This medical module is tailored to professionals in the healthcare industry and provides an overview of the Global Frugal Innovation Skills Course. Guests speakers Dr. Sang and Dr. Depa will discuss the importance of surgical training, challenges faced in medical education, and the design of simulation-based models. They will cover the evolution of surgical training, instructional design, and assessment methods, and share innovative success stories. Participants will have the opportunity to complete the course and apply for funding to develop their own research projects.
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Join us for Module 4 of the Global Frugal Innovation Skills course! Hear from Dr Bhakti Sarang, Dr Deepa Kizhakke Veetil, Mr Josh Burke and Mr Will Bolton and learn the unique aspects of applying frugal innovation principles to systems, processes and training pathways.

Module learning objectives:

o   Describe the difference between innovation for systems and processes

o   Understand how to measure the effect of system innovations

Learning objectives

1. Explain the principles and assessment that go into surgical training 2. Create simulation based models for surgical trainees 3. Describe the challenges of surgical training 4. Describe the importance of empathy towards patients in the surgical training process 5. Critically analyze the evolution of surgical training over the last century and its successes and failures
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The following transcript was generated automatically from the content and has not been checked or corrected manually.

Presentation about the course real quick for two minutes and then I'll let you know. Yes, perfect, perfect. Yeah, brilliant. Well, hi, everyone and welcome to the er next module in the line up for the global frugal innovation skills course. It's my absolute honor to, to welcome those who are joining us live and if you are watching this and catch up, then I hope you're enjoying the convenience of, of the course design here. Um I'm super excited about this module. It's uh something that I'm very, very passionate about and we've got some excellent speakers um from around the world here to, to share their insights, to share their expertise with you. Um But uh before I go on, I just want to introduce my um co hosts for the module today, Mister Josh Burke, who's an academic colorectal surgeon here in the UK. Um Josh, I don't know if you want to say a few words about yourself before we, before we carry on. Yeah, thanks. Well, um I'm an academic colorectal surgeon working in the UK. Uh at the moment in training, I've had um a few different roles in the past looking at um how innovation might help us um learn the skill and the vocation of being a surgeon, er and also um changes to systems in order to facilitate that. Um really excited to have our guest speakers here today. Um and looking forward to seeing what they have today. Thanks all. Thanks Josh. Um Yeah, so Josh and I will be er shouting up very quickly to hand over to our um hand over to our guest speakers and we'll also be fielding any questions in the Q and A. So if you do have any questions for the speakers, please do post them in the chat function on Medal. For those of you that um aren't familiar with Medal. There's a button on the right hand side of the screen that looks like there's AAA me a message um icon. So click on that and you'll be able to post uh any, any questions you've got, I just wanna quickly give you a, an orientation of the course for just a couple of minutes. Um And to sort of in introduce uh it if you, if this is your first module here. So first and foremost, it's run by Gas O, which is the Global Anesthesia surgeon obstetric collaboration. So, an international group of trainees in those specialties that are advocating for ethical engagement in global health. Um And uh our website and Twitter handle is here and we've recently incorporated as a community interest company. Um And uh I'm one of the past presidents of the group. So um I just want to say a huge thank you to our funders, first and foremost. Um the the funder for this course is the Royal College of Surgeons of Edinburgh from via their global Surgery Foundation who are generous enough to provide us uh with the finances and guidance to run this course. Um and also provide um funding for projects for participants of the course. After they've completed the modules, we're also supported by a range of different organizations including Life Box, Med Tech, Foundation, Asset and Medal, as well as the NIH R Global Health Unit uh on global Surgery. So they've been contributing uh their expertise and time to um to deliver the content. So thank you so much to everyone who's been involved so far just very quickly. II II assume potentially that many, many of you know that there's a huge unmet need here. Um There's AAA large, a large number of um surgical devices are aren't er developed with a surgeon as a coin event and the majority of them never achieve widespread adoption. And it's one of the largest contributors to healthcare delivery and new medical technologies. And there's a lack of skills, there's a lack of innovators and there's a lack of collaboration. And that's one of the main reasons behind delivering as few renovation skills courses to empower people from medicine, but also engineering and business to deliver projects for um innovation in global health. So this is just an overview of the innovation skills course, it's comprised of eight modules. Well, the final module is essentially a guided innovation hackathon, which is coming up soon. We're, we're sort of over halfway now, but we've changed some of the order around. So I think we have two left to go. Um And we're on the systems and process and training innovations, one which is labeled in module four on the bottom left hand side of the screen. And the idea is that you work through these modules in your own time, um and take, take, try, try and do them sequentially. Um and they should give you really a, a good foundation on knowledge in all the different skills and steps required to take your innovation from my dear to actually adoption um in a low income and low resource setting, the innovation hackathon at the end that you'll be invited to, it's gonna be, there's gonna be live elements but also um catch up elements where you'll be able to take your own idea forward through a hackathon process and apply for funding um pots of uh a small number of thousands of pounds to deliver your own research project in your local context. So, um that's hopefully really exciting and I want, I want to get as many high quality applications as possible. So please do, er, think about applying to that and you'll have a chance to work with partners on innovation and technology projects. Um And you'll be able to actually hopefully see your ideas come to life. So that's all I wanna say. I'm gonna stop talking. Now, I'm gonna hand over to uh Doctor Sang. Who's gonna, who's our first, um who's our first guest speaker? And I'll let her introduce herself and tell, tell you, tell you all about herself. Thank you so much for your time. Both of you. Um I have a team. Thanks. Thanks, Will. I'll just share my screen and then I'll start speaking. Okey dokey. I might turn my, my face off when you start speaking by the way, but I'm still here. So. Hi. Hi, Will. Hi, Josh. And uh a big hello to all the others who might be your in person or who might be seeing it later. So, uh I'm here myself. Uh I'm a general surgeon by profess profession and associate professor and consultant in an academic uh teaching hospital in New Mumbai, New Bombay, India. And I'll be presenting your own innovations in training along with my colleague, uh, Doctor Depa who's again a general surgeon by provision. She is a consultant in the department of minimal access surgery at Manipal Hospital Delhi. And uh she's a member, uh executor and research division, member of Innovations and Global Surgery also. So, uh I'll start with my presentation a very good evening uh, to all of you and myself and Doctor DEA will be talking about innovations in global surgery on this platform today, as I mentioned earlier. So uh basically, I would like we do for all uh training modules. I would just like to lay out the intended learning objectives out of this whole uh presentation. So we would just like to lay out uh why is surgical training so important, the importance of surgical training and its evolution. Then the principles and assessment that goes in surgical training, the challenges that we face day in and day out in surgical training, we will take you through the process to design simulation based models for the surgical trainees. And we would also want to talk about certain innovations and success stories involved in surgical training. So moving on surgery, uh per se is not only about operating, it needs a holistic approach with an amalgamation of the head, the heart and of course the hands. So a lot along with appropriate knowledge about the disease or the disorder and the operative skills that you may possess. It's very crucial to be empathetic. So, empathy towards patients is also an important aspect of surgical training. So that's how the head heart and hands they go all go together as a holistic approach in surgical training. And it's also important, more important to know when not to operate than when to operate. And as we keep climbing higher and higher along the ladder, empathy towards patients and adequate patient counseling about any disorder or about any surgical procedure forms an important part of patient counseling. So it it involves patient operating a patient, of course involves knowledge, it involves the hands-on operative skills and along with that empathy towards the patients. So over the last century, surgical training has evolved significantly. So before the 19th century, I'm sure you would all know about the history of surgical training and surgeries, powers used to perform surgeries like say tooth extraction or amputations or removing any swellings. And the physicians at that time, they felt that uh doing surgery is way below their acumen. But uh what was observed in this was the mortality when babers used to perform was significant. It it was very high mainly due to the blood loss because the babers didn't know then they knew how to take off the damage part, but they didn't know how to control the blood loss effectively. And of course, infection uh control wasn't really available and patients would die of blood loss and infections. So slowly, slowly physicians, they started taking up surgery. And in the 19th century came in the apprenticeship model. So apprentice a apprenticeship model involves 1 to 1 surgical training. So there will be one trainer and there, there will be one training. So the trainee will have his entire journey along with the trainer. So he'll pick up all the good habits or of and of course the bad habits of the trainer. So the good and bad habits would be passed on from trainer to trainee like how surgical DNA gets transfer. So this apprenticeship model in the 20th century evolved into the health study model. So what exactly is this health Stian model? So it involves see one, do one and teach one. So c one means you observe a surgical procedure, do one. So doing under of course supervision and then you actually go on to perform the surgeries without supervision. And eventually the trainee would start teaching and become the trainer. But again, as the 21st century came in, it was observed that there were many errors which could be prevented with this model. So to avoid the preventable errors, the surgical training, it shifted out of the operating room. So what exactly does that mean? So instead of working directly on patients simulation based training came into effect and competency and outcome based training also came into effect. So this was this is how surgical training has evolved over the last century. And the present focus is on simulation based models. And you define the competency define the thing that you need to learn and you define the outcome before actually starting the process of learning and of course teaching. So uh moving on with the advent of simulation based training, integrating instructional design into skills training has gained a lot of importance. So uh you might find this slide uh with a lot of theories, but I would just try to simplify it a bit. So there are these various learning theories, learning theories, the attributes they form the entire learning model or the skills training model. So there are these four theories, I'll just quickly take you to these theories. The first is a fit and personal theory. It's a three stage theory of acquisition of motor skills. So the first part is the cognitive phase or the learning stage then comes the motor behavioral stage. And eventually, once you start operating, it's the autonomous stage or the expert stage, moving on to the second theory, which is the Bandura theory of social learning. So it focuses mainly on attention. Attention means you observe a procedure retention. Once you observe, you try to retain what you have seen, then you try try to reproduce it. And while you're doing it, you keep motivating yourself to do more. Moving on. The third theory is that you are not theory, it's a theory of stimulation and uh to simplify it, it's script based mental rehearsal. So you keep revising the procedure that you've seen mentally and then you're able to go in and actually perform the procedure. And the final theory is the Erickson's deliberate practice model. So this involves regular reinforcement and feedback to support learning. So uh surgical skills training is a combination of all these four theories. So it involves acquisition of motor skills, it involves mental rehearsal of those skills. It involves reproducing those skills and it involves actually practicing those skills. And the outcomes outcome would be the experiment directly on the patient experiment. As in you actually start performing the procedure on the patients. But while you do that, always, you can use practice models, you, you al already have your mental scripts that are ready with frequent observation of procedures. And of course, as we all know, we always, when we go in for the surgery, we need to watch these instructional videos. So I'm very sorry. Uh a combination of all of these theories and these attributes take you to actually performing the surgeries. Moving on. I would just uh like to lay down when you try to uh learn a complex surgical procedure, your journey is from a novice to an expert. So when you're a novice, you start with observation, you keep observing, you may start demonstrating tiny bits of the procedure under the supervision. While you're doing this, you keep mentally rehearsing it. And eventually, once you've observed it for many, many times, you actually go in and start performing it initially under supervision. And then once you become an expert, you can also start training. And while we are doing this, there are various teaching learning methods that we use. So one is reflective practice. You reflect on what you've seen and learn that way. Transformative learning. You transform from a no wise to an expert cognitive learning that is you try to gain knowledge about the procedure, experiential learning. You learn by experience and beyond this, there is also self directed learning and learning in communities of practice. When you go out in the open, right? Moving further, I would just like to lay out the learning cycle here. So II plan that OK, I need to go, go out and open and teach this procedure. I might go and teach a procedure, but I might realize that the target audience, they really don't need to know this procedure, they don't know this procedure. So the first and foremost thing that is important, the learning cycle is to assess the learner's needs. What exactly the learner needs to know? Once you know the needs of the learner, then you start defining with the intended learning objectives, intended learning objectives means what are the objectives that I need to achieve when I teach these learners, once you have defined the learning objectives, it is an interactive teaching or it can be simulation based education. So initially it may be didactic lectures, then there may be some interaction and then you may actually start teaching the learners on simulation based models. Once you have taught a skill to the learners, you would want to assess them. So assessment can be both formative and summit. And after this assessment process, you want now assess the learner. I would want to provide a feedback to the learner, which is mostly constructive feedback for the learner to improve on what he's actually doing. And the final step is reflections with reflections of the learner. So uh moving on, so this is what the learning cycle is all about assessing the learner's needs, defining the learning objectives, finally, feedback and then comes reflection. Now again, coming on to assessment. In 1990 psychologist George Miller proposed a framework for assessing clinical competence. So at the lowest level of this framework of this pyramid is the knowledge that is what the person knows. Then as you go higher, it is followed by competence, competences knows how to do it, he knows how to do it. Then as you go higher, he's it's performance of the training that just shows how and finally, it's the action that is done, does what he actually does. So work based methods of assessment target, the highest level of this pyramid and collect information on surgical performance based on clinical and operative cuments. So the focus of assessment here is mainly on what is done in practice rather than in practice as in on actual patients rather than an art on artificial testing simulation labs. So this is all about the Miller's pyramid of assessment because any surgical training, once you've trained assessment forms an integral part of the training. But while you're training a trainee, there are many challenges that a trainer, face, trainer as well as the trainees face. So I would just like to highlight a few of the current challenges that are faced mainly. Uh This is about low middle income countries than the H I CS. But there is decreasing patient population in academic centers because many competing healthcare centers are coming up. So there are many new healthcare systems which are not really academic or training centers which are coming up. So the patient population uh gets divided. Then the next thing is rapid development in technology. So earlier, it was an era of just open surgeries. But now more and more minimal access surgeries or laparoscopic surgeries are coming into practice. And these surgeries cannot be really learned in the operating room. They need skilled training outside the operation theater, maybe as courses or workshop. So this kind of training may not really happen in the academic center. So this is another challenge that is faced by the surgical training. Then comes of course a rising medicolegal uh concerns this factor earlier was a problem of the high-income countries. But now it has started circulating in the LM I CS also. So medic there are many medicolegal hassles that uh come in uh with training is performing the surgeries is trying on patients. So that is one concern. Then one major concern is red, reduced number of teaching faculty. So I become a surgeon, then I would want to a lot of money I would like to practice on my own and not really go into teaching which uh people feel that is a low paying profession. So there is definitely reduced number of teachers surgical teachers, then of course, lack of balance between ser service provision and training. And as you all know, surgery uh being uh there is a lot of burnout as compared to other fields of medicine in surgery, in surgical training. The other challenge uh that we it's it's always a two way street. There is a working memory and there is a long term memory that is there. So there is an imbalance between the working memory and the long term memory. So working what is working memory? It is a small amount of information that can be held in your mind and which is used ex execution of cognitive tasks. Whereas long term memory is influenced with vast information, it can be from one's life experiences. So improving working memory processes might be the key for creating long term memory. So small packets of working memory form a part of long term memory. But while we are on to this two way street, a large cognitive load hinders this process of converting working memory into long term memory. And this is one considerable challenge that is it. So there is a lot of knowledge that is being thrown in at you. So it really becomes difficult to convert your working memory to long term memory. So what can be done to deal with this? So what we can do is divide these tasks into very small chunks. So suppose I'll just speak with an example here. I plan to teach an inguinal hernia repair to my patients. And so I divide the whole process, inguinal hernia surgery into small packets, small chunks. So first, I would just like to show the inguinal canal anatomy to my trainees. Then at a later point, I would show them how to anchor the mesh, how to fishtail the mesh, how to perform a Liechtenstein's Tensionfree procedure. So I break down these tasks into smaller chunks. Then the next step would be I simply try simplifying each of the tasks. Then there may be certain tasks which may not be so very important for a procedure. So I may just want to throw out those non important or less important things for. Now, I would want them to focus on the more important aspects of training of the procedure. Then I make sure that I give them all the available resources and that the the trainees are aware of all the resources that are there and while they are performing or while I'm teaching, I try to reduce all the noise or all the unimportant things that the trainees don't need during this teaching learning process. So moving on now that we have discussed each of these challenges. Let's see what a systematic literature review has to say. So uh there was a systematic review on unmet need of surgical training. So the challenges that came up uh in the systematic review are lack of uniform practices or standardized programs in teaching and learning. So say uh uh there is a definite protocol for teaching surgical surgeries in the United States. But that may not be the case in India or that may not be uh uh the case in Uganda. So there is lack of uniformity or any standardized programs. Of course, uh this uniformity is slowly coming in uh as be because now uh there is more focused on competency based education and outcomes. So the standardization is slowly coming in but still there is a long way to go. Then of course, as I mentioned earlier, lack of trained medical per person, lack of teachers, then lack of organized training, as I mentioned earlier. And then of course, both basic and advanced training are lacking. So this is what came up from the systematic uh review uh that was done. So to combat a few of these challenges, uh there exists a definite need for innovation and simulation based education may be the way forward. So simulation based education or training was first reported in 1986 when uh a porcine intestine, a bench of freeze dried porcine intestinal model was used to teach in anastomosis to train. So uh nowadays, you may not use real in in this time, but there are these simulation based models which are coming up. And of course, these models are low cost also with a very uh good or decent fidelity. Now, what what happens with this simulation based training of course, the advantages of these, these are low stress environment. When you actually learn on patients, there is a lot of stress on both sides. The trainer as well as training may feel stressed. Of course, there's no real risk to patient. And when you practice on these simulation based models, there can be objective assessment of skills, better objective assessments of skills in the simulated environment and which holds more validity than what would happen when you're operating on D patients. So these simulation based models can be used to transfer both technical as well as non technical uh skills. So as I spoke before, surgery is an Amalga amalgamation of head, heart and heart. I would like to stress here that surgery is not only about the technical skills, but it also involves a lot of non technical skills like social skills, leadership, then teamwork, good communication, which is essential in the operating room itself. Then cognitive skills like situational awareness, suppose I'm operating, I have uh maybe Nick the IVC uh I need to have situational awareness. Then II need to make a very quick decision of how to deal with it. Then I need to know how to overcome the stress and I need to know how to overcome the fatigue. So this simulation based models can not only teach you technical skills, but they will also teach you non technical skills. And some simulations can be in the form of role plays or they can be in the form of videos or they can be in the form of case scenarios that can be given and you're, you're asked to enact it. And of course, as we discussed for technical skills, there would there can be many low or high cause high or low fidelity models that are there. So uh moving on. So based on uh this experience and based on this uh uh exercise about simulation model, I would uh just like to share an experience. We are presently in the process of designing. Uh There is this global surgery book surgical care in district hospitals. So we are presently designing uh an online learning module with the World Health Organization Academy based in France. So uh here we are actually working on the second edition of this book Surgical Care in District hospitals. So we are making available online resources which include a knowledge based powerpoint along with this powerpoint, which has a lot of pictures that have been shown pictures of all the procedures like acute procedures for acute abdomen procedures for hernia or procedures for many uh other things that we do day in and day out. Along with this powerpoint, there is a supplementary word document for each of these. Proceed. And along with that, we are trying to develop low cost portable learning labs that is very low cost uh simulation based models, which may not be very high in fidelity. But of course, they would help training the surgeons or non surgeons also who are providing care in the district hospitals. So uh when we are designing these models or when we are designing these portable uh learning labs, I would just uh take you through uh the journey of designing these simulation based models. So whenever we plan and design a simulation based model, it's very important to know the target learner group and their needs. As I mentioned earlier in the learning cycle, it's very important to know the target learner group. Once you know the target learner group, then you start with defining your intended learning objectors. What exactly you want the learners to know, then you design your simulator based model. And finally, as I mentioned earlier in the learning cycle is assessment. So you have to align the assessment with your learning objective. So suppose my learning objective is teaching how to take a good su suture. My assignment would uh assessment would be how well the suture has been taken. So uh while, while you design a simulation based model, three very important things I would repeat that you need to know. First is the target learner group. Second is the intended learning objectives. What exactly you need the learner to know? And finally is how do you assess the learner whether the learner has learned it well or not? So with this, I would uh like to pass it on to doctor depa to take it further and uh of course, she would take you through the more interest, interesting part of the talk, which is mainly innovations. So dia I'll just stop uh sharing my screen. Yeah. Uh So thank you so much, but I think uh you will need to change the slides for me. So please uh do share the screen. So thank you for a very uh lucid presentation. But so after having heard on how to do it and why to do it? Let's now see uh whether innovations help in training, we can do this by actually discussing some examples which have worked in some pockets across the globe. So as we all know to take one step forward into the future, we actually need to know all the steps or the efforts we already done in the past because they act as a stepping stones or learnings for the part ahead. So across uh low and middle income countries, I would say frugal innovations have actually been there for years now. It's known by different terms like Jad in India, it's termed as Brio large in French. But the more refined term which is now well accepted as frugal innovations. So it is uh developed out of sheer necessity in the global South. But the COVID-19 pandemic actually reduced all the places to resource limited settings. And that is when the need to co create these frugal solutions was more reinforced among all of us. So there's one infinitely renewable resource available to every one of us and that is the human ingenuity. So using that many frugal innovations have been developed for training. So uh to put it simply frugal innovations means to do more and better with less, for more people. And the three founding principles on which it stands as it needs to be affordable, adaptable, and accessible. So uh I would like to take you through the innovations and training by looking at three different levels. So one is at the individual level, how the training programs have worked at the community level and also at the system level. So coming to the individual level, so the main idea was to train who are available. So as we all know, there is this uh biggest admit need of untrained workforce which is available uh which is present. So what do we do? So we train who are already there, who are present there. So that is in an attempt to convert a nonfunctioning unit to at least a functioning unit next slide. But yeah, so at least bring about a conversion to a functioning unit and I would say a safely functioning unit. So during this uh systematic review which Buckley had shared the initial findings of. So we also came across very interesting solutions to this problem of untrained workforce. So I would like to share a few examples here. So if you look at this paper which was published in 2019, it is a wonderful example of how a South to South collaboration had worked. So what was I met me? There were no trained anesthesia providers in Chad, there was only 0.01 for a population of one lakh. So what was the solution that they came up with? With the help of this collaborative network? The University in Chile, they uh took up this initiative of training the non physicians as they felt that training non physicians is better than having untrained people giving anesthesia. Then the next challenge was to have uh most of the courses were one year or two year long courses. And that was not really feasible uh previously, but so it was not really feasible. So then they came up with this idea of this four full month long courses which is spaced across the year. And this had both online as well as in person workshops. So that there is a better uh assessment of the skills which is being handed down. And there was a continuous support which was provided to these trained non physicians. So that was something which really helped in work um uh solving this unmet need and providing the trained services. Yes, it is not the final definitive solution, but it's definitely a bridging solution until a more formal uh training program was established in that region. Next slide. So there is another study which was basically the target study which was a training program in Gasless Laparoscopy for the rural surgeons of India. So uh there was an unmet need that there was no carbon dioxide available in the remote rural areas. So to overcome that need, there was an innovation which was designed that was a retractor of the abdominal wall in circulation surgery device, that's a raised device. But after coming up with this device, the next challenge was how do we overcome the implementation barrier of actually enabling people to take up this technique? Because this technique was something new, it had to be thought down. So uh how was this done? The solution was to have a staged and supported learning with a continuous feedback and it was a context specific learning. So I would like to show what we mean by that in the next slide. So it was structured across four stages. So the first initial stage of the study, it was online didactic and precourse material which was given to the candidates. And uh the point to be noted is these are surgeons who are already practicing surgery, but they were not doing minimal access surgeries. So the first step was assessed by multiple choice questions. The next stage was the stage of simulation. That's an intermediate stage. Now, here they had to be taught 22 skill sets. So first is they had to be taught the laparoscopic skill sets and that had to be assist. That was through their training program, then they had to be trained for setting up the gasless lift device and that was again assist. So after that simulation set up, once they are confident in setting up the device and they're confident on their skills, then came the stage of the life surgery. Now, this step I feel is really important because most of the training programs, what happens is people are uh they attend a workshop, they are trained in a setting which is not theirs and then they expect it to come back and um uh whatever they have learned, they expected to reproduce there. But that doesn't really happen because there are lots of uh problems in their context, which is not really acknowledged by the trainers. But the target study tried to overcome that. That is the trainers went to the trainees in their setup and they tried to troubleshoot the problems for them in their own context. So a live laparoscopic assessment was done as they were operating and the objective assessment of the gasless lift setup was also done. So this was something which was different from the regular training workshops which are usually held. And of course, the final stage where you do the competency assessment, the knowledge acquisition and you give a feedback. So what the study has enabled is it has demonstrated the feasibility of establishing a contact specific training program. So this continuous hand holding and this feedback that you give, it gives them the confidence to perform better and to uh give their patients the benefit of mi access surgery. So next slide, this was also um um helped by this process of telementoring. So if you look at this picture, the picture on your left is showing the uh mentors who are uh showing the uh setting up of the device in a different setting. Whereas on the right side, they are the trainees who in their own hospitals, they're trying to set it up. So this telementoring process can help at multiple stages. It it offers support at the follow up and also to retrain some aspects of training which might have to be reinforced next slide. So that is as far as individual training, but we surgeons, we cannot work in isolation for us to perform. We need a team. So we need to form a team, we need to train the team and retain the team. So that forms the crux of giving an efficient patient care. So uh a very uh beautiful example of this was uh the Ashwini model. This was a non government organization based training model. Uh This Ashwin acronym that stands for Association for Health Welfare in the Nilgiri. Nil is a mountainous terrain in the southern part of India. So they came up with this program of a health program for the people by the people. Uh They had a huge task, they had to provide health care services to more than 20,000 tribals spread over 3 20 hamlets in a valley of NRI Hills. So they started small, they started training the health workers from the community. So here the term from the community is important. They didn't want to hand down something to them. They wanted to empower that community as a whole. And that is uh the main reason for their success. And now they have evolved slowly and they have formed into a formal nursing school next slide. So their main um reason for their success is they looked at the bigger picture. They tried to empower the tribals to achieve a self reliance through their own endeavor and developed dignity and self-respect. So they didn't just look at only healthcare. They tried to develop the entire group uh of individuals to empower them in a wholesome approach. They strive in creating health expertise within the community. Next slide. So the factors which helped them succeed is they were able to develop a high degree of ownership within the community. They were able to develop a feeling of communal solidarity. They were able to have a strong participative nature and they were able to enable a real time skill transfer within the community. So this is uh aspect which we usually don't really concentrate on when we train our trainees. But this is something which is really important when they finally go out into the community and start working, coming to the system level innovations. So yes, we take the training to the area of need, but then it's important to standardize it. So this is demonstrated by the COSA model COSA the College of Surgeons of East Central and Southern Africa. So what they have managed to achieve is they were able to create a credible surgical training institution which is awarding an internationally recognized surgical qualification, the Fellowship of College of Surgeons. Next slide. So why did they have to do it? So there was a huge unmet need that the surgeons who were trained abroad in UK could not meet the growing needs for surgeons in Africa. They had the regional M ME programs but it did not have the spare capacity. So in 1999 the college of Surgeons was formed, was formed and 2004, their first cohort of surgeons came through and by 2020 they had 557 trained surgeons. But what is more important is nearly 85% of them were retained in their country of training. And why was this possible? Because they had standardized their training module of course with the collaboration in 97 from the Royal College of Surgeons in Edb and 2007 by Royal College of Surgeons Ireland. So they had this networking, they had the collaboration. So they were able to create a uh training which was on the standards we on par with the training elsewhere. So after discussing the individual, the community and the system level innovations, coming to the final innovations of tools of training. This is the most exciting part which all of us feel very excited about. But without those other three, this is not going to work in isolation. Uh So coming to the lab pack, so most of us have seen these box trainers. So there are lots of innovations which have come about in simulation based learning across various surgical specialities, but more so in minimally invasive surgery. So possibly because uh it's outcomes of improving patients recovery earlier return to work. So that's why minimal access surgery is really the need of the. Uh there are lots of uh low cost box trainers available, they can be easily set up. And it also enables the practice and assessment of the skills which are required like the ambidexterity, hand eye coordination, depth perception, precision cut. So what makes lapa different is that it was able to subject uh its tool through an evaluation and usability study. So this enables uh to add credibility to your innovation. So they had 78 participants and they had a pretest and a post test to see how well they're able to perform on it. But apart from that, what was important is the participants felt that that uh tool was lightweight and it was portable and that is the highlights of the lap pack. So it was shown to be a suitable low fidelity simulator for laparoscopic training in the low and limited resource settings. So, but he has given us a very detailed account of the different types of simulation models. There were two terms which kept repeating the low fidelity, high fidelity. So what do we mean by that? So low fidelity means it lacks realism, but it's still very functional. So you have many examples of this like the banana skin for suturing. Then we also already saw the box trainers and there's a Papaya model which I would like to explain it in a bit more detail in the next slide. And of course, the high fidelity models are the ones which appear to feel, feel more realistic, but they're really expensive, like the cric and animal models which come with their own share of rules and regulations for the use and the virtual and augmented reality, which is definitely the future of surgical training. Both these models can be effective as long as they stimulate the participant to practice their skills and hone it better. So this papaya model I just would like to um uh mention it over here. It was uh first published in 2005. It was uh developed from uh by the University of California where they were trying to train their third year medical students. But uh from there, it has evolved, it has uh been used to train uh for many intra uh uterine gynecological procedures, like the risks of instrumenting a uterus, uh the locations to give a para cervical block, endometrial biopsy, IUD insertion. So the figure on your right shows a ra papaya and then the trainee after inserting can see how, whether what he has done, he or she has done is adequate or not. So these are the uh innovative ideas which really make a change and it can help train our surgeons better. Next slide. OK. So the future. So if you look at this, the virtual reality augmented Reality metas, they are already being used for training. But the challenge is to improve their accessibility and affordability and to help them adapt better to the resource limited settings. So efforts are already on uh where you can use your just regular mobile phones and you can couple it with the low cost cardboard VR sets. So you can look on the figure on your left. So those are the low cost cardboard sets where you put in your mobile phone in them and then you have your VR set ready. Then the next uh after you have the set ready, then you need a training module which is context specific. So the training modules from the low and middle income countries are already being created as we speak. The next challenge is to enable the use even in areas where you do not have a stable internet connection or in the offline mode. And this is also an aspect which is being worked on and which is being given you consideration. So uh I would like to uh conclude our talk here for today by saying that innovation will continue to happen as long as humans exist because that raw material which is required for that is human ingenuity and that is going to be there with us. So let's tap into it. Let's continue innovating, learning and training, continue doing that in your own circles of influence and forums like these, which are organized by go actually helps us connect, share our learnings and also helps to keep us motivated. So let us all be leaders as Steve Jobs Court says, and let's try to make an impact. Uh There are few additional reading materials, the who compendium of innovative health technologies for low resource settings, which was published in 2021. It might be something useful for those who are interested to go through. Thank you. Do you Josh and back to you. Thank you for a brilliant talk. Um We've got time for a couple of questions if that's OK. Um Maybe we'll start with Bacti. Um You went over some amazing concepts that um we know are sort of the foundations of surgical training and you highlighted some of the barriers that you've experienced um in training where you work my question to you is what do you think the biggest challenges at the moment that you face in training your trainees? And if you could change one thing to help with that, what what would it be? So uh the biggest challenge according to me uh is uh of course, it's important to train the learners, but then teachers themselves lack the training of how to teach. So, learning to know how to teach is an important skill set which the teacher needs to uh develop. So now uh many um organizations like the f uh A are coming up for training teachers to train uh the learners. So uh it's important that more and more teachers uh take up that kind of a training and know how exactly to train the trainees. So that is one important challenge which I feel and uh more people, more teachers need to come in and pick it up. Amazing. Thank you. And, and there's some parallels there with um certainly our, our practice here in the UK. Um So that's interesting to hear um deeper, perhaps a question for you. Um You mentioned um some of the amazing technolog that you're starting to try and adopt um in India um in the UK, what we found is, although there's lots of um products available, the transition from sort of feasibility studies through to routine use in our training programs. Um isn't quite what it should be and I wondered if you were to predict which of those technologies might become routine use first. Um Which one it would be um or which one do you think it should be? So, I guess uh India speaking for India as it's a low and limited resource setting, I would say that the low fidelity ones are the ones which we need to concentrate on so that it is more easily accessible and reproducible by the majority. Brilliant. Yeah. No, thank you. We, we, we found some of the things the the the low fidelity ones are easier to standardize and so easier to demonstrate that there's efficacy with that training intervention. Um But, but the challenges with some of the higher fidelity things are lack of standardization, I think. Amazing. Um Thank you so much again for, for both, both your talks. Um I've certainly learnt a lot and I'll hand back over to will now to, to wrap us up. Thanks very much Josh, er deeper and back to you for that, that amazing session. Um And thank you for keeping the time. That's, that's also excellent. It's um yeah, it was fascinating to hear. I made, I've made loads of notes and I'm, I'm really hopeful that people enjoyed it um watching live and again, if they, if they're watching on catch up, um I wish you all the best with the rest of your endeavors. Keep on training uh all of the students and trainees that you train and also training the trainers as you said, which is just that cascade training, which is wonderful. So thank you so much. Um And thank you Josh for being my, my cohost for this. Um If people are interested in the the next module, please do follow gas sock on Twitter uh or, or sign up to our mailing list via our website to be first to know when the next module is. It will hopefully be sometime next month. Um But yeah, once again, thank you so much, everyone. I'm gonna stop broadcasting now. So thank you. Thank you. Thank you. Thank you so much.