I recently had the privilege of becoming a Google Glass Explorer. Basically, this means I walk around with a funky pair of glass frames and look strange – even for an urban hospital setting.
The Glass has a built in camera, and a small display that you can see with numerous apps ranging from GPS navigation to searching the Web. As cool as this the technology is – is there any utility in the healthcare setting?
There is the capability of video chat, where a consulting physician can see what I would be seeing in the operating room, and tell me what I may be looking at and what to do next. Pristine Eyesight, based in Austin Texas, is trialing this use of Glass in University of California, Irvine. Applications for nursing are being developed as well. Yet will this truly impact quality? I am not sure.
Yet one thing that intrigues me about the Glass is the perspective given when using the video function. I recorded some small surgical procedures and reviewed the video afterwards. I watched where I placed my hands, how I held the needle driver, where I took my bites, and in general – what I looked at during the case.
I felt like an NFL Coach reviewing game tape. For the first time in my surgical career, I was able to really see what I did, a perspective that I had never before experienced. This lightweight device with built in eye protection was far more comfortable than any helmet-cam I had used, and the line of sight was right in tune with my visual field. So I began thinking – is there a way this tool can improve outcomes in healthcare?
According to the American College of Surgeons, almost 5,000,000 central venous catheters are placed annually in this country. Complications including placement failure, arterial puncture and pneumothorax range from 15-33% in numerous studies. So how is this common procedure taught?
The classic “watch one, do one, teach one” methodology has been modified over the years. Now, after watching a few lines placed, house staff must perform a certain number of central line placements (usually 5) under the supervision of a senior resident, fellow or attending. Once the appropriate number is reached, the trainee is “competent” to perform the procedure on his or her own. Yet are they truly competent? Perhaps the high complication rates result from a flaw in this classic teaching methodology?
Simulation has been tasked with solving many of the training problems that currently exist – running codes for cardiac events, trauma resuscitation and improving surgical skills. Simulation provides valuable training, and clearly has benefits in the health care environment. Yet there are two current problems with simulation.
First – it is incredibly expensive – state of the art simulation centers run millions of dollars, and most physicians do not have access to these centers. Second, as good as simulation is, it still cannot substitute for the real procedure. Reviewing videotape has been used in healthcare. An article by LA Scherer in the American Journal of Surgery in 2003 demonstrated that team member’s behavior improved when they reviewed their performance on videotape. However, these videos were recorded by cameras mounted on the ceiling in the corner of the room – giving the viewer a more global perspective.
Perhaps the newer technologies like Glass will allow us to use what I term Perspective Based Educational Tools (PBET)– of which Glass may be the first PBET in existence. So now, after watching some central lines placed, and while performing the first attempt under supervision – you record the procedure with the Glass.
Video review with the Supervising physician shows the trainee what they were looking at, where they were holding their hands, what they were seeing on ultrasound. It also can show them near misses – when they almost did something wrong but thankfully no complication occurred.
PBETs have obvious utility in airway management, basic surgical skills and small procedures. These tools are cost effective as well. A pair of Glass runs $1500, and can be shared and re-used. As more PBETs are developed, costs will likely decrease and capability increase. Assessment of procedural competencies in healthcare can be expanded – improving quality of care and decreasing complications.
These technologies may even impact how physicians renew their Medical Board certifications. Currently Maintenance of Certification is the way the Medical Boards re-certify physicians to maintain their Board status. A doctor has to submit different exercises, demonstrate continued education, and take an examination every ten years.
Yet these cognitive exercises do not determine the physicians’ true clinical outcomes, and in the case of those doctors performing procedures – whether or not they are competent to do so.
I believe the time will come when to maintain my Board status and recertify, in addition to the educational piece I will be required to submit PBET videos of my surgical cases. At least that is what I see in the Looking Glass………
David E. Stein, MD is the Chief of Colorectal Surgery and Chairs Credentialing and Business Development at Drexel University College of Medicine. He also leads Surgical Performance Improvement and serves as Surgeon Champion for the American College of Surgeons National Surgical Quality Improvement Program.