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"Live surgery" has become a favorite of domestic medical conferences and has been strictly controlled and banned by many countries

The author of this article: Yunye

Anze is a cardiac surgery resident, and at the moment, he is facing the fatigue of the night shift, and he is comparing the expert form, docking with the conference staff, explaining the guests and content, and the conversation in the chat window is rapidly flipping up.

This is his extra job today, all for tomorrow's live operation.

Perhaps because the mentor is the "big coffee" in everyone's mouth, Anze's live broadcast experience is much richer than many senior doctors. From his student days to his current hospitalization, Anze has participated in the team's live broadcast of surgery for no less than 20 times. "When I first enrolled, there were only one or two a year. Three years ago, the hospital updated the operating room and installed a system that can directly access the digital system of academic conferences, and live streaming has become commonplace."

However, the live broadcast of surgery, which is necessary for domestic meetings and popular with doctors, has been strictly controlled and even banned in many countries.

From newcomers to meeting essentials

As Dr. Anze felt, any academic conference with a surgical venue and no live broadcast of surgery seems to mean "no weight".

"Judging from the background data of the academic conference, without the live broadcast of surgery, the data of registration and viewing will be relatively low." Chen Jie, the head of a medical public welfare foundation, who has long supported a number of large-scale international medical academic conferences, revealed the characteristics of background data.

"I started working in 2015, and most of the academic reports related to surgery at that time were recorded in advance. In just a few years, not only the conference has relied on online live broadcasting, but also the live broadcast of surgery has become a necessary column, and it will be used in publicity."

"Without the live broadcast of surgery, it is not dry enough and not high-grade." Chen Jie said with a smile that she really wanted to use the word "lifting coffee" to describe the role of live surgery for current academic conferences.

"Live surgery" has become a favorite of domestic medical conferences and has been strictly controlled and banned by many countries

Surgical live broadcast scene Source: Visual China

Feng Pingzhang, deputy chief physician of the Department of Cardiac Surgery of a third-class hospital in central China, said frankly that he was not surprised that the live broadcast of surgery had such a status.

The most basic way to learn surgery is to observe, and live surgery can allow more doctors to get learning opportunities. At the same time, experts and hospitals at the forefront of technology are very willing to undertake live broadcasts in order to better teach and teach, or to expand their popularity and increase their influence. The needs of both parties met immediately on the carrier of "live broadcast", and the popularity of surgical live broadcast became inevitable.

In the cardiac surgery department where Feng Pingzhang works, the opportunity to directly observe top-notch surgery is very scarce, and the recorded videos that can be found are also very limited: "Although the live broadcast and the recording are both videos, the recorded videos are often some classic surgeries, and it is difficult to see the treatment of unexpected problems after editing, which is only suitable for learning operation specifications."

"Now the live surgeries are much newer and more realistic. For example, the Chinese Heart Conference has had a live surgery week for several years, TAVI and other surgeries have been demonstrated, and there are real-time reviews and explanations outside the venue. It's not that I can do it or have the opportunity to do it, but at least it gives me a chance to learn." Therefore, now listening to meetings, listening to lectures, if there is a live broadcast of surgery, it will attract his attention more.

Uneven medical resources, whether in the mainland or in the world, is a chronic disease, live broadcast doubles the energy of a demonstration operation, so that doctors in different regions can obtain relatively homogeneous learning opportunities. Because of the tangible benefits, live surgery is a new thing, which has become commonplace in just a few years.

But as the live broadcast of surgery flourished, controversy also emerged.

The British philosopher of science and technology Collingridge once concluded that trying to control a technology is very difficult because in its early stages, when it can be controlled, people cannot fully understand its risks, and there is no reason to control its development. But by the time these consequences become apparent, control becomes costly and difficult to control [1].

"Colin Grid's dilemma" seems to be gradually revealed in the live broadcast of surgery.

Patient death after live streaming raises concerns: or increases the risk of surgery

In 2004, a patient in Milan, Italy, died after a percutaneous heart valve implantation livestream. In 2006, a Japanese patient died after a live stream of aortic aneurysm repair. In August 2015, a Japanese doctor performed a laparoscopic live broadcast of liver tumor surgery in India (at this time, there were medical industry associations in Japan that banned the live broadcast of surgery), and the patient died after the operation.

Several patient deaths have raised concerns about the risks of live broadcasting: will live surgery have an impact on the psychology and behavior of the operator, resulting in a decline in the quality of surgery?

A survey of 106 physicians with live surgical experience showed that 32.3% of respondents reported associated intraoperative complications. The majority of respondents (62.4%) admitted to having anxiety or apprehension during the live stream, and 18.3% felt that they did not perform as well as regular surgery during the live surgery [2].

"Live surgery" has become a favorite of domestic medical conferences and has been strictly controlled and banned by many countries

Surgical live broadcast of doctors' survey results Source: Literature 2

Yuan Qing, deputy chief physician of the Department of Vascular Surgery of a third-class hospital in North China, said that it is inevitable that doctors are nervous in the live broadcast, and nervousness may more or less lead to deformation of movements. He further talked about his doubts about performing the operation under the live camera: "Even if some doctors are not nervous, such as my own crazy people are more excited, but will the excitement make their operation deformed? That's something I really can't be sure of."

Yuan Qing feels that perhaps more top experts are used to live streaming and can avoid the impact to a greater extent, but this may really require more research and speak with evidence.

Dr. Anze, mentioned above, said that if the operation is to be livestreamed, the whole team will add a lot of work before and after the live broadcast.

Anze feels that fortunately, the mentor's team is large enough, and the live broadcast experience is very rich, and the operating room configuration is complete. "If you have to adapt to live broadcasting to arrange surgical procedures and presentations, adapt to shooting equipment, and arrange filming personnel, you may also need to take up the time and energy of the surgeon."

Therefore, Anze has another hidden concern: whether live broadcasting will affect the doctor's energy allocation, and thus create surgical risks.

Studies have suggested that frequent interruptions leading to longer surgical procedures, the need to schedule surgical procedures to accommodate meeting times, longer preoperative patient waiting times or sudden cancellations of surgery, longer anesthesia times, and early departure of doctors for the next presentation increase the risk of patients going live surgery. Other studies have shown that issues such as live streaming communication in non-medical technology are also significantly associated with intraoperative adverse events [3].

"Live surgery" has become a favorite of domestic medical conferences and has been strictly controlled and banned by many countries

Factors that may pose risks in surgical live streaming Source: Literature 3

Patients are the bearers of the risk of live surgery, and the risk of infringement of patients' right to informed consent in live surgery is more complex than that of general medical behavior.

For example, the literature points out that when the doctor introduces the method and content of the live broadcast to the patient before the live broadcast, he often induces the patient to participate in the live broadcast with the reduction of surgical fees and nursing fees, which weakens the autonomy of consent; The audience characteristics of the live broadcast and the number of people watching the live broadcast are uncontrollable, resulting in difficulties in knowing; In the live broadcast of surgery, doctors will focus on specific parts in order to explain, and these on-the-spot behaviors are often not notified to the patient in advance, increasing the risk of violation of the patient's right to informed consent [4].

Many countries strictly control or even prohibit it, and the mainland still lacks norms

In 2006, the aforementioned Japanese patient died after live surgery, the medical community was in an uproar, and the Japanese medical community reacted quickly, and the Japanese Thoracic Surgery Association and the Urological Society successively banned live surgery. In the years since, the American College of Surgeons and the College of Obstetricians and Gynecologists have also banned live surgery.

But as mentioned earlier, live surgery does have its indelible advantages, and banning it does not seem to be the best policy. In recent years, some norms have been born abroad to achieve strict management of surgical live broadcasting. For example, the European Urological Association's live broadcast regulations include the following:

The surgeon must be skilled enough to perform a large number of similar cases each year.

Standard cases are preferable to extreme cases; The selected patient must meet the medical education goals.

Patient permission must be obtained in advance to livestream the procedure, including the timing of the procedure; The patient's treatment cannot be delayed in order to achieve a live broadcast of the surgery.

Surgeons must submit a detailed list of preferences in advance, including instruments, disposables and equipment, arrangements for patients, surgeons, and nurse assistants.

The anesthesiologist must be involved in planning the surgical process.

In addition, the association requires that live surgical data be submitted to an online registry and complications reported using the revised Martin criteria. The association will conduct regular audits of the results to assess the adherence and educational role of surgical live streaming [5].

At a time when domestic surgical live broadcasting is emerging and maturing, the problem of imperfect laws and regulations has also received increasing attention.

During the Fifth Session of the 13th National People's Congress last year, some delegates put forward Recommendation No. 4837: completely ban the live broadcast of non-academic exchanges between medical institutions and doctors.

After the proposal was submitted, the National Health Commission replied by citing the Basic Medical Care and Health Promotion Law, the National Action Plan for the Honest Practice of Medical Institutions and Their Staff (2021~2024), the Nine Guidelines for the Honest Practice of Medical Institution Staff, the Key Points for Correcting Unhealthy Practices in the Field of Pharmaceutical Purchase and Sales and Medical Services in 2022, and the Guiding Opinions on Establishing and Improving the Mechanism for the Dissemination and Dissemination of All-media Health Science Knowledge [6].

"Live surgery" has become a favorite of domestic medical conferences and has been strictly controlled and banned by many countries

Source: Literature 6

In March 2023, the article "Improvement and Implementation of Patient Safety and Security System in Hospital Surgical Live Broadcasting" published by China Hospital Management more systematically discussed the management normative problems existing in surgical live broadcast [4]. The article points out that from the perspective of Internet regulation, there are no special and clear requirements for the platform, personnel and content of live streaming for non-profit medical live broadcasting, and the existing rules cannot directly explain only the inevitable bloody scenes.

At the same time, in the live broadcast of surgery, medical prescriptions, patients, live broadcast platforms, and viewers have formed a special medical service relationship around patient safety, and there is no special provision in the current medical and health legislation to adjust and regulate the above-mentioned special medical service relationship formed by the live broadcast of surgery.

The article further mentioned that there is no unified surgical live broadcast access specification for whether a surgical live broadcast can be carried out, and there is a lack of paradigm. At this stage, 88% of live surgical broadcasts are conducted by industry conferences and sponsored by medical device manufacturers, and it is common for the process to be chaotic, and expert judges interrupt and guide the live broadcast doctor's surgical operation [4].

In the absence of rules, many hospitals have temporarily issued some in-hospital regulations, hoping to fill the gap in this link, and Yuan Qing's hospital is one of them.

"The hospital issued regulations last year that there are different rules for academic live streaming and clinical practice teaching live broadcasting, which must pass the in-hospital review. Only doctors who use a certain number of live streaming techniques are eligible to apply for live streaming. At the same time, there are also regulations for the selection of patients, such as being suitable for live broadcast after medical assessment, and fully informing the patient of the live broadcast scene, audience range, broadcast form, etc., and signing informed consent."

From a practical point of view, live surgery has its own necessity. Having a legal framework, specific to the implementation details but no regulations to follow, may be the most noteworthy issue of surgical live broadcast at this stage.

In the text, An Ze, Feng Pingzhang, and Yuan Qing are pseudonyms

Curated by: Yunye | Executive Producer: Gyouza

Source: Visual China

Resources:

[1] COLLINGRIDGE D. The social control of technology [M]. NewYork: St. Martin’s Press, 1980

[2] Khan SAA, Chang RTM, Ahmed K, et al. Live surgical education: a perspective from the surgeons who perform it. BJU Int 2014;114:151–158. 

[3] Knol Joep,Bonjer Jaap,Houben Bert et al. New Paradigm of Live Surgical Education: Synchronized Deferred Live Surgery. [J] . J Am Coll Surg, 2018, 227: 467-473.

[4] LI Yongwei, FENG Lei. The improvement and implementation of patient safety assurance system in hospital live surgery live broadcast[J].China Hospital Management,2023,43(3):59-62.)

[5] European Association of Urology – Live Surgery Endorsement Guide. 

[6]http://www.nhc.gov.cn/wjw/jiany/202211/706c1b8fa5274362a3019fdbc8126d6e.shtml

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