JMIR FORMATIVE RESEARCH

Sekiguchi et al

Original Paper

Live Streaming of the Professor’s Ward Rounds in Undergraduate
Neurology Education: Usability Study
Kenji Sekiguchi1, MD, PhD; Seiji Kawano2, MD, PhD; Norio Chihara1, MD, PhD; Seimi Satomi-Kobayashi2, MD,
PhD; Eiichi Maeda3, MD, PhD; Riki Matsumoto1, MD, PhD
1Division of Neurology, Kobe University Graduate School of Medicine, Kobe, Japan

2

Integrated Clinical Education Center, Kobe University Hospital, Kobe, Japan

3

Division of Medical Informatics, Kobe University Hospital, Kobe, Japan

Corresponding Author:
Kenji Sekiguchi, MD, PhD
Division of Neurology
Kobe University Graduate School of Medicine
7-5-1 Kusunokicho
Chuo-ku
Kobe, 6500017
Japan
Phone: 81 783825885
Fax: 81 783825899
Email: sekiguch@med.kobe-u.ac.jp

Abstract
Background: Although neurology department ward rounds are among the most important medical education exercises in Japan,
they have several issues. Patients may find it unpleasant to undergo repeated neurological tests, especially when in the presenceof several students. Only the front row of students can closely observe the examination findings; moreover, students were prohibitedfrom contacting patients altogether during the COVID-19 pandemic. One possible solution is to use commercial videoconferencing
systems. However, Japanese patients are reluctant to have their medical information or video footage of them sent outside of thehospital via the internet.
Objective: The study aimed to confirm the feasibility of conducting remote teaching rounds using an in-house web conferencing
system in which the patients’ personal data are securely protected. This study also explored whether using remote rounds alongsideface-to-face participation would enhance learning.
Methods: We created an on-premises videoconferencing system using an open-source app. To perform video ward rounds, theprofessor wore a wireless microphone while leading routine in-person rounds and the attending physician carried a tablet device
linked to a web conference, allowing students in another room to watch the rounds on a live stream. In total, 112 of 5th-year
students who entered their 1-week neurology rotation between 2021 and 2022 were instructed to participate in 1-hour in-person
and remote rounds. Students were given questionnaires to evaluate their satisfaction and the educational effects of the remoterounds.
Results: The remote ward rounds were conducted easily with no interference with the in-person rounds, nor any complaints
from the patients. Each examination technique was explained by another teacher to the students who participated in remote rounds
in the conference room. Characteristic neurological findings, such as plantar reflexes (Babinski sign), which are usually seen
only by close observers during in-person rounds, could be visualized under magnification by all students. The postexperiencesurvey (82/112, 73% response rate) showed that the mean score of participants’ satisfaction was 3.94 (SD 0.83; excellent 5 andpoor 1). No participant scoring 1 was noted. The proportion of students who observed 6 representative abnormal neurologicalfindings (Babinski sign, hyperreflexia, cerebellar ataxia, involuntary movement, muscular weakness, and abnormality in sensory
examination) increased by 22% (18/82, range 13-24) compared to in-person rounds alone. When self-rating the learning value,
43% (35/82) of the students answered that remote rounds are equally as valuable as in-person rounds, while 32% (26/82) preferred
remote rounds.

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Conclusions: Live-streaming of neurology ward rounds using a secure in-house web conferencing system provides additional
learning experience without concerns regarding leakage of patient information. This initiative could enhance neurology learning
before entering a clinical clerkship.
(JMIR Form Res 2024;8:e50128) doi: 10.2196/50128
KEYWORDS
live streaming; ward round; web conferencing software; neurological examination; undergraduate education; medical student;
medical education; rounds; remote education; video-conferencing; residents; live-stream; neurology; neuroscience; webconferencing; distance education; technology enhanced learning; mobile phone

Introduction
Ward rounds are considered one of the most important tools ofclinical neurology education in Japan [1]. A professor or clinicaltutor performs a neurological examination of the patient anddescribes the findings for educational purposes in the presenceof a small group of 6 to 7 undergraduate students. The students
are shown the focus areas for the neurological examination
procedure, the order of performance, findings that are specificto the patient and not to the disease, and nontechnical skills
such as manners and attitudes toward patients and methods of
explaining and encouraging patients, thereby fostering
professionalism [2-4]. These rounds afford students, who have
only learned about normal findings in the Objective Structured
Clinical Examination, their first opportunity to observe abnormal
neurological findings and encourage their interest in neurology
and further education. One of the most important learning
objectives of the 5th-year neurology clinical rotation is toconfirm one’s diagnosis by attending the professor’s rounds
after having previously examined the assigned patients andattempted to localize their lesions [1].
While beneficial, from the patient’s perspective, it is not pleasant
to be put on display in the presence of several students who
have not signed a medical contract and endure numerous
repetitive tests, despite experiencing painful symptoms. Onlya few students can observe the examination up close since thepostgraduate residents occupy the best places, and some students
must watch small muscle twitches and pupillary changes inpatients from the second and third rows, where it is also difficult
to hear the professor’s explanation. This ceremonial event istherefore simplified in some universities, and the opportunity
to observe abnormal neurological findings may not be available
until the final-year elective clinical clerkship, when the students
have close contact with patients [1].
Early in the COVID-19 pandemic, medical students wereprohibited from being directly involved in patient care, andteaching rounds were almost completely canceled in Japan.
During this time, students had no access to patients and were
not allowed to enter the hospital and observe medical procedures[5].
The application of web-based conference apps such as Zoom
(Zoom Video Communications) or Teams (Microsoft Corp),
became rampant and changed the structure of society, although
their use was limited in the medical field, where personal
information cannot easily be divulged in the online space. These
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cases, are operated from abroad. The Japanese public was
reluctant to place their medical data and personal information
onto these systems, even temporarily. Therefore, it is notpossible to easily share images or videos of the patient (on ascreen) without substantial investment in a system that is
structured in compliance with various regulations devised byauthorities to ensure secure handling of the patient’s protected
information [6]. Medical students have not been able to benefit
from technological advances because universities are hesitant
to invest in new educational systems, since there is no direct
revenue to be gained.
WebRTC (Web Real-Time Communication) is a technology
used for real-time exchange of audio, video, and other data
between web browsers. It constitutes the core technology forseveral commercially available web conferencing apps. We
built our own educational web conferencing app system in thehospital using BigBlueButton, an open-source conferencing
app based on WebRTC. The system allows the sharing of images
within a closed network in the hospital, without using theinternet, which is more acceptable to patients. Using this system,
we attempted a clinical practice in which the professor’s weeklyrounds, which are important in clinical education during
neurology rotations, are live-streamed to medical students sitting
in a separate room while another teacher provides explanationsof the procedures. We examined the feasibility of remote ward
rounds using this system and its effectiveness compared to theconventional in-person ward rounds.

Methods
Establishment of an On-Premises SecureVideoconferencing System in a University Hospital
In Japan, hospital information systems must conform to the
Guidelines for the Safe Management of Medical Information
Systems (version 6.0), established by the Ministry of Health,Labour and Welfare [6]. This law states that when patient
information is moved from the hospital, including via theinternet, various security risk management measures must be
undertaken. These include information processing to prevent
personal data leakage or using private or leased lines to reduce
the possibility of information leaks en route. Japan does nothave an authorization system such as the HIPAA (Health
Insurance Portability and Accountability Act) in the UnitedStates, which imposes fines for violations; thus, medical
information is generally not taken out of the hospital unlessthere is a specific reason. It is necessary to anonymize personal
information and create generalized content when patient
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information is to be used for online medical education, renderingreal-time clinical education difficult. We have created a web
conferencing system called the KUMEX (Kobe University
School of Medicine Web Conference Lecture System) that can
only be operated within the hospital and is not connected to thehospital information system network, using BigBlueButton, an
open-source conferencing app based on WebRTC. One of thefeatures of KUMEX is that all communicating terminals areconnected using encrypted point-to-point communication via a
web browser, which establishes the connection over a VLAN
(virtual local area network) within the university and not througha wide area network, to avoid the risk of information leaks
enroute. Moreover, communication using the user datagram
protocol with minimal delay is faster than the conventional
client-server model. A signaling server is set up in the hospital
to recognize each terminal, and audio and video media, from a
webcam, can be shared and displayed on each terminal’s screen
immediately. There is no need to install special apps, and anyone
can participate in a meeting from any terminal on the same
network by sharing a unique meeting code generated for eachsession. The app is installed on a server in the Division of
Medical Informatics of Kobe University Hospital and can beused freely 24 hours a day. KUMEX meetings can be held on
any terminal running a modern browser, whether a PC, tablet,or smartphone. No additional installation or operating costs
were incurred.

Preparation for Video-Streaming of Patients’Examinations
Before the COVID-19 pandemic, inpatients were informed inadvance about rounds that would be conducted by professors,
residents, and students as an educational exercise involving
another neurological examination to demonstrate abnormal
findings. Patients were reassured that their privacy would beconsidered, and their verbal consent was obtained. When the
educational rounds were video-streamed, we additionallyobtained written informed consent stating that the examination
would be streamed to the students located in another room of
the hospital using KUMEX, that the connection point would bein the hospital and not via the internet, and that the video would
not be saved without prior consent. Written declarations wereobtained from the students to reconfirm their consideration forthe handling of personal information when viewing and using
the distributed images. Almost all patients who were asked tocooperate in this trial provided consent for participation.

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Video Ward Round Sharing to Undergraduate
Students
The Kobe University curriculum requires a batch of 6 to 7
fifth-year medical students to attend clinics at the Division of
Neurology on a rotating schedule every alternate week. Before
the pandemic, the inpatient medical records were reviewed by
all neurology staff and students in a conference room, following
which all staff and students (more than 20 people) participatedin in-person ward rounds with all inpatients. After the pandemic,
only the attending physician, students assigned to the patient,and professor (approximately 5 people) visited the bedside foreducational rounds, to reduce crowding and infection risk. To
perform video ward rounds, the professor wore a wirelessBluetooth microphone (SmartMic+, Sabinetek) on the lapel of
their white coat, while the attending physician carried a tablet
device (iPad Pro 11-inch, Apple Inc). The attending physician
filmed the examination at an easy-to-view angle. Residents andstudents not assigned to the patient remained in the conference
room watching the professor’s consultation projected onto an
enlarged PC screen used for KUMEX conferences. The
remaining teaching staff described the neurological examinations
performed by the professor, the medical terminology used todenote abnormal findings and their significance, and answered
student questions. Communication was not 2-way and the iPadin the examination room did not carry audio from the conference
room. Each student experienced 1 in-person rounds session andseveral remote rounds during this program. In total, 112
fifth-year students who entered their 1-week neurology rotation
between 2021 and 2022 were instructed to participate in 1-hour
remote and in-person rounds.

Questionnaire Survey of Participating Students
As a method to determine student impressions and achievement,
we chose a questionnaire that was easy to administer and lesscoercive. Some items were allowed multiple-response and somewere allowed to be free-text. A web-based questionnaire wassent to fifth- and sixth-year students who attended the remoteward rounds within the year of this study. The contents of thequestions are listed in Table 1. The survey included questions
on satisfaction, advantages and drawbacks, self-rated learning
value, and specific ratings regarding the opportunity to observeabnormal neurological findings, modeling professionalism, andimproving motivation. It was not compulsory to answer every
question. z tests were used to analyze whether there weresignificant differences in the proportions of each respondent(Q4-Q12). All the analyses were performed using GraphPad
Prism software (version 8.0, GraphPad Software Inc).

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Table 1. Postexperience survey of live-streamed remote neurology ward rounds.
Question number

Question

Q1•

How did you feel about “remote participation in pro- •fessors' rounds”?

Likert scale: 1 (poor) to 5 (excellent)

Q2•

What do you think are the advantages of participating •in video rounds?

Select the prepared option or describe free Advantages
text
I could participate while seated•
I could closely observe the examina•tion
I could listen to the faculty’s com•mentary
It was easy to understand because•
the points to focus on were shown
Nothing•
Allow free description
•

Q3

•

What do you think are the drawbacks of participating •in video rounds?

Select the prepared option or describe free Drawbacks
text
Lack of an immersive experience•
Poor video and audio quality•
Lack of a sense of tension•
Nothing•
Allow free description
•

Q4

•

What do you think of the learning effect of remote•participation in professor’s rounds compared to fol- •lowing the standard rounds, if the learning time is the •same?

Video ward rounds are better
In-person rounds are better
Both are equal

Self-rated learningvalue

Q5-Q10•Were you able to see any of the following abnormal
neurological findings during either of your rounds
during your neurology rotation?
Babinski sign (extensor plantar response)•
Hyperreflexia (exaggerated tendon jerk response)•
Cerebellar ataxia on finger-to-nose test•
Involuntary movement (eg, tremor)•
Muscular weakness•
Abnormal sensory examination•

Could observe in video ward round
Could observe in both
Could observe in in-person round
Could not observe in either

Observation of theabnormal neurological finding

Q11•

In which learning activity did you feel that the profes- •sors and supervisors were more attentive and caring •toward the patients?
••

Felt in video ward round
Felt in both
Felt in in-person round
Could not feel in either

Modeling professionalism

Q12•

Did your neurology rotational training, including remote participation in professor’s rounds, influence
your motivation during your subsequent clinicalclerkship?

Influenced
Unchanged

Improved motivation

Ethical Considerations
All patients who participated in video-streamed ward rounds
using KUMEX were informed and wrote consent forms
approved by Kobe University Hospital as a clinical initiativein advance. Written declarations were obtained from the students
who participated in this study to reconfirm their consideration
for the handling of personal information when viewing andusing the distributed images via KUMEX. The Ethics Committeeof Kobe University Hospital does not review research related
to education, as it is not subject to ethical review, and issued acertificate of exemption [7]. Therefore, we took the utmost
consideration for the students and patients to ensure that thehttps://formative.jmir.org/2024/1/e50128

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Response options

•
•
•
•

•
•

Implication
Satisfaction

project could be carried out ethically. When answering thequestionnaire, the significance of the research was explained to
be understood by the students, and the opportunity to opt out
was offered. Participants including patients and students did
not receive any kind of compensation. All study data presented
in this paper are deidentified.

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Results
Video Streaming of the Neurology Ward Rounds Was
Easily Enabled by KUMEX
The students watched a real-time video streaming of theprofessor examining an inpatient, projected onto a large screenin the conference room via KUMEX (Figure 1). The
communication was conducted over a VLAN within theuniversity, distinct from the hospital information system, andboth the audio and video were transmitted from the iPad via
Wireless Fidelity with an insignificant amount of delay. The

Sekiguchi et alpatients behaved naturally without being excessively consciousof being recorded. Characteristic findings, such as plantar
reflexes (Babinski sign) and fasciculations of the tongue, which
are usually only observed by the students in the front rows
during in-person rounds, could be seen under magnification by
all students. Each examination technique was explained by oneof the teachers and questions from the students were answered
briefly. These additional devices (the professor’s microphone
and the iPad held by the attending physician) never interferedwith the ward round stream and no complaints were received
from the patients afterward.

Figure 1. The schema of the system of a remote ward round using KUMEX which was established securely within the hospital network. Students
watched the live-streaming of the professor examining an in-patient, projected onto a large screen in the conference room via KUMEX. KUMEX: Kobe
University School of Medicine Web Conference Lecture System.

Results of the Student Questionnaire

year: n=77, 94% and sixth year: n=5, 6%) agreed to answer thesurveys (response rate 82/112, 73%).

Results of the postexperience survey for the students are shownin Tables 2 and 3, and Figure 2. A total of 82 participants (fifth

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Table 2. Survey results for questions 1-4, 11, and 12 (N=82, response rate 82/112, 73%).
Question implication

Responses

Q1. Satisfaction
Excellent (5), n (%)

23 (28)

Very good (4), n (%)

37 (45)

Good (3), n (%)

18 (22)

Fair (2), n (%)

4 (5)Poor (1), n (%)

0

Mean (SD)3.94 (0.83)

Q2. Advantages (multiple options allowed, n=159), n (%)
I could participate while seated

42 (26)

I could closely observe the examination

41 (26)

I could listen to the faculty’s commentary

39 (25)It was easy to understand because the points to focus on were shown

34 (21)

I did need not care about not being in the way

1 (1)Nothing

2 (1)Q3. Drawbacks (multiple answers allowed, some options already prepared, n=80), n (%)
Lack of an immersive experience

40 (50)

Poor video and audio quality

19 (24)Lack of a sense of tension

7 (9)I could not look at the fine movements of the patient

1 (1)I could not look at the patient’s expression from my preferred perspective

1 (1)Not better than in-person participation

1 (1)Nothing

11 (14)Q4. Self-rated learning value, n (%)
Video ward rounds are better

26 (32)In-person rounds are better

21 (25)Both are equal

35 (43)

Q11. Modeling professionalism, n (%)
Felt in video ward round10 (12)

Felt in both

48 (59)Felt in in-person round19 (23)

Could not feel in either

5 (6)Q12. Change in motivation, n (%)

aInfluenced

53 (65)a

Unchanged

29 (35)

P=.004 in z test.

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Table 3. Survey results for questions 5-10 (N=82).
Observation of abnormal
neurological findings

Could observe in Could observe
video ward
in both, n (%)
round, n (%)

Could observe in in- Could not observe
person round, n (%) in either, n (%)

Significance in adding Effect size
video ward round to in- (Cohen h)person round (P value)

Q5. Babinski sign (extensor 18 (22)plantar response)

20 (24)12 (15)32 (39).34

0.11

Q6. Hyperreflexia (exagger- 18 (22)ated response to tendon tap)

24 (29)16 (20)24 (29).76

0.03

Q7. Cerebellar ataxia on the 13 (16)finger-to-nose test

20 (24)13 (16)36 (44)

≥.99

0.21

Q8. Involuntary movement(eg, tremor)

19 (23)14 (17)10 (12)39 (47).14

0.09

Q9. Muscular weakness

17 (21)34 (42)

12 (15)19 (23).42

0.20

Q10. Abnormal sensory ex- 24 (29)amination

25 (30)10 (12)23 (28).01

0.38

Figure 2. Percentage of students experiencing abnormal neurological findings during remote ward rounds, in-person rounds, and both (questions 5-10).
Each student experienced 1 in-person rounds session and several remote rounds performed by the professor. The proportion of students who observed
6 representative abnormal neurological findings increased by 22% (18/82, 13-24) compared to in-person rounds alone.

Program Strengths and Weaknesses, Satisfaction, andSelf-Rated Learning ValueIn question 1, which focused on overall satisfaction, the meanscore of participants’ satisfaction for the remote round was 3.94
(SD 0.83; excellent 5 and poor 1). No participant scoring 1 wasnoted.
Common responses to question 2, regarding the strengths ofremote rounds, included “I could closely observe theexamination,” “It was easy to understand because it showed thepoints to focus on,” “I could listen to the faculty’s commentary,”and “I could participate while seated.” On the other hand, mostof the responses related to the weaknesses were that there wasa lack of immersion compared to face-to-face interaction.
Regarding the comparison to in-person rounds, we asked thestudents to rate the learning effects of remote rounds if they
involved the same amount of learning time as in-person rounds.
All students experienced attending in-person and remote rounds
and 43% (35/82) felt that both learning effects were equal, while
32% (26/82) of the participants preferred remote rounds toin-person rounds.
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Additional Experiences
One of the important learning objectives of participation inneurology ward rounds is seeing abnormal examination findings
in real patients. In questions 5 to 10, we asked whether the
student observed major abnormal neurological findings(Babinski sign, hyperreflexia, cerebellar ataxia, involuntary
movement, muscular weakness, and abnormal sensory
examination). Each student observed abnormal findings fromassigned patients during in-person examinations, both bythemselves and watching examinations performed by theprofessor; however, students never saw findings from patientsassigned to other students. In addition to in-person rounds,
remote ward rounds increased the number of students who
witnessed abnormal neurological findings by a mean of 22%(SD 3.5; Figure 2 and Table 3). Although involuntary
movements such as tremors were rarely observed in ward
rounds, adding live video streaming with in-person rounds
resulted in at least 53% (43/82) of students having theopportunity to gain experience. Adding video ward rounds toin-person rounds in sensory testing statistically significantly

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increased the chance of watching neurological findings (Q10,
P=.01).

Changes in Motivation and Behavior
Regarding professionalism, we asked, “In which round format
did you feel that the professors and supervisors were more
attentive and caring toward the patients?” Most of theparticipants answered that they felt these attitudes in bothrounds, but few answered remote rounds only. However, in the
final question, “Did your neurology rotation training, including
remote participation in the professor’s rounds, influence yourmotivation during your subsequent clinical clerkship?” In total,
65% (53/82) of the participants replied “influenced” withstatistically significant (P=.004).

Discussion
Principal Findings
The on-premises web conferencing system enabled
live-streaming of the professor’s neurology rounds in a separate
room in the hospital without concern regarding patients’personal information being compromised. Participation inremote rounds could enhance learning experiences inundergraduate neurology rotators before entering a genuine
clinical clerkship, especially through the observation ofabnormal neurological findings such as tremors.
As the COVID-19 pandemic has resulted in inadequate
undergraduate clinical education, various online education
initiatives have been undertaken at teaching centers worldwide.
However, owing to the lack of extensive experience witheducational initiatives involving live streaming of medical
examinations before the pandemic, an adequate online
educational milieu could not be prepared within a short time[8]. The underdevelopment of this initiative may be attributed
to the fact that before the COVID-19 pandemic, there was noneed to broadcast examinations to other locations since there
were no restrictions on student contact with patients. Anotherreason may have been the belief among educators that learning
directly at the patient’s bedside was the best method for medical
students. There is no doubt that much can be learned throughobserving patients directly. Interestingly, previous studies
indicated that in-person teaching formats with patient contact
were rated significantly higher by students compared to
non–in-person teaching, but that there was no particulardifference in students’ knowledge and skill development
compared to non–in-person learning [9]. Another previous study
showed that there is no difference between the effectiveness ofteaching a procedure by conventionally demonstrating it in thefield and via prerecorded videos [10]. On-demand video
education, which can be repeated in one’s own time, isconsidered to be the favorable method for routine skill training
for well-established procedures that do not vary from case tocase. On the other hand, remote live learning sessions, which
include virtual bedside teaching rounds, were carried out at theheight of the pandemic because direct contact with the patient
was to be avoided [11]. In-person learning at the bedside is abetter teaching method than any textbook for the managementof acute illnesses, as findings vary for each case and conditions
can change on an hourly basis during the same disease. In
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addition, the findings of neurological examinations inneurological diseases do not always manifest with the same
pattern (eg, a lesion in the semilateral cervical spinal cord does
not always indicate Brown-Sequard syndrome), and experience
with a large number of cases can make the neurologicalexamination a useful tool even in the current
neuroimaging-driven milieu [12].
There is a tacit agreement that the medical institution will neverdivulge an individual’s private information, which forms thebasis of the relationship of trust between the medical institution
and patients in Japan. Therefore, extreme reassurance that “thehospital information network must not be connected to theinternet” was commonly required. Hofmann et al [11] used
HIPAA-compliant Zoom to live-stream COVID-19 rounds,
which required financial investment. Now that the pandemic
has subsided, the additional cost of this system should bebalanced with the benefits. There is a tendency to cut costs inmedical education, where the rewards are difficult to see.
Moreover, it is easy to regress to the mindset of shying awayfrom new, high-risk educational initiatives rather than incurringhigh costs to mitigate the security risks of leaking patients’personal information. Countries such as Australia, which havelargely adopted the common use of web conferencing software
in clinical practice, are rare [13]. Tremendous effort is required
to obtain the consent of the facility manager from the perspectiveof network security and personal data protection in our country.
Therefore, the implementation of hospital-based apps using
open-source technology without additional cost, as with our
initiative, can be achieved easily and be useful if the hospital’s
information technology department is staffed by technicallycompetent personnel.
Undergraduate medical education in Japan is based on the“Model Core Curriculum for Medical Education in Japan,”which is a systematically organized model that is formed byextracting the core parts of the curriculum that should becommonly addressed by all Japanese universities when
formulating their own medical education curricula. [14]. In thiscurriculum, the learning objectives are defined in the “learningand assessment items related to skills and attitudes required at
the beginning of clinical clerkship” reported by the public
interest incorporated association, Common Achievement Tests
Organization. Some neurological signs and how to perform aneurological examination were described in the textbook.
However, since practice before Objective Structured ClinicalExaminations is based on examining normal patients, one of
the learning objectives of clinical rotations in neurology is toobserve genuine pathological neurological findings in thepatients. Although various pathological findings should beshown at clinical rounds for all students as often as possible,
those chances were extremely limited because of the shortduration of bedside teaching in the curriculum and because
satisfactory education needs additional effort from the tutor[15]. The experience of examining assigned patients andobserving abnormal findings, such as hyperreflexia and theBabinski sign, was expected to motivate the learners, but thelack of abnormal findings in assigned patients biased theirexperience. Remote participation in the professor’s rounds could
overcome their inequality and drive learning motivation. Indeed,
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our initiative led to 22% (18/82) more students having
opportunities to see abnormal neurological signs compared toconventional teaching, without any additional tutor effort.
During their 6 years in medical school, all students underwent
only 5 days (40 h) of bedside education in neurology, of whichless than 1 hour was spent attending the rounds conducted byprofessors, unless they selected neurology as their elective
practice in the final year. For those with little clinical experience,
the “memory” of the experience is more important than theacquisition of skills at this stage and 65% (53/82) of participants
answered that neurology rotation including remote rounds
influenced learning motivation during subsequent rotations.
Attending a professor’s rounds, such as “Charcot's Tuesday
lectures,” is impressive and informative even for brief periods
and should be essential for undergraduate education inneurology, even if conducted remotely [16]. Our initiative can
not only add educational value to conventional education
methods but also help important traditional aspects of neurology
education to continue, using novel technologies.

Limitations
A key limitation of this study is that not every medical education
facility has the staff to build an in-house web conferencing
system such as KUMEX that can be successfully adapted to thefacility’s system. When they try to outsource the installation ofa similar system, they are often hesitant to implement it becauseof the high initial and maintenance costs. The fact that most
hospitals and medical education facilities do not have dedicatedinformation technology specialists on staff may also be relevant.
Second, in verifying the effectiveness of this initiative precisely,
a comparison should originally have been made between 2
groups, an intervention group and a control group. Since it isdifficult to modify the curriculum for research purposes, ourSekiguchi et al
initiative was designed as an addition to the current curriculum(in which all participants experience in-person rounds, even if
only for a short time), resulting in a comparison of impressions
from each individual, which may have left a more favorable
impression of the remote rounds with their longer time andexplanations.
Third, the effectiveness of the remote rounds was not evaluatedby objective tests, but only by calculating the number of students
who observed abnormal findings. Evaluating the true learning
effects of conducting remote rounds requires a permanent
introduction of remote rounds and a comparison of the level ofacademic achievement between the grades before and after the
introduction of remote rounds, and it is expected that alarger-scale survey will be conducted based on this pilot study.
Finally, no active research has been conducted on thepsychological safety of patients. None of the personal
information was leaked, but it is possible that patients may havefelt uncomfortable. Future studies should investigate the feelingson the part of patients who feature in the relayed scenes of
medical examinations.

Conclusions
Live-streaming of neurology ward rounds using a secure
in-house web conferencing system can be achieved easily andis useful for undergraduate education without concerns about
patients’ personal information being compromised. Thisinitiative could enhance learning by providing direct experienceof observing neurological findings before entering clinicalclerkship and driving learning motivation. Furthermore,
live-streaming of rounds may be a novel style of education thatis more effective than the conventional education process ofattending tutor rounds with some constraints.

Acknowledgments
We would like to thank all the staff at the Division of Neurology and Medical Informatics of Kobe University Hospital for theirsupport. This study was supported partially by the “Plan for Universities/Colleges Aiming for a Smart-Campus Through Digital
Transformation in the Current/Post COVID-19 Crisis” grant from the Ministry of Education, Culture, Sports, Science andTechnology, Japan. The funders had no role in this study’s design, data collection and analysis, decision to publish, or preparationof this paper. The Ethics Committee of Kobe University Graduate School of Medicine deemed that our survey was not considered“research involving human subjects.” The Ethics Committee confirmed that ethics approval is not required for education andtraining. Nevertheless, we ensured that the educational rounds and video-streaming were approved by Kobe University Hospitalas clinical educational activities and were carried out after obtaining written informed consent from all the participants. All
methods were carried out per relevant guidelines and regulations.

Data Availability
Data from this study are available upon reasonable request from the corresponding author.

Authors' Contributions
Conceptualization was performed by KS, EM, and RM. Video-streaming ward rounds were carried out by KS, NC, and RM.
Data acquisition, curation, and analysis were done by KS, NC, and Seimi K. Supervision was by Seiji K, EM, and RM. KS drafted
the outline of this paper; all other authors reviewed and provided substantive comments. The final draft for submission was
prepared by KS and RM and approved by all authors.

Conflicts of Interest
None declared.

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Abbreviations
HIPAA: Health Insurance Portability and Accountability Act
KUMEX: Kobe University School of Medicine Web Conference Lecture System
VLAN: virtual local area network
WebRTC: Web Real-Time Communication

Edited by A Mavragani; submitted 20.06.23; peer-reviewed by Y Asada, D Ikwuka, E de Quincey; comments to author 09.08.23;
revised version received 30.11.23; accepted 25.06.24; published 22.08.24
Please cite as:
Sekiguchi K, Kawano S, Chihara N, Satomi-Kobayashi S, Maeda E, Matsumoto R
Live Streaming of the Professor’s Ward Rounds in Undergraduate Neurology Education: Usability StudyJMIR Form Res 2024;8:e50128
URL: https://formative.jmir.org/2024/1/e50128
doi: 10.2196/50128
PMID: 39172503

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Sekiguchi et al©Kenji Sekiguchi, Seiji Kawano, Norio Chihara, Seimi Satomi-Kobayashi, Eiichi Maeda, Riki Matsumoto. Originally publishedin JMIR Formative Research (https://formative.jmir.org), 22.08.2024. This is an open-access article distributed under the termsof the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work, first published in JMIR Formative Research, is properly
cited. The complete bibliographic information, a link to the original publication on https://formative.jmir.org, as well as thiscopyright and license information must be included.

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