key: cord-0998277-6pnmkfhx
authors: Lima, Diego Laurentino; Lima, Raquel Nogueira Cordeiro Laurentino; Dong, Caroline T.; Morales-Conde, Salvador; Parra Davila, Eduardo; dos Santos, Dalmir Cavalcanti; Malcher, Flavio
title: The Influence of an Online Platform (Hernia U) in Surgical Education and Patient Management
date: 2022
journal: JSLS
DOI: 10.4293/jsls.2021.00085
sha: 04317a0bfd067fea8d8d1156cbc84be3197d523c
doc_id: 998277
cord_uid: 6pnmkfhx

INTRODUCTION: Hernia U was created with the objective to expand the educational landscape of abdominal wall surgery. It is an online platform where surgeons can register with no cost and subscribe for different courses. The aim of this study is to evaluate the impact of the platform on patient management and surgical education. METHODS: A questionnaire regarding the influence of Hernia U in surgical education and patient management was emailed to professionals who had previously participated in any course of the Hernia U. Variables were shown with absolute and relative frequencies. Pearson’s χ(2) and Fisher’s exact test were performed to analyze relationships between variables as appropriate. RESULTS: Nine hundred three participants responded to the questionnaire. Seven hundred fifty-two (83.3%) were men; 248 (27.4%) participants were older than 50 years old; 240 (26.6%) were between 41 and 50 years old. Two hundred seventy-four (30.4%) participants had been in practice for more than 20 years, 242 (26.8%) between 11 and 20 years, and 161(17.8%) between 5 and 10 years. When analyzing the impact of time spent on the platform, spending over an hour per week was significantly associated with self-reported change in practice patterns compared to spending less than an hour per week (p < 0.0003). More experienced surgeons (10 or more years of practice) were less likely to change their practice patterns when compared to less experienced surgeons. CONCLUSION: Hernia U has allowed surgeons to change their daily practice and to boost their education. Surgeons spending more than one hour weekly in the platform are more likely to adopt changes.

The internet has become an essential tool for surgical education, with multiple forms of information delivery emerging online: live lectures, telesurgery, case discussions, journal clubs, and so on. [1] [2] [3] The pioneer website for this technology was WebSurg, from IRCAD, France. 2 Over time, countless other platforms have appeared as alternatives to traditional routes of learning, with social media being the most notable new medium for knowledge sharing. [4] [5] [6] [7] [8] While online forums have allowed individuals to share and compare their experiences and pitfalls with unprecedented ease, this accessibility is often accompanied by both an overload of information and an uncertainty regarding who is actually qualified to give guidance. The solution may be as simple as providing gentle oversight, via a single forum moderator or an entire trained educational team.

Hernia U (www.herniau.com) was created as a formal virtual curriculum for abdominal wall surgery (AWS). This is notable for two reasons: one, as an online platform available to registered users free of charge, surgeons can access curated courses developed by experts in the field from anywhere in the world. Two, as AWS is an evolving surgical field, it allows for continuing education for surgeons of all ages and at all levels of experience. More than 10,000 professionals from 110 countries have already interacted with the platform. The objective of this study is to begin to evaluate the impact of the platform on patient management and surgical education.

A 15-item online questionnaire was created using professional survey software (SurveyMonkey, San Mateo, CA, USA). The questionnaire is available as Supplemental file 1. The questions were created in the English language by two authors (RL and DL) and edited by two other authors (SMC and FM). Before sending the survey, four surgeons (members of Hernia U) tested the survey and further changes were performed in some questions to avoid ambiguity. The Checklist for Reporting Results of Internet E-Surveys was used to ensure survey quality. 9 Prior to beginning the survey, participants were informed of the investigators, the total estimated time to complete the survey, the aims of the study, and the number of questions on the questionnaire. Every page had only one question and the participants could go back to a prior question and change their answers. This study was exempt from institutional review board approval.

Participants were registered members of Hernia U who had attended at least one of the activities available in the platform. The questionnaire was sent by email and was available for six weeks. All responses were password protected to prevent unauthorized access. Reminder emails, text messages, and messages in social media were sent to encourage responses. All survey responses were anonymous; IP addresses were utilized to prevent duplicate responses from a single participant. Furthermore, the survey website allowed an automatic method for capturing responses. The online questionnaire addressed the influence of Hernia U on participants' surgical education and management of patients. The use of online tools such as surveys and their dissemination through email or social media is very common. 5 Our survey was delivered online in different formats that could be accessed by smartphone, computers, and tablets.

Data was analyzed by a biostatistician (DCS) using the R Project Statistical Computing software, version 30.30.1 (www.r-project.org).

Descriptive statistics and dependence analysis were performed. Continuous variables were resumed with position and medial rank measures, and categorical variables with distribution of frequencies. To analyze the relation between variables, Pearson's x 2 and Fisher's exact tests were performed as appropriate. The level of significance used was 5% and the confidence, to the confidence intervals, 95%.

Nine hundred three responses were received and analyzed. Sociodemographic data are listed in Table 1 . Participants were asked how long they had been in practice at the time of completing the survey, with 274 (30.4%) answering more than 20 years, 242 (26.8%) between 11 and 20 years, and 161 (17.8%) between 5 and 10 years. Table 2 reports how participants interacted with the platform. Most participants reported accessing Hernia U during the evening (n = 544; 60.3%), with many using the site on a weekly basis (n = 383; 42.6%), followed by 286 (31.8%) monthly, 170 (18.9%) casually, and 60 (6.7%) daily. Table 3 demonstrates how participants changed their practice after watching the courses online. Six hundred twelve (67.8%) participants reported that they changed their surgical approach. More experienced surgeons (10 or more years of practice) were more resistant to change their practice when compared to less experienced surgeons ( Table 4 ). Using daily changes as reference, older surgeons were more willing to make occasional changes or no changes.

Participants who spent between 1 and 5 hours in the platform are 12 times more likely to change the practice when compared to participants who spent less than one hour. (p < .001) ( Table 5 ). There was no difference between age groups or gender regarding changing their practice after watching Hernia U courses (P = .05, P = .848 respectively). (Tables 6 and 7) In all age groups, the evening was the preferred time of the day to access the platform 

Our results demonstrate that participants who spend one hour or more per week on the platform are more prone to change their practice when compared to those who spend less time. Furthermore, most participants changed their surgical approach after watching one of the courses. This does not necessarily correlate with better surgical outcomes, and the objective of our study was to evaluate the impact of the platform in how surgeons adopt changes on clinical practice around the globe and not to evaluate clinical performance.

Most participants (60%) access the platform at night which is an important detail to know when organizing live events for a broad audience, but still challenging for global events due to different time zones. One solution Notably, 57% of the respondents have more than 10 years of surgical practice, which shows an honest interest in updating their AWS background. Furthermore, almost 70% of the respondents answered they have changed their surgical practice. However, we found in our cohort that more experienced surgeons (10 or more years of practice) are more resistant to change their practice when compared to less experienced surgeons.

An interesting finding in our study was that most surgeons chose laparoscopic TAPP followed by open repair with mesh for inguinal hernias, while the robotic platform was poorly voted for either inguinal repair or small ventral hernias. This is a clear indication that the laparoscopic approach is becoming more popular among surgeons for hernia repair, but they still do not see a clear indication for the use of the robotic platform.

Literature suggests an increased utilization of social media as an educational tool among surgeons, residents, and medical students. [10] [11] [12] A survey applied in surgical groups on Facebook (International Hernia Collaboration, Mini friends, Robotic Surgery Collaboration) showed that among 309 participants, 65% look for surgical education every day. Eightyfive percent would consider changing their practice based on other surgeons' tips and tricks, while 62% had already changed. 5 In our survey, 90.6% of the participants answered that this type of collaboration is important. While the profile of surgeons and residents that participate in these groups or platforms could not be more different, this indicates a very high level of interest in interpersonal, interinstitutional, and international conversation. As may be expected, data from the Hernia U platform also showed an increased audience in 2020 during the COVID-19 pandemic when compared to the same number of lectures in the previous year. 13 From March through October, seven live surgeries were broadcasted in both years. From 2019 to 2020, surgeon¨s attendance increased from 803 to 1202, and mean logins per surgery increased from 114.7 to 195 (P = .021). 13 Internet resources have gained popularity due to the influences of patient safety, work hour restrictions, and cost-effectiveness in surgical education. 14 However, a systematic review of the use of e-learning in surgical education showed that there are few studies showing the impact on long-term retention, transfer of abilities to clinical practice, and changes in patient outcomes. 14 This limitation applies to our study as well as it was not designed to directly evaluate how surgeons improved their surgical outcomes, but to evaluate how the platform has influenced their decision-making process.

There is a broad debate regarding ethical issues related to the dissemination of surgical cases online via either prerecorded videos or live broadcast. The Hernia U platform can only be accessed by medical professionals and students after proper registration and passwordprotected individual log-ins. All clinical photos and videos are edited to protect patients' identities in accordance with the Privacy Rule of the Health Insurance Portability and Accountability Act. 15 The Society of American Gastrointestinal and Endoscopic Surgeons has published a statement for clinical education and consultation endorsing the professional use of social media groups for medical and surgical education and quality improvement, and has also proposed an optional consent template for professionals. 16 E-learning technology for surgical education has several limitations. For practical skills such as knot tying, studies have showed that active learning with individualized feedback by an instructor is superior to passive learning by watching a video with instructions. [17] [18] [19] However, studies that evaluated outcomes of online platforms that provided assessment or feedback showed superior performance. 14 Hernia U platform provides quizzes at the end of every lecture in the courses. Participants can only receive their certificate of attendance after watching the lectures and completing the quizzes with a minimal pass score.

Many studies have also reported concerns with published surgical videos on social media. [20] [21] [22] Despite its popularity and easy accessibility, social media is often questioned for quality of content given the lack of peer review. Medical students and residents should be trained to identify the most reliable and scientifically sound resources provided by specialists in that field. The Hernia U platform is composed of AWS specialists well known in international surgical societies; all material available is vetted by the platform's review board for scientific background.

This study has several limitations. By nature of design, this is a cross-sectional, descriptive study with limited quantitative data. Selection bias may have favored responses by those who are more comfortable with e-surveys, or those who found the platform more useful. There were around 10,000 emails registered in our server at the time we did the survey and we have a low response rate (roughly 10%). Self-reported data necessitates implicit trust in participant responses, which may not always be honest. Furthermore, changes in surgical technique or patient management does not necessarily presume better results. Our results do not answer if the members had better surgical outcomes after attending one of the courses as this was not the objective of the study. The main strength of this study is the large number of total participants, as well as the breadth of experience across both age and nationality which might decrease the selection bias.

The use of online platforms for surgical education has increased in recent years. As more surgeons and students look for education online, the Hernia U platform has allowed users to revisit their surgical technique and patient management. Members that access Hernia U platform for more than one hour per week are more likely to change their surgical practice. However, more experienced surgeons are more resistant to change their practice. While this does not directly translate into improved surgical outcomes, it gives unrestricted access to updated and reliable information from experts on abdominal wall surgery with no cost. 

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Surgical education during pandemic times: How the virtual world can help us in real life? The Hernia U experience

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A Society of Gastrointestinal and Endoscopic Surgeons (SAGES) statement on closed social media (Facebook ® ) groups for clinical education and consultation: issues of informed consent, patient privacy, and surgeon protection

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Acknowledgments: We would like to thank Jennifer Petrie for helping with the manuscript and the survey.Informed consent: Dr. Diego Laurentino Lima declares that written informed consent was obtained from the participants for publication of this study/report and any accompanying images.