point-to-point teleconference as we have described there must be a teleconferencing system on each end of the interaction. The heart of the teleconferencing system is a device called a codec (short for coder/decoder) that converts an analog signal from a video camera (or other similar device) to a prescribed digital format and sends it out on the telecommunications 260
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network. On the other end of the teleconference, the codec can also receive the digital data and convert it back to the analog format suitable for display. To produce an image that is flicker-free to the eye, a minimum of 30 frames per second (fps) is required. Using the H.320 protocol, a transmission rate of about 384 kilobits per second (kps) is required of the network to achieve the 30 fps refresh rate. The network we have used to transmit the digital data is called ISDN (Integrated Services Digital Network) and is commonly available from telephone providers worldwide. An ISDN connection is only able to carry information at a rate of 56 kps on each of two independent channels. Thus, a means to combine both channels of three separate ISDN lines is required to achieve the 384 kps data rate. Fortunately, the commercial teleconference systems utilize a methodology called Triple Basic Rate Interface (T-BRI) to automatically take the analog signal from a video source, convert to digital, send the data over three suitable ISDN lines, decode the digital data, and convert back to analog. The user need only place a phone call using the teleconference system to initiate the conference. The cost of use of ISDN lines varies with distance but is currently approximately $20/hr locally and on the order of $100/hr for long distance. The charge is made to the location from which the call originates, which can be either site or any one site of several. The video source we have used is a standard home video camera equipped with an analog output that is connected to a Video Cassette Recorder (VCR). In some cases, we have interposed a digital video mixer between the camera and VCR to allow the addition of a video camera image of a physiologic monitor to a portion of the scene. Otherwise, we have used a separate data channel to transmit the vital signs data using the data communications capability of the Solar 8000 Marquette Monitor (GE Marquette Medical Electronics, Inc., Milwaukee, WI). At the presentation site, the analog signal from the teleconferencing system is input into a standard video projector for display on a screen.
Appendix 2: Survey Detail A. Survey Questions Ratings: Excellent, Very Good, Adequate, Mediocre, Awful 1. Please rate the overall session 2. Please rate how well the session goals were met 3. Please rate the realism of the scenario 4. Please rate the educational value of this presentation compared to standard case conference format. B. Representative Audience Comments from Survey Positive comments about the presentation format: 1. “This format is much more provocative than a routine case conference.” 2. “This is a fabulous way to reinforce case objectives.” 3. “I would enthusiastically attend a conference at a university medical center with quality like this. It is much more difficult to stay focused with standard case formats. This is far superior.”
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4. “Cannot supplement a conventional case conference but is an excellent teaching tool.” Negative comments about the presentation format: 1. “As with most case conferences, relatively long time (and in this case, expense) for few points.” 2. “While technology is entertaining and fun, a standard case conference can be equally informative and educational.” 3. “Interesting, but is it worth the time or the money?” General Comments: 1. “This should be the format for oral boards—performance can be assessed.” 2. “Telemedicine will be or is indeed helpful. However, don’t you think that HMOs could take advantage and use one physician to telesupervise several operating rooms?” 3. “Technology to new heights! If this could be extended to include info databases about drugs and interactions, it would be a very comprehensive teaching tool.”
4. “Had me fooled early on.” In response to realism of the scenario. 5. “I think it would be much more valuable participating rather than observing.”
References 1. Gaba DM: Simulators in anesthesiology. In: Advances Anesthesia vol. 14, St. Louis, MO: Mosby Year Book Inc., 1997:55–91. 2. Gaba DM, Fish, KJ, Howard SK: Crisis Management in Anesthesiology. New York: Churchill Livingstone, 1994. 3. Gaba DM, DeAnda A: A comprehensive anesthesia simulator environment: recreating the operating room for research and teaching. Anesthesiology 1988;69:387–94. 4. Howard SK, Gaba DM, Fish KJ, Yang G, Sarnquist FH: Anesthesia crisis resource management training: teaching anesthesiologists to handle critical incidents. Aviat Space Environ Med 1992;63:763– 70. 5. Holzman RS, Cooper, JB, Gaba DM, Philip JH, Small SD, Feinstein D: Anesthesia crisis resource management: real-life simulation training in operating room crises. J Clin Anesth 1995; 7:675– 87.
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*Associate Professor of Anaesthesia, Harvard Medical School, Massachusetts General Hospital, Boston, MA Department of Anesthesia, Henrico’s Doctors Hospital, Richmond, VA ‡Instructor in Anaesthesia, HMS, Children’s Hospital Medical Center, Boston, MA §Instructor in Anaesthesia, HMS, Massachusetts General Hospital, Boston, MA ¶Instructor in Anaesthesia, HMS, Beth Israel Deaconess Medical Center, Boston, MA 㛳 Technical Manager, Center for Medical Simulation
**Instructor in Anaesthesia, HMS, Brigham and Women’s Hospital, Boston, MA Address reprint requests to Dr. Schubert at the Department of General Anesthesia, E-31, The Cleveland Clinic Foundation, 9500 Euclid Ave., Cleveland, OH 44195, USA. Supported by the Department of Anesthesia, Beth Israel Deaconess Hospital, Department of Anesthesia and Perioperative Medicine, Brigham and Women’s Hospital, Department of Anesthesia, Children’s Hospital Medical Center, and Department of Anesthesia and Critical Care, Massachusetts General Hospital, Boston, MA. Teleconferencing Equipment provided by GE Marquette Medical Electronics, Inc. Received and accepted for publication March 10, 2000.
This report describes how realistic patient simulation can be used with video teleconferencing to conduct long-distance clinical case discussions with realistic re-enactments of critical events. By observing what appears to be a real procedure unfolding in real time, it is intended that audience members will better learn and appreciate the lessons from conferences. A commercially available mannequin simulator and video teleconferencing technology were used in nine sessions between a free-standing simulation center and different conference sites throughout the U.S. Transmission was via high-speed telephone lines. In each conference, a clinical scenario was simulated on a screen. Audience members asked questions of a live simulated “patient” and family and later advised the care team on routine treatments and management of urgent clinical problems that arose during management of the mannequin simulator in a highly realistic clinical setting. Ninety-eight percent of respondents from one audience of 150 (response rate 60%) judged the quality of the presentation as “very good or excellent.” In response to the statement that “the educational value of the presentation was much greater than that of a standard case conference,” 95% scored 4 or 5 on a five-point Likert scale (where 5 is highest agreement). While all conferences were conducted successfully, there were instances of technical challenge in using teleconferencing technology. Technical information about the teleconferencing system and scenario preparation, contingency planning for failures, and other details of using this new teaching modality are described. Although audiences were enthusiastic in their response to this approach to clinical case conferences, further study is needed to assess the added value of interactive simulation for education compared to standard conference formats. © 2000 by Elsevier Science Inc.
Introduction Realistic simulation is a newly established technology for medical training.1 Its first uses were in anesthesia, but that has since expanded into other medical domains, such as emergency medicine, radiology, critical care, advanced cardiopulmonary life support (ACLS) training, and medical student education. Two educational uses of realistic simulators have been for teaching basic skills and for training in management of critical events (Anesthesia Crisis Resource Management [ACRM]).2 One limitation of this approach is that is does not lend itself to training of large groups. Coincident with the emergence of realistic medical
Journal of Clinical Anesthesia 12:256 –261, 2000 © 2000 Elsevier Science Inc. All rights reserved. 655 Avenue of the Americas, New York, NY 10010
0952-8180/00/$–see front matter PII S0952-8180(00)00148-3
Video teleconferencing: Cooper et al.
Table 1. Simulation Clinical Case Discussion Teleconferences
Type
Date
No. of People (approximate)
Clinical anesthesia conference Clinical anesthesia conference Clinical anesthesia conference Society meeting Society meeting Medical school course Clinical case conference
5/22/97 7/2/97 1/7/98 1/15/98 2/13/98 2/23/98 3/11/98
75 100 75 150 150 100 50
Review course Medical school course
5/22/98 2/22/99
150 100
Location Massachusetts General Hospital (Boston, MA) Brigham and Women’s Hospital (Boston, MA) Children’s Hospital Medical Center Society for Technology in Anesthesia (Tucson, AZ) Society for Pediatric Anesthesia (Phoenix, AZ) Harvard Medical School Pharmacology (Boston, MA) Dartmouth Hitchcock Medical Center Asesthesia Grand Rounds (Lebanon, NH) Harvard Anesthesia Review Course (Boston, MA) Harvard Medical School Pharmacology (Boston, MA)
simulation, the technology for video teleconferencing has evolved to where it is now affordable for routine applications. Its use for meetings conducted at a distance is becoming common, and desktop units are proliferating. We have combined these technologies to conduct longdistance clinical case discussions with realistic re-enactments of anesthesia critical events. We describe how we have applied these technologies and report on subjective evaluations by some participants in the programs.
Description of Teleconferencing Sessions The concept of using teleconferenced, realistic simulations was tested via several two-way, interactive, simulated cases presented to large audiences in different locales (Table 1). Realistic case simulations were enacted at the Center for Medical Simulation (CMS),* which uses a commercially available, life-like mannequin housed in a simulated medical facility (MedSim Advanced Medical Simulation, Ft. Lauderdale, FL). The technology for realistic simulation has been described extensively.1,3,4 In our application, we provide a highly realistic experience as a means to deeply embed concepts relating to critical-event management.5 The simulation environment follows that described by Howard et al.4 by being a recreation of the real medical environment, e.g., operating room (OR), intensive care unit (ICU), or emergency department (ED), and by including actors in the roles of personnel other than those being trained. Figure 1 is a photograph of the simulation environment configured in the OR mode. The first video teleconferencing demonstration was conducted at the Massachusetts General Hospital on May 22, 1997. A scenario was developed based on an actual recent clinical event. An audience of approximately 60 attending staff, residents, and certified registered nurse anesthetists (CRNAs) observed the re-enactment, interacting throughout the procedure with the entire OR team, which included an anesthesiologist, “surgeon,” and “nursing staff” (the latter two were played by other clinical personnel acting in these roles). The two-way video and audio signals *CMS is a nonprofit 501 (c)3 corporation and a collaborative of the anesthesia departments affiliated with Harvard Medical School (www.harvardmedsim.org).
were transmitted over six integrated services digital network (ISDN) phone lines (yielding a transmission rate of 384 kilobaud) via a V-Tel teleconferencing system at both sites. Two images were presented to the audience by projecting the images on a large screen via standard liquid crystal display (LCD) projectors. The video display of the CMS OR was on one screen and the image from a camera trained on a slave physiological monitor was on the other screen. The moderator of the session stood at a lectern at the front of the auditorium, just to the side of the screen. Throughout the conference, participants on both ends could carry on real-time conversations, although the audio characteristics and microphone capabilities limited highfidelity conversations to a subset of about eight individuals while other participants could use a hand-held microphone that was passed between participants. A more detailed explanation of the technology and the steps in conducting a session appear in Appendix 1. The conference began with an interview with a live (simulated) “patient” who was actually at the simulation center, in a simulated patient holding area. The audience was given information about the “patient”’s history and physical examination and then proceeded to question the “patient” (in real life, a retired cardiologist), who had prepared responses appropriate to the situation being simulated. During a short break, a presentation was given about an aspect of the patient’s history, which permitted time to rearrange the setting at the simulation center. The audience then returned to the OR, where the “patient” was now the realistic mannequin simulator on the operating table. The anesthesiologist, with consultation from the audience, proceeded with the induction. There were some minor perturbations in vital signs, which were treated. After another short break and didactic presentation (primarily to simulate the passage of time in the procedure), the audience returned to the procedure in progress. The patient now was experiencing unexplained variations from his previously stable state. The audience asked a broad range of questions, which were answered by the anesthesiologist, who also consulted with the surgeon, interacted with a nurse and technician, and carried out other normal activities. The interactive, rapid-paced dialogue led to discovery of the cause of what was now a J. Clin. Anesth., vol. 12, May 2000
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Figure 1. Center for Medical Simulation configured as an operating room.
deteriorating condition. Treatment was initiated. The scenario ended with the anesthesiologist thanking the audience members for their assistance. A presentation about the technical details of teleconferencing and simulation followed. Eight other conferences have been conducted with variations on the original case and other simulated procedures (Table 1). For example, the scenario for medical students was a simple anesthetic induction with mild hypotension and bradycardia. The audiences have included those in local hospital department rounds and large audiences at three national meetings. At the Society of Pediatric Anesthesia Conference in 1998, each audience participant also was given the opportunity by the anesthesiologist to select from multiple options for actions via a polling system installed at each seat. The results were displayed immediately and used to suggest actions to the clinician who was managing the case. The technical procedures for transmission of the conference varied in each session depending upon the equipment available to us and at the remote sites and as we learned how to optimize the process. For instance, we were able to use as few as three ISDN lines, reducing costs substantially especially for international conferences. In that case, the monitor image is overlaid onto the image of the OR using a digital video mixer. Other details are described in Appendix 1.
assessment of how the methodology imparts learning differently than traditional approaches. But to assess audience opinions regarding our demonstrations of these two technologies, a survey was given to the audience participants in one of our largest teleconferences, which was delivered at the winter meeting of the Pediatric Society of Anesthesia in 1998 (see Appendix 2 for the survey questions). Surveys were distributed to 150 participants; 103 were returned for a 69% response rate. Participants were asked to rate four aspects of the program on a five-point Likert scale (where 1 ⫽ lowest agreement and 5 ⫽ highest agreement). The results are graphed in Figure 2. The overall quality was highly rated (98% of ratings were either “very good” or “excellent”). Ninety-three percent of respondents felt that the goals of the teleconferencing session were met (ratings of 4 or 5). The goals were stated at the outset of the sessions as (1) enhancing value of medical case conferences via use of realistic simulation, (2) demonstrating teleconferencing technology and (3) bringing realistic simulation to a wider audience. The realism of the scenario was rated by 93% of respondents as “very good” or “excellent.” In response to the question “the educational value of the presentation was much greater than that of a standard case conference,” 97% of respondents gave a score of 4 or 5. A representative sample of audience comments about the presentation is listed in Appendix 2.
Evaluation
Discussion
The first several teleconferencing sessions were used to gain some practice in the use of this technology. Anecdotally, the audiences were generally enthusiastic about the value of this approach to teaching, although there have always been some individuals who questioned the benefit versus the cost (see Appendix 2). We have not yet attempted to do a formal experiment or even a large-scale
Our objective in this exercise was to address two specific problems of educating via the traditional case-discussion model used in many medical conferences. First, participants can only imagine what would be the effects of their or others’ actions during an actual event and, second, the presentation and discussion are not acted out in real time, thus losing realism that could enhance learning. Real-time
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Figure 2. Teleconference survey results from the 1998 winter meeting of the Society for Pediatric Anesthesia (n ⫽ 103).
re-enactments could allow testing of alternative hypotheses and explanations for the course of events, thus revealing causes that would otherwise not be identified. By observing what appears to be the real case unfolding in real time, audience members might better learn and appreciate the lessons from conferences. We expect that such teleconferenced training sessions can enhance the traditional mode of case-based clinical education. We subjectively evaluated the concept of doing this through several video-teleconference sessions and collected selected feedback from one of the groups of participants. Each video teleconference presented new technical challenges. This is a new technology to most facilities. New ISDN phone lines usually had to be installed (at a cost of approximately $100 per line; hotel and conference facilities generally add charges beyond the phone company line charge). There are at least five different types of ISDN switches, which are compatible with software adjustments. Video teleconferencing equipment (H.320 standard compatible) must be available at each audience site. Internet connectivity for this application is a likely possibility in the future. The bandwidth of the internet does not yet support this application due to limitations on speed and resolution. We found that considerable planning and practice were required to re-enact the scenarios in a way that could convey the lesson. Just as in our routine ACRM courses, the student or audience can take many paths from the intended lesson. The moderator and the faculty playing the role of patient or anesthesiologist must be sufficiently knowledgeable to respond appropriately when questioned or if the simulation path takes an unexpected turn.
Although there have been some difficulties both technically and with the simulated clinical environment, to date we have not had a failure that disrupted any of our medical conferences. We were, however, prepared to handle failures that could and will someday likely occur given the still fragile nature of the technology used for teleconferencing. The most likely failure is of transmission of the video or audio signal, either of which can happen in several ways, e.g., hardware or software failure in the computer or bad physical connections, human error in setup or use of the software or in making physical connections, mismatched switching systems. All of these have occurred in the preparation process of one or more sessions. In several instances, failures could have caused use of our backup plans were it not for our preparatory process. We believe that the experience of our team in crisis management, gained from the clinical courses that we teach regularly, was also a key factor in our so far failure free performance (we can also credit a bit of luck perhaps as well). The most important preventive measure is to perform a test transmission as far as possible before the actual real session and then to make the actual connection as early as possible on the day of the session. It is also critical to have experienced technical personnel on both ends of the session. Had there been a failure that would prevent conducting a session, we were prepared, instead, to provide a more conventional lecture about simulation and crisis management and/or about teleconferencing, using slides and videotapes from prior sessions. In that event, the audience could not participate interactively, but at least some information would be conveyed about the concept of teleconJ. Clin. Anesth., vol. 12, May 2000
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ferencing, simulation and/or crisis management training, depending upon the objective of the particular session. The integration of realistic simulation with video teleconferencing has the potential for other applications similar in concept to what we have described here. In several conferences, we demonstrated how these technologies can be used for remote monitoring and consultation, i.e., for observing a procedure in progress and providing advice as needed (also called telementoring). The sessions need not be as elaborate or resource-intensive as the above applications. For instance, we have conducted lectures for a pharmacology course for medical students. Here, the clinician conducted a general anesthetic with minor complications (hypotension on induction, bradycardia, etc.) while interacting with the students about the pharmacology of each medication administered. When complications occurred, the clinician asked the students for the appropriate class of medication to ameliorate the problem. This allowed the demonstration of effective and ineffective pharmacology depending on the choices solicited from the audience. If the modality proliferates, the technical challenges wil be mastered and less intensive preparation will be needed to convey the lesson objectives. Given the relatively high ratings of the one conference evaluation and anecdotal feedback from other audiences, we encourage others to employ the video-teleconferencing approach for teaching and learning. In this report, we have demonstrated the feasibility of video teleconferencing for several teaching applications. We have not rigorously evaluated its efficacy; the audience evaluation scores obtained may reflect, in part, the entertainment value of the program. Further study is needed to assess the added value of the interactive simulation for education compared to standard conference formats.
Acknowledgments We gratefully appreciate the efforts of many people who played roles or otherwise participated in creating these educational sessions: Dr. Andre Heuvos, Zachary Raemer, and Noreen Cousins for roles as simulated patients; Dr. Monique Heuvos, Dr. Ronald Minter, and Dr. Ronald Hurley in various acting roles; Dr. James Philip for technical guidance at several critical moments; Jean-Marie Jackson of Global Telemedics Corporation for production management; and all of the CMS faculty and staff who supported these productions.
Appendix 1: Description of Teleconferencing Process Commercial teleconferencing systems are widely available. The system we have used conforms to a standard (H.320) promulgated by the United Nations International Telecommunications Union. For a point-to-point teleconference as we have described there must be a teleconferencing system on each end of the interaction. The heart of the teleconferencing system is a device called a codec (short for coder/decoder) that converts an analog signal from a video camera (or other similar device) to a prescribed digital format and sends it out on the telecommunications 260
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network. On the other end of the teleconference, the codec can also receive the digital data and convert it back to the analog format suitable for display. To produce an image that is flicker-free to the eye, a minimum of 30 frames per second (fps) is required. Using the H.320 protocol, a transmission rate of about 384 kilobits per second (kps) is required of the network to achieve the 30 fps refresh rate. The network we have used to transmit the digital data is called ISDN (Integrated Services Digital Network) and is commonly available from telephone providers worldwide. An ISDN connection is only able to carry information at a rate of 56 kps on each of two independent channels. Thus, a means to combine both channels of three separate ISDN lines is required to achieve the 384 kps data rate. Fortunately, the commercial teleconference systems utilize a methodology called Triple Basic Rate Interface (T-BRI) to automatically take the analog signal from a video source, convert to digital, send the data over three suitable ISDN lines, decode the digital data, and convert back to analog. The user need only place a phone call using the teleconference system to initiate the conference. The cost of use of ISDN lines varies with distance but is currently approximately $20/hr locally and on the order of $100/hr for long distance. The charge is made to the location from which the call originates, which can be either site or any one site of several. The video source we have used is a standard home video camera equipped with an analog output that is connected to a Video Cassette Recorder (VCR). In some cases, we have interposed a digital video mixer between the camera and VCR to allow the addition of a video camera image of a physiologic monitor to a portion of the scene. Otherwise, we have used a separate data channel to transmit the vital signs data using the data communications capability of the Solar 8000 Marquette Monitor (GE Marquette Medical Electronics, Inc., Milwaukee, WI). At the presentation site, the analog signal from the teleconferencing system is input into a standard video projector for display on a screen.
Appendix 2: Survey Detail A. Survey Questions Ratings: Excellent, Very Good, Adequate, Mediocre, Awful 1. Please rate the overall session 2. Please rate how well the session goals were met 3. Please rate the realism of the scenario 4. Please rate the educational value of this presentation compared to standard case conference format. B. Representative Audience Comments from Survey Positive comments about the presentation format: 1. “This format is much more provocative than a routine case conference.” 2. “This is a fabulous way to reinforce case objectives.” 3. “I would enthusiastically attend a conference at a university medical center with quality like this. It is much more difficult to stay focused with standard case formats. This is far superior.”
Video teleconferencing: Cooper et al.
4. “Cannot supplement a conventional case conference but is an excellent teaching tool.” Negative comments about the presentation format: 1. “As with most case conferences, relatively long time (and in this case, expense) for few points.” 2. “While technology is entertaining and fun, a standard case conference can be equally informative and educational.” 3. “Interesting, but is it worth the time or the money?” General Comments: 1. “This should be the format for oral boards—performance can be assessed.” 2. “Telemedicine will be or is indeed helpful. However, don’t you think that HMOs could take advantage and use one physician to telesupervise several operating rooms?” 3. “Technology to new heights! If this could be extended to include info databases about drugs and interactions, it would be a very comprehensive teaching tool.”
4. “Had me fooled early on.” In response to realism of the scenario. 5. “I think it would be much more valuable participating rather than observing.”
References 1. Gaba DM: Simulators in anesthesiology. In: Advances Anesthesia vol. 14, St. Louis, MO: Mosby Year Book Inc., 1997:55–91. 2. Gaba DM, Fish, KJ, Howard SK: Crisis Management in Anesthesiology. New York: Churchill Livingstone, 1994. 3. Gaba DM, DeAnda A: A comprehensive anesthesia simulator environment: recreating the operating room for research and teaching. Anesthesiology 1988;69:387–94. 4. Howard SK, Gaba DM, Fish KJ, Yang G, Sarnquist FH: Anesthesia crisis resource management training: teaching anesthesiologists to handle critical incidents. Aviat Space Environ Med 1992;63:763– 70. 5. Holzman RS, Cooper, JB, Gaba DM, Philip JH, Small SD, Feinstein D: Anesthesia crisis resource management: real-life simulation training in operating room crises. J Clin Anesth 1995; 7:675– 87.
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