[From CASE Reports, Vol. 12, No. 2, 1997]


Yale Surgeon Joins Medicine and Technology in Unique Training Program


While it may sound like the stuff of science fiction, it is indeed science fact. Telemedicine, though still a new concept, is revolutionizing medical training from Costa Rica to Malaysia, and a Connecticut surgeon, James Rosser Jr., is spearheading the effort.

"We're building vital skills with unprecedented speed," says Professor Rosser, director of endo-laparoscopic surgery at Yale-New Haven Hospital, and assistant professor of surgery at Yale University School of Medicine. "And we're doing it in a cost-effective way."

Modern Day Miracle

Professor Rosser is an expert in laparoscopic procedures, which he refers to as "modern day miracles." Through incisions the size of a dime, tiny video cameras, which are attached to lenses called endoscopes, are placed inside the body to help surgeons remove or repair diseased organs. Images are transferred through the lens, to the camera, and then to a television monitor, which the surgeon watches. "In this environment, you don't see, through direct vision, what you're operating on," explains Professor Rosser. "Visualization occurs through the tv screen."

Thanks to this visualization, patients are spared the large incisions that accompany open surgery. Consequently, they are also spared much pain and suffering. Recovery times are generally shorter with this minimally invasive technique, and medical bills are usually less, says Professor Rosser.

Laparoscopic surgery affords clear advantages. But while the simpler procedures are growing in use, the more sophisticated ones are increasing at a notably slower pace. Today, for instance, 95% of all gallbladder operations are performed laparoscopically, yet only 30% of all appendectomies, and a mere 10% of all splenectomies, are handled in this fashion.

At issue, notes Professor Rosser, is a shortage of qualified practitioners. And that's due mainly to a lack of proper training.

"Laparoscopic procedures demand different skills from traditional surgery," he says. To begin with, you're not working in a three-dimensional arena. The angles of attack are also more restricted, which means you must fine-tune your targeting capabilities: to accomplish certain tasks, you have to rely greatly upon triangulation."

Professor Rosser likens the challenge to eating peas with two-foot chopsticks. "Imagine further," he adds, "that you can't look at the peas directly, but have to view them through a television screen."

As in other fields, medicine has been slow to embrace change. Most schools, for example, now include laparoscopy for gallbladders and gynecological disorders in their curricula. But the more complex techniques are not being taught; at present, only a handful of doctors are competent enough to operate laparoscopically on the adrenal glands, pancreas or spine, for instance. And that's part of the problem-these people are simply too new to the practice, and currently too busy, to pass on their knowledge.

"There's been no wide-scale, well-thought-out plan to impart these skills," asserts Professor Rosser. Another concern is the way they're presented. The apprenticeship system, where students learn by observing operations, just isn't feasible with laparoscopic surgery, says Professor Rosser.

Boot Camp for Basic Skills

With a missionary's zeal, Professor Rosser is crusading for change. In his teachings at Yale, he has introduced a number of new strategies to organize, standardize, and impart the skills and knowledge needed, and to do it quickly and inexpensively.

On innovation is a rigorous, educational "boot camp." The program, which was launched last spring, trains students in basic laparoscopic skills, from maneuvering the special instruments to suturing incisions. Attendees pay $2,400 for the four-day session.

A critical part of the program, says Professor Rosser, is ensuring that students polish their skills before they enter the operating room. "It's not like open surgery, where they can work side-by-side with their teachers during the operations," he points out. "There, the professors act as safety nets. They can physically direct a student's hand, or stop them when necessary."

In the boot camp, trainees perfect their skills in the protective climate of a high-tech laboratory. To test their dexterity, for example, they're put through an electronic obstacle course; when they complete it, they receive a percentile ranking which shows where they stand, relative to their peers. Those who score low take remedial training.

"Surgery has long been considered an art form," states Professor Rosser. "This is the first, formal means of measuring proficiency it proves that skills can be evaluated in an objective fashion."

Another exercise helps students develop sound judgment. By simulating operations, it "walks" them through various procedures, where they learn to make crucial decisions before treating actual patients. Professor Rosser compares it to aviation schooling. "Pilots spend a lot of time in computerized cockpits," he says, "before climbing into a $35 million aircraft."

A Telementoring Role

The training, however, doesn't end at Yale. Professor Rosser continues to assist students after they return to their hospitals-this time remotely, in the capacity of a "telementor." Whether they are 50 or 5,000 miles away, he answers their questions, guides them through their first laparoscopic surgeries, and consults on especially tough procedures, while they're performing their operations.

To date, some 700 surgeons have gone through boot camp. It's a promising start, says Professor Rosser, adding that it's important to boost those numbers as hospitals' survival, in this age of service, may soon hinge on providing advanced surgical procedures.

Can all doctors master the requisite skills? Not everyone thinks so, comments Professor Rosser. "Based on our studies, however, I believe that the vast majority-99%-can, with the right training, make the grade."

Classroom of Tomorrow

While students garner their skills in the laboratory, they gain their cognitive education in another of Professor Rosser's creative concepts: the Classroom of Tomorrow. This space is equipped with the latest interactive technologies, all designed to transfer knowledge in a highly efficient way.

Lectures and "boring" tapes are held to a minimum in this classroom, notes Professor Rosser. Instead, it features 21 multimedia stations. These stations are linked to each other, and to a central command module staffed by a knowledge transfer officer. For the most part, the lessons are self-paced: students progress through a series of CD-ROM tutorials, and when they have questions, they can pose them to the knowledge officer through two-way headsets. This allows them contact without disturbing the rest of the class. "It also personalizes the process," affirms Professor Rosser.

Through video-conferencing and the Internet, the Classroom of Tomorrow is connected to the outside world as well. This enables "distance learning" to take place. To illustrate that, Professor Rosser cites Operation Validation, a recent venture with physicians in England. The project involved suturing, one of the hardest techniques to learn, says Professor Rosser.

"We sent the electronic materials, the students collected their data, and then I came in, via telecommunications, and held the final exam over the airwaves," he says. "All told, it was a great success."

Fantastic Journeys in the Future

As the laparoscopic field matures, so, too, will Yale's instructional programs. Standard instruments, for example, have scaled down from 10 to 2 millimeters. And general anesthesia is decreasing in use. "Feeding tube placements, biopsies, taking down adhesions, ligating blood vessels-all are now possible with local anesthesia," explains Professor Rosser.

In April, in fact, Professor Rosser shared the results of his first cases with local anesthesia at a post-graduate course at the American College of Surgeons in San Diego. Yale has reported similar successes in the areas of infertility, he says. "We can now go on fantastic voyages within the human body, while the patient is wide awake, assisting us," he notes.

All of these advances call for new training. And Professor Rosser, not surprisingly, is there at the forefront. "Right now, I'm trying to establish a minimum requirement for laparoscopic skills," he says. "Having a performance standard will be a great help as we head into the 21st century."--Louise Petraitis, Indelible Ink.

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