Should Live Operative workshops be banned?

Live Operating workshops as a mode for training of surgeons has recently been in for a lot of criticism and debate as to whether they should be banned or not. The main reason cited has been rare deaths occurring after surgery being performed in a live workshop for demonstration and training. These raises several issues related to patient safety, patient rights, surgeons training, industry involvement and surgical grandiose.

The protagonists of live operative workshops claim that it is one of the important modes of surgical training for surgeons who wish to learn new procedures or new technologies from the masters of the field. In our country, there are few options for training in newer technologies such as laparoscopy as animal right activists have almost banned training on live animals under anaesthesia, which is fairly justified. Other forms of training include didactic lectures, video training, practice on models or simulators. There is no doubt that live surgical workshops ignite the most enthusiasm amongst the surgeons and are attended the most out of all forms of training. Still, this does not justify the conduct of live operative workshops in its present form. Live operative workshops also provide surgeons an opportunity to see how some of the complications can be managed by experts during a live surgery, which generally are never shown on video training modules.

The antagonists of live operative workshops are equally vehement and believe it is unfair for patients to undergo surgery as a demonstration case. It is true that surgeons operate in an unfamiliar environment with an unfamiliar team, which can produce a less than optimal outcome especially in a difficult and a complicated case. This is especially true for a foreign surgeon operating in India. They believe that most live workshops are more of advertising and marketing gimmicks for private hospitals. Though this is not completely true, the motive behind many a workshops is for projection of private hospitals or even departments and individuals. Most of the patients seeking treatment in live operative workshops are poor patients, who otherwise would not afford a regular treatment. Most of these patients are neither aware of their rights, nor would be capable of raising their voice in times of disaster. This raises several ethical questions in the conduct of these workshops.

The current technology of high speed broadband can actually allow live surgeries to be transmitted from the expert surgeon’s centres anywhere in the world, which would take away the many disadvantages of live operative workshops such as patient factors and unfamiliarity of the environment. This would actually be an excellent way of demonstrating live operative procedures and in the future would be one of the best ways to proceed for live surgical workshops. The only challenge is to manage time zones and plan the slots accordingly.

Actually, having organised many live operative workshops and having participated as a faculty to perform live surgeries in a few of them, I believe that live workshops do some good to some of the patients who would otherwise would not have been able to afford high technology surgery using expensive consumables, being performed by the masters. This would definitely not be an argument to carry out live workshops but is an important factor in our country, as most of the patients in live workshops have either free or highly subsidized treatment. Many individual patients have benefited from live workshops.

This would bring the patient rights into focus. All patients undergoing live surgeries in workshops should be counselled thoroughly about the surgery being performed by another surgeon and the postoperative care being taken by the host surgical team. This can create medico-legal issues if thorough counselling and adequate consenting has not been done.

Coming back to the question, whether live operative workshops should be banned? I would say that live operative workshops have benefited many surgeons for training and many patients with their diseases. It is also true that live operative workshops have been banned by a few associations in developed countries. In India, there are very few training opportunities for surgeons to learn newer procedures, newer skills and get exposed to newer technologies. There are only barely available structured and simulator based training centres for surgeons in India. Thus, in my opinion, live operative workshops should not be banned, but should be properly regulated and restricted. I would suggest following 10 steps to be taken by the MCI to regulate live operative workshops:

1. Any live operative workshop should be registered online on the website of MCI, atleast one week prior to the workshop.

2. All the operating faculties must be having a valid MCI registeration, and their certificates should be uploaded on the website. The programme of the workshop should also be uploaded on the website atleast 24 hours prior to the workshop.

3. Any high risk patient ie. ASA grade 3 or 4 or supramajor surgeries having an expected perioperative mortality of more than 1% should not be performed in a live workshop, but should be beamed live on the broadband from the host centre.

4. All patients undergoing surgery in live workshop should be counselled and adequate consent taken.

5. All patients selected for live workshop should be screened through a committee comprising five persons – one host surgeon, one independent expert surgeon, one host anesthetist, one independent expert anesthetist and one physician with 10 years experience

6. Outcomes of all patients undergoing live surgeries in workshops should also be uploaded on the MCI website, 1 week after the surgery and one month after the workshop.

7. An audit for any complications occurring on any patients in live workshops should be performed by the screening committee and results to be uploaded on the website.

8. Live operative workshops showcase the best surgeons to perform complex tasks. A novice surgeon cannot duplicate these tasks just by watching these master surgeons. The best a live workshop does is to motivate or inspire a surgeon to learn new techniques. It does not actually allow a surgeon to perform such complex tasks without adequate in house training and experience. All live operative workshops can carry such a tagline on its brochure. “Live workshop is a demonstration by experts, and should not be considered a replacement for in-service training of surgeons. Procedures seen here should not be duplicated without adequate training and experience.”

9. All Live workshops should be preceded by a session on selection of patients, indications, contraindications and should be followed by a discussion on complications and outcomes.

10. During difficult steps of the surgery ie during control of a bleed, the operating surgeon should be left alone with muting of the microphone so that he can focus on the problem rather than on the discussion.

With a regulatory framework in place, live operative workshops can actually inspire many surgeons to acquire newer surgical skills and update their skills. This can even benefit many patients who would otherwise not have an opportunity to get a surgery from a master in the field at a highly subsidized rates. The jury is not out yet and the debate would continue…….