Previously funded NOHF project: Use of Proximie for Surgical Teaching

Report written by Professor Dominic Furniss, Professor of Plastic and Reconstructive Surgery, Hon. Consultant Plastic and Reconstructive Surgeon, Head of School of Surgery, NHSE WTE Thames Valley, on behalf of a cross specialty surgical training group.

Background

Proximie is a technology platform (camera system and software platform) that allows clinicians to virtually “scrub in” to an operating theatre, interacting with the operating surgeon in real time, as well as recording the procedures for later collaborative review. Furthermore, a library of key cases can be developed. These cases can be used for pre-procedure study (before a student attends theatre in person to see a case), and for collaborative review, where students and educators from around the region can get together virtually to discuss cases, in a virtual surgical journal club.

The Trustees of the Nuffield Oxford Hospitals Fund provided a grant for a pilot project to deploy the Proximie system within theatres at Oxford University Hospitals to enhance surgical teaching. Following set up, and leveraging other funding from Health Education England, we have been able to deploy the system in the West Wing, Nuffield Orthopaedic Centre, and Churchill hospitals, covering the specialties of ENT surgery, Trauma and Orthopaedic Surgery, and General Surgery (both HPB and Colorectal), and Urology.

Results

In the pilot, the Proximie system was used for 347 sessions, and accessed by a total of 154 participants (trainers and students). Proximie was deployed for live surgery, suture skills sessions, and review of key index cases. Feedback on the utility of the system was given by medical students, and the registrars and consultants who used the system for training purposes.

Medical Students

Overall, medical students had a mixed experience of using Proximie. In ENT, students from all clinical years, both graduate entry and undergraduate medical students, were able to observe a wide variety of procedures, including adenotonsillectomies, bronchoscopy, tympanoplasty, microlaryngoscopy, nasal endoscopy, and myringoplasty. Feedback revealed easy of access to the live surgery, with good quality video and audio. Students appreciated the ability to ask questions of the surgeon. There was a roughly even split of those who preferred attending surgery via Proximie and those who preferred attending in person.

In general surgery, students in the clinical years on surgical placement, found both live surgery and surgical case review teaching sessions using the Proximie platform useful. In particular, they found the review sessions provided in depth teaching in a more relaxed environment than the operating theatre (45% of respondents felt anxious in the operating theatre). They appreciated the targeted nature of edited videos with commentary: “Far better than sitting in surgery not knowing what is going on”. However, they also identified some problems relating to connectivity, clarity of audio, and the definition of the video. Furthermore, independent review of videos without educator input was not found to be useful: “operations are difficult to follow and understand”.

Educators

Narrative feedback was sought from educators. In general, they were much less positive about the system. In general surgery, the lack of ease with which the camera system can be implemented in theatre was a barrier to successful implementation: “the set-up is rather clunky having to have a laptop attached to the console and for laparoscopic stacks it is nearly impossible to connect correctly to the video capture device. For open surgery, particularly in the pelvis and transanal surgery, the hardware does not give good exposure.” Commonly across all specialties, educators noted the need to spend long periods of time editing videos to make them of a manageable size, and to illustrate the key points of a particular procedure: “it takes hours of work, which is not supported by the company”. The quality of the video that is produced was not felt to be of really high quality: “[We found] the recorded footage of poorer quality”. The usage of edited videos beyond scheduled teaching sessions (the “library” function) was also poor: “after all that effort, hardly anyone actually watches the material”. There were also technical issues with the platform, with some educators unable to review videos made by others, and the software platform found to be slow: “I have expressed my frustration with the inaccessible nature of the database. Having to request a download and waiting days for permission is not an acceptable system”.

Educators in Urology were more positive about the system. Whilst acknowledging the shortcomings: “is certainly rather unstable, crashes a lot, and needs a frustrating amount of massaging to be fit for purpose”, they point out that all systems have drawbacks, and editing video for educational purposes takes a long time on any platform: “I expect to spend 8-10 hrs making an 8-minute training video”. They also comment that the technology integrates well with their robotic camera system, with no compatibility or ergonomic problems. However, they do admit that the software platform is not user friendly: “the clunkiness of downloading the video files is a real problem”, and point out that the videos cannot be stored beyond the contract.

Conclusions

Overall, the pilot showed mixed results. Whilst there is a clear appetite from students for virtual theatre sessions, and potentially a library of curated educational cases, significant limitations of the camera technology and software platform mean that Proximie does not provide the ideal solution. In particular, the hardware, supporting software, video editing, and video library facilities are not user-friendly and therefore limit any recommendation for more widespread deployment.

We thank the Nuffield Oxford Hospital Fund for funding the opportunity to pilot this technological platform.