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TELEPRESENCE, TRAINING, TEACHING & THE ISDN
Peter Cochrane
Prologue
The ISDN is now ubiquitous in the UK and available on demand throughout an increasing number of countries world-wide. As the first dial-up digital service offering Nx64kbit/s it makes new modes of working and operation possible across a broad range of industries and activities. Whilst the ISDN is considered by many as expensive, it has to be seen in the context of limited bit rate alternatives, with the principal benefits embedded within applications that realise savings in time, inconvenience and travel costs. There is also a reasonable expectation of rapidly reducing tariffs, and ultimately, bandwidth and distance disconnected from the cost equation.
Money and Markets
A feature of telecommunications markets that is often overlooked, is that there is no new money available. Society at large will only invest in IT and telecommunications by diverting funds from existing activities. Beyond industry and commerce, the primary moneys that can be tapped include the expenditure on; physical travel, entertainment, education, and health care. In each of these sectors the current expenditure is vast - for example: the total for education in the UK is ?27Bn; for company training ?35Bn; traffic jams account for some ?15Bn, and computer games another ?12Bn. Diverting a modest percentage of this expenditure into telecommunications, and specifically ISDN services, would realise a substantial business, and save considerable waste in terms of time, energy, and raw materials. The case for teleworking, teleconferencing, entertainment and telegames over the ISDN are reasonably well established and clear cut. In this paper we therefore briefly examine the prospects for education and training at a distance with specific examples from the medical profession.
Education
The very best of teachers are able to put themselves in the students place, assume the same level of ignorance, and impart their understanding in a graphic and enthusiastic way. Unfortunately, with the speed up of technological development, and subsequent broadening of the curriculum, the masters of this process are becoming all too rare across the breadth of education. To some extent, the hard sciences and technologies overcome this by mathematical and physical models, together with ?hands-on' experience, that rapidly facilitates understanding. However, in other subjects, and in particular the soft sciences, the process is far more difficult and today's students face a bewildering, and expanding, repertoire of problems. At the same time financial budgets are constrained, as is course duration and training schedules, all of which is promoting the need for the quick fix, rapid turn around, with a maximum use of resources. Like other sectors of industry and commerce, education is under increasing pressure to become more efficient.
We might also observe that the UK does not have a single large university - and the resulting small departments are trying to support a widening spread of activity. As a consequence, the same, or very similar courses and lectures are presented in a dozen different locations - often during the same term. Valuable staff resource is thus diverted away from research and related activities that would enhance existing courses and aid the creation of new ones. If only students and staff could be teleported to a common work space for their seminal interaction, and later, their tutorial sessions!
Teleportation by Sight & Sound
A fundamental constraint to medical students gaining sufficient practical experience, is the limited access to patients. Just how many people can physically crowd around one patient to witness and/or participate in an examination or operation? At best only a handful! The use of commercial TV cameras and screens provides a partial solution, but lacks depth of vision and reality. However, miniature cameras are now the size of a shirt button and can be mounted on a spectacle frame worn by a consultant or doctor. The visual scene could then be transmitted to multiple sites where students equipped with Virtual Reality (VR) displays can observe and learn. These VR displays position miniature TV screens over each eye so students experience the event in 3D colour, with binocular depth of vision. A further refinement includes miniature microphones on the head-mount providing stereophonic hi-fi sound for the observers. This increases the sense of realism and allows students to hear the commentary by the consultant, and the interchanges with his staff. Such a ?surrogate head' concept might appear far fetched, but in fact the technology is already at an experimental stage, with miniature cameras and VR displays available in small production quantities. Experiments have been conducted with prototype equipments operating over the ISDN in the UK with satisfactory results. So the key components for the realisation of instant, on demand sight and sound telepresence using the ISDN, are available now.
Teleportation by Touch
The technology for tactile sensation is at a much earlier stage of development, and currently employs pressure transducers mounted on gloves at approximately 2mm spacing - which is close to the spacing of our finger tip nerve endings. The pressure on the fingers can then be transmitted over the ISDN to a reciprocal glove worn by a student where pneumatic bubbles replicate the sensation of pressure. Beyond this, the addition of an exoskeleton (or prosthetic) would allow the transmission of the forces on the fingers and arm. Whilst most of the necessary elements exist, they are bulky and uncomfortable to wear, and unlike a headset, is a great encumbrance. It will probably be another decade before a suitable solution is realised, but the prospect is a tantalising one.
Broadcast
Clearly the development of such techniques could see the rapid introduction of broadcast services to a large number of personnel world wide. The surrogation roles could also be reversed. For example, when a clinician has perfected a technique and people have been teleported to see what he sees, hear what he hears, and feel what he feels, they could then attempt the same operation. Here the role reversal would see the expert effectively sitting inside the skeleton of the trainee, guiding with commentary, sight and feel. Training in the traditional (and restricted) sense will then be obsolete. This will also bring about a dramatic reduction in the time to disseminate information and experience, which in turn will impact significantly on our established means of publication.
Robotics
Logical extensions to these developments include robotic and remote surgery. Early trials have seen robots operating under autonomous control, programmed to remove tumours whilst being steered by a tomographic scanner. They exhibit an ability to achieve far higher levels of accuracy and reliability than the human surgeon and are now being introduced into retinal and joint replacement surgery. However, there remain many areas where human skill is extremely difficult to supplant and we might contemplate the extension of our senses into robotic assemblies for laparoscopy, endoscopy and similar techniques. Trials have already shown that the addition of 3D vision and force (i.e., tactile) feedback from electronically linked controls and manipulators, provides a satisfactory and workable solution. The next obvious stage is to teleport the entire human consciousness to a robotic platform so small that it can be inside the human body, or so large that it can replicate the presence of another human on the outside looking in. Whilst this might seem like science fiction, all the base technologies are to hand. Why then, has this not been done? First, it is probably because of the perfection of such key areas as robotic manipulators, sensory systems and telecommunications have not occurred simultaneously, and second, major changes in medical culture, ethics and thinking are required.
Information Networks
Electronics has seen a doubling of computer power every year since 1960, and so the PC on your desk can be expected to be 1000 times more powerful within a decade, and a million times more powerful within two. Artificial Intelligence (AI) systems are now available for applications in finance through to drug administration and decision support for military and commerce. In medicine AI systems will seek out and gather the latest information, correlate symptoms, cause, diagnostic accuracy, and treatment, and thereby provide a new tool for the rapid identification and treatment of problems. Interestingly, many patients prefer to talk to a computer when divulging details of their ailments rather than relating directly to a doctor. They also tend to be more candid, which facilitates more information being obtained and of greater accuracy. In addition, trials are already being conducted with electronic monitoring systems attached to patients' to record the affect of drug dosage and analyse the efficacy of a treatment. The systems currently restrict patients to the hospital ward, but technological advances are certain to extend this to the home and place of work, with remote surveillance by the hospital computer and some treatments being administered remotely.
Virtual Reality in Medicine
VR is generally thought of as a games environment, but in fact it offers a plethora of new possibilities. For example, it is now possible to reconstruct tissue and bone that has been damaged by accident or some disorder with virtual operations in virtual space. In the case of a crash victim with facial injuries it is feasible to scan photographic information into a computer and construct a 3D virtual image of the face, and then the surgeon can peel back the virtual tissue, reposition bone and reconstruct many times until he gets a good facsimile of the original face. He may have to persist through 20 or 30 attempts to achieve a satisfactory result, but when this point is reached he is then able to operate for real, and get it right first time. Patient trauma and the build up of scar tissue is reduced, the tying up of valuable resource is negated and the surgeon has the potential of realising a better result in a shorter time. Whilst this technology is in its infancy, it is clear from trials that it works, and now requires refining before being deployed to medical establishments throughout the world. Again the ISDN could play a vital role in the form of wide band communications links between the research and application institutes. The potential for surgeons to perfect their craft in VR is obvious and probably on a par with pilot training, where more flying hours are now being clocked up than in real planes!
The Future
As we move into the 21st century we can look forward to a world where the global sharing of information and ability will become the norm through telecommunications linking centres of need and expertise. Research will become more focused through the rapid dissemination and application of new, and beneficial methods. In addition, entirely new ways of educating and training new entrants and those already established in the profession will be promoted. Most importantly, it is probably the only way of balancing the conflicting demands of rapidly growing expectation, with an expanding technology base and a student curriculum that has a fixed internship. In the case of medicine, it is we can expect to see the wide spread deployment of many techniques and technologies that are currently centralised in large regional hospitals. The future GP may see a time when a consultant and complex facilities are available to him any time, any where, not just in the surgery but in the patents' home or the site of an accident via the ISDN.
Whilst for convenience we have cited specific medical examples, these can be generalised to all the professions, and indeed into the home and domestic environment. The dial-up encyclopaedia, homework club, plumber, information networks etc are possible today!
About the Author
Peter Cochrane joined the British Post Office in 1962 and was employed as a technician until 1966. He graduated from Trent Polytechnic in 1973 (BSc Hon) and Essex University in 1976 (MSc), 1979 (PhD) and 1993 (DSc) respectively. He is a fellow of both the IEE and IEEE, a visiting professor to Essex and Southampton Universities, an honorary professor at the University of Kent, and a visiting fellow to UCNW at Bangor. He joined BT Laboratories in 1973 and worked on a variety of analogue and digital switching and transmission studies. He has been a consultant to international companies on systems, networks and test equipment development. In 1978 he became manager of the Long Lines Division and was responsible for the development of optical fibre systems. He received the Queen's Awarded for Technology in 1990, and in 1991 was appointed to head Systems Research Division which is concerned with future advanced media, computing and communications developments. During 1993 he was promoted to head the Research Department with 620 staff dedicated to the study of future technologies, systems, networks and services.