Telementoring at UPMC: the Newest Frontier in Surgical Training

The 20-plus-hospital integrated University of Pittsburgh Medical Center (UPMC) health system continues to pioneer in many clinical and technological areas. Among these is in an emerging area called “telementoring,” in which physicians at UPMC are making themselves available virtually to their colleagues in other countries, in order to optimize training and mentoring processes around challenging, emerging clinical procedures.

For example, the UPMC Center for Cranial Base Surgery was the first such center established in North America, and has been a leading center for the development of new surgical techniques for the treatment of patients with tumors and other conditions affecting the base of skull, nasal, and sinus areas, and some areas of the brain. Surgery in this area is dependent on endoscopic technology, with visualization provided by thin endoscopes while a team of surgeons (otolaryngologist and neurosurgeon) work together to remove a tumor. The surgery is technically demanding, and requires extensive training over years to achieve proficiency.

Carl Snyderman, M.D., and his colleagues at UPMC (the cranial base surgical team includes three neurosurgeons and two otolaryngologists; Dr. Snyderman and Paul Gardner, M.D., have been the telementoring leaders) have, since 2005, trained more than 500 surgeons from over 30 countries, in cranial base procedures. The challenge is that many surgeons who have had live training at UPMC then go back to their home organizations and find that they have difficulties reproducing the same levels of success as when they were training live under UPMC physicians’ supervision. In response to the need, the cranial base team at UPMC earlier last year created a surgical telementoring program, with the first telementored surgery taking place between UPMC surgeons and their colleagues at the University of Maribor in Slovenia in November 2011.

Dr. Snyderman spoke recently with HCI Editor-in-Chief Mark Hagland regarding the telementoring program, and its implications for medical training more generally. Below are excerpts from that interview.

Please tell us about how this process works. The first step is training at UPMC in Pittsburgh, correct?

Yes, currently, it begins with a four-day course including lecture, anatomy, etc. About 60 percent of the attendees are international physicians; and we do a lot of education abroad, too, onsite. So what happened was, after people take our course, they struggle doing the surgery. They may have done the surgery a couple of times, but they’re trying to take it to a higher level. And so they’ll send us e-mails asking for advice, for example. And we had a group of people taking our course from the University of Maribor in Slovenia. They came to us, and then invited us. So they came to us two years ago, and about a year and a half ago, we went over and did a course with them. And we were looking for ways to help them develop into a center of excellence. And they have a fairly modern setup in terms of technology in their operating room. So we brainstormed and said, you can watch us do surgery, and we can watch you do surgery. So we started watching them do these endoscopic skull-base surgeries. They had been routinely doing pituitary surgeries, which is how most centers get started; and they’d probably been doing that for more than a year. So we helped them do more challenging cases.

Are these cases they would otherwise have sent to another country, for instance, to your team in the U.S.?

No, our goal is not to try to teach someone to land an airplane who’s never flown an airplane before. They might not have gotten all of the tumor out or reached the same level of exposure. So we’re trying to get them to the next level.

How many telementored surgeries have taken place so far?

We’ve done it twice so far, and we’re going to do it as often as they want. In most places, these are not common surgeries around the world; surgeons don’t see a lot of these cases, so I’m seeing a maximum of once a month or every other month. The first one we telementored was last fall. It’s telementoring, combining telemedicine with surgical education. And this would be distinguished from telesurgery.

You’re not manipulating anything directly on a physical level, yourselves, corrected?

No, but with our technology setup, we see exactly what they see. We also have telestration capability; we can control a cursor that shows up on their screen, and can point to things on their monitor.

Basically, what do you need to do this, from a technological and physical standpoint?

This is all done over the Internet, so we’re using existing Internet connection. There are sort of two levels of investment; there’s the standard telemedicine capabilities, using different types of cameras; and then there’s specialized telementoring—people are creating proprietary devices with lower-bandwidth needs or added audiovisual capabilities. But someone can create a basic telementoring robot for about $15,000, or it can be done even more cheaply than that. But there are very low-budget solutions, even for countries that are very resource-poor; so we could even do this with countries in Africa.

Are you thinking of expanding this to other universities in other countries?

Yes, we have relationships with universities all over the world. And first, we need a good surgical team with some surgical experience already. And it has to be in a geographic location with a clinical need, in an area in which there’s a concentration of patients. So we’re trying to create centers of excellence around the world, so that we can train whole regions. And obviously, there can’t be significant language barriers.

So we’re looking at places in China and other sites in East Asia and India; and there may be sites in Latin America and Europe, in Canada. In Asia, we have contacts in Singapore, Malaysia, Hong Kong, South Korea, Japan, and Australia. We’re still in an exploratory phase, in that regard.

What should CIOs, CMIOs, and other healthcare IT leaders know about this?

It involves a basic IT infrastructure that most hospitals are capable of handling; and also, it involves a common surgery. So you can really have a broad array of surgical services in which you have multiple services involved. And using existing Internet connections. We were in Brighton, England, and were able to watch a surgery here. And we also did that from Belgium, as in both cases we wanted to participate in surgeries back home. So there are applications other than just telementoring. You can monitor junior surgeons, you can provide emergency interoperative consultations if someone’s have trouble. And it’s a way to demonstrate new technologies; and also provide ongoing credentialing of surgeons.

Is there anything else that you’d like to add?

One thing that might be worth emphasizing is that the standard model of surgeons traveling places and trying to do a bunch of surgeries, really has a limited impact, because a surgeon can only treat one person at a time, so it’s not a cost-effective model. And by telementoring a surgeon or team of surgeons, we’re really expanding the model. And it’s probably the most cost-effective model or this type of work. Certainly, there are some legal, privacy, and liability issues that need to be worked out; we’re trying not to let those be an impediment. And also, there’s no financial model for this yet; right now, we’re doing this on a charity basis. And obviously, you need a strong basic technology foundation, you can’t have the Internet connection be broken. Also, these are experienced surgeons, they’re not beginners. They just struggle to get to the next level. And so they come to Pittsburgh and take our course, and do cadaveric dissection and watch our surgeries, and then they go back to their home countries, and we continue through telementoring. And at some point, there might be a need for us to go back, but this is a way for sort of weaning them off that onsite relationship.