Live video streaming of neurology ward rounds for undergraduate medical students can replace conventional bedside teaching

doi:10.21203/rs.3.rs-1712184/v1

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Research Article

Live video streaming of neurology ward rounds for undergraduate medical students can replace conventional bedside teaching

https://doi.org/10.21203/rs.3.rs-1712184/v1

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Background

Although teaching ward rounds of the neurology department are considered amongst the most important educational exercises during medical learning in Japan, they are beset by several issues. Patients may find it unpleasant to undergo repeated neurological tests and think that they are being put on display in the presence of several students. However, unfortunately, only the students standing in the front row can closely observe the examination findings. Moreover, students were prohibited contact with patients during the coronavirus pandemic. To overcome these problems, we developed a secure on-premises video conferencing system for conducting live video neurology ward rounds to replace conventional bedside ward rounds

Methods

We created an on-premises web conferencing system called the Kobe University School of Medicine Web Conference Lecture System (KUMEX), which can be operated only within the hospital, using BigBlueButton, an open-source conferencing application based on Web Real-Time Communication. We attempted to broadcast live videos of the professor’s ward rounds to medical students located in a separate room. Studies were provided questionnaires to evaluate the utility and feasibility of participation in remote ward rounds.

Results

The students watched a live-streamed video of a professor examining an inpatient on a large screen in the conference room. Each examination technique was explained to the students by another teacher, who could immediately answer questions without worrying about the patient. Characteristic findings, such as plantar reflexes and fasciculations of the tongue, which are usually seen only by the students in the front rows during normal faculty rounds, could be observed under magnification by all students. This program was rated as fair or excellent by 93.7% of students who participated in the remote rounds.

Conclusion

Live-streaming of neurology ward rounds using an on-premises secure in-house web conferencing system enabled a novel style of clinical neurology education without hampering trust in the patient-physician relationship and could replace conventional bedside teaching.

live streaming

ward round

web conferencing software

neurological examination

undergraduate education

“Attending ward” rounds are considered one of the most important educational tools of clinical education in neurology in Japan. A professor or clinical tutor performs neurological examination of the patient and describes the findings for educational purposes in the presence of a small group of 6–7 undergraduate students. The students are shown the areas of focus for the neurological examination procedure, the order of performance, findings that are specific to the patient and not to the disease, and are also taught non-technical skills such as attitude toward patients, and manner of conducting interaction, explanation, encouragement, etc., in order to foster professionalism. These rounds afford students, who have only learned about normal findings in the Objective Structured Clinical Examination, their first opportunity to observe abnormal neurological finding, and encourage their interest in neurology and pursuing further education.

On the other hand, from the patient's perspective, it is not pleasant to be put on display in the presence of several students who have not signed a medical contract, and endure numerous repetitive tests, despite experiencing discomfiting symptoms. Only a few students can observe the examination up close, since the postgraduate residents occupy the best places, and some students have to watch out for small muscle twitches and pupillary changes in patients from the second and third rows, from where it is also difficult to hear the professor’s explanation. This ceremonial event is therefore simplified in some universities, and the opportunity to observe abnormal neurological findings may not be available until the final-year clinical clerkship, when the students have close contact with patients.

In the early days of the coronavirus disease (COVID-19) pandemic, medical students were prohibited from being directly involved in patient care activities, and teaching rounds were almost completely cancelled in Japan. During this time, students had zero access to actual patients, and were not allowed to enter the hospital and observe medical procedures.

The application of web-based conference applications such as Zoom or Microsoft Teams became rampant and changed the structure of society, although their use was limited in the medical field, where personal information cannot easily be divulged in the virtual space. These third-party servers exist outside the hospital and in some cases, are operated from abroad. The Japanese public was reluctant to place data related to their medical health, including personal information, on these systems even temporarily. Therefore, it is not possible to easily share images or videos of the patient (on a screen) without substantial investment in a system that is structured in compliance with various regulations devised by authorities to ensure secure handling of the patient’s protected health information. Medical students have not been able to benefit from technological advances because universities are hesitant to invest in new educational systems, since there is no direct revenue to be gained.

Web Real-Time Communication (WebRTC) is a technology used for real-time exchange of audio, video, and other data between web browsers. It constitutes the core technology for several commercially available web conferencing applications. We built our own educational web conferencing application system in the hospital using BigBlueButton, an open-source conferencing application based on WebRTC. The system allows sharing of images within a closed network in the hospital without the internet, which is more acceptable to patients. Using this system, we attempted clinical practice in which the weekly rounds of the professor, which are important in clinical education during neurology rotations, are live-streamed to medical students sitting in a separate room, and another teacher provides explanations of the procedures. This method was found to have several advantages over conventional rounds.

Establishment of an on-premises secure video-conferencing system in a university hospital

In Japan, it is mandatory for hospital information systems to conform to the Guidelines for the Safe Management of Medical Information Systems, Version 5.1, established by the Ministry of Health, Labour and Welfare. This law states that when patient information is moved from the hospital, including via the internet, various security risk management measures must be undertaken, such as processing the information to prevent leakage of personal data, or using private or leased lines to reduce the possibility of information leaks enroute. Therefore, Japan does not have an authorization system such as the Health Insurance Portability and Accountability Act (HIPAA) that imposes fines for violations; thus, medical information is generally not taken out of the hospital unless there is a special reason. Therefore, it is necessary to anonymize personal information and create generalized content when patient information is to be used for online medical education, rendering real-time clinical education difficult. We have created a web conferencing system called the Kobe University School of Medicine Web Conference Lecture System (KUMEX) that can be operated only within the hospital, which is not connected to the hospital information system network, using BigBlueButton (https://bigbluebutton.org/), an open-source conferencing application based on WebRTC. KUMEX differs from the conventional client-server model, since the communicating terminals are connected using encrypted communication (point-to-point) via a web browser, so that there is no risk of enroute information leaks, while communication using the user datagram protocol is fast with minimal delay. A signaling server is set up in the hospital to recognize each terminal, and media such as videos (using a webcam) and audio can be shared and displayed on each terminal's screen. There is no need to install special applications, and anyone can participate in a meeting from any terminal on the same network by sharing a unique meeting code generated for each session. The application is installed on a server in the Division of Medical Informatics of Kobe University Hospital and can be used freely 24 h a day. KUMEX meetings can be held on any terminal running a modern browser, whether it is a personal computer (PC), tablet, or smartphone. No additional installation or operating costs were incurred.

Preparation of video-streaming of patients' information

Prior to the COVID-19 pandemic, inpatients were informed in advance about rounds that would be conducted by professors, residents, and students as an educational exercise, and that another round of neurological examination would be performed to demonstrate abnormal findings, and that their privacy would be considered, and the patients’ verbal consent was obtained. This time, when the educational rounds were video-streamed, we additionally obtained written informed consent stating that the examination would be streamed to the students located in another room of the hospital using KUMEX, that the connection point would be in the hospital and not via the internet, and that the video would not be saved without prior consent. Written consent was also obtained from the students to reconfirm their consideration for the handling of personal information when viewing and utilizing the distributed images. Almost all patients who were asked to cooperate in this trial provided consent for participation.

Video ward round sharing with undergraduate students

The Kobe University curriculum requires a batch of 6–7 fifth grade medical students to attend clinics at the Division of Neurology in a rotating schedule every alternative week. On the second day, the medical records of the inpatients are reviewed by the attending physicians, staff, residents, and students in a conference room, following which all the students immediately go round the wards. After the pandemic, only the attending physician and professor visited the bedside for educational rounds to reduce crowding and the risk of infection. The professor wore a wireless Bluetooth microphone (SmartMic+, Sabinetek, Beijing, China) on the lapel of the white coat, while the attending physician carried a tablet device (iPad pro 11-inch, Apple inc., CA). The attending physician filmed the examination at an easy-to-view angle. Residents and medical students, who remained in the conference room, watched the professor’s consultation, which was projected on an enlarged screen of the PC used for the KUMEX conference. The remaining faculty members described the names of the neurological examinations performed by the professor, terms used to denote the abnormal findings and their significance, and answered questions posed by the students. Communication was not two-way and the iPad in the examination room did not have audio access to the conference room.

Questionnaire survey of participating students

A web-based questionnaire form was sent to students who attended the video ward rounds. The questions were as follows, 1. What grade are you in? 2. What did you think about the video ward round? 3. What was good about video ward round (multiple answers allowed)? 4. Did you think it was better than the actual rounds attended by you? 5. What was bad about the video ward round (multiple answers allowed)? 6. Did you learn a lot from video ward round?

Answers were not compulsory. The Ethics Committee of Kobe University Hospital does not review research related to education, as it is not subject to ethical review. When answering the questionnaire, the significance of the research was explained and understood, and the opportunity to opt out was offered; thus, written consent was not obtained from the students.

The students watched a real-time video of the professor examining an inpatient projected on a large screen in the conference room via KUMEX.

The communication was conducted over a virtual local area network (i.e., LAN) within the university, distinct from the hospital information system, and both the audio and video were transmitted from the iPad via Wi-Fi with an insignificant amount of delay. The patients behaved naturally without been excessively conscious of being recorded. Characteristic findings, such as plantar reflexes and fasciculations of the tongue, which are usually observed only by the students in the front rows during normal faculty rounds, could be seen under magnification by all students. Each examination technique was explained by one of the teachers and questions from the students were answered briefly. Thirty-two of 57 (56%) students who had attended the video ward round answered the questionnaire (Table 1). The responses to question 2 (What did you think about the video ward round?) were "excellent" (28.1%) and "fair" (65.6%). The most common responses to question 3 (What was good about video ward round?) were as follows: "I could see the findings up close," "I could understand where to pay attention," "I could listen to the teachers' explanations," "I was able to sit down and look at them (the patients) carefully." As several students did not have prior experience of attending rounds in person, some answers were guesses; however, 40.6% responded that "video ward rounds were better," 25% said both modes were "equal," and 34.4% answered that "attending rounds are better” in response to question 4 (Did you think it was better than the actual rounds you attend?). The responses to question 5 (What was bad about video ward rounds?) were as follows” 62.5% of respondents stated that there was "No sense of tension or presence because it is not face-to-face" and 53.1% said that the interaction was characterized by "Poor video and sound," and only a few other opinions were recorded. For question 6 (Did you learn a lot from video ward rounds?), 46.9% of the students answered, "strongly agree" and 46.9% answered "agree," which accounted for 93.8% of the total student population. In the miscellaneous comments, students stated that they appreciated the fact that all students could derive a uniform educational experience, since it was often not possible to see patients up close during the actual bedside rounds attended previously.

As the COVID-19 pandemic has resulted in inadequate undergraduate clinical education, various online education initiatives have been undertaken at teaching centers worldwide. However, owing to the lack of extensive experience with educational initiatives involving live streaming of medical examinations before the pandemic, an adequate online educational milieu could not be prepared within a short time.¹⁾ The underdevelopment of this initiative may be attributed to the fact that prior to the COVID-19 pandemic, there was no need to broadcast examinations to other locations, since there were no restrictions on student contact with patients. Another reason may have been the blind belief among educators that learning directly at the patient’s bedside was the best method for medical students. There is no doubt that much can be learnt by observing patients directly. Interestingly, previous studies indicated that face-to-face teaching formats with patient contact were rated significantly higher by students compared to non-face-to-face teaching, but that there was no particular difference in students' knowledge and skill development compared to non-face-to-face learning.²⁾ The availability of various types of educational methods in the medical field should be utilized to create different learning frameworks, including online education, depending on the educational content, in order to increase learning efficiency within a limited amount of time.

For example, studies have shown that there is no difference between the effectiveness of teaching a procedure by demonstrating it conventionally in the field and pre-recorded videos.³⁾ Furthermore, the principal advantage of the latter is that the videos can be reviewed repeatedly. On-demand video education is considered to be the best method for routine skill training for well-established procedures that do not vary from case to case.

On the other hand, at the height of the pandemic, teaching students about the management of COVID-19 was of paramount importance, but direct face-to-face contact with the patient was to be avoided, leading to the utilization of virtual bedside teaching rounds.⁴⁾ Face-to-face learning at the bedside is a better method than any textbook for the management of acute illness, as findings vary for each case and conditions change on an hourly basis for the same disease. The findings of neurological examination in neurological disease also do not always manifest with the same pattern (e.g., a lesion in the semi-lateral cervical spinal cord does not always indicate Brown-Sequard syndrome), and experience with a large number of cases can make neurological examination a useful tool even in the current neuroimaging-driven milieu.⁵⁾ Hofmann et al. used HIPAA-compliant Zoom to live-stream COVID-19 rounds, which requires financial investment. ⁴⁾ Now that the pandemic has subsided, the additional cost of this system should be commensurate with the benefits. There is a tendency to cut costs in medical education, where the dividends are difficult to see; moreover, it is easy to regress to the mindset of shying away from new high-risk educational initiatives rather than incurring high costs to mitigate security risks. Therefore, the implementation of hospital-based applications using open-source technology, such as our initiative, can be realized easily if the hospital’s information department is staffed by technically competent personnel.

While bedside teaching, which involves attending rounds, is extremely important, this method is beset by numerous shortcomings. Several teachers tend to prioritize their practice and research over teaching. Moreover, there are time constraints, in addition to the stress of the responsibility of a large number of students.⁶⁾

These problems can be overcome by conducting small rounds, sharing the videos thereof with multiple students, and saving and archiving the live stream with the patient’s consent. Thus, the abnormal neurological findings of various diseases can be accumulated and used as on-demand learning content that can be viewed repeatedly. This content can be used as a preliminary study before face-to-face clinical education.

One of the reasons for medical professors’ hesitancy to adopt commonly used video-conferencing tools seems to be the public’s vague concern about the leak of medical information. Despite daily news reports of major companies leaking customer data, there is a tacit agreement that the medical institution will never divulge an individual’s’ private information (which has been entrusted to the institution), which forms the basis of the relationship of trust between the medical institution and patient. This mutual assumption also constitutes the concept of extreme safety that “the hospital information network must not be connected to the internet. In the real world, network security is not a routing problem but a human problem, whereas network management is also not a routing but an authentication problem; thus, a worldwide trend in information security entails cloud-based information management by trusted external vendors, which is much safer. However, not all members of the public follow up-to-date security concepts. Countries such as Australia, which have largely adopted clinical practice using common web conferencing software, are rare. Tremendous effort is required to obtain the consent of the facility manager from the perspective of network security and personal data protection in our country.⁷⁾

The students who participated in the video ward rounds generally provided good feedback. During their six years in medical school, all students underwent five days (40 h) of clinical training in neurology without elective practice, of which less than two h were spent attending the rounds conducted by professors. For those with little clinical experience, the "memory" of the experience is more important than the acquisition of skills. Although this has not been verified, team rounds in a small group are probably more useful than video ward rounds in a large group to foster subsequent self-learning. However, it is preferable that education using new technologies is used to replace traditional methods of diminishing value by adding value and improving efficiency, rather than as a substitute for conventional and necessary educational methods. Future medical education should evolve using methods that can add new value to the existing technologies.

KUMEX: Kobe University School of Medicine Web Conference Lecture System

HIPAA: Health Insurance Portability and Accountability Act

Web-RTC: Web Real-Time Communication

Ethical Publication Statement: The Ethics Committee at Kobe university graduate school of medicine deemed our survey not human subjects’ research. The Ethics Committee confirmed that ethics approval for education and training are waived. On the other hand, we confirmed that the educational rounds and video-streaming approved by Kobe University Hospital as clinical educational activities, were carried out with written informed consent by all subjects. All methods were carried out in accordance with relevant guidelines and regulations.

Consent for publication: Not applicable

Availability of data and materials: The data that support the findings of this study are available from the corresponding author on reasonable request.

Competing interests: The authors have no competing interests to declare.

Disclosure of Conflicts of Interest: The authors have no conflicts of interest to disclose.

Funding: No funding has been obtained from any source for the study.

Author’s contribution:

Conceptualization: Kenji Sekiguchi, Eiichi Maeda, Riki Matsumoto

Data Curation; Kenji Sekiguchi, Norio Chihara, Seimi Kobayashi, Seiji Kawano, Eiichi Maeda, Riki Matsumoto

Formal Analysis: Kenji Sekiguchi, Norio Chihara, Seimi Kobayashi, Seiji Kawano, Eiichi Maeda, Riki Matsumoto

Investigation: Kenji Sekiguchi, Norio Chihara, Seimi Kobayashi, Seiji Kawano, Eiichi Maeda, Riki Matsumoto

Methodology: Kenji Sekiguchi, Norio Chihara, Seimi Kobayashi, Seiji Kawano, Eiichi Maeda, Riki Matsumoto

Supervision; Seimi Kobayashi, Seiji Kawano, Eiichi Maeda, Riki Matsumoto

Writing - Original Draft Preparation; Kenji Sekiguchi

Writing - Review & Editing; Kenji Sekiguchi, Norio Chihara, Seimi Kobayashi, Seiji Kawano, Eiichi Maeda, Riki Matsumoto

Acknowledgments: Not applicable

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Table 1 Results of the survey of students who participated in the remote ward rounds (32 out of 57 (56%) students responded)

No.	Question	Answer
1	What grade are you in?	5^th grade (94%), 6^th grade (6%)
2	What did you think about the video ward round?	Excellent (28.1%), Fair (65.6%), Not good (3.1%), Bad (3.1%)
3	What was good about the video ward round?	"Could see the findings up close," "Could understand where to pay attention," "Could listen to the teachers' explanations," "Could sit down"
4	Did you think it was better than the actual rounds you attend?	Video ward round was better (40.6%), equal (25%), or worse (34.4%)
5	What was bad about video ward round?	"No tension or realism because we are not face to face," "Poor video and sound," ”Difficult to ask questions on the spot,” "Unable to observe from the perspective I want to see"
6	Did you learn a lot from video ward rounds?	Strongly agree (46.9%), Agree (46.9%), Disagree (3.1%), Strongly disagree (3.1%)

No competing interests reported.

Download PDF

Version 1

posted

You are reading this latest preprint version

Live video streaming of neurology ward rounds for undergraduate medical students can replace conventional bedside teaching

Status:

Version 1

Abstract

Background

Methods

Results

Conclusion

Background

Methods

Establishment of an on-premises secure video-conferencing system in a university hospital

Preparation of video-streaming of patients' information

Video ward round sharing with undergraduate students

Questionnaire survey of participating students

Results

Discussion

Abbreviations

Declarations

References

Table

Additional Declarations

Status:

Version 1