Live surgeries have been around since the dawn of medical education. The place surgeons operate in is called a theatre for a reason. The surgeon of yore was the master performer! He had to be skilled, efficient and dextrous as there was limited anesthesia. Bold, decisive surgical strokes executed with flair and precision were the norm. In between cases, they held their knives between their teeth to save time. One surgeon had the dubious distinction of having a 300% mortality! The patient, the assistant, and one of the audience members were the victims.
Then came further scientific advancement and suddenly the glamour was gone. With the advent of high-speed internet, we were back to performing with the world as our stage.
Surgeons have always been perceived to be flamboyant, skilful, and egotistic. Doctors performing interventional procedures are uniquely placed in medicine, where one combines fine judgment, many thought processes, and technical skills with one’s hands while caring for the patient.
History
Rapid advances in medical technology and technology in general have allowed the broadcast of surgical procedures worldwide. In 1996, three separate laparoscopic procedures were transmitted successfully from an institution in California to Buenos Aires via the internet during a medical meeting.
I shall be referring primarily to surgeons, but all that I have to say applies equally well to any interventional branch as the principles are the same.
Benefits of Live Procedures
Watching a master demonstrate the art of surgery should be a win-win situation. The students (whether medical students or practicing surgeons) get an opportunity to watch and learn procedures — from simple to complex — by experienced, highly skilled, and peer-acclaimed surgeons (the most challenging thing in life is to get acclaim from one’s peers). A student may not have such an opportunity in their practice. The demonstrating surgeon benefits from these discussions, especially if he is humble and open to suggestions. Many times, the observers raise fine discussion points that make the surgeon reflect and incorporate some of the ideas to improve their practice.
One can also discuss the procedure and its intricacies, learn the ‘tricks of the trade,’ and ask the master questions. The surgeon must put the patient first, providing their expertise and experience to achieve optimal results.
In a utopic world, there would be no debate on the value of live surgeries. Unfortunately, many questions about the ethics and safety aspects of live surgeries have been raised. Utopian ideas quickly degenerate in the face of human greed, vanity, convenience, and the desire to be a prima donna. Surgeons are human, after all!
Position of Surgical Societies
Many surgical societies in Japan, England, and USA have banned the practice of the live surgical broadcast. Some societies like the European Association of Urology recognizes the educational role of live surgery and endorses live case demonstration at urology meetings that are conducted within a clearly defined regulatory framework.
Do Live Sessions Fulfil the Educational Need?
Rodney Peyton 1 of the Royal College of Surgeons, has popularised the four steps to effective learning of procedural skills:
Demonstration: The trainer demonstrates at normal speed without commentary
Deconstruction: The trainer demonstrates while describing steps
Comprehension: The trainer demonstrates while the learner describes steps
Performance: learner demonstrates while learner describes steps
This four-step approach ensures that the teacher breaks the process into manageable steps, and progress is made from one stage to the next as each step is mastered.
In live surgeries, the first step is compromised. When one surgical team is operating, hundreds or even thousands of surgical colleagues may be watching. Even if only a small number of them have questions, it results in an avalanche of questions, comments, observations, and criticisms. In the 23 sessions observed, it was found that students asked four times as many questions and were left with fewer unanswered questions during live transmissions compared with OR teaching sessions.
While a competent and effective moderator may be able to filter out and tone down the number and quality of audience interventions, a significant number of questions still interfere with the surgeon’s ability to get on with the job on hand.
The Downside of Live Procedures
Less than Optimal results
From ancient times:
“To do two things at once is to do neither.” – Publius Syrus
In modern times:
“You can do two things at once, but you can’t focus effectively on two things at once.” – Gary Keller
We have all experienced ‘Flow’ as described by Mihaly Csikszentmihalyi, where work becomes effortless, we are so absorbed in what we are doing that apart from the work on hand, we are entirely shut off from the environment.
Flow – Concentration is so intense that no attention is left to think about anything irrelevant or worry about problems.
By definition, if I am operating, I am the cynosure of all attention, and my attention to my work is constantly interrupted by those watching, so I cannot perform at my best. If I cannot perform my best, it is a disservice to the patient on whom I am operating.
I may have had some surgical mishap that may not have happened if I had focused fully. There have been many mishaps reported where patients have died during live operative sessions.
Surgeons tend to rationalize by saying that even though it is not their best (if they admit it in the first place!), it still is better than not getting this surgery done for the patient. That is a slippery path with no coming back!
Equipment manufacturers outbid each other to sponsor live surgical events. The sums of money involved can be substantial. Naturally, they insist that the operating surgeon use their equipment to demonstrate the procedure. If the surgeon is unfamiliar with that equipment, that is one more point for a sub-optimal result.
Assuming the demonstration goes off smoothly, let us see how much the audience benefits from the surgery:
- Only the experienced surgeons in the audience can handle missing the first of the four steps of Peyton’s approach to learning procedural skills.
- The younger lot is watching a flawless performance as overawed and dazzled. Their surgical ego is awakened, and they are ready to have a go themselves when they get to their theatre. The Dunning Kruger effect is out to get you, though! An extreme example was this recent case from Saran, Bihar, where a doctor tried to perform a lap cholecystectomy after watching a YouTube video, only for the patient to die on the table.
3.The demonstrating surgeon has got there by overcoming thousands of obstacles, some small, some big. During discussions, she may mention some of these in her journey, but human memory is fallible, and not many surgeons are forthcoming about their blunders.
4.Even assuming several steps in the procedure that the surgeon performed flawlessly, it would be rare for the audience member to remember each one of them and be able to translate them into one’s practice.
The Ethics of Operating Live
Having discussed the educational value of live surgeries, let us get on to the thornier part of the discussion: the ethics of live surgeries.
Most live surgery programs are decided months in advance to allow people to arrange their schedules to attend. From the organizer’s point of view, the larger the number of attendees, the greater the number of cases, the greater the variety of cases, and the star rating of the operating surgeons all contribute to the program’s success.
If I have too many cases, I need to collect them well in advance. It necessarily means that these patients will have to wait unnecessarily long to get a surgery done. Some of the patients don’t turn up, so the organizer needs to have more than one case ready for the event. Finally, there may only be time for a few cases to be done, which leads to further disappointment to the patient who could not be operated on during the meeting. A hype has already been created that an eminent expert in the field will operate you. The patient waits because he has no choice but to wait for availability or economic reasons, only to undergo delay and be disappointed.
Once selected, the patients are on the scheduled list for the day. For various reasons, time management is highly optimistic. I always marvel at the number of patients the organizers and the surgeons hope to operate in any session. Anesthesia is the first casualty as a far greater number of workshop patients receive general anesthesia than in routine OT lists (87⋅5 versus 44%)
If there is a technical glitch in the transmission, and a crucial step is being demonstrated, it is very common for the surgical team to take a breather waiting to be live again. It certainly can’t benefit the patient!
The residents and fellows are scrubbed up or preparing the next case to go live. Postoperative care may take a hit.
While the patient benefited from surgical expertise, the overall management is almost certainly much poorer than what would be available otherwise.
Recommendations
- Go for pre-recorded operative videos – Unhurriedly, you have already performed the surgery with your team in familiar surroundings.
- Be on hand to answer questions firsthand. You can focus on the audience, be in a flow, and be a Power Ninja consultant.
- If you must have live procedures, stay home and transmit over the Internet. Take the next flight to the conference. You can bask in the adulation and enjoy your moment of glory.
If you must have live procedures, have skin in the game! Be legally responsible for a sub-optimal choice of patient, procedure, or result.
Remember, the spotlight is on you today, but it will shift. Nobody better than Sahir Ludhianvi penning the song sung immortally by Mukesh, mouthed by Amitabh
कल और आएंगे नग़्मों की खिलती कलियां चुनने वाले
मुझ से बेहतर कहने वाले तुम से बेहतर सुनने वाले
To translate,
“There will be others tomorrow who will sing these songs,
Performers better than me, and audiences better than you!”
Self-Declaration
- I have demonstrated live surgeries in the past. In my defence, I have been thinking of what I have been doing and this is my current position on the topic.
- I don’t get invited to demonstrate live surgeries too often, so it may be a case of sour grapes (It is likely that I will refuse if asked to demonstrate).
Reference:
Artibani W, Ficarra V, Challacombe BJ, Abbou CC, Bedke J, Boscolo-Berto R, Brausi M, de la Rosette JJ, Deger S, Denis L, Guazzoni G, Guillonneau B, Heesakkers JP, Jacqmin D, Knoll T, Martínez-Piñeiro L, Montorsi F, Mottrie A, Piechaud PT, Rane A, Rassweiler J, Stenzl A, Van Moorselaar J, Van Velthoven RF, van Poppel H, Wirth M, Abrahamsson PA, Parsons KF. EAU policy on live surgery events. Eur Urol. 2014 Jul;66(1):87-97. doi: 10.1016/j.eururo.2014.01.028. Epub 2014 Jan 30. PMID: 24560818.
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