Teaching Minimal Access Surgery in Africa Using Skype

Allan uses telesimulation to teach a surgeon in Botswana laparoscopic suturing

Laparoscopic general surgeon Allan Okrainec's research focus is on the use of simulation for surgical education. He is currently completing a Masters degree in education at the University of Illinois in Chicago. Two years ago, Georges Azzie, paediatric surgeon at the Hospital for Sick Children, invited Allan to accompany him to Botswana to participate in Georges's long term project providing surgical care and education in Gaborone and Francistown. Lloyd Smith, a gifted laparoscopic surgeon from St. Joseph's Hospital joined them to help with the training. Because of his focus on education, Allan wanted to include the simulation-based Fundamentals of Laparoscopic Surgery (FLS) course as part of the educational program. FLS is a rigorous training course comprised of simulation training exercises and a written test. It was developed by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), and is now also endorsed by the American College of Surgeons.

The Botswana surgeons were able to double their initial scores after the training visit. However, only two of twenty surgeons were able to achieve an overall score required for FLS certification. The challenge was how to continue and reinforce the hands-on training. We have learned from Allan's colleague Carol-Anne Moulton at the Wilson Centre for Research in Education that distributed practice over time is superior to intensive short term training. Since the trip to Botswana is a 26-hour sojourn from Toronto to Frankfurt to Johannesburg to Gaborone, regular follow-through training sessions were not feasible. Allan solved this problem with telesimulation using Skype, the software for video conferencing over the internet.

Telesimulation uses the internet to link simulators between an instructor and trainee in different locations. Using two simulators, computers, and a series of webcams, the instructor can teach a trainee as if they were in the same room. Conditions in Botswana provided a natural experiment that could validate the telesimulation approach. Surgeons in Gaborone had good internet access; surgeons in Francistown did not. Both groups had unlimited opportunities to practice with the simulation box. Allan and Georges applied for and received a SAGES grant to test the telesimulation hypothesis. Seven of eight surgeons in the telesimulation curriculum passed the FLS exam, while only one of eight in the control group succeeded. The experiment has been extended to Columbia where 20 of 20 students qualified, and to Peru where 15 of 15 have qualified. The success of the program has been catalyzed by Oscar Henao, a surgeon from Columbia and current research fellow in the telesimulation lab at Toronto Western Hospital. Oscar travels widely for the project and translates for the teleconferences. Oscar is a fully-trained surgeon who will become a clinical fellow in the University of Toronto laparoscopic surgery program starting in July. There is currently a telesimulation course ongoing in Guyana, and soon others will start in Hungary and Nigeria. The next frontier is China.

One of the unsolved problems involves training of the entire medical team as well as maintenance of infrastructure. Cleaning and maintenance of equipment, preparation as well as handling of the instruments by operating room personnel all require deepening of the educational process. To address these needs, Allan and his colleagues are developing a Centre for Studies in Telesimulation and International Health Education at Toronto Western Hospital. Through this centre the team will broaden their educational programs to train other health care personnel. The focus will be on "training the trainers" in the hopes that students in the program will ultimately go on to teach others in their own countries. The equipment for telesimulation has thus far been purchased through the SAGES grant and a generous donation from a former patient, but funding for the program remains a challenge. Allan continues to seek external grant funding, as well as support from private donors and foundations.

Allan Okrainec with wife Joelene and daughter Madison

Allan was born in Gatineau, Quebec. He completed his medical degree and minimally invasive surgery fellowship at McGill, the latter under Gerald Fried, a pioneer in laparoscopic surgical education. Allan finished his general surgery training at McMaster in 2005. During medical school at McGill, Allan met his wife Joelene who is a paediatrician currently doing her fellowship in developmental paediatrics. Joelene and Allan recently welcomed a new addition to the family. Their 10-month-old daughter Madison has already traveled with them to Hawaii, Italy and Holland. Allan enjoys hockey, snowboarding and traveling. His telesimulation laboratory, ably staffed by Oscar, is always open for residents and faculty to develop their skills. Click here to link to The Globe and Mail article describing Allan's work.

M.M.