key: cord-0706045-gbliuyyx authors: Dinis, Jacob; Prsic, Adnan; Junn, Alexandra; Hsia, Henry; Alperovich, Michael title: The Efficacy of Virtual Subinternships as a Novel Educational Platform for Education and Recruitment date: 2021-09-07 journal: Plast Reconstr Surg DOI: 10.1097/prs.0000000000008364 sha: b9e4adddc0c429fabbb224c1376de553a5dcbd9a doc_id: 706045 cord_uid: gbliuyyx nan A scientific law is no more than a prediction of observed phenomena, whereas civil law is a set of rules to prevent social unrest or disobedience. We are not exempt-the "Ten Commandments" of Gillies demanded compliance with his basic principles of plastic surgery. 2 The esteemed Robert M. Goldwyn took a different approach; his "Laws of Plastic Surgery" were simply observations "of earthly happenstance and human behavior," for example, "the patient with only a fair result is your most enthusiastic supporter" or "the dissatisfied patient never moves away." 3 These tenets were "akin to the laws of gravity and energy." 3 Could plastic surgery be no more than an application of the basic laws of physics? 1. Fundamentalism: Physical principles provide a solid foundation for the other scientific disciplines, all in essence examples of "applied physics." 4 Plastic surgery is fundamentally the problem solver for all specialties 5 -are we not the last true general surgeons? 2. Classicism: Newton's laws of mechanics describe object motion under the influence of forces, but lose validity at the extremes of quantum physics or velocity. 4 The trainee best obeys the recognized standards of form and craftsmanship of their mentor, but the duty of both must be to evolve or else both perish. 3. Randomness: The random path of "Brownian motion," Einstein explained, was not random at all, but caused by invisible atoms ricocheting off those larger. 4 A "random" flap was never random, but survived by means of a discrete circulation to the intradermal plexus. 4. Chaos: The slightest difference in initial conditions can lead to vastly different outcomes; if uncontrollable, unpredictable outcomes. 4 Yesterday, we controlled our daily schedule; today, only to initiate the "time out." The rest is chaos. 5. Inertia: A tendency to resist any change in motion. 4 Roadblocks everywhere impede appropriate patient care. 6. Gravity: A weak force explained by general relativity. 4 "What goes up must come down," to occupy every flat surface in the operating room. 7. Time dilation: At relativistic speeds, time slows down in one frame of reference compared to another. 4 Every scrub nurse is expert in special relativity-understanding the surgeon's reality that "this will only take 10 minutes." 8. Entropy: The second law of thermodynamics, seeking the lowest energy state? Who said anesthesiologists? 9. Uncertainty: In quantum mechanics, all properties cannot be determined simultaneously with absolute precision. 4 Goldwyn's "imprecision of precision." 3 This is why every free flap must be monitored, for successful take-back. Should it be surprising that the "traditional" today will tomorrow be the "classic?" That "perfection is the enemy of good [uncertainty]," "time fills all space available [time dilation]," "only one object can occupy a given space at a given time [inertia]," and "all the world is preoperative [fundamentalism]?" We live on the razor's edge, fearing gravity will drag us downward. The "laws of physics" cannot be escaped. Plastic surgery-applied physics. T he coronavirus disease of 2019 pandemic has created unprecedented challenges disrupting medical education. Most academic surgical societies have recommended against visiting clinical rotations, which have historically served as critical educational opportunities for students and an important tool for programs to interact with residency candidates. 1,2 Competitive surgical subspecialty programs specifically have traditionally relied heavily on in-person interaction for recruitment. 3, 4 With the inability to host in-person clinical rotations, programs have instituted virtual platforms. 5 Our institution created a virtual surgery rotation mirroring a traditional rotation in its structure. Students were immersed in the existing resident curriculum: biweekly educational conferences, grand rounds, visiting professor lectures, and interactive resident teaching sessions. Students also received daily faculty-led, student-focused teaching in the form of indications conferences and teaching sessions. A daily live-streamed surgery component was incorporated to simulate the interactive environment in the operating room as well. Given the novelty of virtual subinternships, we objectively evaluated the efficacy of a virtual subinternship as an educational and recruitment platform. We hope that by sharing our experience, other institutions will be encouraged to implement virtual experiences of their own. Eleven students from 11 schools participated in the first virtual course offering. Students completed a 48-question knowledge assessment before and after initiating the rotation. Students, residents, and faculty completed a 360-degree assessment of perceptions and efficacy of the virtual subinternship. A Likert scale ranging from 1 (strongly disagree) 5 to (strongly agree) was used. Knowledge assessments were completed by 100 percent of students and the participant feedback survey Table 1 I feel the virtual subinternship has provided a valuable educational opportunity. 4 .9 (4-5) The number of lectures was appropriate for the 1-wk virtual subinternship. 4.6 (4-5) The number of live cases was appropriate for the 1-wk virtual subinternship. 4.3 (2-5) The variety of lecture topics gave me a good understanding of the breadth in plastic surgery. 4 .7 (4-5) The variety of cases gave me a good understanding of the breadth in plastic surgery. 4.8 (3-5) Participating in streamed live operations made me feel engaged. 3.9 (2-5) I was able to see anatomical details and gained a better understanding of the human anatomy. 4.0 (2-5) I was able to see anatomical details and gained a better understanding of the technical aspects of the case. *Scores graded on a Likert scale, with options including 1 (strongly disagree), 2 (somewhat disagree), 3 (neither agree nor disagree), 4 (somewhat agree), and 5 (strongly agree). †Options ranged from strongly negative to strongly positive. ‡Options ranged from very unlikely to very likely. was completed by 90.9 percent. Student participant responses across multiple statements revealed that virtual subinternships had educational merit (nine questions; mean Likert scale score, 4.3), which was further substantiated by the increase in average examination scores from 50.0 percent to 68.0 percent (Table 1) . Furthermore, responses from our postrotation survey supported that the virtual subinternship was successful in providing a modality to effectively recruit and develop interest in a program (11 questions; mean Likert scale score, 4.6). Individuals generally agreed that through participation, they gained a better understanding of the academic environment and culture at Yale and became more familiar with the faculty and program. Based on survey results, the virtual subinternship impacted the perceived quality of training at Yale and drastically improved overall impression of the program. Faculty and residents had a 100 percent and 93.8 percent response rate, respectively. Although student participant responses supported that the virtual 3.1 (1-4) 3.9 (2-5) The virtual subinternship provided insight into the participant's overall quality as an applicant. 2.9 (1-4) 3.5 (2-4) Participation in the virtual subinternship will be viewed favorably by me when selecting applicants for an interview. 4.0 (3-5) 4.3 (3-5) Participation in this virtual subinternship will be viewed favorably by me for the rank order list. 3.6 (3-5) 3.8 (3) (4) (5) *Scores listed as mean (range) graded on a Likert scale, with options including 1 (strongly disagree), 2 (somewhat disagree), 3 (neither agree nor disagree), 4 (somewhat agree), and 5 (strongly agree). subinternship was effective in building familiarity with a program, faculty and resident responses did not reciprocate a parallel increase in ability to evaluate applicants' personalities, interpersonal skills, or how well of a match they would be for our program (eight questions; mean Likert scale score, 3.0) ( Table 2) . Despite this, faculty and resident responses confirmed that participation would be viewed favorably when selecting applicants for interviews and in the rank order list (two questions; mean Likert scale score, 3.9). The responses we received from students indicate the virtual subinternship is effective as both an educational tool and a recruitment tool. Given the effect coronavirus disease of 2019 has had on visiting clinical rotations and its uncertain course, virtual subinternships may continue to serve as a powerful resident recruitment tool for the foreseeable future. R ecently, there has been much speculation and prediction regarding the effect of upcoming United States Medical Licensing Examination Step 1 change to a purely pass/fail examination on residency applicants and programs; however, there have been no posited potential solutions. 1, 2 Although this pass/fail change might reduce student stress early in medical school, there are several drawbacks for students interested in applying to an integrated plastic surgery residency program. These drawbacks include late determination of the applicants' competitiveness because the Step 2 Clinical Knowledge examination (which most likely will replace Step 1 as the main "filtering" examination) is taken shortly before residency applications, and there is very little recourse for all students to showcase their individual passion and inclination to plastic surgery. 1, 2 In addition, the trend to change United States Medical Licensing Examination to pass/fail is likely to extend Electrons go viscous-and zippy Plastic peregrinations Laws of plastic surgery Physics in Minutes Innovation: A sustainable competitive advantage for plastic and reconstructive surgery Association of American Medical Colleges. Final report and recommendations for medical education institutions of LCME-accredited Executive Summary_Final_05112020.pdf American Council of Academic Plastic Surgeons. Important COVID-19 related announcements Do audition electives impact match success? Resident selection protocols in plastic surgery: A national survey of plastic surgery program directors Establishing a virtual curriculum for surgical subinternships The first two authors should be considered co-first author. This study was funded by a Yale Department of Surgery COVID Research Grant Award.