REMOTE TRAINING

Modern computer and communication technologies enable to get remote training in medicine as similar to internal instruction as possible. It took several decades to form the system of internal instruction and improvement of professional medical skills. This system has demonstrated its efficiency achieved due to the appropriate combination of its instruction and interactive methods of thorough study of different subject matters and practical training with further consultation and examination. Because of this, remote training within any telemedicine network should be based on this far-devised system of internal instruction and be amplified with the opportunities that modern computer and telecommunication technologies are offering.

The system of remote training and improvement of professional medical skills should be composed of:

1. Remote delivery of lectures on subject matters or on current medical trends. The said lectures should be read by leading medical experts.
2. Seminars for detailed study of the subject delivered in the lecture.
3. Practical training in making diagnosis, treating and operating and individual telemedical consultation.

Reading Lectures at a Distance

Remote lectures can be read both on subject matters within a course of lectures and on individual topical matters. The remote lectures primarily aim at delivering the subject material that gives the students basic ideas for further detailed study both at seminars and individual studies.>

Most of the leading doctors of medical centers and institutions are involved in different instruction processes and have materials to read lectures for students of different levels. The said materials can be presented as manuscripts, printed matters, wall charts, slides, computer presentations, roll video films, etc. Because of this, the telemedicine system used by lecturers must be able to deliver any of the above matters to remote students. During remote lecturing the students must be able to see and hear the lecturer, to see the illustrating matters and objects on display, to ask questions as well as to hear questions of the colleagues and answers of the lecturer. Only in this case remote lecturing can be as efficient as internal instructing. And as this takes place the send-site environment should be as similar to the normal environment at a regular lecture for internal students as possible. Thus it is very desirable in addition to the lecturer to have an audience of several full-time students in the room where the telemedicine unit for remote training is installed. This helps the lecturer read the material in the most natural way and not experience any mental problem of teaching at a distance. And yet, he is aware that not only 10 but also several hundreds of students can see and hear him. With no full-time students available it might be reasonable to display images of two or three remote students on the monitor of the telemedicine unit that will help the lecturer to avoid the mental problem of acting as a TV announcer.

For reading lectures from a distance the DiViSy TM21 telemedicine unit has been designed. It gives the following opportunities to the lecturer and his assistants:

• Parallel two-channel video input. One of the video cameras is directed on the board (screen) where the teacher presents texts, drawings, formulas, etc. The other video input either displays the image of the teacher or a general view of the room where the lecture is read or is connected to one of the medical units: a microscope, an endoscope, an ultrasound or x-ray unit, etc.
• Audio channel between a teacher and a student and in doing so it is possible to fade the sound out at some of the remote sites.
• Text exchange between the teacher and the students. Such exchange is good if some one wants to ask questions. The text exchange allows any student to send his or her questions to the teacher. It is desirable to send such questions not directly to the teacher but to one of his assistants who could generalize the questions received and redirect them to the teacher at the most convenient time without interrupting the lecture or the seminar. Questions can be asked by a microphone but only when the teacher encourage doing it.
• Transmission and displaying of matters executed in the following office programs: MS Power Point, MS Word, MS Exel, etc. In doing this parallel displaying of images is provided in small windows on the monitors: the teacher or the room in one of the windows, texts, illustrations, slides, drawings, roll video films, etc. in the other window.
• Recording of the matters required in the students' databases during the remote instruction session.
• Opportunity to involve printed, graphic, video and audio information for preparing training materials. The unit allows to prepare (due to non-linear editing) and to demonstrate video/audio materials, charts, presentations, animation and a number of other video illustrations.
• Interactive work of the teacher and the students with the images to be studied on the common working-table. For example, the teacher places on the common working-table the image of an object from the microscope, ultrasound or x-ray unit. This image is transmitted to each remote student. It is possible to place on the working-table not only the images that have been prepared beforehand but also those that are transmitted in real time from any units used during the lectures.

Thus the DiViSy TM21 telemedicine units being both at the lecturer's site and the students' sites make the lectures as effective as possible.

Remote Seminars

The methods of conducting seminars have much in common with the methods used in reading lectures. However, remote seminars have additional functions due to greater interaction and larger involvement of the students. During seminars it is reasonable if both the teacher and the students use real medical equipment. This unique opportunity is possible only within remote education in the MTN(Moscow telemedicine network)information media. It should be noted that during the seminar both the teacher and the students can stay at their hospitals and institutions, at their workstations, and use their own equipment.

Here's the scenario for a seminar on histology.

The aim of this seminar is to study histologic specimens. To make the remote instruction effective in this case it is required to fulfil the three following conditions: a continuing watch over all diagnostic moving images in real time by all participants of the seminar, a duplex-sound exchange among all participants of the seminar, an opportunity to make immediate record of the most important diagnostic stages during the session, after the session an opportunity to do individual digital editing of the (video, audio, text) records done by the students to store and review the material. In this case the participants of the seminar are given a full idea how to make diagnosis and what methods are used for making histologic diagnosis. During the seminar the teacher can ask a student or students to point out locations with concrete signs on the image being studied. Each student can choose a marker of any color (to point out the concrete point(s)) or a line (to circle a fragment on the image) and send his or her results to the teacher. And the teacher is aware that the student from hospital #1 uses the blue color, green is the color used by the student from hospital #2, and the student from hospital #3 marks out in red, etc. The teacher can store this image with the marks of each student in his or her database.

If a computer-aided microscope is available, the teacher can ask any of the students to perform testing of the histologic preparation. In this case the student performs testing from a distance, and the teacher and the students can see and hear the comments on what is being done.

The realization of this scenario is possible only for remote education. The DiViSy TM21 telemedicine unit can provide all these opportunities.

Seminars on ultrasound and x-ray examinations, endoscopic diagnosis and surgery, etc. would be conducted in much the same way.

During the seminar some medical examinations can be done by a student under the teacher's supervision. Thus complicated examinations or operations are carried out with direct participation of the more skilled colleague.

Practical Training and Individual Telemedical Consultation

Practical training in various methods of diagnostics, treatment and surgery provides for a task entrusted to the student by the teacher to be done independently at his or her equipment. In this case the teacher and the other students can watch the whole process of examining and operating. An important peculiarity of this process is the opportunity for the teacher to correct the student's actions. If the student examining or operating starts making errors the teacher can correct his actions. The other students can watch the whole process and it will enable them not only to avoid similar mistakes in their independent work but if needed to be able to correct possible consequences.

In a similar manner, practical telemedical consultation would be carried out for real patients. So-called video consultation becomes possible where several physicians are involved in medical examination or operation.

Telemedical consultation and remote training

The traditional system of internal education has one important limitation that can be get over only with the help of modern computers and communication technologies. Because of the limited sizes of operating rooms, laboratories for diagnostics, hospital wards, etc. the real actions of skilled and experienced physicians cannot be simultaneously watched in all the details by several students. And skilled physicians may have not much time for teaching because their main duty is to treat patients. The DiViSy TM21 technologies and equipment may currently help not only get over this limitation but also gives a unique opportunity to the users of telemedicine video networks to watch all actions of skilled physicians during real sessions of diagnosing, treating or operating and thus to get trained in the most effective way. At the same time the skilled physician being at his working site can supervise over all actions of his student, help him or her to avoid many mistakes. Thus a new system of training is formed, the education is based on watching real diagnostic and treatment processes and individual practical work under supervision of the more skilled colleague that results in improving professional skills. And as it takes place all physicians stay at their working sites.

All technologies and equipment for telemedicine and remote training have been developed basing on the requirements of the traditional internal education and adding opportunities of modern computer and communication technologies. Thus the DiViSy TM21 technologies and equipment give maximum opportunities to medical institutions to create corporate systems of consultation and remote training.

Some tens or hundreds of remote lectures, seminars, practical training or individual telemedical consultations, if conducted, may cause evolutional reformation of the educational and health care systems that will integrate the experience of internal education of many years' standing and modern technologies of remote interaction between teachers and students, consulting physicians and persons receiving consultation.

Realization of practical educational and consultation telemedicine sessions within the Moscow telemedicine network formed on the basis of Comcor Public Company fiber-optical communication channels and DiViSy telemedicine terminals has shown real perspective of this trend. Please refer to site www.divisy.ru to find out more about telemedical consultation.

Summary:

As for now, the technologies and equipment developed can provide effective remote medical education and improvement of professional skills in various fields of diagnostics, treatment and surgery.