Newly developed video-conferencing technologies are being successfully used by medical schools and hospitals to transmit lectures, lab sessions, and other content in real time over wide geographic areas. While this technologically advanced approach to medical education offers the ability to increase physician enrollment and retention in a cost-effective way, the rapid advance of video-conferencing technologies and the high costs of system implementation demand intensive pre-planning and commissioning.
The University of British Columbia (UBC) medical school successfully implemented a state-of-the-art, video-conferencing system as part of a 2002 government initiative to double medical student enrollment in the geographically vast province by 2010. The system, which was implemented with leadership from Vancouver-based AMBiT Consulting, uses advanced video-conferencing technology to connect instructors and medical students at three separate locations—UBC’s main campus in Vancouver, the University of Victoria on Vancouver Island, and the University of Northern BC in Prince George—with other sites across the province that provide clinical and post-graduate education.
Interactive lecture theaters, laboratories, and meeting rooms at each campus are wired for sound and image transmission over a dedicated, high-speed network. Each 350-seat lecture theater features three screens. The instructor is shown on a central screen while classmates at remote sites appear on a second one in split-screen mode. Presentation images selected by the instructor are displayed on the third. Each seat is individually wired with push-button microphones. When a student pushes the microphone button they appear on a screen in all classrooms. The instructor orchestrates camera changes and presentation images using a dedicated “confidence monitor.”
UBC’s gross anatomy lab is outfitted with high-definition (HD) cameras and a robotic control system operated by the instructor.
“I believe UBC is the first medical program to start teaching gross anatomy using these distance education tools. A tremendous amount of the anatomy curriculum has actually been coming out of the smaller Victoria campus because the University has an excellent anatomist there,” says Dan Zollmann, a principal with AMBiT Consulting.
Thanks to the success of the video-conferencing system, the University doubled medical student enrollment from 128 students in 2004 to 256 students in 2007—three years ahead of the government target. Students do pre-clinical studies at one of the three main campuses, then move for their third and fourth year to wired teaching hospitals spread across the province, where many are expected to eventually retain residency.
Lights Cameras Action
Creating a functional distributed medical education program at UBC demanded the development of specialized infrastructure at all sites.
“Integrating this technology into the building is not as simple as going out and buying a television set. You have to pay close attention to things like acoustics, lighting, and camera angles, and consider how to provide power and network connectivity to the individual devices,” says Katya Wilson, also a principal with AMBiT Consulting.
Experience has shown that camera and lighting quality have a much greater impact on viewer perception than high-speed network connectivity.
“You can have all the bandwidth in the world, but if it’s a dimly lit room, or the camera isn’t high enough quality, the experience is going to be terrible,” says Zollmann.
While there is an obvious emphasis on transmitting instructional-quality images, providing clear audio is just as important.
“Because of space constraints at universities and clinical sites, organizations often want to create multi-purpose rooms, which can make it very difficult to manage sound transmission and may render a room unusable,” says Wilson.
Getting it Right the First Time
Implementation of a distributed educational video-conferencing system is expensive, logistically complicated, and carries a high cost for failure. Program success depends on extensive pre-planning, equipment testing, and facility commissioning.
“Regardless of whether you’re talking about a 350-seat lecture theater or a small seminar room, you really want to over-service things at the startup. Those first few months have to be very successful. There have been instances of medical schools that tried to go to distributed modes where the faculty literally revolted. If it fails the first time, they’re not going to come back for a second time,” says Zollmann.
During a typical lecture there will be one technician at the presenting site and one technician at each of the remote sites passively monitoring things to ensure a smooth transmission.
New Technologies, New Approaches
Probably the most significant challenge in developing a distributed teleconferencing system involves combining the three strongly established, but culturally divergent, sectors of A/V, IT, and medical education.
“It’s important to keep in mind that A/V people and IT people are very different in the way they approach things. They are completely different cultures that also need to be merged with a medical education culture,” says Zollmann.
At launch, UBC’s implementation team consisted of three technicians, a part-time manager, and a faculty liaison who was tasked with bridging the culture gap between the technology staff and the faculty.
“If there’s one position that I would say was critical for UBC’s success, it was the faculty liaison, because you’re taking faculty members who have been teaching the same way for 20-plus years and putting them in one of these high-tech classrooms and asking them to interact with sites that are hundreds of miles away,” says Zollmann.
He emphasizes that the role of faculty liaison should be filled by a non-tech person who is first and foremost a strong communicator.
“We had a couple different people play that faculty liaison role. Some had administrative backgrounds, some had communications backgrounds. In the end, it’s all about their ability to interact with people,” says Zollmann.
Including the faculty in commissioning of the facilities is an important step towards success. Before rollout, UBC did a significant amount of early testing to make sure they had it right.
“You really want to bring in your staff and have them sign off on the facility. The level of buy-in you can get by showing it to them before the first day of classes is amazing. We actually flew students out to both Prince George and to Victoria and ran a week of the curriculum in advance to test out the technology and, more importantly, to make sure that there was confidence that it could be done,” says Zollmann.
Cost of Change
Infrastructure improvements for a small seminar room can range between $15,000 and $80,000, depending on what upgrades are required. Medium-sized seminar rooms (up to 40 people) cost an estimated $250,000, while a large lecture theater is around $450,000.
“When you start developing budgets for these rooms, everybody thinks the equipment is going to be the most important thing, but there are a lot of building upgrades that also need to be done—everything from painting the walls and treating the windows to putting in backing to hold up the video conference screens,” says Wilson.
According to Wilson the primary cost driver is not the technology, but the number of sites and the size of the rooms.
“You have to look at how many different locations you are distributing to, and how many of those are originating sites versus simply receiving sites. After that, you can pick between different technological solutions,” she says.
Due to the rapid change in video-conferencing technology, there is no benefit to early procurement. Rather, it’s better to wait as late in the construction process as possible in order to get the latest technology at the lowest price possible.
“One of the most important things to realize is that there’s no one right vendor of technology. This is a very immature area and the standards are very loose so there are still issues about compatibility between different vendors. This dynamic is just getting worse because everybody’s moving toward HD now, and they’re a lot of different flavors of high definition to consider,” says Zollmann.
Because of the logistical complexity, the estimated timeline for installing and commissioning an educational teleconferencing system ranges from four to six months.
“That might seem like a long time, but it’s not just a matter of putting monitors up on the wall. The A/V people have to go in and install all the push-to-talk mics and cameras, and test all the camera angles so they coincide when a student is talking,” says Wilson.
Development of UBC’s system required considerable experimentation. When the first prototype of the anatomy lab was tested in 2004, a number of problem issues were immediately identified for revision.
“Originally, the A/V designer suggested a touch-screen technology, which in practice proved difficult to use with gloves on. So this is the kind of thing where the designers and reality sometimes need to be brought together,” says Wilson.
Ultimately, the solution involved off-the-shelf HD camera equipment combined with high-powered lights. In the gross anatomy lab, a $30,000 camera is mounted overhead on a robotic arm which is controlled by the anatomist using a joystick and provides high levels of image magnification without vibration. A second mini-camera mounted on a flexible stem allows the anatomist to focus on internal cavity details that can’t be captured by the ceiling-mounted camera.
“Advances in video conferencing have allowed UBC to place students in rural areas where they would not have otherwise been able to be placed, which is tremendous because then you’re talking about not only using tele-education to place medical practitioners in remote settings, but actually democratizing healthcare,” says Zollmann.
By Johnathon Allen