Abstract

The TETRASUR project (TElematics TRAiningfor SURgeons) is a project funded by regional medical research grants toinvestigate the effectiveness of telematics applications in the deliveryof training for surgeons.  TETRASUR is a collaborative project combiningthe expertise of University of Plymouth, Royal Naval and National HealthService academics. Major participants include Derriford General Hospitalin Plymouth, the Royal Cornwall Hospital, Treliske and the Gloucester RoyalHospital.

TETRASUR employs a number of multi-modedelivery and learning support systems, including ISDN videoconferencingand MPEG2 digital satellite TV and data transmission techniques. Surgeon tutors and their trainee groups are linked remotely throughoutthe South West region of the UK, enabling the delivery of synchronous andinteractive keynote lectures, tutorials and case studies.

Although the project is at a very earlystage of development, evaluative procedures are already in place. User satisfaction and technology benefits analyses will be measured usinga combination of questionnaires, interviews and quantitative methods. Initial results are reported in this paper with a full project evaluationpublished later.

Introduction

Training surgeons in rural hospitals canbe problematic, due to the costs and travel time involved.  When surgicaltrainees spend time away from the surgical area to attend lectures andseminars other practitioners must fill the gap.  Distance learningdelivery using telematics was found to provide an answer to these problems,enabling trainees to remain within their parent hospital whilst continuingtheir studies.

The South & West Region of Englandcovers a large geographical area with 3.5 hours travelling time betweenits remotest hospitals.  There are over 350 basic surgical traineesstudying in the 14 teaching hospitals.  There is therefore a verystrong case on practical and economical grounds to support surgical educationby distance teaching.

Telematic Technologies

The University of Plymouth enjoys exclusiveaccess to the European Space Agency digital satellite up-link.  Thesatellite used has a footprint covering the British Isles and Western Europe. The distinct advantage of live digital satellite transmission is the superioraudio and visual quality over and above computer based ISDN conference. In the last five years over 40 regional community telematic centres havebeen established alongside the South West Area Network, in addition toInstitute of Health Studies learning centres (Vranch & Wheeler, 1997).

The TETRASUR initiative was set up as apilot to evaluate the use of distance teaching in hospitals.  TETRASURinitially utilised telematics technologies to deliver the Member of theRoyal College of Surgeons (MRCS) course to 2 hospitals with a view to include14 other hospitals in the region from Penzance to Cheltenham.  In Derriford and Gloucester hospitals digital satellite receivers and ISDN2video conferencing equipment were installed to deliver the course materials. Video conferencing was integrated live into the satellite transmissionsto bring in guest lecturers "at a distance" and for interactive discussionswith the trainees.  Support sessions via video conferencing were usedto follow up the main lectures in the form of seminars and discussion groups. This approach of highly visual, good quality keynote lectures by satelliteplus the interaction via video conferencing proved to be effective andpopular with the trainees following the course.

In its second year TETRASUR has been extendedto 4 additional hospitals, using the telematics Study Centres set up thereby the University of Plymouth Institute of Health Studies.  TheseStudy Centres were equipped with digital satellite receivers but do nothave ISDN video conferencing facilities.  Feedback is at present limitedto standard voice telephone into the studio.  It is hoped to equipthese Study Centres with low-cost ISDN2 video conferencing equipment, bringingthem in line with the TETRASUR centres at Gloucester and Derriford. This would enable better interaction conferencing.  It would alsoenable lecturers at all five sites to contribute to the course delivery"at a distance" by integrating video conferencing into the TV broadcast. The fact that these three telematics centres set up by the University inhospitals for distance education for nurses have been made available todoctors on the MRCS course demonstrates a clear commitment to multi-professionalworking.  Indeed the technology itself has been a key factor in encouraginga multi-disciplinary working culture.  Clearly, the delivery infrastructurecan be used to deliver other courses to hospitals.

In addition the whole or selected partsof the modular teaching sessions can be saved on video tape for futureusage or for revision by trainees. Trainees will be spared the necessityof travelling long distances and can learn in a dynamic and stimulatingenvironment.

The MRCS Course

The MRCS course was initiated in Plymouthin 1997 and is a comprehensive fortnightly day-release scheme, coveringover one year in 21 full days of teaching, the entire MRCS syllabus ina structured programme of learning.  The syllabus includes focusedsessions in trauma, intra-operative and post-operative management and surgicaltechniques. The course includes lectures, case presentations and interactivediscussions by video-conference and satellite TV links.  The courseis supported by 140 tutors and teachers from the South & West Regionin England with 350 surgical trainees participating in 14 teaching anddistrict general hospitals in 3 counties in South West England.  SinceSeptember 1997, 42 modules have been successfully delivered from Plymouthwith trainees attending from 4 other hospitals and a pilot satellite linkhas been established at Gloucester which is 2.5 hours travelling distanceby road from Plymouth.  At the beginning of the 1998 academic year,satellite links were established 4 more hospitals with further links planned.

The majority of trainees sign up for theRoyal College's distance learning STEP course which provides the basisfor the factual knowledge required to pass the written examination. The clinical and viva voce examinations require factual knowledge togetherwith intellectual and clinical skills that cannot be taught exclusivelyfrom the STEP course.  To fill this gap in the teaching and learningrequirements, a regional day-release training scheme was set-up (Kingsnorthet al, 1999).
 
140 volunteer teachers and tutors wereidentified from within the South & West Region including surgeons,physicians, radiologists, pathologists, and anaesthetists.  From theseindividuals lead faculty tutors were identified for each of the 42 modulesand they were requested to select their team of teachers from the 140 volunteers.

The surgical tutor then devised a coursemanual with an introduction outlining the principles of adult learningfor the teachers and tutors.  This included advice on teaching styletogether with practical arrangements of timing, location and teaching aids. Guidelines were offered concerning the team of teachers to be involvedsupplemented by case scenarios, case presentations and practice examinations. Not all of the sessions were suitable for broadcasting by teleteachingbecause of their practical nature.  Theatre safety, principles andtechniques of suturing are examples.

Future developments

Building on these technological developments,several new directions can be envisaged.  Links could be establishedto transmit or receive selected course modules from suitably equipped sitesoutside the UK.  This possibility is being actively explored at thepresent time. Similarly other countries may wish to contribute modulesin their own right.  Selected modules may be appropriate for the supportof surgical education in developing countries.  With the advent ofnew technologies, such as V-SAT and integrated network solutions, globaleducation initiatives may be on the horizon (Vranch & Wheeler, 1997).

Evaluation

To date, evaluation of the project hasconsisted of post-course interviews with trainees to obtain levels of satisfaction. Generally, feedback from the trainee groups has proved very positive. Severalareas of concern were raised: Firstly trainees commented that althoughthey were supportive of the delivery technology, there were a few shortcomingsparticularly with ISDN videoconferencing.  Secondly, trainees highlightedtechnical issues including inferior visual quality and time lag. Trainees also suggested that presenters should intersperse their talkswith question and answer sections to enhance the interactive nature ofthe lectures.  Finally, trainees indicated that introductory lecturematerial need not be delivered, as the course manuals provided this input. All of the above comments have been taken into consideration in the planningfor future telematic course delivery.  A studio facilitator or 'anchor'person will also be used in future satellite TV transmissions to obviatethe problems of pausing whilst presenters wait for remote sites to contributeto discussion.

Future plans for evaluation include furtherinterviews and quantitative analysis of learning activities and user perceptionsto learning at a distance.  Benefits analysis will also be measuredusing recently developed tools (Vranch & Wheeler, 1998).

References

Kingsnorth, A N, Campbell, J K, & Vranch,A T (1999) Teleteaching -A practical and economical method of deliveringsurgical education.  Annals of the Royal College of Surgeons of England. 82, 66-70.

Vranch, AT & Wheeler, S (1997) Distancelearning and convergent technologies: evaluating the benefits of telematics. Information Technology in Nursing.  9, 6, 7-12.

Vranch, A T & Wheeler, S (1998) A benefitsanalysis tool: Applications to ISDN video conferencing.  Online EducaConference, Berlin, Germany.  4-6 December, 1998, 255-259.

Biographies

Andrew Kingsnorth is Professor of Surgeryat the University of Plymouth.  He has recently developed an interestin delivering education for junior surgeons using telematics.  Hehas also been appointed as Tutor in Telemedicine to the Royal College ofSurgeons of England.

James Campbell is Surgeon Commander inthe Royal Navy.  He has used satellite technology to communicate betweennaval vessels and shore bases for training purposes.  He is currentlytutor in surgery at Derriford General Hospital, Plymouth.

Adrian Vranch is Academic DevelopmentsManager at the University of Plymouth.  He is responsible for theco-ordination of the university's telematics infrastructure developments,and is active in research into integrated technologies and benefits analysis. Adrian was a lecturer in engineering and IT for 15 years before takingon his current role.

Steve Wheeler is Senior Lecturer in distancelearning through telematics in the University of Plymouth and has spent20 years working in media and IT.  He is currently involved in researchingthe psychological impacts of telematics for distance learning and is engagedin developing benefits analysis models for integrated technologies.