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PRSonally Speaking
Monday, March 31, 2014
What are the reasonable limits of online (medical) education?
by Jon Ver Halen, MD FACS
Comment on “Assessment of Resident Microsurgical Skill Using an Online Video System.” By Taylor NW, Webb K, Neumeister MW, Bueno RA. Plast Reconstr Surg. 2014 Jan.
I first want to congratulate the authors on a fascinating application of technology to resident education.  Two aspects of the study, microsurgery and education, are topics very dear to me.  Microsurgery is unique in that simulators are likely to play a greater role in the acquisition of surgical skills with the increasing role of patient safety. In addition, with the increasing transparency and standardization of graduate medical education, having a “video record” of a given trainee’s (or practicing physician, in the instance of MOC) performance could feasibly become a standard evaluation tool.  My only suggestion is that microsurgical performance in the operating room is rarely as straightforward as sewing two vessels together, end to end. Vessel exposure, alignment and positioning, and design of the vessel inset all have relevance to the success of a given anastomosis (and hence flap). Thus, I do not think it is sufficient to just assess a given trainee’s facility with device handling and suturing.  At my previous position, we trialed an in situ device for skills training, and we varied scenarios (end to end, end to side, vessel mismatch).  I suggest that such varied clinical scenarios become part of the microsurgical skills training curriculum.
I have a second reason for addressing this article.  Using technological aides as a “virtual presence” is here to stay, and we will either be early adopters, or “late laggards”.  For instance, “virtual patient visits,” vis-à-vis phone calls, secure emails, or remote patient access to his or her own medical record rose from 4.1 million in 2008 to 10.5 million in 2013. Moreover, you can obtain an MBA, PhD, Bachelors and/or Masters degree, and professional degrees (law school, veterinary school) entirely online. You can even become a Count of Sealand, or a Lord in the Scottish Highlands with a simple online application.  The Plastic Surgery Education Network also offers updates and technical pearls with regard to surgical techniques and topics in plastic surgery. 
Recently, planning started for a Global On Line Fellowship in Head and Neck Surgery and Oncology. The goals for the undertaking are noble: outside of major medical centers, care for head and neck cancer is fragmented and irregular, and it is not realistic to expect every practicing surgeon or oncologist to take a year (or more) from their personal and professional lives to obtain specialized training. The vast majority of any medical education is based on knowledge acquisition, and I suppose there is no reason you can’t learn that from a book, online lectures, tests and/or remote tutorials.  But what about surgical skills acquisition? To date, there are no disciplines requiring a component of manual dexterity, which can be completed solely online (e.g., auto mechanic, aircraft pilot, nursing, scuba diving). The standard for this new program is a two-month “observership” at a pre-determined high volume center for head and neck oncology. Is this reasonable? Prerequisites for the program include:
1. A minimum of five years of surgical training and Board certification or its equivalent in their country of residence, in the specialty of general surgery, otolaryngology, plastic surgery, maxillofacial surgery, or similar field.
2. Certification and letter of support from the head of the institution where the candidate conducts his/her clinical activities indicating a commitment by the candidate to the specialty of head and neck surgery and oncology.
3. A complete list of operative procedures performed during the preceding year showing a significant proportion of head and neck cancer/tumor cases, (over 50%) where the candidate was either the operating surgeon or first assistant.
4. Commitment of the candidate to complete the Fellowship by a letter of intent and commitment for the required time and effort to complete the Fellowship.
Is board certification, and a “significant proportion of head and neck cancer/tumor cases” a reasonable surrogate for traditional, apprenticeship-style learning? If you complete this program, does that mean that you are a fully-trained head and neck surgical oncologist? I would anticipate that the degree/certificate does not confer some type of equivalency for US Medical Boards, such that foreign medical graduates could obtain a US license. Regardless of the details, it is clear that the global medical training paradigm is changing. As a specialty, to what extent do we want to adopt these changes? In addition, how can existing (and evolving) technologies be leveraged to improve our specialty and our patients’ lives?
About the Blog

Plastic and Reconstructive Surgery

PRSonally Speaking is the official blog of Plastic and Reconstructive Surgery, the journal of the American Society of Plastic Surgeons. Visit our blog for exclusive previews of and discussions on hot topics in plastic surgery as well as insider-tips on open access content. PRSonally Speaking is now powered by frequent contributions from the American Society of Plastic Surgeons’ Young Plastic Surgeons Forum (YPS); these practicing plastic surgeons provide the personal side of the plastic surgery story, from daily challenges to unique insights. PRSonally Speaking is home to lively, civil debate on hot topics and great discussions pertaining to our field. So, bookmark us, subscribe to the RSS feed and join in the on-going conversation with Plastic and Reconstructive Surgery. This is your Journal; have fun, be respectful, get engaged and interact with the PRS community.

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Anureet K. Bajaj, MD is a practicing plastic surgeon in Oklahoma City. She completed residency and fellowship in 2004, had a brief stint in academia at the University of Cincinnati, and then chose to join her father (Paramjit Bajaj MD, also a practicing plastic surgeon) in private practice in OKC, where she focuses on breast reconstruction and general cosmetic surgeries.

Devra B. Becker, MD, FACS, is an Assistant Professor of Plastic Surgery in the Department of Plastic Surgery at University Hospitals/Case Western Reserve University School of Medicine in Cleveland, Ohio. She completed Plastic Surgery residency at Washington University School of Medicine in St. Louis, and completed fellowships with Daniel Marchac and with Bahman Guyuron. She currently has a primarily reconstructive practice.

Henry C. Hsia, MD, FACS is at Robert Wood Johnson Medical School of Rutgers University in New Brunswick, New Jersey and also holds an appointment at Princeton University.  When he’s not working hard trying to be a good father and husband, he runs a practice focused on reconstructive surgery and wound care as well as a research lab focused on wound biology and regenerative medicine.

Stephanie K. Rowen, MD is a senior physician at The Permanente Medical Group in San Jose, California.  She joined TPMG upon finishing residency and a hand surgery fellowship in 2005.  She has a primarily reconstructive practice, about 50% hand surgery.  Outside of work she enjoys participating in triathlons and spending time with her family.

Jon Ver Halen, MD is currently Chief of plastic surgery, Baptist Cancer Center; Research member, Vanderbilt- Ingram Cancer Center; Adjunct clinical faculty, St. Jude Children's Research Hospital. He also acts as Program Director for the plastic surgery microvascular surgery fellowship. His practice focuses on oncologic reconstruction.

Tech Talk Bloggers

Adrian Murphy is a plastic surgery trainee in London, England. He studied medicine in Dublin, Ireland and has trained in Ireland, Boston, MA and the United Kingdom. He is a self-confessed geek and gadget aficionado.

Ash Patel, MD is Assistant Professor of Plastic Surgery and Associate Program Director at Albany Medical College, in Albany NY. His practice is primarily reconstructive.