The intervention, known as ARC/S, or Augmented Reality for Safe Caesarean Section, was implemented by the international non-profit Jhpiego in partnership with the World Federation of Societies of Anesthesiologists and the Makueni County Department of Health. It layered the Proximie digital platform onto an existing Obstetric Safe Surgery program that had been running in the county since 2020. The platform allows a remote mentor to watch an operation through live video streams from multiple camera angles in the operating theater, and to draw augmented reality annotations directly onto the surgeon’s field of view. Every case is also recorded and uploaded to a secure cloud-based library, where it can be reviewed asynchronously for training and quality assurance purposes.

The scale of the surgical workforce problem the technology addresses is staggering. The Lancet Commission on Global Surgery and the World Health Organization have recognized timely access to safe and affordable surgical care as a fundamental component of universal health coverage, yet nearly five billion people, three-quarters of the global population, lack access to essential surgical services. In low- and middle-income countries, more than 90 percent of the population remains underserved. The distribution of specialists is even more skewed: only 12 percent of the world’s specialist surgical workforce serves Africa and Southeast Asia, despite those regions being home to a third of humanity. In Kenya, medical officers staffing district hospitals are supposed to receive ongoing mentorship from specialists, but those specialists are concentrated in a small number of urban facilities, and the travel distances involved make regular in-person support impractical.

Makueni County illustrates the geography of the problem. The five high-volume public hospitals participating in the study are separated by substantial distances: Makueni County Referral Hospital lies 69 kilometers from the Mbooni Sub-county Hospital it supports, while Makindu Sub-county Hospital must travel 60 kilometers to reach Sultan Hamud and 24 kilometers to reach Kibwezi. A single in-person mentoring visit was estimated to consume eight hours of a mentor’s time, including travel, at a total cost of 25,396 Kenyan shillings once travel expenses were added. A virtual mentoring session on the platform, by contrast, averaged 1.22 hours including feedback time and cost just 3,056 shillings per event.

Between February and October 2022, the technology supported 191 virtual mentorship sessions across the five hospitals, complemented by 17 in-person sessions. A total of 180 elective and emergency caesarean sections were carried out with the platform’s support, and 142 surgical providers were trained on its use. Of the recorded procedures, 125 were successfully reviewed for adherence to safe surgery standards; the remaining 55 recordings were excluded because intermittent internet connectivity produced incomplete files. The platform-generated data, cross-referenced with operational records, gave the research team an unusually objective picture of how the digital tool was actually integrated into surgical service delivery, capturing session durations, participant attendance, mentorship roles, and clinical checklists for each case.

The acceptability results were strikingly positive across every group surveyed. All 60 mentees reported that the platform improved provider and team performance in adhering to best practices, 98 percent felt it improved patient safety, and 92 percent found it easy to use during live procedures and said it enhanced team confidence in the operating theater. All nine mentors believed the technology strengthened the existing mentorship model, and all seven information and communications technology personnel reported that surgical teams were ready to use the platform for every caesarean section. Patients were equally receptive: 90 percent of the 125 post-caesarean mothers surveyed said they had been adequately informed about the use of cameras in the operating theater, and 89 percent said they would recommend the approach to other mothers.

The recorded cases also revealed uncomfortable truths about baseline surgical quality. Direct observation by expert mentors, using the World Health Organization Surgical Safety Checklist as a rubric, found variable adherence to critical safety practices. Correct completion and use of the checklist met standards in only 39.2 percent of the 125 reviewed cases, while timely administration of antibiotic prophylaxis met standards in 53.6 percent. Adherence to proper surgical scrubbing and appropriate use of personal protective equipment met standards in 45.6 percent of cases. The authors note that these quality gaps, detectable only because the platform enabled systematic video review, would likely have gone unnoticed through traditional audits, opening the door to targeted refresher training and site-specific quality improvement initiatives.

The economic analysis, while deterministic and based on a single county, proved robust to most sensitivity tests. Doubling ongoing training costs, increasing feedback time, or raising the discount rate from 3.5 to 10 percent each produced only small reductions in the benefit-to-cost ratio. The most consequential assumption was the time required for an in-person mentoring visit: halving it from eight hours to four cut the ratio to 4.85, still a substantial return. Conversely, assuming two mentors attended half of all in-person visits pushed the ratio up to 12.78. The authors emphasize that the efficiency gains represent potential value as programs expand rather than immediate budgetary savings, and that virtual mentoring is designed to complement, not replace, hands-on in-person training, which remains essential for complex cases and direct supervision.

The study’s technical findings offer a practical roadmap for other regions considering similar programs. The platform requires a stable connection of at least 5 to 7 megabits per second for each high-definition video stream, with 20 to 30 megabits per second of dedicated bandwidth preferable when multiple feeds run simultaneously. Standard laptops with at least 8 gigabytes of memory or mobile devices from 2020 onward are sufficient, and a wired network connection consistently outperformed 4G and 5G backups. Yet the researchers found that success depended far more on basic infrastructure and staffing than on device specifications: reliable power, protected outlets, at least one designated ICT focal person, and established workflows for permissions and data governance mattered more than hardware. Intermittent electricity, limited bandwidth, and absent leadership support pose greater barriers in lower-readiness sites than the technology itself.

The authors are candid about the pilot’s limitations. Clinical outcomes were not assessed, so no conclusions can be drawn about improvements in maternal or neonatal outcomes attributable to the intervention. The technology was embedded within an existing capacity-building program, making it difficult to disentangle its independent effects, and social-desirability bias may have inflated survey responses. The single-county setting, with relatively strong digital infrastructure and committed local government, may limit generalizability. Framed through Kirkpatrick’s four-level evaluation model, most outcomes measured learner reaction rather than objective learning or sustained behavior change. Still, the study demonstrates that in a geographically dispersed surgical network, combining onsite training with augmented reality-enabled virtual mentorship is feasible, acceptable to clinicians and patients alike, and dramatically more efficient than travel-dependent models, offering health systems in low- and middle-income countries a credible path toward decentralizing surgical expertise and strengthening workforce capacity.

Subject of Research: Augmented reality-enabled virtual surgical mentorship for building surgical workforce capacity in resource-limited settings

Article Title: Virtual surgical mentorship: a cost-efficient solution for building workforce capacity in resource limited settings

Article References: Mallender, J., Ferenchick, E., Worku, T. A., Shibata-Germanos, S., Varallo, J., Muthengi, M., Kiiru, S., Mbithi, D., Ruto, D., Nyaga, F. K., Mwatha, S., Muia, C., Bertram, M., Musila, P., Ndolo, S., Mwanthi, C. K., & Hachach-Haram, N. (2026). Virtual surgical mentorship: a cost-efficient solution for building workforce capacity in resource limited settings. Global Surgical Education – Journal of the Association for Surgical Education, 5(1), Article 125. https://doi.org/10.1007/s44186-026-00490-x

Image Credits: AI Generated

DOI: 10.1007/s44186-026-00490-x

Keywords: augmented reality, surgical mentorship, global surgery, caesarean section, Kenya, telementoring, health workforce, low- and middle-income countries, digital health, obstetric surgery, cost-efficiency, surgical training

The work, led by dermatologists and collaborators at Penn State, including Matthew Helm, Jordan Willis, Thomas N. Helm, Kelly Gerard, and Galen Foulke, tested whether the Extension for Community Healthcare Outcomes, or ECHO, model could be adapted to dermatologic biologic education. Project ECHO, originally developed at the University of New Mexico to train rural clinicians in hepatitis C management, operates on a simple but powerful premise: rather than routing patients to distant specialists, it routes specialist knowledge to the clinicians patients already see. Academic experts deliver short didactic presentations over videoconference, then participants discuss real cases together, building competence through repeated, case-based learning rather than one-off lectures.

The rationale for applying this model to biologics is grounded in a well-documented distribution problem. Research published in JAMA Dermatology found substantial disparities in dermatologist density between urban and rural counties in the United States, and more recent calls to action in the dermatology literature have emphasized that rural patients face long travel distances and long waits for specialty appointments. For conditions like chronic plaque psoriasis, where network meta-analyses of systemic treatments show that biologic agents often outperform older systemic therapies, the consequence is a two-tiered system: patients near academic centers access cutting-edge therapy while those in rural areas may go undertreated. Studies of health care resource use for psoriasis have shown that where a patient lives materially changes the care they receive.

Compounding the geography problem is the nature of the medications themselves. Biologics are large, complex proteins typically administered by injection, and their use demands knowledge of drug classes and targets, screening requirements, monitoring protocols, side effect recognition, and the labyrinthine prior authorization processes insurers impose. Surveys of physicians have found that hesitation to prescribe biologics often stems less from skepticism about efficacy than from unfamiliarity with logistics, safety management, and the paperwork of patient assistance programs. That unfamiliarity is precisely what a structured telementoring curriculum can address, and it is what the Penn State team set out to test.

The pilot was deliberately small and pragmatic. Before recruitment, the team used a survey to assess whether the program was feasible to run in their setting. They then recruited eight primary care providers through flyers and email for an eight-session series accredited for continuing medical education credit. Each session followed the classic ECHO structure: a 20-minute talk from an expert on topics such as the major biologic classes, their approved dermatologic indications, monitoring and adverse effects, and strategies for navigating prior authorization, followed by case-based discussions in which participants brought their own clinical dilemmas to the group. A pharmacist collaborator contributed expertise on prescription assistance programs, a crucial and often overlooked barrier to getting these drugs into patients’ hands.

To measure whether the curriculum moved the needle, the researchers administered surveys after each session, asking participants to self-report changes in their knowledge of biologics, their ability to care for patients who might be candidates for these drugs, their plans to change their practice, and their sense of professional isolation around biologic prescribing. Professional isolation is a recurring theme in rural medicine: clinicians who rarely interact with specialists can lose confidence in managing complex therapy, and that lost confidence translates directly into patients who are never offered the treatment. Implementation science frameworks, including validated measures of implementation outcomes referenced by the authors, informed the survey design.

The results, while preliminary, were encouraging across all measured domains. After the sessions, participants reported increased knowledge of dermatologic biologics, improved confidence in their ability to care for relevant patients, concrete plans to change their practice, and a decreased sense of professional isolation. In other words, the program did not just transfer information; it appears to have shifted self-efficacy, the belief that one can competently manage a therapy, which behavioral research consistently identifies as a key determinant of whether new practices are adopted. For a short pilot with eight participants, that pattern of self-reported movement in the intended direction is a meaningful proof of concept.

The study’s authors are careful about scope. This was a short report on a pilot program, not a trial with objective endpoints; self-reported knowledge gains are not the same as demonstrated prescribing competence, and eight providers cannot represent the full landscape of rural primary care. The participants did not consent to public sharing of their data, so detailed results are not available. Still, the findings align with a growing evidence base. A dermatology-focused ECHO program reported in Rural and Remote Health in 2018 already demonstrated the model’s promise for extending dermatologic expertise, and the landmark New England Journal of Medicine study that launched ECHO showed primary care providers could achieve hepatitis C cure rates comparable to specialists when properly mentored. The dermatologic biologic application extends that logic to one of the most consequential therapeutic shifts in modern skin medicine.

Equity considerations give the work added urgency. Studies of safety-net clinics and uninsured psoriasis populations have documented persistent barriers to biologic access even when patients do reach specialty care, suggesting that the problem spans both referral pathways and prescribing behavior. If telementoring can equip primary care providers, who see patients where they live, to identify biologic candidates, initiate workups, navigate payer requirements, and connect patients to assistance programs, it addresses the access bottleneck at multiple points simultaneously. The ECHO model’s low cost and reliance on existing videoconference infrastructure make it especially attractive for health systems with limited resources.

The Penn State pilot, supported in part by grants from the National Center for Advancing Translational Sciences and reviewed as exempt by the university’s institutional review board, offers a template rather than a finished solution. Larger cohorts, objective measures of prescribing quality and patient outcomes, and longer follow-up will be needed before telementoring can be declared a validated route to biologic access in underserved communities. But the conceptual advance is clear and, in an era when virtual education has become routine, timely. The medications that can clear a patient’s skin and transform their psychological wellbeing already exist; the challenge is moving expertise, not patients, across the distance between academic medical centers and the rural exam rooms where care actually happens. A modest series of 20-minute talks and shared cases may prove to be a surprisingly effective bridge.

Subject of Research: Telementoring of primary care providers in dermatologic biologic therapy to expand access in underserved rural communities

Article Title: Expanding access to biologics: a pilot ECHO program for primary care providers

Article References: Helm, M., Willis, J., Helm, T. N., Gerard, K., & Foulke, G. (2026). Expanding access to biologics: a pilot ECHO program for primary care providers. Archives of Dermatological Research, 318(1), Article 472. https://doi.org/10.1007/s00403-026-04976-y

Image Credits: AI Generated

DOI: 10.1007/s00403-026-04976-y

Keywords: Project ECHO, biologics, telementoring, rural dermatology, primary care, psoriasis, atopic dermatitis, access to care, continuing medical education, health equity, Expanding, access