Surgical tele-mentoring using a robotic platform: initial experience in a military institution.

BACKGROUND: Surgical tele-mentoring leverages technology by projecting surgical expertise to improve access to care and patient outcomes. We postulate that tele-mentoring will improve surgeon satisfaction, procedural competence, the timeliness of operative intervention, surgical procedure efficiency, and key intra-operative decision-making. As a first step, we performed a pilot study utilizing a proof-of-concept tele-mentoring process during robotic-assisted surgery to determine the effects on the perceptions of all members of the surgical team. METHODS: An IRB-approved prospective feasibility study to determine the safety and efficacy of remote surgical consultation to local surgeons utilizing robotic surgery technology in the fields of general, urology, gynecology and thoracic surgery was performed. Surgical teams were provided a pre-operative face-to-face orientation. During the operation, the mentoring surgeon was located at the same institution in a separate tele-mentoring room. An evaluation was completed pre- and post-operatively by the operative team members and mentor. RESULTS: Fifteen operative cases were enrolled including seven general surgery, four urology, one gynecology and three thoracic surgery operations. Surveys were collected from 67 paired survey respondents and 15 non-paired mentor respondents. Participation in the operation had a positive effect on participant responses regarding all questions surveyed (p < 0.05) indicating value to tele-mentoring integration. Connectivity remained uninterrupted with clear delivery of audio and visual components and no perceived latency. Participant perception of leadership/administrative support was varied. CONCLUSIONS: Surgical tele-mentoring is safe and efficacious in providing remote surgical consultation to local surgeons utilizing robotic surgery technology in a military institution. Operative teams overwhelmingly perceived this capability as beneficial with reliable audio-visual connectivity demonstrated between the main operative room and the Virtual Medical Center. Further study is needed to develop surgical tele-mentoring to improve patient care without geographic limitations during times of peace, war and pandemic outbreaks.

Tele-mentoring - a way to expand laparoscopic simulator training for medical students over large distances: a prospective randomized pilot study.

BACKGROUND: Studies have shown the clinical benefits of laparoscopic simulator training. Decreasing numbers of operations by surgical residents have further increased the need for surgical simulator training. However, many surgical simulators in Sweden are often insufficiently used or not used at all. Furthermore, large geographical distances make access to curriculum-based surgical simulator training at established simulator centres difficult. The aim of this study was to evaluate whether tele-mentoring (TM) could be well tolerated and improve basic laparoscopic surgical skills of medical students 900 km away from the teacher. METHODS: Twenty students completed an informed consent and a pre-experimental questionnaire. The students were randomized into two groups: (1) TM (N = 10), receiving instructor feedback via video-link and (2) control group (CG, N = 10) with lone practice. Initial warm-up occurred in the Simball Box simulator with one Rope Race task followed by five consecutive Rope Race and three Peg Picker tasks. Afterwards, all students completed a second questionnaire. RESULTS: The whole group enjoyed the simulator training (prescore 73.3% versus postscore 89.2%, P < 0.0001). With TM, the simulator Rope Race overall score increased (prescore 30.8% versus postscore 43.4%; P = 0.004), and the distance that the laparoscopic instruments moved decreased by 40% (P = 0.015), indicating better precision, whereas in the CG it did not. In Peg Picker, the overall scores increased, whereas total time and distance of the instruments decreased in both groups, indicating better performance and precision. CONCLUSIONS: Simulation training was highly appreciated overall. The TM group showed better overall performance with increased precision in what we believe to be the visuospatially more demanding Rope Race tasks compared to the CG. We suggest that surgical simulator tele-mentoring over long distances could be a viable way to both motivate and increase laparoscopic basic skills training in the future.

Preliminary design and evaluation of a remote tele-mentoring system for minimally invasive surgery.

BACKGROUND: Tele-mentoring during surgery facilitates the transfer of surgical knowledge from a mentor (specialist surgeon) to a mentee (operating surgeon). The aim of this work is to develop a tele-mentoring system tailored for minimally invasive surgery (MIS) where the mentor can remotely demonstrate to the mentee the required motion of the surgical instruments. METHODS: A remote tele-mentoring system is implemented that generates visual cues in the form of virtual surgical instrument motion overlaid onto the live view of the operative field. The technical performance of the system is evaluated in a simulated environment, where the operating room and the central location of the mentor were physically located in different countries and connected over the internet. In addition, a user study was performed to assess the system as a mentoring tool. RESULTS: On average, it took 260 ms to send a view of the operative field of 1920 × 1080 resolution from the operating room to the central location of the mentor and an average of 132 ms to receive the motion of virtual surgical instruments from the central location to the operating room. The user study showed that it is feasible for the mentor to demonstrate and for the mentee to understand and replicate the motion of surgical instruments. CONCLUSION: The work demonstrates the feasibility of transferring information over the internet from a mentor to a mentee in the form of virtual surgical instruments. Their motion is overlaid onto the live view of the operative field enabling real-time interactions between both the surgeons.

Minimally invasive tele-mentoring opportunity-the mito project.

BACKGROUND: Simulation training is a validated method for acquiring laparoscopic skills. Training sessions may be sporadic or lack continuity in oversight by instructors since traditional programs mandate in-person teaching and evaluation. This study presents the development, implementation, and results of a novel smartphone application that enables remote teacher-student interaction. This interface is used to complete a validated program that provides learner-specific feedback. Outcomes of training via Lapp were compared to outcomes of traditional in-person training. METHODS: A web-based and mobile iOS and Android application (Lapp) was developed to enable a remote student-teacher interaction. Instructors use Lapp to assess video recorded training sessions of students at distant locations and guide them through the laparoscopic skill course with specific and personalized feedback. Surgical trainees at two remote training centers were taught using Lapp. A control group was assessed during traditional simulation training at the training facility, with in-person feedback. Pre- and post-training performances were video recorded for each trainee and blindly evaluated by two experts using a global rating scale (GRS) and a specific rating scale (SRS). RESULTS: A total of 30 trainees were trained via Lapp and compared with 25 locally taught. Performance in the Lapp group improved significantly after the course in both GRS and SRS scores, from 15 [6-17] to 23 [20-25], and from 12 [11-15] to 18 [15-20], respectively. The results between both groups were comparable. CONCLUSION: Laparoscopic simulation training using a mobile app is as effective as in-person instruction in teaching advanced laparoscopic surgical skills. Lapp provides an effective method of teaching through simulation remotely and may allow expansion of robust simulation training curriculums.

Strengthening the clinical laboratory workforce in Cambodia: a case study of a mixed-method in-service training program to improve laboratory quality management system oversight.

BACKGROUND: Laboratory diagnostic testing service delivery and compliance with international standards for laboratory quality are directly influenced by laboratory workforce competency. Many hospital laboratories in constrained resource settings such as Cambodia struggle to cope with the training needs of laboratory professionals in an environment of competing healthcare development priorities. Resource-limited countries need an adaptable and effective approach to provide laboratory professionals with job-specific quality oversight training to ensure the accuracy, timeliness, and reliability of diagnostic services. CASE PRESENTATION: Here, we describe the results of an in-service training and mentoring program conducted with the Cambodia Ministry of Health at 12 tertiary-level hospital laboratories to drive improvements in laboratory quality management systems toward ISO 15189 accreditation, which demonstrated significant progress between baseline and outcome audits in a concurrent study. This case study describes the program, and evaluates how the four primary activities, including actionable gap assessments and planning, centralized and in situ training curriculum, in-person mentoring, and remote tele-mentoring via video communication technologies, contributed towards quality improvement in the participating laboratories. We evaluated participant responses to Likert scale and free response questions from program and training evaluation surveys, and we used thematic analysis to develop a model of best practices within the program's four primary activities to inform future training approaches. Of these activities, participants agreed most highly that in-person visits and planning based on gap assessments contributed to their learning and ability to improve laboratory operations. Tele-mentoring was rated lowest by participants, who were critical of excessive group dialogue and distraction during web-conferencing; however, feedback suggests both in-person and remote mentoring contribute to continuing education, accountability to action, and peer collaboration and problem solving to improve workforce efforts toward improved quality management systems. CONCLUSIONS: We recommend here a package of in-service training activities for laboratory quality management system improvement initiatives in resource constrained settings that includes needs-based curricula and personalized action plans for participants; interactive and on-site training workshops; and in-person mentoring, complemented with well managed and regular tele-mentoring that focuses on knowledge retention, accountability to goals, and collaborative problem solving. Our model presents an adaptable approach to human resource development for quality improvement in medical laboratories.

Caring for the Caregivers: Improving Mental Health among Health Professionals Using the Behavioral Health Professional Workforce Resilience ECHO Program.

Behavioral health professionals are at high risk for burnout and poor mental health. Our objective was to understand the impact of the Behavioral Health Providers Workforce Resiliency (BHPWR) ECHO Program on the resilience and burnout of participating behavioral health professionals. We assessed the first two years (March 2022 to March 2024) of the BHPWR ECHO, a national program operating from the University of New Mexico (N = 1585 attendees), using a mixed-methods design. We used a retrospective pre/post survey (n = 53 respondents) and focus interviews with 1-3 participants (n = 9 participants) to assess for changes in knowledge and confidence and assess changes in burnout and resilience. We found that participants increased their knowledge of how to respond when (1) their workload was more than they could manage, (2) they felt that they lacked control, (3) their work did not feel rewarding, and (4) they were experiencing compassion fatigue. They increased their confidence in (1) building a support system and (2) using the wellness tools taught in the course. Respondents were less burnt out (score: 26.0 versus 17.8, p < 0.01) and more resilient (29.9 versus 34.9, p < 0.01) compared to when they started attending the program. Tele-mentoring programs like the BHPWR ECHO Program may improve wellness among health care professionals.

Evaluating a Project Extension for Community Health Outcomes Pediatric Behavioral Health Series in a Rural and Frontier State: An Exploratory Investigation.

Background: Idaho, a predominately rural state, has a high prevalence of mental illness with minimal access to care. Barriers in diagnosis and treatment of pediatric behavioral health disorders could be mitigated with an accessible and effective specialty training program. Methods: A 10-session Project Extension for Community Health Outcomes (ECHO) series was designed to expand provider knowledge about pediatric behavioral health conditions and improve perceived clinical practice skills. Pre- and postseries evaluation surveys and individual session evaluations were used to assess the program. Results: A total of 148 individuals attended at least 1 of the 10 sessions. Participants reported high satisfaction with individual sessions and indicated that attendance positively impacted their knowledge and competency. Participants also reported that the knowledge and skills gained from the series would benefit more than half of their patients or clients. Conclusion: The short ECHO series appears to be a viable and valuable option to provide Idaho providers with effective specialty training that is well attended and well received.

Surgeon satisfaction and outcomes of tele-proctoring for robotic gynecologic surgery.

Surgical proctoring requires increasing resources in growing healthcare systems. In addition, travel has become less safe in the era of COVID-19. This study demonstrates surgeon satisfaction and safety with tele-proctoring in robotic gynecologic surgery. This pilot study assesses surgeon satisfaction and operative outcomes with a novel operative tele-proctoring system with a continuous two-way video-audio feed that allows the off-site surgeon to see the operating room, surgical field, and hands of the robotic surgeon. After thorough system testing, two experienced surgeons underwent tele-proctoring for hospital credentialing, completing 7 total cases. Each completed pre- and post-surveys developed from the Michigan Standard Simulation Experience Scale. Surgical characteristics were compared between tele-proctored cases and 59 historical cases proctored in-person over the last 8 years. Surgeons reported unanimous high satisfaction with tele-proctoring (5 ± 0). There were no major technologic issues. Five of the tele-proctored cases and 35 of controls were hysterectomies. Mean age was 48.2 ± 1.4 years, mean BMI was 29.6 ± 0.9 kg/m2, and mean uterine weight was 152 ± 112.3 g. Two-thirds had prior abdominal surgery (P > 0.1). Tele-proctored hysterectomies were 58 ± 6.5 min shorter than controls (P = 0.001). There were no differences in EBL or complication rates (P > 0.1). Tele-proctoring resulted in high surgeon satisfaction rates with no difference in EBL or complications. Tele-mentoring is a natural extension of tele-proctoring that could provide advanced surgical expertise far beyond where we can physically reach.

Advanced virtual mentoring of dentists in oral cancer screening and tobacco cessation - An interventional study.

Context: Oral cancer is the third common cancer in India. Its mortality can be reduced through early detection and tobacco cessation ideally by dentists owing to their forte of work. Aim: This study was conducted to discuss effectiveness of an advanced tele-mentoring programme in oral cancer screening and tobacco cessation for dentists across India. Settings and Design: Online, interventional study. Methods and Material: The 14-week long training programme with 52 participants/spokes from across India had weekly hour-long online sessions comprising of an expert-led didactic and case discussions by spokes. Online evaluation (pre- and post-training, post-session), weekly and post-one-year feedback were conducted. Successful spokes attended a hands-on workshop subsequently. Statistical Analysis Used: One and independent sample t-tests determined the significance of the evaluation scores of the participants. Findings on attitudes and practice-related questions are presented as simple percentages. Results: A notable increase in the overall and per-session mean knowledge score, and confidence in oral cancer screening was observed. Many participants started these services at their clinics, thereby reducing further referrals, and were also motivated to spread community awareness about the same. Conclusion: This tele-mentoring programme, based on the novel Extension for Community Healthcare Outcomes model, is the first oral cancer screening training programme for dentists. This model-comprising of expert didacts, case discussions, and significant spoke-expert interaction-is a promising best-practices tool for reducing the disparity in knowledge and skills regarding oral cancer prevention among dentists across different locations. This would enable these most appropriate healthcare providers to contribute toward the overall goal of oral cancer prevention.

Evaluation of user-interfaces for controlling movements of virtual minimally invasive surgical instruments.

BACKGROUND: Recent tele-mentoring technologies for minimally invasive surgery (MIS) augments the operative field with movements of virtual surgical instruments as visual cues. The objective of this work is to assess different user-interfaces that effectively transfer mentor's hand gestures to the movements of virtual surgical instruments. METHODS: A user study was conducted to assess three different user-interface devices (Oculus-Rift, SpaceMouse, Touch Haptic device) under various scenarios. The devices were integrated with a MIS tele-mentoring framework for control of both manual and robotic virtual surgical instruments. RESULTS: The user study revealed that Oculus Rift is preferred during robotic scenarios, whereas the touch haptic device is more suitable during manual scenarios for tele-mentoring. CONCLUSION: A user-interface device in the form of a stylus controlled by fingers for pointing in 3D space is more suitable for manual MIS, whereas a user-interface that can be moved and oriented easily in 3D space by wrist motion is more suitable for robotic MIS.

Towards development of a tele-mentoring framework for minimally invasive surgeries.

BACKGROUND: Tele-mentoring facilitates the transfer of surgical knowledge. The objective of this work is to develop a tele-mentoring framework that enables a specialist surgeon to mentor an operating surgeon by transferring information in a form of surgical instruments' motion required during a minimally invasive surgery. METHOD: A tele-mentoring framework is developed to transfer video stream of the surgical field, poses of the scope and port placement from the operating room to a remote location. From the remote location, the motion of virtual surgical instruments augmented onto the surgical field is sent to the operating room. RESULTS: The proposed framework is suitable to be integrated with laparoscopic as well as robotic surgeries. It takes on average 1.56 s to send information from the operating room to the remote location and 0.089 s for vice versa over a local area network. CONCLUSIONS: The work demonstrates a tele-mentoring framework that enables a specialist surgeon to mentor an operating surgeon during a minimally invasive surgery.

A Qualitative Evaluation of the Pain Management VA-ECHO Program Using the RE-AIM Framework: The Participant's Perspective.

Introduction: Veterans frequently seek chronic pain care from their primary care providers (PCPs) who may not be adequately trained to provide pain management. To address this issue the Veterans Health Administration (VHA) Office of Specialty Care adopted the Specialty Care Access Network Extension for Community Healthcare Outcomes (VA-ECHO née SCAN-ECHO). The VA-ECHO program offered training and mentoring by specialists to PCPs and their staff. VA-ECHO included virtual sessions where expertise was shared in two formats: (1) didactics on common pain conditions, relevant psychological disorders, and treatment options and (2) real-time consultation on patient cases. Materials and methods: VA-ECHO participants' perspectives were obtained using a semi-structured interview guide designed to elicit responses based on the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework. A convenience sampling was used to recruit PCPs and non-physician support staff participants. Non-physicians from rural VHA sites were purposively sampled to gain diverse perspectives. Findings: This qualitative study yielded data on each RE-AIM domain except reach. Program reach was not measured as it is outside the scope of this study. Respondents reported program effectiveness as gains in knowledge and skills to improve pain care delivery. Effective incorporation of learning into practice was reflected in respondents' perceptions of improvements in: patient engagement, evidenced-based approaches, appropriate referrals, and opioid use. Program adoption included how participating health care systems selected trainees from a range of sites and roles to achieve a wide reach of pain expertise. Participation was limited by time to attend and facilitated by institutional support. Differences and similarities were noted in implementation between hub sites. Maintenance was revealed when respondents noted the importance of the lasting relationships formed between fellow participants. Discussion: This study highlights VA-ECHO program attributes and unintended consequences. These findings are expected to inform future use of VA-ECHO as a means to establish a supportive consultation network between primary and specialty care providers to promote the delivery evidence-based pain management practices.

Changes in Opioid Prescribing Behaviors among Family Physicians Who Participated in a Weekly Tele-Mentoring Program.

A weekly tele-mentoring program was implemented in Ontario to help address the growing opioid crisis through teaching and mentoring family physicians on the management of chronic pain and opioid prescribing. This study assessed opioid prescribing behaviours among family physicians who attended the tele-mentoring program compared to two groups of Ontario family physicians who did not attend the program. We conducted a retrospective cohort study with two control groups: a matched cohort, and a random sample of 3000 family physicians in Ontario. Each physician was followed from one year before the program, which is the index date, and one year after. We examined the number and proportion of patients on any opioid, on high dose opioids, and the average daily morphine equivalent doses prescribed to each patient. We included 24 physicians who participated in the program (2760 patients), 96 matched physicians (11,117 patients) and 3000 random family doctors (374,174 patients). We found that, at baseline, the tele-mentoring group had similar number of patients on any opioid, but more patients on high dose opioids than both control groups. There was no change in the number of patients on any opioid before and after the index date, but there was a significant reduction in high-dose opioid prescriptions in the extension for community healthcare outcomes (ECHO) group, compared to a non-significant increase in the matched cohort, and a non-significant reduction in the Ontario group during the same comparable periods. Participation in the program was associated with a greater reduction in high-dose opioid prescribing.

Dermatology ECHO: A case presentation demonstrating benefits of specialty telementoring in primary care.

Allergic contact dermatitis (ACD) is a common dermatologic disorder that is estimated to affect 15-20% of the general population. Because of its prevalence, it may be expected that ACD should be easily recognized. However, it can present with many clinical variations that may complicate diagnosis. Although ACD is a treatable condition, patients from rural and underserved areas suffer if timely access to specialty care is limited. Dermatology Extension for Community Healthcare Outcomes (Dermatology ECHO) telemedicine sessions were created to mentor rural primary care providers (PCPs). To illustrate their benefit, we present the case of a 19-year-old female patient who suffered from worsening undiagnosed ACD for over nine months following a laparoscopic appendectomy. During that time, the surgeon and multiple PCPs treated her with antibiotics, antivirals, and Scabicide without improvement in her condition. The de-identified patient case was presented by her PCP during the Dermatology ECHO session. The Dermatology ECHO specialty team mentored and educated the PCP in the diagnosis and treatment of ACD. After making the diagnosis, the patient received new treatment and her condition improved significantly. Dermatology ECHO provides a knowledge-sharing network for participating PCPs that may improve patient outcomes and reduce patient suffering.

Evaluation of an innovative tele-education intervention in chronic pain management for primary care clinicians practicing in underserved areas.

INTRODUCTION: Inadequate knowledge and training of healthcare providers are obstacles to effective chronic pain management. ECHO (extension for community healthcare outcomes) uses case-based learning and videoconferencing to connect specialists with providers in underserved areas. ECHO aims to increase capacity in managing complex cases in areas with poor access to specialists. METHODS: A pre-post study was conducted to evaluate the impact of ECHO on healthcare providers' self-efficacy, knowledge and satisfaction. Type of profession, presenting a case, and number of sessions attended were examined as potential factors that may influence the outcomes. RESULTS: From June 2014 to March 2017, 296 primary care healthcare providers attended ECHO, 264 were eligible for the study, 170 (64%) completed the pre-ECHO questionnaire and 119 completed post-ECHO questionnaires. Participants were physicians (34%), nurse practitioners (21%), pharmacists (13%) and allied health professionals (32%). Participants attended a mean of 15 ± 9.19 sessions. There was a significant increase in self-efficacy (p < 0.0001) and knowledge (p < 0.0001). Self-efficacy improvement was significantly higher among physicians, physician assistants and nurse practitioners than the non-prescribers group (p = 0.03). On average, 96% of participants were satisfied with ECHO. Satisfaction was higher among those who presented cases and attended more sessions. DISCUSSION: This study shows that ECHO improved providers' self-efficacy and knowledge. We evaluated outcomes from a multidisciplinary group of providers practicing in Ontario. This diversity supports the generalisability of our findings. Therefore, we suggest that this project may be used as a template for creating other educational programs on other medical topics.

Effectiveness of NIMHANS ECHO blended tele-mentoring model on Integrated Mental Health and Addiction for counsellors in rural and underserved districts of Chhattisgarh, India.

The present study was conducted to ascertain the effectiveness of Project ECHO, a Hub and Spokes tele-mentoring model to bridge the urban-rural divide in mental health and addiction care in the context of a developing country like India. The Counsellors from 11 rural and underserved districts of Chhattisgarh were periodically connected to NIMHANS multidisciplinary specialists by smartphone app and underwent virtual mentoring to learn and translate "best practices" in Mental health and Addiction by using "patient-centric learning", a core component of NIMHANS ECHO model. The outcome evaluation was modelled on Moore's evaluation framework focusing on participant engagement, satisfaction, learning, competence and performance. Over the period of 6 months i.e. 12 tele-ECHO clinics, 41 patients case summaries were discussed by the Counsellors with NIMHANS Hub Specialists. Half of the counsellors could join >80% clinics and overall there were no drop-outs. There was a significant increase in learning and self-confidence after six months. The participants liked "relevance of the courses to clinical practices". "group based discussions" and "a reduction in professionals isolation". The results indicate promise of the NIMHANS ECHO tele-mentoring model as one with potential for capacity-building in mental health and addiction for remote and rural areas by leveraging technology.

The Current State of Telemedicine in Urology.

Telemedicine use in urology is an evolving practice. In this article, the authors review the early experience of telemedicine specifically as it relates to urologic practice and discuss the future implications and the utility of telemedicine as it applies to other fields.

A tele-mentoring tobacco cessation case consultation and education model for healthcare providers in community mental health centers.

Smoking prevalence among individuals with mental and behavioral health needs is considerably higher compared to the general population, but evidence-based smoking cessation therapies are underutilized in mental and behavioral healthcare settings, despite the fact that these treatments are both safe and effective. The goal of this paper is to present the background, design and pilot of Project TEACH (Tobacco Education and Cessation in the Health System) developed to improve clinical practice by offering specialized training in the provision of smoking cessation interventions to care providers in community mental health centers in Texas. This is achieved through engaging the expertise of clinicians at the MD Anderson Cancer Center's Tobacco Treatment Program and disseminating this expertise to care providers by means of a novel tele-mentoring approach called Project ECHO (Extension for Community Healthcare Outcomes). Evaluation of our pilot ECHO training project demonstrated that the training was very well received and resulted in self-reported enhancement of the providers' professional practice. This is the first project to extend the collaborative ECHO model to train healthcare providers in smoking cessation. This approach has potential to reduce smoking rates among smokers with mental and behavioral health needs, and consequently contribute to the prevention of cancer and other chronic diseases in this vulnerable population.

Beyond 2D telestration: an evaluation of novel proctoring tools for robot-assisted minimally invasive surgery.

Experienced surgeons commonly mentor trainees as they move through their initial learning curves. During robot-assisted minimally invasive surgery, several tools exist to facilitate proctored cases, such as two-dimensional telestration and a dual surgeon console. The purpose of this study was to evaluate the utility and efficiency of three, novel proctoring tools for robot-assisted minimally invasive surgery, and to compare them to existing proctoring tools. Twenty-six proctor-trainee pairs completed validated, dry-lab training exercises using standard two-dimensional telestration and three, new three-dimensional proctoring tools called ghost tools. During each exercise, proctors mentored trainees by correcting trainee technical errors. Proctors and trainees completed post-study questionnaires to compare the effectiveness of the proctoring tools. Proctors and trainees consistently rated the ghost tools as effective proctoring tools. Both proctors and trainees preferred 3DInstruments and 3DHands over standard two-dimensional telestration (proctors p < 0.001 and p = 0.03, respectively, and trainees p < 0.001 and p = 0.002, respectively). In addition, proctors preferred three-dimensional vision of the operative field (used with ghost tools) over two-dimensional vision (p < 0.001). Total mentoring time and number of instructions provided by the proctor were comparable between all proctoring tools (p > 0.05). In summary, ghost tools and three-dimensional vision were preferred over standard two-dimensional telestration and two-dimensional vision, respectively, by both proctors and trainees. Proctoring tools-such as ghost tools-have the potential to improve surgeon training by enabling new interactions between a proctor and trainee.