Geraldine Hartshorne & Stephen Hicks, Department of Biological Sciences, University of Warwick
Aims and rationale
This proposal aims to present clinical procedures, live, to students attending professional courses, while minimising intrusion upon the patient’s privacy. Networked web-cameras will be used to view clinical procedures and project non-identifying images in a seminar room where observation can take place remotely.
I am course leader of a Post-graduate Award in Assisted Reproduction Technology (ART). This area of medicine – the treatment of infertility - is highly sensitive for patients, raising personal, private issues and requiring intrusive examinations and treatments.
The students are a mixture of doctors, nurses and scientists, most already working in this area. Their number is limited by the opportunities for clinical observations. Balancing the number of students observing with the perceived intrusion upon the patient’s privacy is sometimes delicate.
We plan to use technology as a potential solution. Using computer networking, the key instructional elements of the clinical intervention, such as images from a scanner or microscope, will be presented, while identifying information, such as the patient’s face will be avoided.
We shall evaluate this mode of teaching by questionnaires to students and feedback gained from teaching staff and patients. We shall also evaluate the technical quality of the images produced.
Design and planning
Our experience running this PGA for the first time in September 2005 provided the impetus for this innovation. One day of the 5-day residential course was devoted to clinical observations, simulations and practicals. A variety of relevant learning opportunities were arranged and students rotated through observational and other activities, planned around the schedule of clinical procedures. While this worked quite well, there were low numbers of certain procedures that students were interested to see. Moreover, some patients declined to be observed (which they are free to do) compounding the limited observation opportunities. Thus, some students did not see all the procedures and had periods of unproductive waiting in an otherwise frenetic schedule. While this possibility had been explained to students in advance, improvements would be welcome.
Emergence of the idea
Possible mechanisms to improve performance were discussed at a post-course debriefing session with academic and clinical staff. The availability of observation opportunities depends upon patient throughput on a given day. This depends upon individual women’s responses to hormones, which are unpredictable. Advance consenting, so that only patients who consent to observation receive appointments on a particular day (as arranged for some medical teaching), was considered inappropriate for our clinics.
We had accepted 20 students onto the course (and declined a further 5). In retrospect, 20 was an optimistic number to be accommodated, and might need to be reduced in future if clinical observations remain on the syllabus. Student feedback was that the observations were extremely useful, and they would generally like more of them. Parallel or split sessions, more days of observation, or hosting courses more often than annually, were all discounted as impractical in the hectic clinical setting.
I had experienced live ‘televised’ demonstrations of a new laboratory method several years earlier, so the possibility of a technological solution arose. The cost of television cameras is prohibitive, but newer technology in the form of web-cameras, might be a possible alternative. This would enable remote visualisation of the key clinical aspects live.
The educational and professional context
Ethical issues raised by the presence of observers in the clinical setting have been recognised by bioethicists (Ainslie, 2000) and patients (Ryder et al, 2005). The invasion of privacy occasioned by an observer, whose reason for being there is not directly concerned with the immediate good of the patient, needs to be balanced with the potential good that may result from their presence in the longer term, whether for research or training purposes (Harris, 2005). For this reason, care is taken to ensure that patients are able to consent or decline without there being any effect upon their treatment or the way in which staff interact with them.
Before entering the consulting room, patients are asked by a member of the clinical team, usually a nurse, whether they agree to the presence of observers. The number and nature of the proposed observers (eg, doctor, nurse, scientist, medical student) and their reason for being there (eg, training) is explained, as well as the fact that their treatment will be unaffected regardless of their decision. The patient gives a response and is not questioned on this. If the patient gives permission, the observers are installed in the room before the patient enters. Conversely, if the patient does not give permission, observers will not be present when the patient enters. A similar approach will be taken when requesting patient consent for use of the web-cam, with explanation of the number and nature of observers present remotely and what they might see via the camera.
Our experience suggests that few patients object to the presence of observers, however, the prospect of several students being present at once may deter patients. The staff involved in requesting consent will be sensitive to patients’ concerns and alert to patients’ perspectives on remote observation while requesting consent.
Such verbal permission from the patient is generally considered to be sufficient, however, it could be argued that patients feel disadvantaged by the power imbalance between the clinician and the patient, and could be pressured into giving consent (Goodyear-Smith and Buetow, 2001). Our practice aims to empower patients to make their own decisions. However, the literature shows that patients may feel uncomfortable with students present, concerned particularly about their privacy and standard of care (Ryder et al, 2005). While the evidence suggests that the standard of care is unlikely to decrease and may even increase when observers are present (Zisberg et al, 2003), the issue of privacy remains. Our idea to use cameras to project non-identifying images of patients or their material could potentially enhance their privacy, improving confidentiality, since their identity would be protected. However, even non-identifying images remain the patient’s ‘property’ and permission must still be obtained (Andrews, 2005).
The educational use of projected images via video, internet, photography etc is widespread, notably in distance learning, where the pros and cons of remote projection, from both practical and educational perspectives are reported (eg, Magee and Wheeler, 1997). Frequently, recorded material is placed online as a resource. Alternatively, live transmission of lectures is used to overcome geographical isolation, however, the consequent loss of interaction is recognised and its partial restoration by, eg, videoconferencing is valuable (McGee and Wheeler, 1997). Live observation of eg, operations by surgeons to assist colleagues in more remote situations is increasing, and many other medical applications exist (Kirriemuir 2002).
There is, however, a surprising lack of literature about the involvement of patients as participants for remote observation. There appears to be little academic record of its use or impact. One publication reports the improved student experience of observing open surgery via fixed video cameras (Broderick et al, 2002). Another report highlights the three-way encounter of student, patient and clinical teacher, surmising that the presence of the patient is essential for the optimal learning environment (Kroenke et al, 1997). We cannot provide such one-to-one teaching, however, feedback from the first course suggests that we did provide an excellent interactive learning environment that was appreciated by the students.
The legal framework surrounding assisted reproduction is more rigorous than in many other disciplines due to its sensitivity. Great emphasis is placed on patient choice, confidentiality, and avoidance of unnecessary distress (HFEA, 1990). One key advantage of live (unrecorded) transmission is the reduced potential for copying or theft of the images (Harper, 2001), particularly pertinent in our discipline.
Our experiences in establishing this system may therefore offer other educational providers a new viewpoint. It will be important that we document and evaluate the outcome fully and disseminate our findings, as the literature in this area is minimal.New regulations for clinical laboratories demand conditions approaching ‘cleanroom’ standards (EU Directive, 2005). In future, observers may be excluded from laboratories, and so cameras will become the only option to observe laboratory activities.
The anticipated outcomes
Anticipated outcomes of the successful introduction of a live link would therefore include:
• Increased likelihood of patients consenting to observations
• Improved respect for patient privacy and confidentiality
• Increased capacity for the course, which would then be limited by the capacity of the seminar room.
• Universal student access to all observations, avoiding the problem of some students missing out.
• Improved coordination with the surrounding teaching programme, with live links slotted into the schedule more easily than arranging clinical observations in small groups.
Refining the plan
The debriefing meeting supported pursuing this idea, with the caveat that some patients might feel more concerned about a camera with remote projection, than people that they could see. Exploratory discussions with non-involved individuals suggested that this should not be a frequent problem provided that the patient was reassured that her face and details were not on show. The explanation and manner of requesting consent are clearly important steps towards a positive response.
The technical requirements were discussed with the Trust’s technology innovation experts in Computer Network Services (CNS), who concurred that the project was feasible and that they would be pleased to help. Minimum requirements included that the projection facility was on the Trust network and maintained through Trust procedures. These include stringent measures guarding against computer hackers, data theft etc. They agreed to provide appropriate software free of charge, and a ‘trial run’ to iron out any technical hitches.
Some equipment that we wish to link has networked computer imaging attached already, eg microscopes. Other equipment does not, eg, ultrasound scanners. Different mechanisms may be needed to facilitate projection in each situation. The purchase of two high-specification web-cameras and a data projector was recommended. The availability of network points in the seminar room was confirmed and networked computers will be provided from within the Trust. A lecturer familiar with the clinical procedure would be present in the seminar room to explain to students what was happening on the screen.
A further opinion was gained from Mark Childs at CAP who has experience of using such technology. The possibility of using the devices to record images for later presentation was discussed, but is technically challenging and raises particular issues for patient data. Additional consent would be necessary for recording and such facilities would entail a ‘security’ assessment by the Trust. Such judicious handling of medical information and patient confidentiality is crucial, as demonstrated by a complaint from a patient unaware of the presence of observers during a video-consultation in the United States (Tang and Hearst, 2000). The loss of the ‘live’ element would also detract from the student experience, turning the ‘clinical observation’ into a ‘video’ session, with consequent loss of immediacy. The option of recording was therefore not pursued further, although it may be revisited if our evaluation of live imaging indicates that such developments are necessary or desirable.
Extensive pre-purchase testing cannot be undertaken unless funding is assured. If successful, the award would be used to purchase these items and evaluation would take place subsequently. The available funds would not support sound transmission, however, clinician to lecturer communication to facilitate timing etc will be achieved in the first instance by telephone. Future developments might include sound, as well as provision of more visual links.
The planned innovation can be applied in any situation where remote projection of clinical, laboratory or otherwise inaccessible activity is being conducted. The technology is therefore generalisable to any other teaching setting within the University, Trust, or outside, where a computer network is available. With this in mind, the Short Courses Unit of Biological Sciences is keen to contribute to this pilot and apply it in other courses. Examples include remote projection of laboratory techniques demonstrated by an experienced practitioner. Remote demonstration is desirable if students lack a licence for a specific technique, or where health and safety preclude a 'hands on' approach.
The PGA will run for the second time 8-11 May 2006 and annually thereafter. We plan to evaluate this innovation by running the clinical observations for this event using the technology described. Key milestones would therefore be:
Notification of award: February 2006
Planning meeting: February 2006
Acquisition of equipment: March 2006
Installation and trial run: March-April 2006
Troubleshooting: March-April 2006 as necessary.
Course presentation: 8-12 May 2006
Evaluation: May 2006
Compilation of evaluation data: May-June 2006
Report preparation: June 2006
Manuscript submission: Summer 2006
We have amended our planned time scale to accommodate delays in the processing of our application, however, this has resulted in our time scale for implementation becoming extremely tight. If installation and testing prove straightforward, evaluation at our May 2006 course may still be feasible. However, if this schedule proves too short, evaluation will occur at the next iteration of this course.
Our evaluation will include:
• Technical assessment of (1) functionality and educational quality of the images and (2) stability and ease of management of the system. This will be a subjective assessment of experiences of the IT specialists and staff involved in teaching or being observed using the web-cams.
• Views of students, sought by questionnaire to assess the extent to which they found the projections useful, and whether multiple remote projections are preferable to a few observations in person.
• Perceptions of patients, gained from patient panel and support group representatives, about the acceptability or not of non-identifying web-cam projection or presence of observers at clinical procedures. These individuals regularly provide patient perspectives on planned developments.
• Impressions of clinical staff requesting consent or treating patients as to whether patients find web-cams more or less intimidating than observers in person.
We shall disseminate our findings through several outlets.
Patients will receive feedback through the patient panel and patient support group. Students will receive feedback via staff-student liaison mechanisms. Staff involved in the course would receive feedback in person.
In addition to publication in Interactions, we shall write up our work for an educational journal, and provide reports for the Trust and the CRM Annual Report.
A presentation for a CAP function will also be provided.
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