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?