INTRODUCTION
Pre-registration radiation therapy training features a mixture of University-based academic blocks interspersed with practical experience in a clinical department. Increasing use of simulation in academia is blurring the boundary between academic and clinical learning for treatment techniques, but there is still a need for students to gain experience of clinical planning software before placement in order to maximise their learning. Most University Courses provide students with an opportunity to use a non-clinical planning system to produce a range of 3D conformal plans in the academic environment.
At Queensland University of Technology (QUT), teaching activities using planning software are facilitated by a team of clinical and academic tutors providing at-elbow support with software use and planning insight. Further support is provided by peer tutorsReference Bridge, Ellemor, Carmichael and Gibson1 and plan evaluation using the Virtual Environment for Radiotherapy Training (VERT) system.Reference Appleyard and Coleman2 As with many University Courses, the Bachelor of Radiation Therapy cohort is drawn from a wide geographical catchment area and includes learners from school leavers to mature students with challenging additional commitments. Academic attendance for some of this cohort can therefore be difficult, especially when timetabling restrictions provide a less-than-perfect schedule.
Under these circumstances it is easy to see the appeal of remote access and communication systems (or ‘telemedicine’ solutions) that allow planning practice to be gained without travelling to the academic environment. Olsen et al.’sReference Olsen, Bruland and Davis3 paper proposed different levels of telemedicine with ‘Level 3’ being characterised by remote workstations being used to perform tasks remotely. This paper predicted the value of telemedicine solutions for radiotherapy planning while acknowledging the severe restrictions owing to large data transfer and handling requirements. Much of the evidence base surrounding telemedicineReference Donnem, Ervik and Magnussen4, Reference Ntasis, Maniatis and Nikita5 is concerned with video conferencing and facilitation of collaboration, or specialist input from afar to support satellite centres, rural areas and distant clinics. Early experiments in NorwayReference Norum, Bruland and Spanne6 and JapanReference Ogawa, Nemoto and Kakuto7 clarified the feasibility of extending this to remote treatment planning. With the advent of faster network connections and more sophisticated software, Level 3 solutions are now relatively simple to facilitate. The use of remote planning to overcome staff shortages has been debated,Reference Zellmer, Klein and Orton8 whereas Kesarwala et al.Reference Kesarwala, Belard and Dolney9 reported the value of remote proton planning systems to provide wider access to expensive software in the United States. Remote access to treatment planning software is increasingly common in the clinical environment but has not previously been reported as an educational tool. The planning infrastructure at QUT relies on the Pinnacle Smart Enterprise solution with a central server being accessed by client workstations across the campus. In conjunction with virtual network access, this allows students to access the treatment planning software from any PC, provided they have authenticated network access. A similar system is now in use in many clinical departments.
The following case details the experiences of an undergraduate radiotherapy student who utilised remote access for his educational planning practical experience throughout a Year 2 planning Unit. The practical experience and assessment for this Unit presented students with a series of five patients to plan, and was designed to test a student’s ability to achieve and evaluate tumour coverage, normal tissue dose limits, acceptable plan setup and optimal patient’s quality of life. Perspectives from both student and tutor are presented to provide insight into this novel approach to radiotherapy planning education and discussion relating to potential future adoption of this format.
MATERIALS AND METHODS
The installation of the new Smart Enterprise version of the Pinnacle planning system allowed students at QUT to access the software from any PC on campus. Although remote access was not offered to students, the virtual private network (VPN) capability of the wider University system meant that this was technically possible. The student in this report was mature with 10 years experience in the film and computer industry. This provided him with a relatively high level of technical understanding of remote access IT infrastructure. The student lived in a semi-rural area with a challenging journey to the University Campus and this provided a strong motive for remote access. Additional related factors arose from the limited availability of on-campus workstations and challenges relating to timetable commitments. Although the University does have excellent facilities available for the students to use, the sheer number of students from across all the faculties can sometimes frustrate attempts to locate a vacant workstation. This is further compounded by timetabling spaces that often coincide with peak workstation demand.
Undergraduate RT students are provided with lectures and tutor-led practical sessions in planning, however, there is an expectation that additional independent planning is conducted to attain planning goals and consolidate learning. In this case study, the student was highly motivated and clearly desired additional working time in order to master the complexities of planning. Although the student felt that sufficient allocation of time was provided by the University for planning within the allocated tutorial times, extra time was desired to help consider and reflect why techniques were not working. This additional time was also conducted from the student’s home. The convenience of remote access and the potential to experiment with new approaches to improve the learning experience were key motives.
Access to the software was gained using a VPN client with the appropriate domain name to add the remote computer to the University network. Authentication via the University login process then allowed use of a remote desktop shortcut (RDP) to access the planning software login stage. The student was able to access the five ‘patients’ they were tasked with planning and worked from home. The main issue encountered related to screen resolution, which for Pinnacle is 1,680×1,050; far in excess of standard laptops. This meant that essential sections of the display could not be visualised or used to control the software. This problem was solved by connecting the laptop to a home TV system via HDMI cable to provide a 1,920×1,080 resolution. Planning was then conducted with visualisation on a 50 inch plasma screen from the comfort of a sofa as seen in Figure 1.
Remote radiotherapy planning setup.
It is important to state that this remote access mode was discouraged by the tutor as at-elbow support could not be provided as per the usual booked sessions. Problems encountered during plans were therefore raised during individually arranged problem-shooting meetings on campus with the Unit tutor, a facility available to all students. This allowed for clarification of points and discussion of alternative solutions as well as identification of errors or difficulties. Student performance in planning assessments was hard to determine owing to the increased complexity of plans compared with previous planning Units, but the student reported satisfaction with their performance and understanding.
DISCUSSION
The following discussion aims to provide critical evaluation of this experience along with some thoughts as to potential implications of a more widespread adoption of this approach in future cohorts.
The student perspective: advantages
Remote access to an educational planning system poses some interesting advantages from a student’s perspective. Continuous (‘24/7’) access to the system allows the learner to potentially increase their time available for active problem-based learning over and above what would be possible through allocated tutorial times on campus. By increasing the time spent working with the system, students can develop skills through trial and error, whereas also experimenting with their own creative solutions to the posed planning challenges. This can facilitate powerful engagement with the learning materials, whereas reinforcing a deep understanding of previously taught dosimetry skills from class. This type of experimental learning has the ability to increase a student’s confidence, proficiency and problem-solving capability when presented with complex issues.
Although it must be acknowledged that this mode of learning is generally suited to autonomous learners who are able to manage their own time and learning effectively, the potential exists for suitably motivated students struggling with practical problems and technical aspects to work on these from home. Off-campus access could allow these students to have remote ‘one-on-one’ sessions with tutors to help troubleshoot and further reinforce the learning experience.
Another clear advantage arises for students that have geographical complications in accessing on-campus facilities. The student in this case lived 100 km from campus facilities and sparse public transport systems within this area necessitated a 2-hour (one way) journey to use the planning software. Evidently, by allocating the transit time to the planning practical experience, greater experimentation was able to be performed allowing this student to test advanced methods and techniques seen used in clinical placements. Although some of these methods were outside of the scope of the current planning level, having continual access facilitated the ability to trial these techniques and has allowed for a deeper and enriched learning experience of applied radiation planning strategies.
The student perspective: disadvantages
Clearly, ‘24/7’ access brings advantages in time management and experimentation with the system, thus giving a greater learning capacity. The problem with allowing students to creatively find their own solution is that fundamental learning concepts can be compromised. Simple techniques should be built upon from previous semesters learning and allowing students to plan solely from home, and can lead to an overly complicated solution when the student tries to use techniques seen utilised in the clinical setting. Less at-elbow support can lead a student to create systematic mistakes throughout the planning tasks, causing wastage of time troubleshooting a solution. This is particularly galling when a simple mistake in the early stages of the plan is not identified. Although this process does provide valuable learning in itself, the increased troubleshooting time could negate any potential gains arising from greater access through remote sessions. Furthermore, if a solution is unable to be found by the student, the use of a support facility is vital to allow the student to continue development of their work.
In this case study, the student pre-arranged one-on-one support sessions that enabled the student to seek specific help with problems. This support did indeed identify systematic errors arising from an early misconception. This highlights the need for tutor support, especially when the majority of the errors made were easily rectified. In most cases, the support followed in excess of 2 hours trying to identify the error and solve the problem autonomously. This increased troubleshooting time impacted not only on the planning Unit itself but also other classes in which the student was enrolled. It is therefore vital that solely remote access planning is only used by students that are self-directed and have a good understanding of their own limitations, thereby seeking timely help when required.
The drawback to a pre-arranged meeting is that the student must arrive prepared with a clear list of the complications they are experiencing and pose these throughout the meeting. If a student was to attend a tutorial session unprepared, this reduces the value of the session and limits their learning. Another issue arises if another error is encountered directly after the meeting, this can impede the amount of work done by the student until another tutorial session is organised.
In the presented case, the student attained a mark of 76% in the practical component of the assessment, this was <86% scored in the previous semester’s planning assessment. This reduction may indeed indicate an advantage to ‘in-class’ learning with the addition of both academic tutor support and clinical tutor perspectives. Comparisons between different Units, however, are limited by the different levels of content and learning outcomes.
The tutor perspective: advantages
Timetabling of specialist software laboratories and appointment of clinical tutor staff is costly and logistically challenging with increasing cohort sizes. Remote access ‘classes’ could potentially alleviate pressure on these spaces, reduce costs and possibly reduce teaching load, although this does need to be balanced against the need to provide remote support. A 3-hour planning practical for 30 students using three tutors could be replaced by 30 individual intensive 15-minute tutorials (spread over three tutors). Total time commitment per tutor drops from 180 to 150 minutes (assuming each student requires 15 minutes per week).
Although perhaps not ideal for all students, the use of remote access planning systems should increase autonomy and encourages independent working, all good preparation for clinical work. Autonomy is important for these students on two levels. Learner autonomy as outlined by HolecReference Holec10 in his seminal paper refers to the ability of students to learn independently and direct their own learning. For pre-registration, health students’ learner autonomy is an essential pre-requisite for a lifetime of reflective practice and continuing professional development. Autonomy in the wider medical professional sense is linked more with the capacity to think and act independently, a high-level clinical skill that should be encouraged in health professional students. Providing students with the opportunity to plan independently should facilitate an autonomous approach to both clinical practice and ongoing education.
The tutor perspective: challenges
Although it can be seen that there is great potential for encouraging autonomy, there are disadvantages in a ‘deep-end’ approach to learning. Some students who may struggle with IT systems or independent learning may become discouraged, and indeed disadvantaged by a remote learning pedagogy. The use of self-directed learning methods should be introduced gradually with some students requiring considerable support to make the most of their learning with this technique.
The other potential issue related to the underlying pedagogy arises from the reduction in opportunity for direct discussion of cases. Currently, this is provided by a range of clinical and academic tutors as well as peer learning through a facilitated programmeReference Bridge, Ellemor, Carmichael and Gibson1 or from neighbours in the classroom. Alternative methods for facilitating peer and tutor support within a remote planning paradigm should be sought. In particular, the provision of rapid troubleshooting support is necessary to ensure that errors are identified readily and corrected at an early stage of the process. In wider pedagogical terms there are plagiarism issues if students cannot be observed creating their own work, although this is relatively easily addressed by use of appropriate assessment practices, plan evaluation and live invigilated planning exercises rather than summative assessment of produced plans.
There are some technical issues related to license management, with a classroom-based system it is straightforward to provide students with adequate licenses but when distributed access is available this can be challenging. The presented case made no impact on license management but when multiple cohorts are accessing the same software there should be either enough licenses for all students or a system in place to prioritise different cohorts at different times. The final issue arising from this case study concerns data security. Students who are able to access anonymised patient datasets in an uncontrolled environment need to be made aware of the professional requirements surrounding data security, as a learning exercise this is, of course, highly valuable.
Feasibility of wider adoption
Remote access to a treatment planning system for educational purposes is feasible, although there are several potential pitfalls and requirements for rigorous guidelines for usage. Students would need clear instructions and training before attempting remote access and will also need to be able to guarantee minimal technical requirements. Implementation of access is relatively easy and can be facilitated by providing access to the RDP file as a download from the class home page. The main problems that would need to be addressed by students arise from the display requirements of the system and access to a screen capable of meeting the minimum requirements of resolution. Furthermore, with the variability of personal computers from a range of vendors, students may have access problems when using a system that has an OS-X-based platform.
Although there are several clear advantages in facilitating remote planning for pre-registration learning, these must be weighed against the disadvantages for individual students. Technological challenges and reduced contact time could potentially be detrimental for some students and wholly remote access should be prioritised for students who are dedicated, self-directed and display excellent time management skills. A sensible option could be to adopt a blended approach with remote access being available for students who can facilitate it and who are confident autonomous workers while retaining on-campus sessions for others. Autonomous planning can be challenging and without the ability to actively seek other informed opinions when necessary can lead to a less than ideal solution. The demand on troubleshooting skills would, perhaps, be best used with final-year students who should be independent learners, this also has the potential to provide valuable clinical skills. When combined with peer-support mechanisms it is clear that a collaborative problem-based approach would mimic the strong team approach utilised in current clinical planning departments with challenging plans.
Provision of support for remote access students is clearly the key to success with this approach and a number of potential solutions can be identified. A formal remote access support system would be a sensible approach with tutors trained to access plans remotely upon request and provide comment or assistance via discussion boards, telephone or e-mail. Real-time remote control of student plans by tutors could in turn allow for immediate illustration of alternative solutions or ideas and further encourage autonomous working and plan evaluation skills. Input from clinical experts can also be utilised in a similar manner as could peer support from a more experienced learning partner. Even with these systems in place, the role of direct contact time should not be underestimated, but this could move towards more directed troubleshooting and evaluation activities, perhaps including VERT plan evaluation sessions or multidisciplinary feedback. If adequate support can be provided and students accept the responsibility of initiating this in a timely fashion, the resulting gains in autonomy, troubleshooting and evaluation skills would be advantageous.
Licensing arrangements would need to ensure that the potential maximum numbers of students could access the software simultaneously and students will require training in logging out correctly. Further guidance should address ethical issues arising from accessing CT datasets off campus to ensure the patient data are treated with the same respect for privacy and data security as would be expected on campus and in a clinical environment.
CONCLUSION
This single-case feasibility study suggests that remote access to treatment planning software is logistically feasible in an educational role. Guidance with setting up access, monitoring access and ensuring screen resolution requirements are met is vital for implementation. Written guidelines relating to data protection are also recommended. Great care should be taken to facilitate student support, particularly with students who struggle with motivation and autonomous study. Regular online or at-elbow tutor support for troubleshooting, feedback provision and progress monitoring is essential. Remote access can alleviate pressure on facilities, whereas reducing student travel time and increasing time available for practice. Controlled and supported provision of remote access to planning software is, perhaps, a potentially useful enhancement to on-site practical teaching sessions for more mature independent learners. Further cohort-wide studies will help to clarify more formally the advantages, disadvantages and possible role of remote access for radiotherapy planning education.
Acknowledgement
None.
