*Imperial College London, London, United Kingdom; †School of Computer Science, Bangor University,
wynedd, North Wales, United Kingdom
2
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OBJECTIVES: Mentoring, for physicians and surgeons inraining, is advocated as an essential adjunct in work-basedearning, providing support in career and non-career relatedssues. The World Wide Web (WWW) has evolved, as a tech-ology, to become more interactive and person centric, tai-
oring itself to the individual needs of the user. This chang-ng technology may open new avenues to foster mentoring in
edicine.
DESIGN, SYSTEMATIC REVIEW, MAIN OUTCOME MEA-SURES: A search of the MEDLINE database from 1950 to
012 using the PubMed interface, combined with manualross-referencing was performed using the following strat-gy: (“mentors”[MeSH Terms] OR “mentors”[All Fields]R “mentor”[All Fields]) AND (“internet”[MeSH Terms]R “internet”[All Fields]) AND (“medicine”[MeSH Terms] OR
medicine”[All Fields]) AND (“humans”[MeSH Terms] ANDnglish[lang]). Abstracts were screened for relevance (UJ) to the
opic; eligibility for inclusion was simply on screening for relevanceo online mentoring and web-based technologies.
RESULTS: Forty-five papers were found, of which 16 wereelevant. All studies were observational in nature. To date,ll medical mentoring applications utilizing the World Wide
eb have enjoyed some success limited by Web 1.0 and 2.0echnologies.
CONCLUSIONS: With the evolution of the WWW through.0, 2.0 and 3.0 generations, the potential for meaningful tele-nd distance mentoring has greatly improved. Some engage-ent has been made with these technological advancements,
KEYWORDS: Medical Mentoring, World Wide Web, Web.0, Web 3.0
COMPETENCIES: Medical Knowledge, Professionalism, In-terpersonal and Communication Skills
INTRODUCTION
Much is expected of the current medical trainee. Training mustfacilitate them to be clinically able, up to date with their knowl-edge, conversant with research and teaching methodology andbe effective communicators.1,2 The latest digital technologiesmay be a key enabler to support these requirements. The De-partment of Health in the UK has recently published a “Frame-work for Technology Enhanced Learning” that advocates theuse of e-learning and simulation to enhance learning wherethere is a clear benefit to patient care.3
What Is Mentoring?
The advent of the European Working Time directive has led toa subsequent reduction in junior doctors’ working hours. Thishas resulted in a reduction of experience and an apparent skillsgap emerging. This problem is particularly felt in the practical-based specialties, such as surgery.
The educational theory of constructivism4 and the principlesof andragogy (adult learning theory5,6) both emphasize learn-rs’ autonomy, initiative in problem solving and self direction.ndragogy principles also emphasize that the learning environ-ent should feel safe, and that the learner should feel comfort-
ble to express themselves openly.Junior doctors often need guidance as to strategies that can be
mployed to overcome hurdles associated with modern dayurgical training. Timely and good mentoring is a way in whichurgical trainees may be helped through these difficulties in a man-er compatible with the principles of adult learning. Mentoringay be best achieved in a “just in time” fashion where an appro-
riate mentor is available to facilitate problem solving in responseo a real world need. In order for this mentoring to be achieved incomfortable learning environment, a knowledgeable, yet not nec-
ssarily proximate mentor may be most suitable.
tors in Surgery 1931-7204/$30.00erved. http://dx.doi.org/10.1016/j.jsurg.2012.06.024
The Standing Conference on Postgraduate Medical andDental Education (SCOPME), in the UK, describes mentoringas “The process whereby an experienced, highly regarded, em-pathic person (the mentor), guides another individual (thementee) in the development and re-examination of their ownideas, learning, and personal and professional development.The mentor who may or may not work in the same organisationor field as the mentee, achieves this by listening and talking inconfidence to the mentee.”2
The roles of the mentor are many and have previously beenreviewed.7 Briefly, these include Adviser; coach; counselor/uide and role model. A good mentor may have knowledge andwareness of the difficulties the mentee may experience. Asomeone who has successfully negotiated some of these difficul-ies, a mentor may offer motivation, hope and advice for theentee. As technology increasingly becomes part of a managed
earning process, expert mentoring of trainees, facilitated byechnology, may become essential for ensuring patient safety.
Increasingly, mentoring has assumed an official rather thann ad hoc role in facilitating trainee doctors to becoming com-etent for independent practice. The benefits of mentoringave been well established in allied Medical specialities.8-10 Ex-
sting practices suggest that medical trainees find having a men-or a useful adjunct to career development.11,12 It has beenreviously reported that trainees often do not have mentors orre unaware of the role of the mentor and therefore do not haveeneficial meetings with them.7,12
The Royal College of Surgeons of England strongly advo-cates mentoring in all stages of training.13 A survey of Americanfemale medical students reports that being influenced by a men-tor has a significant impact on final career choices.14 The rolesof the mentor are many and varied as are the needs of thementee.15
Mentoring in UK Post Graduate MedicalTraining
In the UK the roles of Clinical and Educational supervisors havebeen introduced to assist in delivery and assessment of thetrainee. Concomitantly, the educational supervisor may act in amentoring role. The Educational supervisor may be from thesame or a different department where the trainee works. TheClinical supervisor is the trainee’s immediate supervisor.
Supervisors may or may not have received training in men-toring. The educational supervisor oversees the junior doctor’sprogress and acts as a contact between the doctor and trainingprogram director. The educational supervisor ensures the com-petencies set out by the junior doctor’s training program aremet and that the trainee is receiving regular education and isbeing supported within the surgical team. They act as a mentorfor developing professional skills. Meetings with supervisors areflexible and ideally would implement recommendations for asuccessful mentoring relationship.16
A criticism for these currently ad hoc arrangements are that
individuals who have accepted a mentoring role may not be
122 Journal of Surgi
expert in issues in which the mentee requires mentoring or haveaccess to necessary information.
With the evolving complexity of medical roles, subspecialtiesand careers, mentoring needs are also increasingly complex.Complex and varied mentoring needs may require multiplementors addressing individual specialist interests. Also, appro-priate mentors may be at a distance from mentees. Internet-based technology developments, including the WorldWideWeb (WWW), allow for increasing interactivity and may be ofuse in fulfilling tele- and multiple mentoring needs.
The paradigm of on-line mentoring to meet the needs oftrainees is one which has been implemented in nursing.17 A
entoring model developed for academics in the University ofrkansas uses a multilevel Peer-Onsite-Distance (POD) ap-roach. Here a network of mentors is used by a mentee to meetheir varied needs.
There has been an evolution of the ways that interaction isacilitated and information processed and retrieved in the
WW. The newest incarnations of the WWW provide for anmmersive, interactive, collaborative and information rich po-ential resource for medical mentoring. We review the literatureegarding the evolving nature of the WWW and concomitanthanges in paradigms of on-line medical mentoring.
METHODS
A search of the MEDLINE database from 1950 to 2012 using thePubMed interface, combined with manual cross-referencing wasperformed using the following strategy: (“mentors”[MeSHTerms] OR “mentors”[All Fields] OR “mentor”[All Fields]) AND(“internet”[MeSH Terms] OR “internet”[All Fields]) AND(“medicine”[MeSH Terms] OR “medicine”[All Fields]) AND(“humans”[MeSH Terms] AND English[lang]). Abstracts werereviewed by UJ for relevance to the topic. Inclusion criteria wereany study pertaining to the topic. Search outcome: 45 papers werefound of which 16 were relevant to the topic. All were observa-tional or case control studies.
Three Phases of WWW Evolution
With Internet use soaring in the late 90s and early 2000s, theWWW evolved beyond its original form. Successive genera-tions of the WWW are denoted by the terms Web 1.0, Web 2.0and Web 3.0.18 Technological advances in the successive gen-erations allow for greater degrees of user interaction. The salientfeatures of each will be briefly reviewed with applications rele-vant to medical mentoring.
Web 1.0
Web 1.0 was the first generation of the Web. During this phasethe focus was primarily on building the Web, making it acces-sible, and commercializing it for the first time. Web 1.0 allowedfor dividing the WWW into usable directories (taxonomies)
and allowed everyone their own private corner in cyberspace.
cal Education • Volume 70/Number 1 • January/February 2013
us
The WWW only consisted of web pages being linked viahyperlinks. These pages were static, with information being ona “read only” basis that users could access. Apart from the cre-ation of web sites, web based business models, and the growth ofkey portals on the WWW were features of this era.
Web 1.0 has been successful implemented in web-based cur-ricula. A case control study in the setting of teaching women’shealth found that participants undergoing self-directed webbased learning, scored higher on knowledge tests and resulted inmore and higher level discussions with faculty as compared tothose having traditional lectures.19
Web 1.0 and Medical Mentoring
Several online medical education and mentoring resources wereset up as reference web sites, in the Web 1.0 format. Web sitesprovided information to be accessed by both mentors and men-tees independently to one another. As Internet usage and com-puter literacy became commonplace, online educational port-folios became a key part of trainees’ educational developmentvia access to uploaded workplace based assessments by the clin-ical and educational supervisors. Mentoring however, was notformally incorporated into online portfolio programs in theUK, such as e-portfolio20 and Intercollegiate Surgical Curricu-lum Program.21 Electronic portfolios have been encouraged as ameans of educational reference, for trainees to keep track oftheir professional progress and also as a way for training pro-gram directors to review trainees and advise areas for develop-ment, further reinforcing the mentoring process.
Further to this, other electronic mentoring schemes havebeen trialled. A recent review has demonstrated that e-mentor-ing has a beneficial role in continuing professional developmentalthough it acknowledged that further research into this area isrequired.22
Web 2.0
Technological advancements, increasing Internet speed and achange in what users require from the Internet, lead to thedevelopment of the Web 2.0 format. According to Wikipedia,Web 2.0, a phrase coined by O’Reilly Media in 2004,23 refers toa supposed second generation of Internet-based services—suchas social networking sites, Wikis, communication tools, andfolksonomies—that emphasize online collaboration and shar-ing among users. Where Web 1.0 is characterized by taxono-mies, folksonomies in Web 2.0 are fluid and flexible categoriesuniquely created by each interest group to provide quicker,more relevant access to practice specific knowledge.24
These sites are based on interaction and are able to be con-stantly updated by users, allowing online conversation that canbe viewed by all. Hence Web 2.0 facilitates collaboration, de-bate, feedback, and provides a platform to build associations.Web 2.0 better facilitates group interaction25 and helps perpet-
ate a sense of community in what can be perceived as a coldocial climate.26 Better support for multimedia resources, such
as movies and 3D computer graphics were also a part of Web
Journal of Surgical Education • Volume 70/Number 1 • January/Febr
2.0. Several examples of using 3D computer graphics to teachand explain medical procedures appeared during this time.27
Web 2.0 Technology for Medical Mentoring
E-mentoring has developed to use Web 2.0 technology, wherementee and mentor can use the Internet as an interactive me-dium. Where users of Web 1.0 sites were limited to viewing ofpage content that had been created for them, Web 2.0 providesa forum for users to communicate within an online community.
Web 2.0 mentoring opens many doors. Instead of havingmentor and mentee using an Internet-based program to facili-tate the process and track developments, the mentee and men-tor exchange can be through an Internet based portal. Interac-tivity without mentor and mentee being physically in the sameroom at the same time allows for the potential of meaningfulmeetings to take place online. This is of benefit as “meaningfulmeetings” has been found to be a key factor in trainees percep-tions of beneficial mentoring programs.7
It has been found in the context of teaching ethics that onlinediscussions tend to be deeper, more diverse and engage studentsmore than classroom discussions.28 This has an important corol-lary to the mentoring context. Additionally, one mentor can have agroup of mentees that are able to contribute to the conversationand are able to give feedback on each other’s performance.
Educational institutions, for example Oxford University29 andImperial College London,30 utilize e-mentoring schemes for stu-dents through web based programs, such as Brighter Journals andEmentor Pro. The Academy of Medical Sciences has an onlinementoring scheme for clinical academic trainees that is supportedby the National Health Service and the National Institute forHealth and Research (NIHR).31 Furthermore, E-mentoring hasbeen successfully implemented in the nursing sector and has dem-onstrated beneficial results using Web 2.0 technology.8,9,32
Another early example demonstrated how an interactive sim-ulation of the steps required for a lumbar puncture procedurecould be delivered through a Web Browser (Figure 1). Severalparticipants access the simulation at the same time. The mentorcan be in control and demonstrate the steps required to thestudents, or a student can be given control and observed by thementor. Validation studies conducted using this tool showed asignificant improvement in the training group in terms of per-formance as compared to the control group.33
Recently a group has succeeded in running an internationale-mentoring scheme from the United States to an African educa-tional program which has not previously enjoyed the benefits ofmentoring.34 The program aimed to develop what it called a “com-munity of learners” to help trainees concentrate on developingprofessional skills through monthly case based teaching sessionswith the e-mentor. In addition students were encouraged to workthrough cases within their “community,” with the sessions over-seen by a local facilitator. Analysis of the sessions revealed thatmentees found e-mentoring beneficial and placed high value oncollaborative learning and community building as part of mentor-
ing. This program demonstrates a successful mentoring scheme
uary 2013 123
amhW
nt.
where face to face contact is kept, while allowing remote oversightby someone experienced in mentoring.
This has been taken further by the Eastern Vascular Societyin the United States who have created a system whereby men-tees are “paired” to mentors, tailoring mentoring schemes tospecific career requirements.35
A number of online course management suites are commer-cially available. These incorporate Web 1.0 course informationand teaching management tools as well as solutions to enableteachers to interact with multiple students. Such suites includethe WebCT, originally developed in the University of BritishColumbia. This has now been incorporated into the Black-board Learning System.36 A similar system spanning Web 1.0nd 2.0 is the Moodle Open Source Virtual Learning Environ-ent. This system also provides information in the traditional
ierarchical manner as well as providing forums, databases andikis to facilitate interaction.37
In addition, another group from the United States have trialledpatient-patient based mentoring for transplant recipients.38
E-mentoring of this type has allowed online patient support groupsto be developed, using similar Internet based technology.
In another development, the authors have adapted a peermentoring application for the social networking site Facebook.Mentoring groups can be set up to share data and case reports inthe field of vascular ultrasound, allowing users to build a port-folio of evidence of learning and also to facilitate peer mentor-
FIGURE 1. Mentoring tool for teaching a Lumbar Puncture procedure. Tmanager and chat interface for the participants. One participant is in contsimulator allows a virtual lumbar needle to be inserted into a virtual patie
ing by sharing experiences. Group members are able to interact
124 Journal of Surgi
using this web 2.0 format, can comment on each other’s workand can act as mutual mentors. Users can demonstrate profes-sional development and a database can be built from users shar-ing data. This database is accessible to newer users allowing forrapid knowledge acquisition.
Technological advances within Web 2.0 have allowed a newdimension of mentoring to be developed and are being ex-panded to encompass what some consider to be the beginningsof Web 3.0 format. Online virtual worlds have been created toutilize the enormous potential of the online metauniverse topromote medical health and education. Such environments,mostly considered Web 3.0, are varyingly referred to as MassiveMultiplayer Online Role Playing Games (MMORPG), Web3D or virtual worlds and are discussed below.
Web 3.0
The term Web 3.0, a phrase coined by John Markoff of the NewYork Times in 2006, refers to a supposed third generation ofInternet-based services that collectively comprise what might becalled “The intelligent Web”39.
The Web 3.0 format encompasses virtual worlds, the seman-tic web, microformats, natural language search, data-mining,machine learning, recommendation agents, artificial intelli-gence and augmented reality technologies. The underlyingtheme involves machine-facilitated understanding of informa-
lication runs in a web browser. The left hand side provides a conferencee 3D simulator (shown top right) while the other participants observe. The
he approl of th
tion to provide a more productive and intuitive user experience.
cal Education • Volume 70/Number 1 • January/February 2013
tps
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The “semantic web” involves the development of semanticweb standards to help computers “understand” and read webpages and make connections between them. This would dra-matically improve the effectiveness of search engines and helppeople to access web based information more effectively.
Augmented reality involves a fusion of our existing physicalreality and the Internet. Virtual worlds, including Second Life(SL) by Linden Laboratories40 and Olive by Forterra systems41
provide content as a three-dimensional environment in whichwe can navigate as virtual representations of ourselves, avatars.Second Life, currently the most popular virtual world, facili-tates streaming audio/video/TV/YouTube collections, 3D vir-tual libraries, virtual tourist attractions and destinations.42 In-eractions between SL residents may benefit each others’articipation via networks which allow for dynamic, evolvingystems all made possible by “semantic” web technology.43
Meskó summarized educational applications’ uses of secondLife44. He discusses potential advantages as being: Global col-laboration without boundaries; interactivity in a manner betterthan a videoconference with use of videos, presentations, im-ages and web links at the same time in one place. Being able todraw from a worldwide pool of experts and having the ability toestablish exhibits which are not possible via videoconference ora web site are also cited as advantages.45,46
SL interaction for educational goals seems to align well withconstructivist and constructionism educational theory. Thepsychologist Jean Piaget, who explained constructivist theory,suggests that knowledge must be built through interacting pur-posefully with the world. It would seem that Web 3.0 is wellaligned with constructionism learning theory with its personaland social dimensions.
Innovations in Web 3.0 Technology and aPotential Future for Medical Mentoring
It has been demonstrated previously that trainees quickly adaptto a virtual environment and find it an experience that is bene-ficial to their professional development.47 The authors’ experi-ence of this resource has been through the utilization of the“Second Life” virtual online environment. Users interact onlineas characters known as avatars and are able to explore an onlineworld, complete with an economy, and can meet other avatars,create and trade virtual property and be involved with groupactivities through instant message, text chat and voice commu-nication. It has been shown previously that virtual reality re-sources are being successfully used as educational resources.48
Example include training for endoscopic procedures,49,50 cor-nary intervention51 and endovascular intervention.52
Another example of this has been creating an operatingtheater within a second Life hospital. A recent study hasutilized second Life to run an operating room induction. Itwas demonstrated that virtual induction was beneficial fornovice members of the operating theater team to prepare forwork in this high stress environment.53 It was shown that
here was no significant difference in perception of realism
Journal of Surgical Education • Volume 70/Number 1 • January/Febr
etween virtual and real world scenarios. Furthermore, run-ing a virtual induction was significantly cheaper than a real
ife induction and negated the need to use potential operat-ng theater time and space. Inductees could access the induc-ion from their own computer and at any time.
Other specific models include using second Life for the train-ng of nursing skills,54,55 communication skills56 and for public
health education for patients with learning difficulties.57
The authors have developed a mentoring environment, Mentor[second Life].58 Avatars assemble in a registration area, where theyhave a range of mentoring databases available to them (Figure 2),each run by a different mentor, depending on which aspect of theirprofessional development is being concentrated on. Mentors areable to log on to second Life as avatars and provide mentoring,through virtual world communication, to their mentees. A range ofonline mentoring resources is available to both mentor and menteeas there are links to other mentoring resources from Web 1.0 (Fig-ure 3). This software has potential future utility to mentor outsidethe field of medicine.
The e-mentoring resource is being trialled currently with initialfeedback from users being positive, with both mentees and mentorsfinding thementoring stylebeneficial andenjoyable.Communicatingusing new methods not possible through previous online methods hasenhanced the mentoring process. Trainees find the online environ-ment adequately realistic and learn quickly to use communicationprocesses, suchasInternetvoicedialogue,anduser interfacetonavigatetheir avatar.
An increasing number of institutions are exploring virtualworlds as a means to provide medical education.47,59,60
Medical education is evolving to utilize the latest Internet-based resources.61 It is therefore important that mentoringschemes keep technologically up to date and user-friendly asthe use of web 3.0 facilities broadens. Second Life, in partic-ular, is a large resource area that can be utilized not just formentoring but also for other educational activities. Furtherdevelopment is needed for this resource to be used to its fullpotential in the postgraduate training context.
There may be barriers to the adoption of these new tech-nologies for medical mentoring. Hansen recalls Roger’s dif-fusion of innovation theory in explaining attributes of a newtechnology affecting an individual’s decision to adopt.62
These attributes include the relative advantage of the inno-vation over the idea it supersedes; how the innovation meetsthe needs of potential adopters; how difficult the innovationis to understand and use; how the innovation may be testedin a timely fashion; and how outcomes associated with theinnovation are visible to others.
CONCLUSIONS
Web 2.0 and 3.0 technologies provide very interesting advancesin terms of possibilities for medical mentoring. The informa-tion storage and organizational structure offered by Web 1.0provides a data repository that, although informative, is diffi-
cult to access, engage with and is static. Web 2.0 technology
uary 2013 125
kcases”
allows for greater interaction with the Internet, hence web med-ical mentoring will evolve with this interaction. The folkson-omy principles in Web 2.0 allow for the trainee to search effec-tively multiple sources of online information on an “asrequired” basis. The advent of Web 3.0 technology harnessesaspects of machine learning, and interpretation of informa-tion, to provide individualized help via more immersive“natural” interaction in 3D environments. The 3D immer-
FIGURE 2. In world screenshot of “boo
FIGURE 3. Avatar in mentoring room in Se
126 Journal of Surgi
sive environment with a mentor the trainee may not neces-sarily know in real life may well fulfill the “safe learningenvironment” requirements of andragogy. The evolution ofthe WWW to facilitate greater access to relevant informationand greater interactivity with potential mentors seems tohave facilitated well the principles of adult learning in re-sponse to real world need. The effectiveness of this technol-ogy has not yet been fully evaluated.
housing mentor and mentee databases.
cond Life awaiting arrival of mentor.
cal Education • Volume 70/Number 1 • January/February 2013
ACKNOWLEDGMENTS
The authors have no conflicts of interest to report relative to thepreparation or publication of this study.
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cal Education • Volume 70/Number 1 • January/February 2013
