Online workshops on the teaching and practice of endoscopic sinus surgery techniques during the COVID-19 pandemic*

2 Department of Otorhinolaryngology, National Hospital Organization Osaka National Hospital, Osaka City, Osaka, Japan 3 Department of Otolaryngology, Kindai University Faculty of Medicine, Sayama City, Osaka, Japan 4 Department of Otorhinolaryngology–Head and Neck Surgery, Osaka Rosai Hospital, Sakai City, Osaka, Japan 5 Department of Otorhinolaryngology, Osaka Habikino Medical Center, Osaka Prefectural Hospital Organization, Habikino City,

Surgical methods can be learned through shared video files, but comprehending a surgeon's intent through videos alone is difficult. By conducting workshops and explaining surgical videos, research group members have worked to educate doctors about surgical techniques for endoscopic sinus surgery (ESS). Because the COVID-19 pandemic has restricted face-to-face meetings, we switched to virtual modality. We received numerous participant responses regarding the virtual meetings which gave us scope for improvement. We therefore introduced innovations to a recent meeting. An additional file shows details of methods (Supplemental Figure 1).
We utilized real-time surveys during the lecture and asked questions focused on participant experiences regarding surgical methods. Table 1 summarises the answers to each question.
Although 21 participants were confident about intranasal antrostomy, only five physicians reported extensive canine fossa incision experience.
Following the lecture, 30 participants completed the postsurvey and Table 2  In the questionnaire results analysis based on otolaryngology experience and board certification, there were no significant differences in terms of online tool usage experience, participant location, equipment used, or impressions of the meeting (Supplemental Figure 2). Regarding video quality evaluation, 33% of the doctors with less than six years' otolaryngology experience and 40% with 6-10 years' experience reported no problems, whereas 81% with more than 10 years' experience faced a slight problem; similarly, a higher percentage of board-certified doctors identified problems in video quality. We observed a similar tendency in video comprehension (Supplemental Figure 2A).
Contrastingly, 44% of the participants with less than six years' experience responded positively to the voting function. This trend was slightly lower than that of physicians with 610 years' (100%) and more than 10 years' experience (88%; Supplemental Figure 2B). Furthermore, physicians with less than six years' experience (67%), 6-10 years' experience (80%), and more than 10 years' experience (88%) preferred online-based future training (Supplemental Figure 3).
It has been difficult to conduct workshops while preventing the spread of COVID-19 (1) , which has encouraged a shift towards the online modality. We therefore digitised the content of our ESSrelated technical workshop (2) . This online lecture had been well received, but opportunities for improvements existed. Therefore, we conducted the current online lecture after making some improvements to its design. Compared to the first lecture, almost all of the participants had experiences of using the online conferencing tool, showing a marked increase. This may have been due to the uncontrolled spread of COVID-19 which has led to increased participation in virtual workshops. Interestingly, equal number of participants took part from home and work.
While a typical conference requires a visit to its venue, online workshops eliminate the need for travel. Recently, many doctors have shortened their working hours to provide childcare, which has reduced workshop participation (3,4) . Accordingly, the possibility of home-based participation was considered extremely advantageous. Video streaming presents one major problem: video delay (5,6) . In the previous workshop, we distributed unedited videos to participants beforehand. Despite delayed video delivery, this step enabled the audience to freely review the relevant technique. Nonetheless, participants found watching the presentation and identifying parts of the video handout that described the technique in real time difficult. Therefore, this time, we did not distribute the video beforehand, instead creating an edited video. Additionally, we reduced the image quality and frame rate to facilitate smoother delivery. The audience responded favourably to this change.
Further, we observed that answers pointing out video problems increased along with the relevant user's experience. This may have been because operation experience increases with years of experience. Hence, video quality was evaluated more strictly in such cases. Previous reports showed that online lectures had problems regarding interactivity. Thus, we aimed to enhance interactivity through a voting function that identifies audience ideas and experiences in real time (7)(8)(9) . The questionnaire results, which were compiled and analysed smoothly, indicated high audience satisfaction. Moreover, we also found that the level of experience concerning opening the maxillary sinus through a canine fossa incision was far lower than that of ESS. This

When do you open the maxillary sinus?
A  Table 2. Post-survey results.

How did you feel about the online video lectures?
A: There were no problems B: There were a few problems C: There were intermittent problems D: There were many problems E: There were extensive problems Online workshops will retain their importance during the CO-VID-19 pandemic because large gatherings remain infeasible.
Organising study groups to increase participant satisfaction may help explore ways for physicians to improve their practice quality in such challenging environments.