Adopting Gold-Standard Procedures During COVID-19

By Matt Phillion

Healthcare always aims to ensure the best outcomes and the safest care for patients. This often means staying on top of the latest best practices and procedures to ensure organizations are offering the gold standard of care, whether that involves new techniques, innovative technologies, or a combination thereof.

But what happens during a pandemic when surgeons and other clinicians can’t learn about these care advancements in the normal way? Doctors, healthcare organizations, and even technology providers have found ways to work with or through the limitations of social distancing, though they’re not happy about it.

“Things have changed, and we’re hamstrung by not being able to see things in person—that’s the traditional way of doing things,” says Dr. Apurva Thekdi, an ENT specialist with Houston Methodist. “Medicine is a very old-school industry. We don’t tend to adopt technology very quickly, and things need to be tried and true before we accept things.”

Out of necessity, the medical community has made do with remote learning during COVID-19, whether that’s through Zoom®, Webex®, or other online platforms. “It’s phenomenal that we have these options, but it’s not the same,” says Thekdi. “The allure of going to conferences is the spontaneity—meeting people you wouldn’t ordinarily talk to or hearing ideas you wouldn’t ordinarily hear.”

When the gold standard is out there

Dr. Smita De is a urologist with the Cleveland Clinic and has explored techniques on how to make training for holmium laser enucleation of the prostate (HoLEP) more accessible for surgeons when traditional training methods are not available, such as during the COVID-19 pandemic.

“Doing a fellowship, having a mentorship, these seemed to be more successful as far as picking up how to use a holmium laser to perform HoLEP,” says De.

A number of studies examining surgeons trying to teach or learn HoLEP via less extensive options, such as weekend courses, shorter mentorships, or watching simulations, found that while the surgeons may have wanted to introduce HoLEP to their practice, they felt the altered training didn’t leave them comfortable with completing the surgery on their own. That’s a problem, since those who can perform the procedure consider it second to none.

“The notion that HoLEP should be the gold standard has been demonstrated, the outcomes are superior, but not that many people are doing it,” says De. “A lot of my patients are not local, and many HoLEP surgeons find patients are coming from all over because no one is doing it locally on a regular basis.”

Unfortunately, surgeons have traditionally relied on conferences and face-to-face training to learn about new procedures, gain hands-on practice, or talk with peers who are already using a new device or procedure. So what can be done to help more surgeons adopt techniques like HoLEP?

“Develop better simulators,” says De. “Simulation is huge, whether it’s a box trainer or virtual reality simulator or some combination of the two.”

The pandemic has organizations looking at ways of advancing online training as well. “For example, the Endourology Society has held quite a few courses online, talking about topics from straightforward concepts to nitty-gritty details like how do we improve a very specific aspect of prostate surgery,” says De.

While these courses have been highly valuable, De points out that many organizations haven’t yet taken into account that online learning meshes differently with a surgeon’s job responsibilities. A conference enables a surgeon to step away from care duties and focus wholly on learning and improvement. With travel off the table for the past year, surgeons find themselves trying to participate in online courses during or after a day working with patients, which doesn’t set up the best learning environment.

“We want to get educated on state-of-the-art equipment and advances,” says De. “But asking people to do that on their own time is hard when before you could jam it into a four-day conference. The requirements of the job have not changed.” There’s also a concern that, after a year or more without travel, organizations may view traveling to conferences as unnecessary and discourage doing so even after travel restrictions are lifted.

Not just the courses, but the content

One factor that came up in De’s research was the effectiveness of online learning, which could vary based on presentation. Ideally, a remote learning session wouldn’t just display slides for a physician, but it would get into “Here’s the surgery, and here’s how you do it,” says De.

And when it comes to demonstrations, sometimes it’s best to not pick the perfect take. “It’s really rare to find online training videos in which something goes wrong,” says De.

Understandably, demonstrations often aim to present a flawless recording—an ideal patient, a surgery without hiccups. But De says, “I don’t need another perfect video. What I need to see is when something goes wrong, what should I do, how does one handle it. I think that’s most useful. It is important to know that not everyone will do it perfectly every time, and you have the ability to get out of it safely if something goes wrong.”

In a time when in-person learning is a challenge, this is particularly useful because sometimes the nearest trained expert on a gold-standard procedure is in another state. “We often have someone we consider a ‘phone-a-friend,’ someone who you can call on for help, but with HoLEP, my phone-a-friend was in Tennessee! There was only so much she could do for me from there,” says De. “Even with a very safe procedure, it’s important to have more people trained who can back you up, to help assess a situation.”

How other physicians work

De talks about the potential for live mentoring through video rather than a recorded demonstration of a case. “When you’re presenting to thousands, you’ll want to pick the perfect case, have everything perfectly orchestrated, and be very careful what they see,” she says. “But if it’s a one-on-one scenario, [the live video mentoring will] be more relaxed and the surgeon can treat it more like how it would be on a daily basis.”

This would allow the mentor to consider how they teach a trainee, particularly when the procedure is a single-person job with one scope, one instrument, and one place to sit. That doesn’t make for an ideal in-person teaching situation, but a live video scenario could provide a better option.

“Right now if I’m training someone in person, I place my hand on top of the trainee’s hand to guide them, which can be awkward,” says De. “But listening to how someone else teaches this, what words they use, which steps they let the trainee do versus what’s an advanced level—I love to see that. It provides a different perspective than how I learned.”

And even experienced surgeons can learn from a live video scenario, De says. She explains how she recently watched a fellow surgeon trialing the new Moses™ 2.0 laser, which was still in the testing phase at the time.

“I got to see how she trains her fellow, but also I could see her equipment and setup,” De says. She even noted that there was a particular way the other surgeon set herself up physically that improved the experience not just for the patient, but also for the surgeon. “There are little things that can be hugely disruptive, and I got to see her entire operating room setup, not just how she used the laser, and that’s something you get from being there or having an opportunity to watch live.”

That particular learning experience was a fluke, arising out of an invite from a colleague, but any opportunity to watch someone or hear about their experiences can be a chance to improve, De says. “Sometimes it’s luck, sometimes it’s seeking out opportunities, but I tell my fellows: ‘I’m trying to teach you everything I can, everything I’ve learned, and every mistake I have made, but be open to every opportunity and take advantage of it.’ ”

Mobile training on the road

Some medical technology companies have taken their training on the road, literally. Thekdi has connected with Lumenis, which sponsors a countrywide road trip with the LuMobile RV to give talks and lectures outside. It’s a chance to capture some of the spontaneity of medical conferences without travel or other pandemic challenges.

“People really enjoy getting together again, even if it’s socially distanced and outside,” says Thekdi. “It makes a huge difference the kinds of conversations you can have when you’re in person.”

The company also brings lasers and tech support staff from research companies or labs to offer training, which gives surgeons the chance to see things with their own eyes. “One of the first things we’re taught is to doubt: don’t take everything at face value,” says Thekdi. “It’s hard to adopt a new technology when you can’t question and get responses. We also want tactile feedback, the chance to do or see something for ourselves.”

Even the best Zoom call doesn’t offer that kind of interaction, Thekdi notes. And while on-the-road sessions obviously can’t offer live patient procedures to truly see the technology in action, Thekdi participated in the hands-on course at one outdoor event and says even this modified approach still beats out Zoom courses. “We make do and learn [with remote training], but there’s a benefit to making it more accessible.”

The impact of COVID-19 on advancement

With travel at a minimum and adoption of gold-standard procedures held back, has medical technology been slower to advance during the pandemic?
“For sure there’s been stagnation,” says Thekdi. “There’s a density of ideas that occurs when you can bounce things off each other, a chance for more rich, innovative ideas.”

The pandemic has also seen a slow in funding for research that’s not related to COVID-19. “This was understandable—[COVID-19] was on the forefront of everyone’s mind in our day-to-day, minute-to-minute existence,” says Thekdi. “And it’s not like we’re falling behind other countries or communities, but compared to our normal pace of innovation, we’ve slowed the past year.”

Between the inability to travel and get face-to-face training and the limited contact with organizations developing technologies or procedures due to social distancing, medical advancement is only now starting to ramp up again.

“We’re going to see a rebound in conference and travel, but it’s not going to happen all of a sudden,” says Thekdi. “It’ll ramp up slowly. But I would anticipate that [eventually,] things are going to be back to pre-pandemic levels, maybe even a little rebound in attendance—as people are going to be itching to get back, learn new skills, brush up on old skills, and learn new techniques.”

As we begin to see social interaction return, will online training avenues remain? “I think they’re here to stay,” says Thekdi. “They add value. There’s a preference to meet in person, but conferences do take physicians away from their practice and family. With hybrid options, if you can’t make it to an in-person event, the opportunity will still be available.”

Matt Phillion is a freelance writer covering healthcare, cybersecurity, and more. He can be reached at matthew.phillion@gmail.com.