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Uh Good morning. Uh I'm Aller Asthma Ahmed. I'm a pediatric orthopedic surgeon based in Palestine. And uh I'm doing a lot of global activities related to uh scoliosis training in low middle income countries. Here. I'll talk today about the role of artificial intelligence in improving the training and education, especially the skills, the surgical skills. And I'll put the spine as an example for that. Uh When we talk about global activity and education, actually, we need to differentiate between two issues. This is very important. One is the financial resources. Unfortunately, some of the people think this is the main resource that need to be acknowledged in this thing. What is the financial like surgical equipment have equipments, having material and of course the time the doctors donated or the health workers donate in in the in this activity. But uh we don't acknowledge a lot of the most important one with which is the organizational resource, like the guidelines, protocols, uh equipped nurses and assisting staff, uh effective training, uh clear protocols about communication between different healthcare institutions, incentives for data collection and many other things. This is a problem that we face in global training and global education because there is always weakness in the organization, especially the local organizations that we deal with this thing. And if we deal that the financial resource is the most important thing. Of course, the doctors are thankfully giving their time volunteering. But without giving some structural changes and long term activities, this will stop sometime and it will be just a temporary measure that will do some services more than uh giving uh long term or sustainable program that will give a chance for the local doctors uh to do uh to have these skills. So the program might end because of uh financial problems and the funds will stop uh for whatever reasons, whether political or regional reasons and this will stop the program. And that's what happened for many programs. Besides that, there are challenges for the local surgeon that he or she has a huge burden uh for developing a program. Uh And uh the surgeons are unlikely to be motivated to be able to engage with high risk surgeries like the spine or keep up with the best global practices and surgical care quality is likely to remain poor. So we need to train the surgeons in the local country. This is the priority, especially if we know that 80% of the doctors orthopedic surgeons in the world are resided in 26 advanced economy countries. So here, if we discussed the difficulty related to specific surgery that like the spine training is that we have variation of skills need to be learned. And there are new procedures that are evolving all the time that the surgeon need to be updated and being engaged with high performing institutes. And also there is a lack of spine education in the residency program in most of the low middle income countries. And also there is coincidental exposure based on random experience, two cases. So you might see for example, a tumor in the spine once per year and this cannot be enough to make the surgeon efficient to do the surgeries alone. So for example, if you want to have an efficient training program for young surgeons in low middle income countries, for the spine, for example, you should allow them to repeat and fail and repeat and you need to have a feedback for the performance and the education is safe and no risk environment and also metrics based for evaluating the residents should be there. So as to have an efficient training, but still with the pyramid that we see that uh the least efficient training process is the passive one like lecturing, reading, audio visual demonstration. And the most effective one is through participation of the student through lecturing or teach others or practice doing so how can we do that in limited income countries? We need a feedback, we need a goal directed practice and monitoring, appropriate monitoring. So we'll talk about some educational tools that would fit with these things. One of them is the blended learning. What is blended learning is merging of uh web based with the face to face teaching process. So in the blended learning, you need to have needs assessment, you need to have learning objectives, you need to have quizzes taken before and after the course and you need to have a group discussion during the online and face to face. So what are the learning objectives and the learning objectives should be prepared at least two weeks before beginning of the actual course. Uh The first question, how do you rate your current level of on this learning objective, the current status that you have. And the second, how do you rate your desired level on this learning objective? And how do you read the likelihood of using this learning tool on your practice in the future? So the advantages of blended learning is that the students have more flexible Thai and can be engaged more in the teaching process not to be centralized on the uh teacher intentional in teaching concept through specific modules and questions and more professional teaching through monitoring of the students and providing different ways of learning. So we'll go for another educational tool which is the three D printing models. Uh It is so simply that you have a specific spine, for example, a CT scan or an X ray and you, you reproduce the anatomy of it, using the three D printing, it will give the trainee a chance to uh do the tasks through these models that are reproduced by the three D printing. And they can use it preoperatively for preparation and even inter operatively to have safe, more safe tasks that can be done by putting, for example, the screws uh in difficult spine surgeries. As we said, it's even used for preoperative planning and intraoperative guidance of how three D planning works. Uh It's an example from all in the Institute of Medical Sciences. So you have here the CT scan and you put a specific vertebra that you want to have a model for the three D printing model. This is the model three D printed and you can uh sympathize it as you can see and you can relate it to the vertebra and you can put it as we can see here as a guidance for your screw to put or drilling, put forward, putting the screw. This is an example. Who how can you use it uh intra operatively? So you put this the three D printed model on the vertebra related to it and it will guide you to drill and put the screws appropriately. Again here, we can see that the three D printed model is put on the vertebra related vertebra and the trainee or the resident will have more chance to be more safe in putting the screws in difficult cases like that. So now we'll talk about another learning tool which is the tele proctoring and it's assistant assistance and evaluation of a surgical procedure by Emma Proctor who is not at the, at the same time in the operating room and with the surgeon and he or she is away from them but guiding them. So this is an example uh of a surgery that is done in Cardiff. And the guiding surgeon is from Amsterdam, the expert. And we can see here the hand of the expert as if he's in the are with them, he's guiding them where to go and what to do. And you can see on the upper right part in the surgery, the surgeons uh the actual surgeons are look, are looking at the monitors here or the computers, the screens here. So they can see where he is aware. The expert is uh guiding them to and what he's talking about and they can do exactly what he is guiding them through. So as you can see from the previous slide that the experience surgeon was guiding them and we did the spine uh same uh through scoliosis surgery, guiding them. Uh I was in Palestine and this program was in Nicaragua. And you can see here is my hand, the green hand that is aiming in the wound and also the green hand is aiming on the c arm image. So I was guiding them through the surgery that they were doing. So after physically training, uh the doctors there in Nicaragua uh for about 10 cases, five cases each week of uh mission. The, this is one of the cases that were done through the Proctor Ship. I was not with them. We did cases of adults and idiopathic scoliosis that needed uh posterior fusion and instrumentation and they did it with my guidance only through the Proctor Ship program and they did it very well. They did up to my knowledge, three cases in this way. So what are the advantages of the Proctor Ship? First of all, it's not costly except for the cost of the software. But otherwise all what you need is just a computer and an internet to guide the people. The other thing is that up to my knowledge, it's only tool that I know that this Proctor Ship that can support the surgeon in the O R because whatever you do outside the or like augmented simulation or virtual reality, uh still the O R is a total different story that needs to be supported, especially if you are doing it for the first time. Uh Third thing, it can be done for many things. So with this software, it's not just that you'll do scoliosis, but you can do general surgery, can do gynaecology. It's open for 24 7 and you can do it in both ways, either you mentor surgeons doing the surgery or you are doing the surgery and the others are looking and engaged as if they are assistance but they are not in the r to know more and learn about the procedures what we are doing. Now, we had uh we are doing a study about the efficiency in scoliosis surgery of this Proctor ship. So we needed to have uh to develop an assessment rubric for posterior scoliosis surgery and fusion and to have this rubric to assess the competencies that we need to have for the training process and to have a metric evaluation of these competencies. So with the success of this example of Nicaragua or we were encouraged to do more studies about the efficiency of this Proctor Ship in scoliosis surgery, which is a very complex spine surgery. So we established the Delphi panel and we developed a list of competencies with an evaluation of these competencies by the Delphi panel and re evaluation. So we had a consensus about the competencies and then we are looking forward to do a study uh with metric evaluation of each competency according to the Proctor Ship and the development of the skills to see the efficiency of this Proctor ship tool in spine surgery. So we'll talk about augmented simulation and virtuality, a virtual reality as other tours that are educational now. And there are more used in the developed than the developing countries because it's a little bit more costly. Uh And the virtual reality doesn't have the hep ticks but augmented reality, you can have the feeling and you can look and the cost of education is a little bit higher in the augmented reality than the virtual reality. But still both are expensive. So we'll give an example about virtual reality here. So this is all virtual. The patient is virtual and you can have gloves and you can just take the spine out, for example, to do a training about injection uh facet injection or something like that. And you can see here there are guidances for you that you can know where to go. So you can do it 100 times, you can do it in your room, you can do it anywhere as long as you have the headset. And this green line will guide you also to the appropriate technique to do the injection as you can see here. But you don't have the feeling and you don't have the touch. This is one of the problems that you have and beside the expenses of uh the headset and it can be used by one person. Artificial intelligence in training is now spreading all over the world, especially in the developed countries. There are trials for curriculums there but it is more needed in law, middle income countries because there is a combination of overloading work and insufficient man poor that will affect the training process of physical training. And artificial intelligence might play would play a big role in closing this gap. Besides it will overcome the difficulties that the training person is faced with uh the difficulty of having a visa, the financial problems of going to countries uh developed countries to do some training besides the the difficulty of engaging by doing in these countries. So with artificial intelligence, the surgeon or the trainee in low middle income countries can have a chance to work to do and to be monitored and to be evaluated through artificial intelligence within his country and not needing to go abroad. It was a blended learning course that we did two years ago with the help of course CeleXA and uh Well, Cornel in New York and in Tanzania about scoliosis. And uh it was very successful. This was another blended learning course that was done for Latin America with the collaboration of the Secret and uh the Latin American Pediatric Orthopedic Society. And it was very successful having more than 300 participants from all over Latin America discussing uh scoliosis and Children. Thank you for your time. Uh Thank you very much for that. Uh talk. Hi there. It's nice to see you. Um Do you have any questions about what you know in the first instance when uh some of my colleagues talked about this, I thought this is crazy. Why are we doing this? But actually, if we've learned something from the COVID pandemic is that technology can help us reach places we can't reach otherwise and support them. So any questions for uh Hi professor allow, this is Arthur Siddiqui from Oxford Good to see you. Nice to hear from you as well. Um I was hoping to meet you in person actually. I don't know you were virtual. I'm in Prague actually because we have the a a spine. I'm sorry, I would love to be with you. Um Thank you for, for a very uh talk actually, that's very close to my heart because we are uh we're developing some similar programs in Oxford uh for surgical training. Uh And I do work with these three D printed models for pelvic sarcoma as as well. One of the things and I want to hear your thoughts about uh your work in spine with this technology. I think one of the things which we have come across is if the surgeon who's actually performing the surgery is not part of the planning for the model, you can go really wrong. Um Obviously in the world of Sarcoma for us that is margins. And I'm sure in spine that for you is nerve roots and the possibility of going into uncharted territory, especially if you've not been part of the planning process. Uh So what do you think would be, you know, if you use the technology to perform remote surgery or some, you've done the planning and somebody else is performing the surgery in a remote area and at lower and middle income country, would there be some? Um So if you know what, what's your feedback on that, would there be some concerns. Thank you very much for this question. Actually, it's a very important question and we were talking here because uh part of the issue is that a oh is supporting the study that we have to. Uh one important question is that, is that the Proctor ship? Is it for a technique that you monitor or you guide the surgeon with? No, it is improving the performance of the surgeon. The performance means pre intra and immediate post. So it cannot be done like just going and uh going with this and you don't know the plan, you don't know the patient, you don't know the details and you don't approve it. So it's it's something that will improve the performance. For example, just giving you an example in the scoliosis. If you have a case of scoliosis that have some blood dyscrasia or like hemorrhagic disorders, how can you control the bleeding? Actually, one of the most important competencies is that control of the bleeding? So you need to know about the medical history. You need to plan for that. It's not just putting a screw. So this is what I'm talking about. What's this? Thank you. Any other questions? Fill in the chat room? Yeah, we've got a question from the virtual audience from Ashton. Do grow. Can't who's asking how much of these technologies are available in East Palestine? And the follow up question, how can we come and work there? And what are the logistical challenges. Well, uh thank you for uh your desire to come to Palestine. You are welcome, whether there is uh an educational program or not. But uh the thing is that the Palestine is a very small, I mean, if you talk about the West Bank and Gaza Strip, it's a very small area that it's easily accessed. But this program is really important for countries like India, for example, like Iraq, like Iran, like Pakistan that there are many district hospital that need guidance about some procedures that can be done. Uh This is the most important issue until now. Uh We don't have this program in, we have the blended learning course. Of course, we did it in Palestine, but for the Proctor Ship program, uh we are concerned to do it as a holistic issue that can be done. And we are thinking of Kenya to be honest as an example in Africa and we might think about a country like Nepal or Vietnam. Uh And uh it will work like that. So it will be very efficient if we do it for countries that are big enough that the doctors are having hard time to go between the cities or the expert cannot go every now and then to the district area or the oral. Thank you. Any other questions? Uh I thank you very much indeed for that exposure. I think it's uh where we're going, isn't it? Yeah. Yeah, I think this is the future? Thank you very much for having me. Thank you very much meat too. Take care. Bye.