Television Technics in Graduate Surgical Education

VICTOR RICHARDS, MD, San Francisco, California HENRY JACOBS, MA, San FranCiscolCalifornia

"History." said H. G. Wells in a broad sweeping prophetic sentence. "is a race between education arid catastrophe." Little did he realize, however, that knowl- cd,,e was to t~row and accumulate at such a tremendous rate that education was soon to be overwhelmed by the information explosion. M~ln has now reached the stage :~ which he is in danger of losing in understanding what be is g;tining in information. Education itself faces c:~tastrophe unless technics evolve to control the ex- t~k~skm of information by the acquisiiion of under- standing. Our danger in education, to paraphrase John (k:rdner. "is the creeping disaster that overtakes a ~ocietv which little by little loses a commanding grip ,~n its problems and its future." We are dreadfully behind the times in dealing with modern modes of in- formation transfer and in applying modern technology :~ssociatcd with learning to the educational process.

Education is a lifelong process. The information c~plosion not only challenges the undergraduate stu- dent in medicine but also threatens the graduate physi- cian with a progressive information gap and accelerating incompetence. Our teaching practices and our profes- sional medical practices have not yet been soundly !~.ookcd into available methods for the retrieval of in- i,.~rmation and the transmission of knowledge. There is ,~ crying need. in making education simple, continuous, .~nd lifelong, to turn the uses of technology to the con- .enience and benefit of the individual in the retrieval, .,.cquisition, stimulation, and transfer of knowledge.

Technology can be made to serve both the educator :~nd his d!sciple. For the superb educator and teacher '~e audience for the dissemination of distilledinforma- :,on becomes, through film, tape, and sound, the world ~l~d not the isolated individual or classroom. Moreover, ~f technology could make education more convenieni :~:ad economical, the student and physician, particularly the gradhate, could select his own teacher, his own~SUb- jcct. and his own rate of learning in the setting most conducive to his goal which is the better care of patients in health and sickness.

To make technology the servant, not the master, of the educational process, clearcut goals must first be

From tl~e Electronic Learning Research Laboratory of the Children's Hospital. San Francisco, California, This work was supported by a grant from the California Division of the American Cancer Society.

Presented at the Forty-First Annual'Meeting of the Pacific Coast SUrgical Association. San Francisco, California, February 15-18. 1970.

defined. The goal in medicine, broadly speaking, is to improve the quality of medical Care. The objectives, employing television technics,, would be to bring current information, skill, and knowledge to the student (under- graduate or graduate) in a simple, convenient, econom- ical, stimulating, and continuous flow. The !mpact of continuing education would effect a change in !he physi- cian's approach to the prevention of illness, the preser- vation of health, and the imposition of specific diag- nostic and therapeutic skills (such as drugs and surgical procedures) in fulfilling the health care needs of Society.

Our purpose in this pi'esentation is tore late our experiences in the use of television in graduate surgical education, recognizing that the problems in cOmmunica- tion, acquisition of skills, and education are universal to all disciplines.

Background and Initial Development

In 1967 we were awarded a small grant of $20,000 over a two year period tO explore the uses of television. videotape, and related media to continuing medical education in cancer. A small television :studio andre- cordingsystem were designed in an area of less than 500 sqaui'e: feet within the Children's Hospital which" we called the Electronic Learning Research Laboratory. With one Cohu-Kintel 3200 vidieon televisi0n camera witha,q0 to I Zoom lens and one Ampex 7500 C video~ tape recorder, a 1 inch helical scan With .Iwo : audio tracks at a cost of about $12,500, we began/making black ~d white television tapes; We recorded chalk talks, medical eonferences,grand rouhds,l-and surgical procedures, and made for display (o regi0nal.h0spitals a series of talks on cancer, covering- teal Subjects~in- eluding the head and neck; breast,, lung, gastrointestinal tract, rectum and co!on, etiol0gy, virology, immunology; isotopes, and chemotherapy of cancer~ These ~ tapes were evaluated by:written questiopnaires and by record. ing interviews with physicians on :a' Portable tape"re, corder. Each tape lasted approXlmately- "twent)minrutesl

The results o f the eValuati0h were imeresting: Mo~t

~ hysicians filled out the questionnaires as rapidly as ossible, praised the approach tremendouslyas ~ ha(~ing the potential . of copingWith the information explCsion, but rarely took the twenty mifiutes to :cotnplete.the tape for'it was not in their particular fieid oflinterest~ EW:

Volume 120, August 1970 153

Richards and Jacobs

thusiasm ran high, but tile message was far from reach- ing its expressed goat.

Our initial premises were simple: (1) the tapes should be short and concise, not over twenty minutes; (2) the presentation should be real, lifelike, and ill a familiar setting (cinema vdrit6); (3) the tapes should be so convenient as to be inescapable, that is, in the doctors' lounge, office, or hospital cottee room: (4) the tapes shoukt be inexpensive to produce, thus essen- tially disposable: and (5) the density of information transmitted per unit of time should be high to maintain interest and conserve t ime.

The response to the questionnaires praised the con- cept and the presentations, aside from some technical shortcomings, in g,lowing terms: however, we rcalizetl that we had begun to fill an information gap but had not broken the communication barrier. The main prob- lems in the commu,aication barrier seemed to bc: ( I ) the visual images on our modest equipnmnt were of low resolution on copying, that is, tile images were seen at tile physican's convenience, but were of n'todest quality; (2) our images were black and white ~mly, hardly adequate to at'ract the eye of the ph}sician in the present era of electronic sophistication with color. and furthernaore, color presentation is required to pre- sent the tone, depth, and gradations ill visual field required to demonstrate su,'gical tcchrics: f3) our visual display lacked something to stinmlate nnd re- stimulate the interest and eye of the observer, that is. the visual imagery was too monotonous and nol up to the inherent capabilities of the media.

These shortcomings were purely technical and sohmte with better equipment. Of greater concern to us, how- ever. were basic problems in communication centering around the motivation and behavior of the graduate physician viewing the tapes. The graduate physician is primarily interested not in general knowledge but in specific information related to a particular problem of interest at the moment. The motivation to learn comes from a specific need, and the physician would like to use the learning media as he does a book, a journal, or library. We clearly needed a library of television tapes so that the individual physician could view the tape at the desired time.

Furthermore, the transmission of gcneral knowledge in a group setting is greatly enhanced by participation of the student, learner, or audience in the learning process. "-l'he tapes should be available in a given hospital to serve as a leader of group discussion, and the audience should not be permitted to remain a passive spectator in the learning process. Group interaction can make the audience active participators in the educational process. Of equal importance, but harder to achieve, is tile direct feedback relationship between teacher and pupil in the communication of knowledge wherein they share common interests and work as more

or less equal partners in the discussion and acquisition ~I" inft)rmation.

Cur initial premises were simple and sound, but they had now tO be expanded with additional postulates: ( 1 ) colur wus essenti-fl to many presentations, particularly surgery; (2) rnultinwdkt display would sthnulntc, cap- lure. and hohl tile attention el_the learner; (3) nlt~tiva- tion for spceilic learning required a videotape librilry; (4) audience participution of an active m~lure enhanced the le:u'ning process; and (5) direct lWt~+way communi- cation arid fce,.!bnck t~etween teacher and pupil were diflicuh t~ ublain but desirable, l:Educafion IL~ be ati~e and real is an uctivc, motivated, coh)rful, d.,,nanfic, and conml t ,n ieat ivc "vent tire.

The Multirnedia Educational Display System

Consequent to uur initial experiences we soug, ht a system which would give us good coh>r, g~xl ,,isu:d resolution, high-fidelity .y, otlnd. ;.tlld ccoll~.~nly' '..vhich '~,C could util ize to build a tape library. The ~,>.stem would ha~c to stimulate, restimula~e, and hold the c>e of tll~." viewer, a sy,~tcm with a bui l t - in rcfrc,dting, principle. Yet the display had to bc convenient, at the physici~m's beck and call, and have the vitalilv and dynamism of television with the reportorial excellence nf color+stidc photography. To paraphra:,e Nicfd'luha,n, the n~cdium must bc "'the message" and be "hot."

A critical survey of existing mcdi:, was made. Buoks and periodicals, unquestionably essential to the com- munication process and uhimutety irreph~ceabte, were the cau:,e of the infornmtion explosion, the prubtem we were trying to sMve. Movie film,+ (8. 16. 35, and 70 ram) tire ct~stly to produce, lack the spontaneity c,f television, are time-consuming, do not naturally emerge from the day's work. hart no possibility of inexpensive animation, and require extra wo,k and expense for a good sound track. Live radio broadcasts arc often a t an inconvenient time. are still limited to verbal presenta- tion. permit two-way communication between teacher and pupil, but seem to be most valuable when converted to audiotapes which can be heard at the learner's con- venience, that is, the Audio-Digest. Live television is not always broadcast at a convenient time. is expensive, and is often unsuitable for public broadcast. Broadcast videotapes are too costly in tape stock+ video equip- ment. and technical staff for most hospitals and in- dividuals to utilize. 35 mm color slides are inexpensive and have high quality visual resolution, They can be triggered from an audiotape, but this technic does not provide for leading tile eye to specific details within tile slides, and tile vitality of the presentation is not com- petitive with television. The use of 35 mm color slides would provide reportorial excellence and. if combined with television, might provide a promising medium which would fulfill our total postulates. We, therefore, settled on a trial of a multimedia display system in

154 The American Journal of Surgery

Television in Graduate Surgical Education

which the reportorial excellence (ff 35 mm color slides would be l inked and activated by the audiochannel of Ihc live telcvision tape, providing the advantages of television tapes, good resolution, color, eye-refreshing imagery, high-fidelity sound, economy, and case of product ion .

The mult imedia display syslem h:ls the following ~:omponents: ( I ) a vidcotape recording system. (2) 2 ~r more 35 mm slide projeclors. (3 ) a stereo audio- recorder, and t"4) ~l custom designed slide programmer. ,tqgurcs I and 2.) Program materials are a mono- : t - l 'ome vidcot,~pc, a stereo audiotape, and two or more .:ar~uscls of 35 mm color slides. The videot:~pe gen- crutc~ a bhtck ;white television picture with high-fidelity ~ur~d. On the sccc~nd :tudioehannel of the videotape we l~rt~gr~m~ bccp sigmds to advance the two carousels in ~.mdem l 'hc ult imate viewer .',ces three screens which intermittently di,,pluy lwo cc, lor im~.gcs and one tele- ,~si~n m~nocltrt~me mlagc, This on-off characterist ic ~- the t]i,,pl;~y seems to gcner;~te a Pavlovia~ response ~,~ the ~icwcr in the f()rm ()f :mticip~lting the rm,.ppear- ,u~cc of the impact, lhe disph~y constantly rewards, then dcprt~c,; the %,iewer'~ anticip:~tion, kindling, and re- ki)~dlmg ])i,, interest, b()th visual und auditory. The c(~mponelltS :lntl :~rrangcmcnt of the system arc illus- '~r.~tcd in the following di:tgrzm~, and the details of the equipment :~rc described in another publication. The s,.slcm requires 1.330 ~.~,:I_lllS of power, and is portable. ~ a r~obilc cart f~3r use lhroughout lhe hospital.

Product ion o~ Current P rograms

lh product ion of :t progr;m~ remains simple, brief. i~x[.~nsivc, und purely a' the convenience and dis- ~rcuon of the individual teacher. (F igure 2.) The ~cchncdogy serves the teacher and stimulates the viewer. Fhe setting ix famil iar to teacher and student alike; the

production is real, spontaneous, automatic, and can include actual operat ing room scenes, footage from existing movies, existing books, charts, and diverse displays within the mult imedia approach. The finished product can be diversified but requires only the' in- genuity and talent of the individual .teacher and one television operator with an interest in communicat ion. There is no direction, no script, no programming, for it is true to life, real, unrehearsed, and spontaneous. The setting also is real for the student, the old classroom where he !earned best. or the operating room where he acquired wduablc skills and judgment.

The educator assembles his graphic material, such as 35 mm color slides, roentgenograms, photographs, pa- tients, drawings, films, charts, and blackb5ards. By a sparing use of colored construction paper, acetate, and marking pens we can inject color into a slide, frame. group, encircle, and underline. Source credits, including references to journals, books, and articles, can be given easily. The slides are distributed by the speaker into the two empty carousels, alternating left and 'r ight carousels but also interjecting blank slides at irregular intervals to produce the on-off stimulating response in the viewer. The speaker can preview all of his slides and rcvicw the entire subject matter to adjust the scope and lime of the presentation. He is then ready to pro- duce the television program.

The television camera then focuses on the teacher. The teacher can use the media which suits him best at the moment, such us the blackboard, x-rays, slides, or cuts from movies. The camera focuses on the teacher when he is talking, but zooms to the slides, b lackboard, or other media as he utilizes them. A moving pointer, still or electronic, leads the eye to the desired detai l on the color slide. The triple screen permits one screen to present one slide, the second screen another, and the

Figure 1. The portable mult imedia view- mg device (below).

Figure 2. Preparation and production of vtsual material for mult imedia display.

~'~" ,-.~ 1 f ~" "

. . . . [ . . . . . . . . . . ]

Volume 120, August 1970 155

Richards and Jacobs

zoom of the camera to focus on the detail of the slide trader immediate discussion. The slides serve as notes and guides for the talk; however, since the teacher is off camera when the slides are being shown, he can utilize notes, books, or script for his narration without marring the presentation. The pointer focuses attention and is 0isplayed on the television monitor. The uhimate viewer can easily switch back and forth between the original slide, in full and sharp color, and the pointer highlighting the detail on the television image. The zooming quality of the television lense permits excellent highl)ghting of details of any slide. When two blank slides appear side by side. a transition point is indicated from one subtopic to another. The television can]era moves back to the teacher when the slides arc not being shown. When the tape is finishcd, it is rewound and the slides are recycled. The program can be studied, altered, or modified easily at any stage by merely re- doing that portion.

This particular system combines inexpensive black and white television with quality color resolution of 35 mm photograph),'. The use of a color television camera would permit the entire program to be shown in color, and as color cameras become less expensive, the entire master tape can be made in color.

The cost of a twenty minute multimedia videotape with our present black and white television system and color slides, exclusive of the two people involved in the production, is approximately S30 to S35. that is. the I inch videotape is S 16.66, 100 color slides $13.50. and the audiotape $1.00. totaling $30.16. (A one hour tape with slides would cost approximately $.100.)

This is an interesting figure to compare with costs of other media. For example, a twenty minute 16 mm sound fiim can cost from $800 to $8000 depending on film stock, editing, and laboratory costs. A twenty min- ute broadcast color videotape: costs $160 for the tape plus $50 to $5000 per hour for studio and crew. These remain single media and have but one form; they can neither contract nor expand, be easily changed, nor are they modular.

The Communication Package

The multimedia approach has for the moment an- other potential advantage. The educational demonstra- tion can easily be converted to other existing media of communication. For example, the 35 mm slides need only be'reduplicated and the system can be used from a stereotape recorder with the first channel of the tape recorder delivering the'sound and the second channel of the tape recorder triggering the synchronized slide sequences. This of course loses the ability of the tele- vision zoom lens to follow with a pointer the section of the slide under discussion.

Similarly the Slides can be converted to a film strip and the film strip can be utilized on one of the new

desk-type sound-film viewers, such as the Audiscan viewer and 3M disc viewers. These special sound-film viewers arc becoming less expensive and have the advantage of being available in the physician's home or ofl!.cc.

The entire program can be converted to 16 mm or super 8 mm tilm by simple ph3m::~graplaic technics under ideal simple lighting. This converts the multimedia tele- vision tape to a cartridge super 8 mm lilm. The multi- media cycling and viewer-holding devices can be in- corporated by split-image photography.

q'he sound call be converted tc~ a written syllabti~,; and the syllabus and slides can be studied and rc~aincd by the viewer at his convenience. This approach may be required if television display is not pos.,ihtc, but scorns far less desirable as at technic of conllr|unicalion.

Current Uses of the Multimedia System in our Hospital

With the goal of improved patient care we ;uc cur- rent[y exploring the uses of our multimcdi,t tele~i,,ion tape approach to gradualc yttrgicat education in the following areas:

I. ~he creation of a library of surgical tclevb, um tapes on-a great diversity ~ff subjects. l 'hc gradua,tc surgeon would thel~ use these television tapes and slides as he currently uses the books and j,:)urnals t~f the library. This will ;permit us to stud) and evaluate the television tape when the student is moliv.'~ted to tearn a particular subject.

2. Electronic journalism. The graduate surgeon is currently engaged in journal club reviews or in ,.~ys- tematic reviews of surgical topics in current literature. To become an active participant in the ed~cational process and to stimulate him to c, ptimal performance, we will begin having the ~raduate surgeons make multi- media television tapes for our television library. This also permits the individual m review and improve his performance as an active teacher of his confreres. Sur- prisingly go~ visual material and television tapes have been produced by residents who then become anxious to perform, display, and record their knowledge.

3. Detailed case studies and complete presentations. One of our best teaching exercises is a careful review of patients currently undergoing treatment. The graduate surgeon is stimulated by these educational technics to perform, participate, and communicate, all of which enhance the educational process. The material can easily be stored and is available for review, again in library form. The hospita ! begins to evaluate itself and its work by this new educational technic.

4. Instant replay. The learning experience, particu- larly in the operating room and less effectively in the emergency room, can be strengthened by instant surgi- cal replay, an inexpensive playback technic only pos- sible with-television tapes. By this technic the experi-

156 Th~Amertcan Journal of Surgery

cnccd surgeon +an actually demonstrate desirable operalivc skills, the graduate student can a,'tempt to :mulatc them. and the perform:race can be critically analyzed by student and teacher at their convenience. Moniloring in tile recovery room setting is more diM- cull. The operat ing .room, emergency room. and in- ;cn~vc care rooms, however, lend themselves to critical ,qaalvsi~ of urgent problems for which instant decisions :~ltl~! be inade ;.lnd wherein subsequent :malysis of the ~rc and result in critical situations unfold for review w teacher and student. Attention. motivation, and :~.~rlicip;~l~on art: incscapnble as recorded by the tele- .~,lon lapc. and ev,duation of oneself, tile learning . ,pcr icncc. and behavioral patterns emerging from con- :muine education i.', inexpensive, feasible, and rewarding ',, l eacher al'ld student alike.

The ~hort. conc l~,c , prat}matic tape. The material , thccd ;dmo~t :mtomalicallv in the daily care of p:~lcm,, can bc tram, f,~l'mcd into short, concise, practical ".,p~,~ which clearly th.'monstratc the solution to cofllnlon ~:cnt problems, fhcsc tapes arc particularly useful for ~hc pr;;cncing phy.-ician and ancil lary heahh personnel :~,r~kin~ in :u'c:l~ of ~pccial c;,re within the hospital. ~pccific new information is casiiv converted into useful z ~,~wlcd,_,c m pr':gmalic packmgcs of five to ten minutes

The Ultimate Technologic Achievement

('tur,entlv the production of these diIIerent types of ~cic~i~ion t:tpc~ with varying educational and psycho- ,~'_'ic cnhanccn;cnts is beconfing simple, automatic, pontanetms, and iqcxpcr,~ivc. The display of recorded

'~,~.crhd i~ stitl troublesome and somewht expensive. ~)ur system, for example, requires a playback recorder ~:~d two carousel projectors. Other systems invariably ,,:quirc a playback recorder, which for color television

sts currcnth, $7000 to $I0.000. The black and white ,htyback recorder only is far Icvs expensive but still

,.~1~couraging to the hospital and particulnrly to the ',dividual for home use. Black and white playback re- ,,rders range between $700 and $1500.

At the present time it would appear that three ~mpanies will soon have small cartridges tlmt ~ can be :rached to home television units for playback of pecial y processed color television tapes. The Sony .vstem is still undisclosed but will be demonstrated ,hortly, The Columbia Broadcasting System is currently displaying all Electronic Video Recorder fEVR) which will cost under $1000 and which will be available for i~ome use. Radio Corporation of America is developing :~ holographic teclmic for making home television tapes which will permit inexpensive home display in color.

In all of these commercial systems the current tele- vision tapes will have to be converted to a particular home display system. This will be rather expensive initially, but the price will drop shortly. The ultimate in

Television in Graduate Surgical Education

convenience and motivation will be achieved by the development of these home color systems. Excellent color quality at low cost will be available, but the graduate physician will remain passive in this environ- ment and education will be strictly content-oriented.

Advances in educational psychology can make the student an active participant in the educational process. These new educational technics are particularly appli- cable to television and the use of television tapes. The physician need only be aware of his deficiencies. With proper motivation he will select the educational tape of his need and interest. Gaming speculation technics can be applied to the learning process at home so that the student actively participates in the learning process and his education can be controlled and programmed. matching his response to correct responses indicated by starting and stopping the tape at appropriate questions by the teacher. Tapes of this type can be specially prepared and used individually or in group learning experiences, Continuing education of the physician in his home environment or hospital setting will make cducation a daily rewarding experience rather than a struggle with the information explosion. Tile physician will not have to be relieved of the problem of the management of llis day to day practice to' continue his education, and the financial costs of re-learning and continuing education will be meaningful, pleasant, and tolerable. His pattern of medical practice will not have to be reorganized to permit new information to flow into usable knowledge. Ultimately, many organizations and our good hospitals will be engaged in daily lifelong continuing convenient education, and with the new uses of tcchnology, particularly television and developing participatory technics, active learning by the physician will enfible him to cope with the information explosion in his home environment. The universities will with private industry develop the educational concepts and technology, but will share the enormous responsibility of supporting aew emerging programs for a lifetime of learning. The goal of better and improved patient care will be progressively achieved as new educational objectives and technologic advances alter the behavior of ihe practicing physician in his daily work.

Summary

Television technics have tremendous major applica- tion in graduate surgical education. We have devised a multimedia display technic which has the adwmtages of being simple, economical, corivenient, and stimulat- ing. By combining the reportorial excellence of 35 mm color slides with the dynamic qualities of television, we have developed a unit which holds the individual's attention and communicates to him forceably. The rapid, inexpensive production of tapes permits building of a multimedia tape library. We arc looking for future methods of securing two-way communication between

Volume 120, August 1970 157

Richards and Jacobs

the teacher on the television screen and the student in the television audience.

Discuss ion

DONAI.D Bn~,YTON (Los Angeles, Cal i f ) ; Doctor Victor Richards' innovative combiuation of several audiovisual technics into one system undoubtedly is most effective in his hands. The development of audiovisual productions capable of standing alone as leaching devices has been a significant challenge to many of us attempting to use the,~e modalities for wide distribution.

Those of us who are nlernhers of the Council on Medical Television an'd of the Association of Medical Television Broadcasters (AMTvB) have discovered that the proper use of the media ha.,. to be learned slowly and painfully as indicated by Dr Richards. Television is more than just radio with pictures. The professional knowledge and artis- try capable of producing programs that both attract and teach the viewer are rare. As hard'.~are required for the production of intramural program.,, is becoming cheaper. the professionals needed to produce a superior product are becoming dearer. The dillicuhy of the task is evidenced by the decrease in producers of medical educational pro- grams. When the AMTvB was organized in 1965. ten medical teaching institutions were producing programs. some for intramural and others for mass distribution. As of this year, only four are still producing. Of the~. tt~'b largest is the Medical Television Network (MTN) located here in California.

The producers of MTN ha;,e found that for their pro- grants to be effective as learning devices, they must not be merely passive viewing episodes. Each program now produced by the Network is accompanied by d study guide which converts the program to an active learning experience for the viewer.

The audiovisual media are destined to become an in- trinsic part of our teaching armamentarium. They will grow in importance as the student-teacher ratio increases and as more students reared on television come of medical school age. Unlike the physicians of today, they are entirely accustomed to learning from the "tube" and are most capable of benefiiting from the special educational advan- tages television has to offer, such as magnification, storage and retrieval of data, and electronic integr:~tion of materials related to a subject in context but not in time or place.

F. WILLIAM BLAISDELL (San Francisco, Cal i f ) : I would like to raise a negative note Concerning these fascinating and apparently magical teaching aids. Althotxgh they otter a very praclical means of presenting educational material. they are still second best to similar material presented live. Wc have had experience with the rebroadcast of surgical lectures among the teaching inslitutions at the University of California. We have polled our students regarding their assessment of these lectures and presentations. There is no question that the students who see these live lectures and presentations consistently rate the lectures above those who see the re-broadcast. Television has to be used with great skill and imagination if it is to compare with live material, for one dimension is lost. A ~ood lecture becomes a mediocre lecture, and a mediocre lecture becomes impos- sible. What television does do is to obtain a degree of

consistency in the presentat=on of material, One could con- sistently use an outstanding teacller, such as Dr Richards, and therefore ohlain quality control.

It may provide tile answer to mass education, hut [ do not think it x~ill ever replace a meeting, such as that of the Pacific Coast Surgical, where conviviality exists and the interchange of ideas can he carried out.

JollN A. (.flUS (Iowa City, l.owa): l 'hi~ cerlainly is a slimu!ating atnd provocative area of education which v, ill receive increasing attention. However, I me h:wc certain reservat}ons about how el[eclp,e television and other types of electronic communication are iu fulfill ing the teaching nllssion at tile undergraduate and l)OSlgradu;ite level. \\'e have had experience with tclevixmn at tl~e University of Iowa t.hlrlng tile pi~M left .years, and I have h,cerl involved to some degree ,,ince the beginning. Actually, ;re reached a peak two to three years after tclcvi'~ion was fir,,| used after which inlercM fell off sharply. Now there is very little elfeclive teaching done wilh it.

There :ire many objections ,~o the u',e of televi,,ion in ,,urgicatl instruction, such a,: it,, impcrsonahty, lack of patient contact, and poor camera technic, | was impressed with the impair|ante of these criticisnv, when I attempted to teach the etcmentals of ph3sical diagrto,is to ,,cooled year student,L I thought that certain physical ~,ign':,. which I considered to he important but ',~htch are nol always available for demonstration, could he prcscnled through the mediun~ of films, television, slides, and the hkc. How- ever. nearly all students rejected this approach and de- manded the real thing. They decried the use of television and wanted exposure to patients. I learned IlK~t one could suPrdement instruct|on hy nleans Ot television, hut it could not be used in licit of patient material. This of COl_ll~C i~ not surprising.

The use o| black and white television, which Dr Richard~, uses and which we too have used. leaves much to be de- sired. Currently the cost of color equipment is such as to limit the use of color to oqly at few. of the more aitluent centers. Ultimately, however, we will use lelevision as well as other electronic means for storing, processing, and re- producing information nluch mort', in tile fur|ire than we do now.

Recently I was impressed with the application of com- puter-assisted instruction which remain', to be d,zveloped to its full effectiveness. Also. cassette type motion pictures for special purposes or the short single-concept films have ranch to offer.

As 1 listened to Dr Stephens" talk and watched his old mov ie . I thought how wonderful it would be if the great surgeons and teachers with ,~shon't we worked and whom wc loved over the years could be recorded and preserved in living color. Perhaps our new president may elect to pursue this project.

THOMAS 1". WHITE {Seattle, Wash) : 1 would like to discuss how to make a television or movie film of an opera- tion. The problem we have had is that the camera operator does not have any idea what we are going to do even if we discuss the problem with him in advance. I wonder how you are going to get good pictures of operations using non- medically trained personnel. Are you going to put one of your health officers behind the camera'? I take a preliminary

158 The American Journa! of Surgery

,~,per 8 film myself of someone else operat ing to show the ~:aJnera operator wh:tt we want. Each eight to ten minute ~caching film which I have made has taken me a full two ~eeks to produce. As part of the cost of Ibis you have ~ include the salary of the camera operator and the editor :each $12,000 per year) us welt as the physicians and :heir time. Would it not be better to develop a l ibrary of : :chnics from all over lhe cotmtry because we as in- ~x, iduals carmot afford to spend that much time on this? VJc'rOR RICIIAROS (c los ing) : I want to thank all the

:~.,cus.scrs of lhis paper. Doctor Brayton, of course, is the i .ading expert in the field, and ! thoughl his discussion of ~W paper was "~uperb. I agree with every!h ing he said.

The soflw:~re is really important, and is the reason we ;;;e partictflarly interested in methods of presentfi'tion of :,.tcvised m~tClial at low cost. Doctor White, to nlake a ~ovie e