Real-time teleteaching in medical physics
1 Department of Medical Physics, Odette Cancer
Centre, Toronto, Canada
2. Department of Biomedical Imaging, Faculty of
Medicine, University of Malaya, Kuala Lumpur, Malaysia
Medical physics is a relatively small professional
community, usually with a scarcity of expertise that could greatly benefit
students entering the field. However, the reach of the profession can span
great geographical distances, making the training of students a difficult task.
In addition to the requirement of training new students, the evolving field of
medical physics, with its many emerging advanced techniques and technologies,
could benefit greatly from ongoing continuing education as well as consultation
Many continuing education courses and workshops are
constantly being offered, including many web-based study courses and virtual
libraries. However, one mode of education and communication that has not been
widely used is the real-time interactive process. Video-based conferencing
systems do exist, but these usually require a substantial amount of effort and
cost to set up.
The authors have been working on promoting the
ever-expanding capability of the Internet to facilitate the education of
medical physics to students entering the field. A pilot project has been
carried out for six years and reported previously. The project is a
collaboration between the Department of Medical Physics at the Toronto Odette
Cancer Centre in Canada and the Department of Biomedical Imaging at the University of Malaya in Malaysia. Since 2001, medical physics graduate students at the University of Malaya have been taught by lecturers from Toronto every year, using the Internet
as the main tool of communication.
The pilot study explored the different methods that can be
used to provide real-time interactive remote education, and delivered
traditional classroom lectures as well as hands-on workshops.
Another similar project was started in 2007 to offer
real-time teaching to a class of medical physics students at Wuhan University in Hubei, China. There are new challenges as well as new opportunities
associated with this project. By building an inventory of tools and
experiences, the intent is to broaden the real-time teleteaching method to
serve a wide community so that future students entering the field can have
efficient access to high-quality education that will benefit the profession in
the long term. � 2008 Biomedical Imaging and Intervention Journal. All
Keywords: Remote real-time teaching, teleteaching, distant education, medical physics
The medical physics profession is well-positioned to
benefit from remote education. The profession is relatively small; most of them
are concentrated in the USA, UK and Western Europe, as well as in other parts
of the world such as Japan, Australia, Korea, and other countries. However,
there is a growing demand for medical physicists, mainly because of the complex
nature of medical care in a world of advanced technology. There is a projected
shortage of well-trained physicists, as predicted by the American Association
of Physicists in Medicine (AAPM)  in its requirement for
accreditation of graduate student and residency programs .
The demand is probably even more significant in many
rapidly developing countries, where the field of medical physics has not
hitherto existed, at least not in a well-defined and structured way. In order
to meet this growing demand cost-effectively, local students are often
recruited into new training programs and curricula in existing universities and
hospitals. This has created a great need for knowledgeable instructors in the
field of medical physics.
Such experts do exist, but they are usually concentrated
in areas or countries where the field of medical physics is well-established.
In order to facilitate the dissemination of knowledge, the AAPM has established
different committees with the objective of international exchange and education
in the profession .
Parallel to the growing demand and technological advances
in the medical physics field, an even bigger explosion has been occurring in
the field of global communication, primarily in the form of the Internet and
universal video/audio communication. Much of the educational and training
demand has helped create the field of distant education, not just in medical
physics, but in all disciplines of education.
Overview of Distant Education
Asynchronous vs Synchronous
Within the field of distant education, different modes of
delivery have developed. One classification of the delivery methods is
asynchronous versus synchronous. The distinction is that the former refers to
off-line teaching using educational modules while the latter refers to
real-time on-line teaching. In other words, the former simply means that
students are accessing pre-assembled modules of educational material which
generally take on many different formats such as virtual libraries, online
journals, and specialised software such as WebCT, Blackboard , etc., which
enable educators to prepare course modules effectively and in a well-organised
manner. There are several good reviews of the different asynchronous modes of
educational tools, dealing with general questions associated with distance
learning [5, 6, 7].
In contrast, synchronous education very closely resembles
the traditional classroom environment where the course organiser or lecturer
interacts directly with the student. The interaction may take on different
forms depending on the technological tools involved, but the main feature is
that the instructor and the student, or groups of them, are not physically in
the same room. In other words, there could be multiple instructors and students
at multiple locations, interacting directly at the same time, as if they were
'virtually' located in the same room.
The merits of asynchronous versus synchronous modes have
been investigated extensively . In summary, asynchronous delivery provides
flexibility for both teachers and students, and is very cost-effective
especially when delivered on a large scale. The tools of asynchronous delivery
are well-established and most universities now offer course modules based on
Synchronous Mode of Distant Education
Synchronous delivery provides the opportunity for more
individualised interaction, which often is most valuable when difficult
concepts are involved and when each individual student might have different
issues of difficulty. It is in this area that expert guidance is invaluable and
irreplaceable. The nature of synchronous delivery, however, renders the process
relatively expensive, and perhaps because of that, the tools for synchronous
delivery are not as well-developed and established. However, this is rapidly
changing and the traditional high-end products used by corporate businesses for
video-conferencing are gradually becoming accessible for comparatively
small-scale educational projects. In fact, many commercial education projects
have been spruced up, such as remote home tutoring and online language
education. Personal audio / video communication over the Internet has become a
common practice in our society.
Asynchronous delivery has become a key tool in mainstream
university education. Interestingly, even though most universities have
adequate facilities for synchronous delivery, it is still rare to find such
applications in large institutions. So it may be fair to say that synchronous
delivery in educational settings is still in its infancy.
Some of the common platforms for synchronous delivery have
been comprehensively summarised . These tools will be discussed in more
detail in Sections III and IV below.
Distant Education in Medical Physics
There are many examples to show how the asynchronous mode
has been applied in the field of medical physics. The Emerald project was one
of the earliest contributions which promoted the role of teleteaching and the
Internet in general in medical physics education . The AAPM has a
well-established virtual library , while the Biomedical Imaging and
Intervention Journal (BIIJ) website  contains recorded sessions of talks at
conferences and symposia. Most medical physics journals are now available
online. There are also various forms of online tools, such as the Standford
Dosimetry Tool , as well as the MedPhys Wiki tool being developed by the
AAPM Task Group TG-131. In addition, a lot of distant education material for
medical physics are available on the websites of many major institutions and
organisations in the profession, such as the International Atomic Energy
Agenecy (IAEA) , Radiological Society of North America (RSNA)  and
American College of Radiology (ACR) .
On the other hand, the synchronous mode has not been
well-exploited. There are a few reported applications , and the AAPM has a
Webex service for committee meetings, where committee members meet online and
communicate directly via a common PC screen or via regular telephone conference
calls. However, there is only a peripheral element of education in this
Direct broadcast of seminars are also gradually taking
place. One of the authors' host hospitals, Sunnybrook Health Science Centre,
conducts live webcasts of many medical physics seminars, as well as radiation
oncology rounds . However, this service is still in its infancy and the
talks usually end up being recorded and archived to become an asynchronous
educational medium. This is not because of the limitations of technology, but
because of the profession�s unfamiliarity with the format and the concept of
interacting by posting live questions remotely to the speaker.
For the field of medical physics, however, the synchronous
mode has definite advantages over the asynchronous mode. Firstly, there is the
advantage of being able to delve into difficult concepts interactively, rather
than conveying a large amount of information without opportunity for feedback.
Problem-solving situations, which often come up in medical physics, are most
effectively dealt with in interactive sessions, where students'
misinterpretation of some key concepts can be much more readily identified.
Another very useful aspect of synchronous delivery is in
the area of 'hands-on' procedures. This can be divided into two categories
where the synchronous mode would be very valuable. Firstly, many medical
physics tools involve software programs such as treatment planning systems,
dosimetry analysis systems (such as film analysers, beam scan analysers, etc),
and image analyser software. A valuable part of the medical physics training
program is to share a PC desktop and demonstrate how a treatment planning
system works and also why various parameters (such as IMRT cost functions, CTV
margins, DVH analysis, etc) are selected.
Secondly, one could even go beyond sharing the PC desktop
screen, to demonstrating various physics procedures to students in a remote
location. It is feasible to use a portable video camera to go through a Linac
QA process or a TG-51 calibration in a remote session. The instructor explains
each step and the students can question any complicated details, or ask the
instructor to zoom in on a piece of the equipment.
One often reads about 'amazing' stories featuring remote
procedures, such as remote robotically-operated surgery. Instead of the huge
cost required for the equipment in such highly critical procedures, the
above-mentioned educational application does not require any sophisticated or
specialised equipment, or any dedicated network connection. Therefore, the
technological hurdles or associated costs are minor deterrents to these
As mentioned before, a medical physicist's expertise is
often rare in areas where it is most needed. And in many aspects, because of
the fast-paced development in the field, it can be difficult to find experts
even in well-established communities. Developing synchronous delivery into a
routine role would address this issue, as it would allow valuable resources to
be deployed effectively and optimally.
The experts in the field would also benefit greatly from
the synchronous mode. They can address the training of individual groups
efficiently and often quite flexibly. A training session can now include simply
the actual class time rather than all the travelling overhead. Short sessions
can easily be arranged, and there is the flexibility of conducting the session
away from the office and outside of office hours. As mentioned before, the
delivery can be expanded to instructors and students at multiple sites, to
offer even better efficiency and flexibility.
Projects on Synchronous (Real-Time) Teleteaching in Medical Physics
In view of the demand for distant education in medical
physics and with the technological tools in place for exploiting synchronous
teleteaching, the authors launched a pilot project in 2001 to explore the
feasibility of, and various aspects associated with, the concept. The project
has been reported , and is summarised again below. More information can be
obtained from the RRTL (Remote Real-Time Teaching and Learning) website .
Pilot project between University of Toronto and University of Malaya
A collaboration was set up in 2001 between the Department
of Medical Physics at the Odette Cancer Centre (then known as the
Toronto-Sunnybrook Regional Cancer Centre, and affiliated with the University
of Toronto) in Toronto, Canada and the Department of Biomedical Imaging at the
University of Malaya in Kuala Lumpur, Malaysia.
A class of medical physics graduate students from the
University of Malaya attended lectures provided by lecturers in Toronto, using
the Internet as the main tool of communication. There were two aspects to the
project. The first was to experiment with the method of real-time interactive
communication provided, as well as the logistics of the communication, such as
the time differences and the availability of facilities. The second aspect was
to determine the optimal contents and formats of such a remote education
The main �hardware� tools used included a personal
computer (PC) at both the instructors� and students� ends, with both systems
connected to the Internet, a regular telephone connection with a speakerphone,
as well as other personal computer accessories, such as a web-camera, a
microphone and speaker set, a drawing tablet, etc. The software tools included
a screen-sharing program, GoToMyPC , by which the class could view the instructor�s
computer screen and the lectures that were provided using, for example, Power
Point slides. The screen-sharing program also allowed the class to interact
directly by typing or drawing on a whiteboard, as well as by directly
controlling the mouse of the instructor�s computer to interact with specific
programs, with the instructor�s permission. Another software program, Skype
, provided the audio/video communication between the two sides. An
alternative to that was to use the regular telephone for audio communication
only. As part of the study, many of these tools were tested to determine their
usefulness and limitations. The observations have been summarised in the
Journal of Medical Internet Research (JMIR) article by Woo and Ng .
The course curriculum contained a compilation of a series
of lectures with various topics in radiation therapy. The first class (2001)
consisted of 7 graduate students who were enrolled in a regular Master of
Medical Physics program from the University of Malaya, covering both imaging
and therapy courses. The topics for the tele-education course were then chosen
to supplement the regular program, with special attention paid to hands-on
demonstration of software packages, and topics requiring more interactive communication
between the two sides.
A series of one-hour lectures, including software
demonstration, was given during the course of the project. Figure 1 shows a
scenario of the lecture, where the instructor�s PC screen appears on that of
the students� PC, together with the video picture of both parties using the
program NetMeeting . Figure 2 shows a class of students at the University
of Malaya in an actual teleteaching session while Video 1 is a video clip
showing the class of students in an actual session. The details of that pilot
study, including students' evaluation of the project, are described in the JMIR
Project with Wuhan University
This is a new project that has just been launched as a
collaboration between the Medical Physics Department at Wuhan University in
Wuhan, Hubei, China and the Odette Cancer Centre, at the University of Toronto
The Medical Physics Department at Wuhan University is
relatively new, with a young faculty whose experience is mainly in the imaging
area. In the past, the therapy aspect of the program had been provided by
external consultants affiliated with the university. Currently, the radiation
therapy programs in China are undergoing rapid advancements, resulting in
increasing demand for well-trained medical physicists. There are only three
major medical physics programs in China, of which Wuhan is the newest. This
particular project conducts classes on a regular basis for about 10 students
who are in the second year of a 3-year graduate medical physics program. The
initial objective is to assess the level of the students and to identify areas
where this mode of distant education can benefit the program, with the
possibility of expanding the project into a full course if appropriate and
In other words, a definable objective is to establish the
synchronous mode of distant education to offer a standard radiotherapy physics
course on a regular basis, with supplementary help from the local faculty of
the university or hospital.
Some Observations and Experiences Gained from the Projects
Some important and useful experiences were gained from the
first pilot project and have been reported . These observations are
reproduced and summarised below:
The time difference between the two locations was 12 hours
(13 during daylight-savings time - same for both projects). At first sight,
this seemed to pose a significant challenge, and probably would have prevented
any process that required dedicated networking facilities available only at
universities or hospitals. With the prevalence of high-speed Internet at home,
however, this turned out to be quite easily accommodated. Indeed, it was found
to be more practical for the instructor to deliver the lecture from home in the
evening, although the times had to be reversed for some of the workshops where
the software was not available on the instructor�s laptop. In this situation,
the instructor demonstrated the software at the office in the morning, while
the students held the class at the university in the evening. Once the students
were familiar with the software, they were allowed to log onto the instructor�s
office computer using a guest account and run the software program
independently. The students also managed to download the PowerPoint slides for
For the first pilot project, the screen-sharing system
GoToMyPC  required a subscription. Compared to most other synchronous
service providers, it was found to be the most suitable one for our
requirements because of its ease of use, ability to work properly in the
presence of firewalls, and relatively low cost.
In the current project with Wuhan University, another
software platform, Microsoft's LiveMeeting , is used. The main advantage of
this platform is that it offers the flexibility of having multiple sites, for
both the lecturer and the students. This function is very useful since a
projector is not available in the classroom, so the lecture can be viewed at
multiple workstations. In the future this can also provide flexibility to link
up students at other locations. In addition, the multi-site lecturer feature
allows excellent flexibility to recruit experts to participate in a regular
Many other platforms for PC-based video-conferencing have
undergone a lot of advancements in the last few years and are very
well-established. A good summary review is available .
Effective audio communication was very critical to the
success of the lectures. It was found that using the regular telephone network
was most reliable, and the cost was relatively low.
However, using a fixed land-based speakerphone was not as
straightforward as one would assume. In fact, telephone service was not as
easily accessible as Internet service in many classrooms. This posed a
significant challenge to our ongoing project at Wuhan. Fortunately,
voice-over-IP (VoIP) telephone service using the Internet has become very
advanced over the last few years , offering a viable solution for our
application. The software package Skype , which offers free PC-to-PC audio
and video connection, was used for the pilot project in University of Malaya as
well as the Wuhan project. However, the free service provided by Skype was often
unreliable, especially when Internet bandwidth was limited. In these
situations, switching to a paid VoIP service improved the quality
significantly. Even then, the connection could degrade over the time of the
lecture, and the participants would have to disconnect and redial again. The
project also tested the use of dedicated video-conferencing connections and
fixed phone-line connections, and discovered that sub-optimal audio quality was
frequently experienced as well. In conclusion, the audio quality of the lecture
is very critical, even more so than video quality, so this aspect of the
lectures has to be optimised.
In the Malaysian pilot study, there was some success with
the software NetMeeting, but problems often arose due to firewall issues.
However, it is interesting to note that the lectures managed quite well without
video communication, although it did serve as a valuable feedback mechanism.
With the Wuhan project, video was transmitted via Skype or
LiveMeeting. The experience with LiveMeeting was not satisfactory. However,
Skype was often more acceptable especially if the audio communication was
handled separately, for example through another PC running VoIP. Again, video
linkage was not critical for the lectures, but it added to the quality of the
In the beginning, the presence of a firewall proved to be
a major hurdle which prevented the use of a lot of common software tools such
as MSN messenger , Yahoo Messenger , QQ , etc. On the one hand, the
simple combination of GoToMyPC and the telephone proved to be sufficient to
complete a series of one-hour lectures, but on the other hand, if a connection
could be established without the firewall then the method of communication
could be more flexible and powerful. It is recommended that the computer
department of the organisation or university be involved to help solve the
issue of the firewall.
A standard medical physics curriculum already existed for
the Master of Medical Physics program at the University of Malaya, so a series
of special topics, such as IMRT (Intensity Modulated Radiation Therapy), was
selected for the lectures. A demonstration of a treatment planning system was
also carried out. It was found that lectures delivered using Power Point slides
were the easiest to conduct, but topics such as �Dose Calculation�, which would
be most beneficial using the synchronous mode of delivery, require more
blackboard-type illustrations and lecturer-student interactions. A whiteboard
feature in the software (GoToMyPC and LiveMeeting) allowed this to take place,
and turned out to be very useful even though some practice was required to be
familiar with the drawing tools.
Class and Instructor Interest
The students in both projects welcomed the opportunity to
interact directly with foreign experts in the field. Moreover, instructors also
found the experience interesting and rewarding. The technology did pose a lot
of challenges and demanded a lot of patience, especially in the initial
trial-and-error stages, but the flexibility and the usability of the process
rendered the overall experience very positive.
It is encouraging to report that the cost of the
remote-education program was kept to a bargain level. This, of course, depended
on the availability of fast Internet access. The software program used cost
about US$100 per year to install on the instructor�s computer and could be used
legally and freely by the students. The other costs such as phone costs, minor
hardware items, etc., were insignificant compared to the travel costs that
would have been incurred to attend workshops. The major cost that remained was
the lecturer�s fees, but since the process offered the lecturer a great deal of
flexibility in terms of time and place for the lectures, the lecturer�s cost
could also be kept to the minimum. This is a new and exciting process that many
people in the field will be interested to participate in. Hopefully this will
encourage lecturers to donate their time for an affordable and worthwhile
To start a real-time interactive remote education program,
careful planning must be undertaken. In a recent case study on using the
Internet to teach health informatics , various technical difficulties, in particular
for synchronous communication, were discussed. Computer and network problems
can be very frustrating and minor glitches can discourage both the instructors
and students. It is highly recommended that a new program should be carried out
with a minimal but reliable set of tools, such as the standard telephone used
in our project, and preferably with the support of knowledgeable computer
In addition, it is crucial to have extensive support from
the local department at the students' university or hospital, in terms of IS
(Information Systems) expertise as well as organisational assistance, such as a
local course organiser or teaching assistant. These are people who are more
familiar with the local requirements, as well as protocols, procedures and
limitations. When the course is deemed to provide real and tangible value, then
the organisational and technical aspects of the synchronous delivery will be
In conclusion, the project has proven that real-time
interactive remote education of medical physics is a viable concept that is
ready to be carried out for selected places and groups. It serves a useful
purpose and is a very cost-effective way to promote closer communication and
dissemination of knowledge and information within the medical physics
community. There are certainly limitations and any new programs must be
carefully planned. The increased usage of this method will more speedily
eliminate some of the existing limitations.
Figure 1 Typical scenario of a lecture. The instructor�s PC screen appears on that of the students� PC, together with the video picture of both parties using the software program NetMeeting.
Figure 2 A class of students at the University of Malaya in an actual teleteaching session.
Movie 1 A video clip showing the class of students in an actual session.
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|Received 28 December 2007; received in revised form 25 Februari 2008, accepted 4 March 2008
Correspondence: Department of Medical Physics, Odette Cancer Centre, Toronto, Ontario, Canada. E-mail: firstname.lastname@example.org (Milton Woo).
Please cite as: Woo M, Ng KH,
Real-time teleteaching in medical physics, Biomed Imaging Interv J 2008; 4(1):e13