Cardiol Young 2001; 11: 526–531
© Greenwich Medical Media Ltd. ISSN 1047-9511
Original Article A national network for the tele-education of canadian residents in pediatric cardiology J. P. Finley, 1 M. J. Beland, 2 C. Boutin, 3 W. J. Duncan, 4 J. D. Dyck,5 M. C. K. Hosking, 6 D. Nykanen7 1
IWK Health Centre, Halifax, NS; 2 Montréal Child ren’s Hospital, Montréal, PQ; 3 Hopital Ste-Justine, Montréal; B.C. Child ren’s & Women’s Health Centre, Vancouver, BC; 5Alberta Child ren’s Hospital, Ed monton, AB; 6 Child ren’s Hospital of Eastern Ontario, Ottawa, ON; 7Hospital for Sick Child ren. Toronto, ON, Canad a 4
Abstract A trial of 11 video-conferenced teaching sessions for residents in pediatric cardiology was performed by the 7 training programs in Canada in order to share expertise in specialized areas, to expose trainees to educational telemedicine, and to acquaint residents with other programs and personnel. Topics included cardiac pathology, arrhythmias, magnetic resonance imaging, fetal physiology, pulmonary hypertension, and cardiomyopathy. The sessions were evaluated by 93 residents by questionnaire for content and technology. Session content was highly rated. Videoconference picture quality was highly rated, but sound quality and visual aids were rated as neutral or unsatisfactory by a significant minority, related to problems with several early sessions, subsequently corrected. 60% of respondents rated the videoconferences as good as live presentati ons. Presenters were generally satisfied although they required some adjustments to videoconferencing. The average cost per session was $700 Canadian. Videoconferencing of resident educational sessions was generally well accepted by most presenters and residents, and the trial has formed the basis for a national network. Adequate organizational time, and careful attention to audiovisual needs, are most important. Videoconference guidelines are suggested for presenters based on this experience. Keywords: Medical education; videoconference; telemedicine; cardiology
P
OSTGRADUATE TRAINING IN MEDICAL SPECIALTIES
occurs in most medical schools, and usually includes a combination of formal lectures or seminars in addition to supervised clinical experience. The range and quality of the formal presentations are determined by the expertise of the faculty of the school, while the clinical experience depends also on the number and variety of patients available. With increasing specialization, many medical centres may not have expertise or outstanding teachers in all subspecialties. With the use of telecommunications Correspondence to: Finley JP, MD, Head, Pediatric Cardiology, Department of Pediatrics, Dalhousie University, IW K Health Centre, PO Box 3070, Halifax, NS, Canada B3J 3G9. Tel: 902 428 8407; Fax: 902 420 6616; E-mail:
[email protected] This study was supported by an educational grant from the Royal College of Physicians and Surgeons of Canada. Accepted for publication 27 April 2001
technology, expertise and outstanding teaching could be shared among medical centres for the benefit of their trainees. W hile there is much experience with continuing medical education delivered by videoconference, 1–6 and several examples of undergraduate videoconferencing, 7–9 there are few reports of postgraduate education provided in this way. The internet has been used to provide a resource for distance education in radiology, 10 and grand rounds are distributed by videoconference by many hospitals worldwide, in part for education of postgraduate residents who are on clinical rotations at sites outside their teaching hospital, where they may be relatively isolated from peers and removed from an academic setting. In Canada, education in pediatri c cardiology is provided in seven accredited centres. In order to share expertise among these sites, the Residency Program Directors designed a trial of eleven video-conferenced
Vol. 11, No. 5
Finley et al: Tele-education in pediatric cardiology
resident teaching sessions with the following aims: to share expertise in highly specialized areas such as congenital cardiac pathology to expose residents in pediatric cardiology to educational uses of telemedici ne to expose residents to programs and personnel across Canada. This report details the evaluation of this trial.
Materials and methods The seven Directors of the Canadian Programmes in Pediatric Cardiology (Izaak Walton Killam Health Centre, Halifax, Nova Scotia; Montreal Children’s Hospital and Hopital Ste. Justine, Montreal, Quebec; Hospital for Sick Children, Toronto, Ontario; Children’s Hospital of Eastern Ontario; University of Alberta Children’s Hospital, Edmonton, Alberta; and British Columbia Children’s and Women’s Health Centre, Vancouver, British Columbia) agreed to a series of eleven video-conferenced sessions over about two years. A test videoconference was conducted among three sites in May 1998, and the first presentation linking all sites occurred in October 1998. Educational design: topics were chosen by consensus among the Program Directors to be suitable for their programs designed for teaching residents in pediatric cardiology. Special attention was given to topics which would take advantage of unique expertise or an outstanding teacher in certain centres. Each presentati on was made by a staff cardiologist, or in two cases by a visiting professor. Guidelines for presentation suggested a duration of about 50 minutes, with 10 minutes for questions, and that the residents should be encouraged to ask questions during the presentati on, or if desired the presenter could ask direct questions of the audience. Although the presenters were asked to look into the camera when in view, and to try to relate equally to the remote and local audiences, presenters had little or no experience and no other coaching with teaching via videoconference. No guidelines were given about slides or visual aids, although all presenters were experi enced with teaching via the medium of lectures and seminars. Resident attendance was encouraged but not mandatory. As the sessions were designed for education of residents, participation of attending staff was not encouraged except for the presenter. Videoconference design: 384 kbps bandwidth was used, by means of 6 ISDN lines, for two way videoconferencing with the H.320 protocol. Sites used PictureTel, Zydacron, Polycom or General Datacom systems with room based or workstation monitors located in studios or classrooms. A commercial bridge
527
was used, located in Toronto, which was the site with the minimum mean distance from other sites, thus minimizing costs of transmission. In each site, a local coordinator operated the equipment and in most sites was present for the session. On the day of presentation, following dial-up of all sites by the bridge a few minutes prior to the scheduled start, the presenter was introduced by the session chair located in Halifax with a welcome to participating sites. The session chair played no part in the presentation except to monitor problems with video or sound transmission, to ensure remote microphone muting, to monitor time, and to close the session. Most presentations used 35 mm slides and a digital data projector, but others used computer based slide presentations, a document camera for pathological specimens or electrocardiograms, a video camera on projected slides for electrocardiograms, or a super VHS video recorder for echocardiograms. Evaluation: At the end of each session, each resident was asked to complete a previously circulated evaluation form (Appendix ) which was tabulated by the coordinating cardiologist. The evaluation was prospective and included eleven statements regarding content, presentati on and organization, as well as videoconference technology and overall impression. Respondents were asked to indicate on a five point Likert scale11 their agreement or disagreement with each statement (1 5 strongly disagree, 2 5 disagree, 3 5 neutral, 4 5 agree, 5 5 strongly agree). They were also asked to give suggestions for improvement of the content and technical presentation. No formal evaluation by presenters was performed, but after most presentati ons the coordinating cardiologist telephoned the presenter to discuss impressions of the session. The coordinating cardiologist attended most sessions, and kept notes regarding problems and successes with the presentation, coordination and technical aspects.
Costs These included a combination of bridge, booking and long distance fees which were collated by the coordinating centre. No charges were included for setup or monitoring time by videoconference personnel, nor for physician time to prepare or present the teaching sessions. The project was supported by an educational research grant from the Royal College of Physicians and Surgeons of Canada.
Results There were 11 regularly scheduled videoconference sessions during the study. Two sessions were not evaluated: early in the study one session was incomplete
528
September 2001
Cardiology in the Young Table 1. Session content: individual scores (N 5
Question
93) and (sessi on median scores) for all 9 sessions.
Strongly disagree 1
1. I received new information 2. Content relevant 3. Content appropriate depth 4. Well presented 5. Enough opportunity for discussion
Disagree 2
Neutral 3
Agree 4
Strongly agree 5
Total
1
4 4 9 (1) 7 26 (2)
54 (5) 37 (3) 39 (3) 30 (3) 37 (6)
31 (4) 51 (6) 42 (5) 51 (6) 17 (1)
90 92 90 89 89
1 9
Table 2. Videoconference technology evaluation: individual scores (N 5
Question
Strongly disagree 1
1. Picture quality satisfactory 2. Sound quality satisfactory 3. Effective interaction among sites 4. Clear transmission of visual aids 5. Videoconference as good as live
due to bridge problems, and a later session was not evaluated in the absence of the coordinating cardiologist. Thus nine sessions were fully evaluated. Of six possible sites, there were a median of four participating, with a range from 3 to 5. One site ceased to participate after the first three sessions since they no longer had a resident. There were a total of 93 respondents for the nine sessions. For each session the range was from 3 to 22, with a mean of 10.3, including 2 to 19 residents at the “local” presenting site, and 3 to 11 “external” respondents. The overall response rate to the questionnaire is estimated at over 80% of the residents in all programs at any one time, although exact numbers of participants were not recorded. The topics included three sessions of congenital cardiac pathology, two of arrhythmias, and one each of cardiac magnetic resonance imaging, fetal physiology, pulmonary hypertension, and cardiomyopathy. Five sites presented, with two sites conducting three sessions and the others one each. No presenter conducted more than one session, but one had presented the initial test session before his regularly scheduled session. Content (Table 1): the scores of 93 respondents in presenting and receiving sites were combined, since there was no appreciable difference between their scores. Both individual and session median scores indicated agreement or strong agreement that the content, presentation and organization were well received. Of respondents, however, 10% thought that there was not enough time for discussion (question 5), and 29% were neutral about this statement. This response was distributed over all nine sessions.
58) and (session medians) for 9 sessions.
Disagree 2
Neutral 3
Agree 4
Strongly agree 5
Total
3 9 4(1) 9 11
9 8 (2) 15 10 (4) 11 (3)
37 (9) 31 (6) 25 (6) 26 (4) 22 (6)
4 8 (1) 11 (1) 7 (1) 10
53 56 55 52 54
Table 3. Overall impression of session: individual scores (median session scores) for 9 sessions. Poor Overall impression
Fair
Average
Good
Excellent
4
5
47 (7)
33 (2)
Technology (Table 2): This was only evaluated for receiving sites. There were 58 respondents, although not all answered each question. The majority of participants agreed that videoconference technology was satisfactory for this teaching application. Median scores for individual sessions confirmed this but, as seen in Table 2, the individual scores indicated a reasonable number of neutral or disagree scores which were distributed across almost all sessions. Overall impression (Table 3): Respondents scored this overwhelmingly as good or excell ent for all sessions. Open comments: these related mainly to technical or presentation problems. Two respondents indicated problems with video, related to bridge incompatibility with one site. There were two criticisms of slides which were inadequate for videoconferencing. Respondents also noted distortion of transmitted video images of electrocardiographic slides projected on a screen. There were also occasional problems with low audio volumes traced to microphone position, and one occasion where audio was lost due to a bridge problem. Magnetic resonance images from slides were unintellig ible for one presentation, possibly related to projector intensity.
Vol. 11, No. 5
Finley et al: Tele-education in pediatric cardiology
Costs The cost for a one hour videoconference varied from $415 Canadian to $827, depending on the number of sites participati ng. Thus, for 9 sessions, the approximate cost was $6300. The cost per residenthour was approximately $67. For comparison, a 9-hour conference involving travel, accommodation and meeting facilities for 10 attendees and eight staff would cost approximately $18,500, or $205 per resident-hour. These prices are based on quotations recei ved for Toronto.
Presenter reactions Most presenters were very satisfied with their session, but had some adjustments to the combination of a local and remote audience. In one case, this led to reconfiguration of the equipment. Technical problems in three early sessions were very unsettling to the presenters and led to some receiving sites being dropped or seriously compromised. Non-muted remote microphones were an occasional source of annoyance. The absence of an electronic pointer hampered some presentations, as did the inability to display electrocardiograms to the remote audiences while a remote participant is speaking. This is because the conference video feed is voice activated to display the speaking site and could not be quickly switched off. Coordinator’s notes: The visual aids-video playback of echocardiograms was very successful, with excellent resolution, in contrast to electrocardiograms which presented best from the original using a document camera. Monitor resolution may not be sufficient however, and advance circulation of copies is advantageous. For display of pathological specimens, a secondary incandescent light source is needed in addition to the fluorescent lights of the document camera. We found certain room based monitors had higher and more acceptable resolution than others. An assistant is helpful to manipulate zoom, focus and lighting for specimens while the presenter demonstrates. Organization: considerable organizing time is required by the coordinating cardiologist to survey the Program directors and attend sessions for moderating and quality assurance. We tried one presentation using one-way video and two way audio, thinking the audience might be less inhibited in asking and replying to questions but no improvement was noted and the presenter preferred to see the participants. Participants have been very reserved, even after attending several sessions, and have rarely asked questions during or after sessions despite encouragement and their frequent
529
comments that not enough time was available for discussion. Residents were asked informally after one session whether the presence of video equipment interfered with the presentation to the in house audience and they felt it did not.
Discussion Our study demonstrates the feasibility and acceptability of presenting seminars to residents in pediatric cardiology at multiple sites by videoconference. Despite some early technical problems, both content and videoconference technology were generally highly rated by the 93 respondents over nine sessions spaced over two years. Presenting faculty were also very positive about their experience. Several staff who had attended sessions as observers requested that future sessions be open to staff as well as residents, and be made available to sites without residency programs for their continuing education. The strengths of this cooperative educational program are the ability to enlist experts and outstanding teachers from all participating programs, especially in areas where expertise is scarce such as cardiac pathology. Using videoconferencing is economical and gives residents exposure to, and presenters experience with, educational applications of telemedicine, a rapidly expanding area with which they will need to be familiar. The residents were also exposed to future colleagues in pediatri c cardiology across Canada, since all but one program presented sessions. This could hold future benefits for them in interviews and build a sense of community, as has been found for other discipli nes using educational videoconferencing. 12 We were concerned that the presence of videoconference equipment might interfere with the presentations to in-house audiences. Informal questioning of presenters and residents indicated this was not a problem, except during infrequent malfunctions. This finding agrees with a recent survey of recipients of continuing medical education. 12 Drawbacks to these multisite videoconferences were minor. They included cost, a considerable time commitment to organization for the coordinator, and adjustment to videoconferencing by presenters and audiences. With experi ence, the audiovisual problems and challenges are being addressed and interrupti ons are infrequent. The experience from this trial has taught us other valuable lessons. The presentati on format did not stimulate discussion as we had hoped. From research in continuing medical education, it is evident that interactive programs have more impact on learners, who are more likely to apply new information clinically. 13 Thus, the reluctance of residents to ask
530
Cardiology in the Young
questions may be overcome by a more interacti ve design for the presentations, perhaps involving them also in the planning of the sessions. Training presenters in slide preparation and videoconference delivery (Appendix), and instructing the audiences in videoconference etiquette, would also be valuable. This study was not designed as a comparison of modes of learning or retention of knowledge, which would be much more complex and require considerable resources. Future developments in multisite education of residents, nonetheless, might include quizzes on electrocardiograms, echocardiograms and heart sounds, presentations by residents, and series on statistical analysis, pathology, and other topics. Webbased instruction could also be integrated into the videoconferences. 14 In summary, our experience with video-conferenced education of residents in pediatri c cardiology has encouraged us to continue and develop this form of multi-site education. Other highly specialized areas of postgraduate medical education may similarly benefit from videoconferencing.
Acknowledgements We thank Dr M. Allen and M. Loane for their advice with this manuscript, and the telemedicine site coordinators for organizational help.
References 1. House AM, Roberts MJ, Canning ME. Telemedicine provides new dimensions in CME in Newfoundland and Labrador. Canadian Med Assoc J 1981; 124: 801–804.
Appendix Guidelines for Videoconference presenters The Room: Walls should be light grey or a medium soft blue Lights should be variable Videoconferencing unit and camera should be located so both camera and local audience can be viewed together Audio should use omni mike and speaker’s mike On Camera: Speaker should address both local and remote viewers and not move too much Audio: Mute all mikes at remote sites until question period or they will echo
September 2001
2. Lindsay EA, Davis DA, Fallis F, Willison DB, Biggar J. Continuing education through telemedicine for Ontario. Canadian Med Assoc J 1987; 137: 503–506. 3. Jennett PA, Hunter BJ, Husack JP. Telelearning in health: a Canadian perspective. Telemed J 1998; 4: 237–247. 4. Wasyluk JS, Wegrzyn Z, Minkowska B, Orton PK. An assessment of the quality and usefulness of the EuroTransMed satellite programmes in continuing medical education. J Telemed Telecare 1999; 5: 111–117. 5. Blignault I. Multipoint videoconferencing in health: a review of three years’ experience in Queensland, Australia. Telemed J 2000; 6: 269–274. 6. Langille DB, Sargeant JM, Allen M. Assessment of the acceptability and costs of interactive videoconferencing for continuing medical education in Nova Scotia. J Cont Educ Health Prof 1998; 18: 11–19. 7. Gul YA, Wan AC, Darzi A. Use of telemedicine in undergraduate teaching in surgery. J Telemed Telecare 1999; 5: 246–248. 8. Chang BL, Trelease R. Education of professionals using a proposed telehealth system. Proc AMIA Symp 1999: 496–500. 9. Tangalos EG, McGee R, Bigbee AW. Use of the new media for medical education. J Telemed Telecare 1997; 3: 40–47. 10. Ritenour ER, Goldberg ME, Walling W R. High definition remote teaching of radiology residents: choices in use of emerging communications technologies. Second International Conference on the Medical Aspects of Telemedicine. Rochester 1995: 1(abstract) 11. Likert R. A technique for the measurement of attitudes. Archives Psychology 1932; 140: 55–60. 12. Allen M, Sargeant J. Nova Scotia Telemedicine Network Evaluation of Videoconferenced Grand Rounds. Report prepared for Nova Scotia Dept of Health July 1999. 13. Davis D, O’Brien MAT, Wolf FM, Freemantle N, Mazmanian P, Taylor-Vaisey A. Impact of formal continuing medical education. Do conferences, workshops, rounds and other traditional continuing medical education activities change physician behaviour or health care outcomes? JAMA 1999; 282: 867–874. 14. Geibert RC. Integrating Web-based instruction into a graduate nursing program taught via videoconferencing. Challenges and solutions. Comput Nurs 2000; 18: 26–34.
Visuals: Slides-black or navy on white transmit better than white on dark Font 28 or 32 Arial or sans serif, not Times New Roman font 5–7 lines of text only per slide Images and line drawings-simple contrasting colours (avoid red), bold lines, large font, few words Electrocardiograms-use document camera, consider advance distribution X-rays, Resonance image – experiment first, consider digital images Pointer – digital devices are available, lasers are distracti ng Pathology specimens – use document camera, use extra small gooseneck incandescent light for highlighting, use assistant for focus and light adjustments
Vol. 11, No. 5
531
Finley et al: Tele-education in pediatric cardiology
National Pediatric Cardiology Resident Seminars (via Videoconference) Participant Evaluation Subject: Participated from: Vancouver A. Evaluation of Session content Presentation and organization:
Presenter: Edmonton Toronto Scale:
1. The programe provided me with new information. 2. The content is relevant. 3. The content was covered in the appropriate depth for me (please comment if inappropriate). 4. The session was well presented. 5. There were sufficient opportunities for discussion and questions.
Date: Ottawa
Montreal
Halifax
Strongly disagree Disagree
Strongly Neutral Agree agree
1 1
2 2
3 3
4 4
5 5
1 1
2 2
3 3
4 4
5 5
1
2
3
4
5
1 1
2 2
3 3
4 4
5 5
1 1
2 2
3 3
4 4
5 5
1
2
3
4
5
How could the content and presentation be improved?
B. Evaluation of videoconference technology: 6. The picture quality was satisfactory. 7. The quality of the sound was satisfactory. 8. The videoconference equipment allowed for effective interaction among sites. 9. Visual aids (slides, etc.) were transmitted clearly. 10. The videoconference format works as well as live presentati on.
How could the content and presentation be improved?
C. Overall impression of session:
General Comments:
Poor 1
Fair 2
Average 3
Good 4
Excellent 5
