handsON Anatomy:
Creating a Web-based, Navigatable and Annotatable 3D Model of the Hand As a Collaborative
Knowledge Building Tool for the Surgical Community
Stefania Spano, MScBMC Candidate
Prof. M. Dryer, Supervisor
Dr. P. Binhammer, Content Advisor
Mr. M. Corrin, Second Voting Member
MSC2004H Research Methods
Professor S. Wall
7th
June 2011
TABLE OF CONTENTS
Abstract
3
List of figures
4
“handsON Anatomy: Creating a Web-based, Navigatable and Annotatable
3D Model of the Hand As a Collaborative Knowledge Building Tool for the
Surgical Community”
6
References
18
Figures & tables
21
2
ABSTRACT
Hand surgery fellows in particular are in a precarious position: their specialty is multidisciplinary,
and thus keeping their knowledge current involves collecting literature from several types of specialty
publications. However, surgeons are notoriously limited for time. Traditional educational tools for hand
surgeons fall to one of two trends: the static, two-dimensional, theoretical world of lecture slides and
anatomical atlases; or the dynamic, three-dimensional, practical world of surgical skills centres and the
OR, yet these resources have inherent design limitations that impede their success as educational tools.
Furthermore, neither trend addresses the role of collaborative knowledge building. A third trend is
harnessing the Internet for individual education and for collaborative knowledge building. Current
resources such as physician-only forums, list serves and wikis (Eaton, 2001) combine continuing
education with peer-to-peer social networking, but they are limited and leave much to be desired.
Surgeons require a tool that uses the Internet to efficiently unite static 2D theory and dynamic 3D praxis
while addressing the generative capacities of real-time group discussion and interaction. This project
proposes an open-source, web-based, 3D model of the hand in the style of GoogleTM Earth: an
amalgamation of educational, interactive 3D modelling and social networking tools to provide surgeons
with a manipulatable, annotatable navigation tool for collaborative knowledge building.
KEY WORDS:
hand surgery, social networks, collaborative knowledge building, Unity, 3D technology, interactivity,
tagging, personal semantic annotations, accommodation, assimilation, continuing medical education,
knowledge-creating theory, co-evolution
3
LIST OF FIGURES & TABLES
Figure 1. Current trends in educational tools for hand surgeons. (a) Hand
surgeons are currently faced with two educational options: the static, 2D,
theoretical world “A” of lecture slides and anatomical atlases; or the dynamic, 3D
practical world “B” of surgical skills centres and surgical observation. (b) This
project proposes a third movement “C” that amalgamates options A and B while
promoting collaborative knowledge building via web-based social networking
tools.
6
Figure 2. A model of collaborative knowledge building. Reproduced from Liang,
2009, after Stahl, 2006.
7
Figure 3. AO Surgery Reference: Hand Overview. (a) Users navigate around a
static 2D image of the bones of the hand. (b) Selecting different anatomical
regions leads the end user to a related case studies. The tool is rich in surgical
technique educational tools, including step-by-step surgical illustrations with
textual directions on how to repair a multitude of fracture types.
8
Figure 4. Screen captures of “Mapping Migraine Pain: Familial Hemiplegic
Migraine”, a model of “interactive cartography”. While the anatomical portion
of the interface cannot be manipulated, a slider bar allows the end user to zoom
into increasing levels of detail and magnification. The slider is paired against a
cross-sectional cut of the cortex, thus providing a constant orientation image for
the user
9
Figure 5. Comparisons of live OR footage (a) and simulated animations (b) of
the same procedure. (a) Select stills from “Carpal Tunnel Release”, OrLive, Inc.
and U.S. National Library of Medicine. (b) Select stills from “Endoscopic Carpal
Tunnel Release Procedure”, Nucleus Medical Art.
10
Figure 6. Screen captures of “Interactive Hand”, Primal Pictures. This
interface juxtaposes visuals with written information about the anatomical
structures being depicted. The model proper is thorough and makes use of colour
coding and mouse-over highlighting/text box pairings for ease of use. Users can
also “peel away” structures and rotate the object around a Y-axis.
10
Figure 7. Screen captures of DoctorsHangout.com. (a) Home page. (b)-(d)
Users are encouraged to participate in knowledge transfer through videos, images,
forums and more.
12
Table 1. Analysis of physician social network link activity, Highlight Health
Web Directory. These sites are retrieved from the top-ranking webpage for a
Google search of the phrase “physician social networks”. Descriptions are derived
from Highlight HEALTH (2011).
12
4
“The illiterate of the 21st century will not be those who cannot read and write,
but those who cannot learn, unlearn, and relearn.”
Alvin Toffler
5
INTRODUCTION
The contemporary physician is faced with an interesting challenge: staying up-to-date in a fastpaced field whilst attending to daily professional duties on a strictly budgeted schedule. In addition to
patient care, physicians are saddled with the need to stay ahead of the educational game. This includes
reading about the latest research and technologies in their specialty (and possibly conducting research of
their own), pursuing continuing medical education (CME) and additional accreditations, and networking
with other professionals in their field. Surgeons are especially notorious for having limited time. In the
U.S. alone, practising, full-time orthopaedic surgeons (20% of whom pursue fellowships in hand surgery)
report spending at least 86% of their time in clinic, and only 2% each on research and related activities
(Watkins-Castillo, 2006). Hand surgery fellows in particular are in a precarious position: their specialty is
multidisciplinary, and thus keeping their knowledge current involves collecting literature from several
types of specialty publications (Eaton, 2001). Suddenly, the need to expand academic and professional
growth by efficient and effective means is even greater.
Visualization Problem
Traditional educational tools for hand surgeons fall into one of two trends: the static, twodimensional (2D), theoretical world of lecture slides and anatomical atlases; or the dynamic, threedimensional (3D), practical world of surgical skills centres (such as the facilities at Toronto’s Mount Sinai
Hospital) and surgical observation in the operating room (Figure 1). Each trend is complementary to the
other; however, hand surgeons simply do not have the time required to use each of these resources to their
maximum potential, and neglect of one reveals the gaps in the educational capacity of the other. Several
attempts have been made to bridge the gap between streams, such as simulated animations, interactive
anatomical models and live OR footage. While these innovations have triggered new ways of approaching
education, they too have inherent design flaws that impede their success as educational tools.
Furthermore, neither trend addresses the role of collaborative knowledge building, a co-evolution
wherein the cognitive processes of an individual contribute to the social processes of a group and vice
versa (Figure 2; Kimmerle, Cress & Held, 2010). As the field of medicine continues to embrace the
6
digital age, a third trend is surfacing: a harnessing of the Internet for individual education and for
collaborative knowledge building. Current resources such as physician-only forums, list serves and wikis
(Eaton, 2001) combine continuing education with peer-to-peer social networking, but they are limited and
leave much to be desired. Surgeons require a tool that uses the Internet to efficiently unite static 2D theory
and dynamic 3D praxis while addressing the generative capacities of real-time group discussion and
interaction -- in short, a tool that pulls the best of three worlds together into one efficient information hub
(Figure 1b). This project proposes an open-source, web-based, 3D model of the hand in the style of
GoogleTM Earth: an amalgamation of educational, interactive 3D modelling and social networking tools to
provide surgeons with a manipulatable, annotatable navigation tool for collaborative knowledge building.
LITERATURE REVIEW
A Matter of presentation: Current educational tools
Medical education has long relied on the use of static, two-dimensional teaching tools (Figure
1a). In their infancy, resources such as lecture notes and anatomical notes were portable, reproducible,
easy to distribute and allowed for easy addition of personal annotations. The digital age has only made
these tools more accessible, more easy to distribute. Thanks to digital databases, online journals, eBooks
and the ever-increasing storage capacities of electronic devices, users have access to even more
“classical” resources, leading to increasingly large personal libraries . Technology addresses the issue of
physical storage, but accessibility is still limited to surgeons who have access to personal portable
electronic devices and Internet access. Furthermore, the actual content of these resources remains the
same. Lecture notes and anatomical atlases are useful for developing semantic knowledge, but are limited
in their ability to teach the procedural. Surgery is a heavily visual, inherently dynamic profession, from
learning basic anatomy to understanding the steps and mechanisms of particular surgical techniques.
Lecture notes can be text-heavy, using cumbersome language where an image would suffice. Alternately,
anatomical atlases may use static visuals that either lack sufficient textual explanation, or are didactically
ineffective on their own and need additional personal annotation to aid in user comprehension. Even
7
successfully rendered atlas images can be insufficient beyond the introductory stages of knowledge
assimilation, simply because they are static 2D objects attempting to represent dynamic 3D processes.
There is no opportunity to interact with the image, to manipulate an anatomical drawing to anything other
than the classical anatomical position. Lecture notes and anatomical atlases have little to no room for
active user participation in the learning process; the user simply reads the text, views the artwork.
Modern technology has attempted to solve issues of interactivity and user participation in
educational materials for hand surgeons. AO Surgery Reference offers a suite of online resources,
including the Hand Overview (Fricker, Kastelec & Nunez, 2011). This tool uniquely correlates interactive
hand gross anatomy with practical case studies relevant to hand surgeons. Regions of the model proper
can be clicked on, and through a series of submenus, the end user is led to a case study relating to the
initial anatomical region (Figure 3). The tool is rich in case studies and surgical technique education,
including step-by-step surgical illustrations with textual directions on how to repair a multitude of fracture
types. The detail and thoroughness of the ensuing content on fracture type, location and repair, as well as
the static procedural images therein are commendable. However, the hand model presented is shown in
the classical anatomical position, is 2D and cannot be manipulated in 3D space. It appears to function
more as a pictorial navigation tool more than an inherently educational anatomical rendering. Thus, while
textually thorough, the static hand is a missed opportunity to annotate the tool in regions lying outside of
classical anatomical view -- the dorsal side of the hand, the side of a finger. Lastly, while Hand Overview
is very anatomically thorough, it is so at only one systemic level – bone. There is nothing to be said of
muscle, nerve, tendon or skin, thus limiting the scope of the case studies dramatically.
One possible design solution for a polysystemic hand model is interactive cartography, as
demonstrated in Ardis Cheng’s “Mapping Migraine Pain: Familial Hemiplegic Migraine” (2007; Figure
4). While the anatomical portion of Cheng’s interface cannot be manipulated, a slider bar allows the end
user to zoom from gross (the skull) to microscopic (the neural synapse). The slider is paired against a
cross-sectional cut of the cortex, thus providing a constant orientation image for the user. This allows the
user to correlate changes in anatomical architecture with a translational movement down through cortical
8
levels. Each change in level corresponds to a different piece of textual information to the left of the
model. Colour coding in the images is present but not reflected in the textual information, which would
have provided useful visual cues for uniting concepts between text and image. Additionally, interactive
cartography does not address earlier questions of object manipulation; the end user is again locked into
the view dictated by the object’s designer, and the object gives no further information about spatial
relationships as a 3D object might.
Instinctually, one might believe that the best option for such spatially-cognisant educational tools
would be those derived from the operating room itself -- that is, cadaveric work, live OR footage and
simulated animations. After all, the majority of surgical training occurs in the operating room
(Binhammer, 2011). Yet cadavers are costly in financial and human resources, as are the surgical skill
centres that offers technique training in surgeon “off time”. Human cadaveric work, while practically
useful, is a limited resource and may not be viable for several reasons, be they academic, financial or
political. Use of deceased, non-human material is a convenient alternative to high-maintenance cadaver
work, but creates some dissociation between theoretical knowledge and practical application.
Additionally, such resources and facilities exist as part of well-established and well-funded healthcare
systems within which not all surgeons are privileged to practise.
Web-based providers such as Medline’s ORLive offers narrated footage of actual surgical
procedures (ORLive, Inc. and U. S. National Library of Medicine, 2010). ORLive makes effective use of
a split-screen technique, where one half may depict the surgery proper and the other half may contain
supplementary information – most often, a lecture slide detailing the symptomatology of the diseased
structure at hand or the technical approach that the surgeon will take (Figure 5a). This multimodal
approach to education is a solid means of appealing to different learning styles. Previously-recorded
surgical footage allows end users to go through the narrative of a surgical procedure at their own pace,
rather than in the strictly timed (and sometimes chaotic) environment of the operating room proper.
However, the end user is limited to the surgeon’s and/or the classic anatomical view, which may not prove
informative to the less trained eye and does not allow the resident to change viewpoint to better
9
understand the anatomy presented. Additionally, the live surgical field exhibits an abundance of
extraneous visual information that may not be conducive to understanding the underlying story that the
footage tries to convey – namely, the anatomy and the surgical technique. Simulated animations of
surgical procedures make an effort to reduce this visual noise, but as linear narratives, they still restrict
viewers to the point of view of the camera as decided by the animator (Figure 5b). Multiple camera
panning techniques take the viewer through different anatomical levels within and without the hand, but
at times, the view becomes disorienting, and this particular animation offers no narration or textual labels
as visual cues.
It appears the best method for granting end user autonomy over an anatomical object is an
interactive, 3D model that the end user can manipulate as they see fit. Interactive anatomical models are
excellent focal tools in that they can reduce visual noise by stripping away the surgical environment in its
entirety (Figure 6). Primal Pictures has developed a very thorough 3D model of the hand with a clean
interface and rich content (Teo et. al., 2003). The interface juxtaposes visuals with written information
about the anatomical structures depicted. The model proper is thorough if somewhat geometric, and
makes use of colour coding and mouse-over highlighting/text box pairings for ease of use. Users can also
“peel away” structures from superficial (skin) to deep (bone). End users can rotate the object around a Yaxis, providing limited manipulation of the model. There is also no zoom function, thus keeping the user
at a fixed viewing distance from the model; this disallows the opportunity for users to move through and
see relationships between gross and fine anatomical structures. The additional textual information is
standardized by Primal Pictures, and thus the end user does not have the option of adding to the proffered
knowledge bank. Furthermore, there does not appear to be a “bookmarking” option that catalogues the
end user's favourite structures, information panels, etc.
Thus, the current trends in educational tools for hand surgeons are cumulatively necessary but
individually insufficient solutions for supporting and expanding the education of hand surgery at the level
of the individual.
A matter of collaboration: Networking and “social surgery”
10
As the influence and integration of the Internet in daily activities grows, its technological trends
exert an equal influence on how hand surgeons practise. The pervasiveness of social media networks such
as Facebook and Twitter increasingly emphasize the role of the individual as part of a larger community.
Likewise, there is a pull to translate the individual practitioner’s knowledge into a shared commodity for
consumption by the surgical population at large. While formal peer review via committees, conferences,
editorial boards and the like are not to be undervalued, not all surgeons have access to such resources;
even then, publisher turnover rates of journals and textbooks are notoriously slow, and conferences are
strictly scheduled. The 24/7 accessibility of the internet allows for informal real-time peer reviews
through e-mail, wikis and forums. Social surgery encourages the sharing of personal libraries (videos,
articles, anecdotes, photographs, et cetera) so that physicians can discuss, debate and discover new ways
of practising that traditional methods of discourse do not facilitate. According to Kimmerle et al’s
(Kimmerle, Cress & Held, 2010) co-evolution model of individual and collective knowledge, this is a
crucial tenet of collaborative knowledge building, where an individual externalizes their cognitive
process for internalization by a group and vice versa. This allows individual and group to assimilate new
information where there is a void (thus changing the quantity of one’s cognitive processes), or to
accommodate new information where there is a change in comprehension (thus changing the quality of
one’s cognitive processes).
A Google search of the phrase “physician social networks” generates nearly 25 million hits, the
first of which is Highlight HEALTH Web Directory (Table 1; Highlight HEALTH, 2011). Surprisingly,
this directory only lists eight physician social networks; two are inactive; one, Sermo, is only accessible
after confirmation of a member’s professional certification (Sermo, Inc, 2010). None cater specifically to
the surgical community, let alone to the hand subspecialty. The top-listed website, DoctorNetworking, no
longer exists. Listed second is DoctorsHangout.com (Doctors Hangout, 2011), which boasts features and
user types that overlap with the remaining networking sites. There is a clear willingness to participate in
knowledge transfer through videos, images, forums and other types of digital artefacts (Figure 7).
A DoctorsHangout search of the phrase “hand surgery” pulls up digital artefacts (digital records
11
of externalized knowledge) of varying formats -- discussion topics, videos and photographs -- much as a
Google search would offer. The result is a wiki-type collection of multimedia resources contingent on the
specificity and success of the end user’s search terms. The user must sort through search results -- a timeexpensive activity to which most hand surgeons cannot afford to dedicate themselves. DoctorsHangout
lacks any sort of visible social tagging system, wherein digital artefacts are annotated with keywords for
the benefit of a community of end users (Cheng, 2007). Social tagging is efficient, allowing for quick,
refined searches according to subject matter. It is also invaluable for providing metadata about a digital
artefact, and a solid opportunity for the end user to form associations between what they already know,
what they are trying to learn through their searches, and in what ways other end users have interpreted an
artefact and related it, via keywords, to other artefacts (Kimmerle, Cress & Held, 2010).
At a more basic design level, physician-oriented social media networks lack the merits of the
aforementioned arsenal of educational tools, whilst still bearing several of their shortcomings. While
interaction with other professionals is increased, interaction with the discussion content itself is passive:
text is read, a video is watched. Forums, wikis and search engines do not use anatomical objects as
navigation and data visualization tools, nor is there a strong visual object (such as a 3D model of the
hand) connecting the anatomical subject (such as the multilevel anatomy associated with a scaphoid
fracture) and the associated digital artefact (such as a description of how a scaphoid fracture is treated).
Thus, the current trends in social networking for hand surgeons are useful tools for promoting
individual and group knowledge through real-time discussion and debate from a diverse population.
However, such networks suffer a large disconnect from current traditional and digital educational tools. A
medium that synthesizes presentation and collaboration has yet to be found.
VISUAL RESEARCH QUESTION
How can the power of current educational resources and social media networks be harnessed and
distilled into one interactive, dynamic, accessible and annotatable tool that encourages collaborative
knowledge building among hand surgeons outside of the OR?
12
RESEARCH OBJECTIVES
1. Design a prototype that is a novel hybrid that synthesizes the design strengths of previous educational
tools and bridges the gap between 2D media (textbooks, photographs, footage) and live observation.
2. Design an interface with editing capabilities that provides annotative power to end users. This will
allow the tool to evolve alongside the academia and praxes of the surgical profession as well as support
end users in specifically tailoring the tool to suit self-directed learning.
3. Investigate how to develop an inexpensive, readily accessible educational tool that uses a 2D vehicle
(such as the screen of a computer or mobile device) to display a 3D environment.
4. Use 3D technology to promote tacit learning of spatial relationships in hand anatomy, while still
respecting the user's interactive and navigational needs.
5. Provide the complete functionality of an educational and aesthetically pleasing 3D environment
without overwhelming the end user with a steep learning curve or extraneous features.
METHODS & ANTICIPATED RESULTS
The final prototype of this research will be “handsON”, an interactive, 3D model of the hand in
the style of Google
TM
Earth that can be used by hand surgeons and can support flexible and public
annotations. The following methodology will be used to achieve the aforementioned research objectives.
Ethics Approval. To begin, I plan to evaluate the handsON prototype iteratively. Thus, I will
submit a research proposal for approval by the University of Toronto’s Research Ethics Council for June
2011. Due to the low-risk and low group-vulnerability nature of the research, I anticipate that this
proposal will be submitted for a delegated review and receive approval.
Needs Evaluation of Surgical Residents. Pending ethics approval, I will conduct a needs
evaluation of a sample of junior and senior plastic surgery residents under the supervision of Dr. Paul
Binhammer. The evaluation will take the format of a questionnaire. The questionnaire will cover topics
such as type and perceived value of current educational tools; how subjects typically use their time;
13
typical workflow during self-directed learning; prevalence and perceived value of personal mobile device
use for professional success; and general design questions. The questionnaire will also include a comment
box for free-form responses. Questionnaire results will directly influence the content and design of the
final prototype. I anticipate that these results will match the observations made in my literature review;
namely, that hand surgeons are becoming increasingly dependent on portable, web-based technologies for
real-time research and communication, and that current educational tools are in need of a proper
partnership with increasingly popular social networking tools.
Learning Unity. To program the interactive elements of the prototype, I will take an introductory
course with Michael Corrin in Unity, a piece of software often used for game design. I will also pursue
self-directed learning through independent study and online tutorials. I anticipate that the interactive
design of the prototype will be shaped by both the needs evaluation and the capacities of Unity to
program such interactivity. Recent studies suggest that, in addition to traditional graphical user interfaces
(GUIs), 3D web applications can also benefit from post-WIMP (windows, icons, menus, pointers) user
interface models (Bistrom et. al., 2009); this is especially relevant in the advent of bimodal and touch
input technologies for mobile devices. Thus, I will also explore which GUI option best accommodates the
accessibility and interactivity required by end users.
Modelling in Maxon Cinema 4D. The 3D hand proper will be modelled in Maxon Cinema 4D
with the guidance of Michael Corrin and Prof. Marc Dryer. I will create individual models of the separate
systems of hand anatomy: skin, muscle, tendon, bone, nerve, and vasculature. I will refer to other
available resources to determine which structures to include in each model, as well as consulting Dr.
Binhammer for his professional opinion and his knowledge of surgical curricula. Once complete, the
models will be exported to Unity for synthesis into one cohesive model, thus ready for programming of
interactive elements.
Interactivity in Unity. The three core interactive elements that I will develop will be SpinSphere,
LayerLife and PinPoint. SpinSphere is a spherical navigation object against which an XYZ axis is plotted,
allowing full rotation of the hand model. Such ergonomic manipulation mimics intuitive user movements,
14
thus facilitating use of the tool overall. LayerLift will allow the peeling away of major anatomical
systems from superficial to deep, either through the use of on/off toggles or alpha sliders. This option is
unique in that it allows for a polysystemic understanding of hand anatomy that is dictated by the end
user’s needs and actions. Lastly, PinPoint will provide the annotative features that support “bookmarking”
and collaborative knowledge building. With PinPoint, end users can add a “pin” to a region of the hand
model. When clicked/tapped, this pin will reveal a pop-up window, and end users can simply drag and
drop digital artefacts into the pin -- videos, photographs, textual anecdotes, hyperlinks. Authors can also
add tags to pin entries. Pins can be colour-coded according to the systems associated with the content of a
pin. For example, a pin entry on the scaphoid bone may be white, whereas as a case study involving a
scaphoid fracture may have a multicoloured pin to denote the inclusion of skin (pink), bone (white) and
vasculature (red) in the injury. Pins can also be toggled on/off according to colour/system. PinPoint is an
especially complex idea, and will be the primary means of satisfying the social network criteria of the
prototype. I predict that time, practicality and Unity capabilities will largely dictate the functionality of
PinPoint. For simplicity, the handsON prototype will have only one end user with annotative power.
Prototype Evaluation. My committee will be integral in the design process; I will meet with them
regularly to offer progress reports and receive constructive criticism of the prototype. I will also enlist
fellow classmates to attempt to “break” the prototype, as well as to critique its communicative aspects of
the prototype. For scientific and communicative evaluation of the final handsOn prototype, I will conduct
focus groups with junior and senior surgical residents under the tutelage of Dr. Binhammer.
DISCUSSION
There are several clearly anticipated benefits to the handsON project. Research in construction
education suggests that students working actively with 3D models and virtual environments were more
adept at spotting flaws in construction designs, as well as demonstrating better active decision-making
and understanding of structural design overall (Cheng, 2007). These skills can be translated to hand
surgeons who must understand normal anatomy and potential pathology in trauma situations. The ability
15
to manipulate a model (rather than simply watching an animation or clicking navigational arrows) also
aids in the understanding of an object’s spatial geometry and primes the brain for mental rotation of
objects -- a useful skill when limited by a patient’s range of motion, trauma and/or the setup of the OR
(ORLive, Inc. and U. S. National Library of Medicine; 2010, Cheng, 2007). In a world of keypads,
pressure sensitivity, motion sensors and touch screens, there is an increasing propensity for users to
engage in naturalistic motions when interacting with modern technology, such as swiping a finger across a
screen to simulate a flipping or scrolling act. The suggested tactile relationship between user and model
when manipulating something such as handsON supports the role of designs that support active
participation, as well as working with the natural exploratory tendencies of the hands and the brain's
ability to understand spatial relationship through tactile experience. This may work especially well with
touch-sensitive devices. Interestingly, surgeons are able to deftly identify anatomical structures when
indicated, yet many have difficulty understanding the order and spatial relationships of anatomical
structures when transitioning from superficial to deep and back (Cheng, 20070). This shortcoming is not
addressed by anatomical atlases and other static 2D tools; a combination of active object rotation
(SpinSphere) and manipulation of structure visibility (LayerLift) can help in this comprehension.
The choice to make handsON a heavily interactive tool is also based on the belief that degree of
interactivity and user attitude are positively correlated (Teo et. al., 2003; Kettanurak, Ramamurthy, and
Haseman, 2001). Increased perceived interactivity correlates with more time spent on each page, thus
allowing a larger window for knowledge acquisition; for handsON, where users are expected to acquire
and apply new information, this is critical, and gives a clear advantage over lecture notes and anatomical
atlases. One possibility is that the ability to deliver content in an interactive environment at a user-defined
rate adds less pressure on the user, unlike the steady flow of live OR footage or animated simulations.
Additionally, it may be that information unfolds in the user's preferred order and manner, thus
customizing the pleasantness of the website experience according to user preference.
16
The social, annotative capacities of handsON are the most novel of its features, and likely
the most powerful. Studies suggests that a participatory approach to education significantly impacts
learning comprehension (Wilson-Pauwels, 2007). By adding PinPoint pins to the hand model, users are
forced to externalize their knowledge and thus increase their cognitive processes -- in short, the more one
adds, the more one learns (Cress & Kimmerle, 2008). Secondly, surgeons prefer to have an increase in
quality and quantity of visual cues available when learning a new technique (Wilson-Pauwels, 2007).
Whenever a pin is present, users are offered at least two modalities of learning: the 3D model, and the
affiliated digital artefacts of the pin. A pin containing a video of a novel surgical procedure has the added
benefit of being connected to a referential anatomical object -- the 3D hand below the pin.
Lecture notes, photographs, diagrams, movie clips and private library miscellanea enrich the
experience of the end user by offering real-time points of discourse. Geographical variations in quality
and quantity of surgical procedures has been well-documented (Burke, Fournier & Prasad, 2003). A webbased platform breaks down geographical, political and cultural barriers, exposing different communities
to how each practises hand surgery, to new risk insights, and to innovations in technique. Furthermore,
real-time publication of pins offers real-time feedback as digital artefacts are edited by various users of
diverse backgrounds (Kimmerle, Cress & Held, 2010). Skill acquisition theory suggests that psychomotor
tasks are learned in three stages: cognitive, associative and autonomous. External feedback promotes the
associative stage, as individuals critique themselves by comparing their performance against that of a
professional, and correct their errors accordingly (Rogers, 200). A pin contributor can receive feedback
from other end-users about the contents of their pin. Thus, the quality of the contributor’s knowledge
improves (helping the individual) and the quality of the pin itself improves (helping the user community).
The tool, its digital artefacts, and the cognitive artefacts of its users become autopoeitic (Cress &
Kimmerle, 2008), promising an exciting hybrid of education and collaboration that evolves with its users.
17
REFERENCES
Anastakis, D. J. , S. J. Hamstra, and E. D. Matsumoto. 2000. Visual-spatial abilities in surgical training.
The American Journal of Surgery 179 (6, pp. 469-471): June.
Beermann, J., R. Tetzlaff, T. Bruckner, M. Schoeebinger, P. Mueller-Stich, N. Gutt, H. P. Meinzer, M.
Kadmon, and L. Fischer. 2010. Three-dimensional visualisation improves understanding of
surgical liver anatomy. Medical Education 44 (9) (Sep): 936-40.
Binhammer, P. 2011. Personal communication.
Bistrom, J., A. Cogliati and K. Rouhiainen. 2009. Post-WIMP User INterface Model for 3D Web
Applications.
Burke, M. A. Fournier, G. M., Prasad, K. 2004. Physician Social Networks and Geographical Variation in
Medical Care, Florida State University working papers.
Caldwell, BS. 2008. Group cognition: Computer support for building collaborative knowledge.
Cheng, Ardis. 2007. Mapping Migraine Pain. Mapping Migraine Pain: Familial Hemiplegic Migraine.
http://www.bmc.med.utoronto.ca/~ardis/mrp/prototype/mmp.html
Cho, M., C. Hui and S. Chung. 2010. Testing an integrative theoretical model of knowledge-sharing
behavior in the context of wikipedia. Journal of the American Society for Information Science and
Technology 61 (6) (06): 1198-212.
Cress, U. and J. Kimmerle. 2008. A systemic and cognitive view on collaborative knowledge building
with wikis. International Journal of Computer-Supported Collaborative Learning 3 (2) (Jun):
105-22.
Doctors Hangout. 2011. DoctorsHangout.com - A Personal& Professional Networking Site for Doctors&
Medical Students Worldwide. DoctorsHangout.com. http://www.doctorshangout.com/
Eaton, C. 2001. Use of web sites in hand surgery. Techniques in.Hand & Upper Extremity Surgery,
December 01 5 (4): 216-30.
Fricker, R. M. Kastelec and F. Nunez. 2011. Hand - Diagnosis - AO Surgery Reference. AO Foundation.
http://www2.aofoundation.org/wps/portal/!ut/p/
c1/04_SB8K8xLLM9MSSzPy8xBz9CP0os3hng7BARydDRwML1yBXAyMvYz8zEwNPQwN3A
6B8JJK8gUWAm4GRk6m_oUl wgBFIHr9uP4_83FT9gtyIcgCExWfz/dl2/d1/
L2dJQSEvUUt3QS9ZQnB3LzZfQzBWUUFCMUEwOEVSRTAyS jNONjQwSTEwRzA!/?
showPage=diagnosis&bone=Hand&segment=Overview
Garg, A., G. Norma, L. Spero and I. Taylor. 1999. Learning anatomy: do new computer models improve
spatial understanding? Medical Teacher 21(5): 519-522.
Golder, S. 2006. Usage patterns of collaborative tagging systems. Journal of Information Science 32 (2):
198-208.
Highlight HEALTH. 2011. Physician Social Networks | Highlight HEALTH Web Directory. Highlight
Health Web Directory. http://www.highlighthealth.info/medicine-20/physician-social-networks/
18
Kettanurak, V. , K. Ramamurthy, and W. D. Haseman. 2001. User attitude as a mediator of learning
performance improvement in an interactive multimedia environment: An empirical investigation of
the degree of interactivity and learning styles. International Journal of Human-Computer Studies
54 (4) (04): 541-83.
Kimmerle, J., U. Cress, and C. Held. 2010. The interplay between individual and collective knowledge:
Technologies for organisational learning and knowledge building.
Lee, M. J. W., C. McLoughlin, and A. Chan. 2008. Talk the talk: Learner-generated podcasts as catalysts
for knowledge creation. British Journal of Educational Technology 39 (3, pp. 501-521): May.
Liang Yu. Principles for collaborative learning platform design. Paper presented at (2009). 2009 1st
International Conference on Information Science and Engineering (ICISE 2009)(pp.3384-3386).
Piscataway, NJ: IEEE.; 2009 1st International Conference on Information Science and Engineering
(ICISE 2009), 26-28 Dec. 2009, Nanjing, China. .
Mayer, RE, and R. Moreno. 2003. Nine ways to reduce cognitive load in multimedia learning.
Messner, J., I. Sai, C. M. Yerrapathruni, A. J. Baratta, and V. E. Whisker. 2003. Using virtual reality to
improve construction engineering education. Paper presented at 2003 ASEE Annual Conference &
Exposition: Staying in Tune with Engineering Education; Nashville, TN; USA; 22-25 June 2003.
2003; 2003 ASEE Annual Conference & Exposition: Staying in Tune with Engineering Education,
Nashville, TN; USA.
Nucleus Medical Art. 2009. Youtube - Endoscopic Carpal Tunnel Release Procedure. Medical Legal Art.
http://www.youtube.com/watch?v=wyXlrj2ICIY
ORLive, Inc. and U. S. National Library of Medicine. 2010. ORLive, Inc. and U. S. National Library of
Medicine: Carpal Tunnel Release. MedlinePlus. http://www.orlive.com/hartfordhospital/videos/
carpal-tunnel-release?view=displayPageNLM
Primal Pictures Limited. 2009. interactive_hand_2009 - Primal Pictures 3D anatomy software demo.
PRIMALPICTURES.COM. http://www.primalpictures.com/demo.aspx?
f=interactive_hand_2009.swf
Rogers, D. 2000. The impact of external feedback on computer-assisted learning for surgical technical
skill training. The American Journal of Surgery 179 (4): 341-3.
Sermo, Inc. 2010. Sermo.com. Sermo. http://www.sermo.com/
Stahl, G. 2006. Group Cognition: computer support for building collaborative knowledge. Acting with
technology series, MIT press:193–199.
Smith, G. G.. 2005. Why interactivity works: Interactive priming of mental rotation. Journal of
Educational Computing Research 32 (2): 93-111.
Teo, H., L. Oh, C. Liu, and K. Wei. 2005. An empirical study of the effects of interactivity on web user
attitude. Computing Reviews 46 (1) (Jan.): 55.
19
Torres, D., A. Díaz, H. Skaf-Molli, and P. Molli. 2009. Supporting personal semantic annotations in P2P
semantic wikis. Paper presented at 20th International Conference on Database and Expert Systems
Applications, DEXA 2009, startdate 20090831-enddate 20090904.
University of Toronto. UofT Surgical Skills Centre at MSH, “Tendon Repair” and “Z-Plasty or Skin
Lesion Removal”. University of Toronto Surgical Skills Centre. http://www.utoronto.ca/ssc/
procedures.htm
Watkins-Castillo, S. 2006. Orthopaedic Practice in the US 2005-2006. AAOS Department of Research and
Scientific Affairs.
Wilson Pauwels, L. 2007. Biomedical communications: Collaborative research in scientific visualization,
online learning, and knowledge translation. Clinical Pharmacology Therapeutics 81 (3): 455-9.
20
FIGURES & TABLES
(a)
(b)
Figure 1. Current trends in educational tools for hand surgeons. (a) Hand surgeons are currently faced with two
educational options: the static, 2D, theoretical world “A” of lecture slides and anatomical atlases; or the dynamic, 3D practical
world “B” of surgical skills centres and surgical observation.
(b) This project proposes a third movement “C” that amalgamates options A and B while promoting collaborative knowledge
building via web-based social networking tools.
Figure 2. A model of collaborative knowledge building. Reproduced from
Liang, 2009, after Stahl, 2006.
21
(a)
(b)
Figure 3. AO Surgery Reference: Hand Overview. (a) Users navigate around a static 2D image of the bones of the hand.
(b) Selecting different anatomical regions leads the end user to a related case studies and surgical technique educational tools,
including step-by-step surgical illustrations with textual directions on how to repair a multitude of fracture types.
22
(a)
(d)
(g)
(j)
(b)
(e)
(h)
(k)
(c)
(f)
(i)
Figure 4. Screen captures of
“Mapping Migraine Pain: Familial
Hemiplegic Migraine”, a model of
“interactive cartography”. While the
anatomical portion of the interface
cannot be manipulated, a slider bar
allows the end user to zoom into
increasing levels of detail and
magnification. The slider is paired
against a cross-sectional cut of the
cortex, thus providing a constant
orientation image for the user
23
(a)
(b)
Figure 5. Comparisons of live OR footage (a) and simulated animations (b) of the same procedure.
(a) Select stills from “Carpal Tunnel Release”, OrLive, Inc. and U.S. National Library of Medicine. ORLive uses a splitscreen technique, where one half may depict the surgery proper and the other half may contain supplementary information.
(b) Select stills from “Endoscopic Carpal Tunnel Release Procedure”, Nucleus Medical Art.
24
(a)
(b)
(c)
(d)
(e)
(f)
Figure 6. Screen captures of “Interactive Hand”, Primal Pictures. This interface juxtaposes visuals with written
information about the anatomical structures being depicted. The model proper is thorough and makes use of colour coding and
mouse-over highlighting/text box pairings for ease of use. Users can also “peel away” structures and rotate the object around a
Y-axis.
25
(a)
(b)
(d)
Figure 7. Screen captures of DoctorsHangout.com. (a)
Home page. (b)-(d) Users are encouraged to participate in
knowledge transfer through videos, images, forums and more.
(c)
26
DoctorNetworking
(inactive)
http://www.doctornetworking.com/
“As a member of DoctorNetworking, you can connect and
interact with an expanded network of physicians whose
collective knowledge you can contribute to and benefit
from. Your professional relationships are key to your
professional success. Your network consists of your
connections, your connections' connections, linking you to
thousands of qualified professionals.”
DoctorsHangout.com
http://doctorshangout.com
“A social networking website for doctors and medical
students. DoctorsHangout is your place to share videos,
audio, photos, and stories with other DoctorsHangout
users. Join now and get your own profile page, blog and
unlimited media uploads!”
MedicSpeak
http://medicspeak.com
“MedicSpeak is a powerful networking site for Physicians,
Biomedical Researchers, Medical/Biomedical Students.
The objective is to enhance communication, collaborations,
exchange of ideas and sharing of knowledge. Keep in
touch with your mentors, colleagues and students. Create
clubs and invite people who share your interests.Upload
videos about your lab, surgical procedures etc. Have fun!”
New Media Medicine
http://www.newmediamedicine.com/
“New Media Medicine is an online Social Network of over
42,000 doctors, medical students and pre-med students.
Make friends with other medics in the discussion forum,
view free medical videos and read user blogs.”
RelaxDoc
http://www.relaxdoc.com/
“RelaxDoc.com is a private, online community created
exclusively for physicians. It is a highly selective portal for
physician-pertinent content, offering physicians the
opportunity to network, find information and access
services that meet both their professional and personal
needs.”
Sermo
http://www.sermo.com
“With Sermo, physicians can aggregate observations from
their daily practice and then - rapidly and in large numbers
- challenge or corroborate each others opinions,
accelerating the emergence of trends and new insights on
medications, devices and treatments. You can then apply
the collective knowledge to achieve better outcomes for
your patients.”
SocialMD
(inactive)
http://www.socialmd.com
“SocialMD is a social network for medical students,
residents, fellows and attending physicians. Using
SocialMD you can search for and connect with study
partners for USMLE, interview partners for Residency
Match, other fellowship applicants, physicians looking for
jobs, physicians offering jobs and a whole lot more.”
Tiromed
http://www.tiromed.com/
“Tiromed is a professional knowledge network exclusively
for students of medicine and physicians. The purpose of
this network is to facilitate communication not only
between peers at the same academic and professional level,
but to allow communication between all levels.”
Table 1. Analysis of physician social network link activity, Highlight Health Web Directory. These sites are retrieved
from the top-ranking webpage for a Google search of the phrase “physician social networks”. Descriptions are derived from
Highlight HEALTH (2011).
27