key: cord-1035087-sb45v082
authors: Plancher, Kevin D.; Shanmugam, Jaya Prasad; Petterson, Stephanie C.
title: The Changing Face of Orthopedic Education: Searching for the New Reality After COVID-19
date: 2020-04-27
journal: Arthroscopy, sports medicine, and rehabilitation
DOI: 10.1016/j.asmr.2020.04.007
sha: ec3c9a268670c22d752663daff9fce6dbdd65cbe
doc_id: 1035087
cord_uid: sb45v082

Abstract The COVID-19 pandemic has had immediate impact on the practice of medicine and orthopaedic education. As the practice of social distancing has been put into place to help slow the spread of disease as well as to conserve medical supplies and equipment, elective surgery has come to a grinding halt. This dramatic change has forced our leaders to critically evaluate the delivery of education and skills training for our residents, fellows as well as all orthopaedic surgeons. We must continue to develop technologies such as virtual meeting platforms, distance learning, simulation-based training, virtual reality andaugmented reality to augment the new world of orthopaedic education.

COVID-19 has forced us to rapidly adopt, integrate, and use technology to help us survive during these challenging times. We must think ahead and develop strategies for integration of technology to minimize interruptions for residency and fellowship training programs and orthopaedic education in general. How will COVID-19 change the landscape of teaching and learning now and in the future? The following is a discussion about rapidly emerging educational delivery methods and the utilization of technology platforms, some that exist, some that must be developed further. These platforms may or may not be the new reality we must accept as we search to create the 'New World of Orthopaedic Education'.

Web-based meetings 4 have almost become the norm for both start-up ventures as well as multinational companies. The technology of virtual meeting platforms has allowed businesses to overcome the burden of in-person meetings by decreasing costs of travel and time away from the office or in some instances when businesses are completely remote operations 2 . Some common platforms for online meetings include Skype, Google Voice, WebEx, and Zoom audiovisual conferencing. The ease of sharing documents, photos, and videos helps to facilitate the meeting, no different than face-to-face events. Newer platforms are also being investigated to incorporate artificial intelligence to record pre and post meeting tasks 5 .

Attendance at daily or weekly educational activities or even multiple conferences in a calendar year is almost impossible for an orthopedic surgeon under normal circumstances. Residents and fellows have variable schedules, often making attendance at grand rounds and journal clubs difficult for everyone to share. Virtual attendance using web-based services may be helpful to circumvent these issues.

Virtual meeting technologies afford the possibility of educating surgeons around the world from the comfort and safety of their own home. However, the question that must be raised is how we can integrate these technologies into national and international meetings on a much larger scale. If virtual meetings become the standard, can they offer the same benefits of in-person meetings, e.g. networking over a coffee, dynamic interactions on the podium, case-based panels with question and answers? Will there be a loss of passion in these live question and answer sessions due to broadcasting delay. Some presenters might selectively answer questions, which may frustrate participants. Watching live surgery is exciting, but does watching in isolation without meeting other faculty stifle important questions and not allow the subtleties of a technique to be brought to light?

Attending in-person conferences and trainings, allows the participant to walk away from personal and job demands and submerse themselves in rigorous training and education. Will this same sense of submersion happen with virtual conferences or pre-recorded educational events? Will the responsibility to report to work assumed by their supervisors take over? Will there be environmental distractions such as dogs barking in the background, when food is being served to you from a family member, or when someone is speaking next to you at home while you are trying to listen on the computer? Will this lead to a loss of focus and retention of the educational materials? Will technological malfunctions such as microphone feedback and delay in broadcasting take away from the educational experience? These are answers we question but truly don't know at the present time.

We have been taught, medicine is an art and a science. Medicine is a field dependent on human interaction. As a profession, we must critically evaluate the value of the face-to-face interaction and whether virtual meetings can serve as a substitute, particularly in a field that is dependent on human interaction and technical skills? Additionally, we must ask ourselves if these technology platforms afford the same networking opportunities as an in-person event. Will the human touch that can be so powerful during the healing process be lost?

Distance learning has become part of the curriculum in many universities. Many orthopaedic societies have also already added educational materials on their websites. 9 This type of learning utilizes electronic technologies to learn outside a traditional classroom. Presentations can be pre-recorded or presented live, allowing participants to either learn at their own pace and even provide the opportunity to go back and review what they have already learned. Some common programs include Blackboard, Moodle, Vista or Angle. Many of these platforms have interactive features such as chat and messaging where listeners can actively interact with the presenters, no different than traditional question and answer periods 4 . Webinars and podcasts can be added to this list of opportunities for participants.

Attendance can be registered and monitored through these platforms to ensure accountability and provide continuing medical education credits.

Like virtual meeting platforms, e-learning circumvents geographic and scheduling constraints avoiding costs associated with travel, food and lodging. Each institution can create their own curriculum while the residents and fellows can enroll and learn on their own time and at their own pace. It also allows for consistency among programs, providing the ability to learn from national and international experts rather than relying on the strengths of the faculty on staff.

While this great opportunity exists, we again must ask does removing education from the classroom or clinic/hospital setting fail to teach the art of human interaction and personal connection?

Does e-learning afford the young resident the ability to understand the social determinants of the patient? Will the future of our workforce be able to recognize through e-learning that the patient they have just given a prescription to will never fill that prescription because of a transportation or a financial issue? Does that resident realize that person can't even afford a new pair of shoes? Technology is a powerful tool that will likely emerge to enhance educational experiences but should not serve to be the sole replacement.

The breadth of orthopaedics and the specialization of physicians and surgeons has increased over the past few decades. While this has led to improvements in patient care, the spectrum of surgeries, the diversity in pathologies, and the technological advances in each specialty area has made it extremely difficult for a resident or a fellow to master all the operative techniques in a limited period of time. Further, legal accountability for medical services and patient safety monitoring has placed increased pressure on operational performance and outcomes. The restrictions imposed with social distancing and the availability and cost of cadavers for training also pose difficulties. Disruptive events such as COVID-19, disturbs the typical mentor-mentee relationship and traditional teaching that occurs in the operating room as well as the clinic. Limited face-to-face interactions with mentors as well as patients, has upended our traditional teaching models and clinical learning opportunities.

Simulation-based surgery is a rapidly evolving field. Trainees can practice a multitude of surgical procedures on one platform in a risk-free setting 6 . This technology can boost the surgeon's confidence and reduce the steepness of her/his learning curve, especially with technically-demanding arthroscopic or open procedures. Simulation surgeries should be evaluated by experts and its effectiveness quantified before instituting into a training program. Institutions should have a method to record the trainee's performance and track his or her progress in the long term. Although still a newer technology, simulation-based surgery has the potential to greatly influence surgeon training and efficiency. While attractive, simulation training is not without its disadvantages or barriers to be implemented. Simulation machines are very costly and often take up a significant amount of space that many hospitals and programs do not have, and only allow for a few specific surgical procedures to be performed.

Further research is needed to better understand the transfer and retention of skills attained in a simulation-based surgical skills training to live surgical cases. 7, 8 Additionally, does simulation-based training compromise nontechnical skills essential to patient care? While there is likely a balance between the simulation-based, cadaveric skills training, and live surgical cases, this balance has yet to be determined.

Virtual reality (VR) uses computer technology to create a realistic, three-dimensional simulated environment as well as provide visual feedback from body movements 1 . First emerging in the gaming and entertainment industries, virtual reality has now made its way into surgical skills training as a tool to provide repeated exposure to a skill or procedure.

VR can provide either augmented or mixed reality 3 . Augmented reality (AR) may enhance the training experience by overlaying a real clinical environment into the experience rather than performing in a virtual world. Some examples of commercially available VR, AR, and mixed reality headsets include Occulus Rift, HTC Vive, Microsoft Hololens, and perhaps the more widely known mobile application Pokemon go which utilize this reality. VR helps the surgeon with constructive learning, improves problem solving skills, and provides a safe environment to make mistakes. In the future, virtual meeting platforms can be combined with VR technology to provide the participant with a real time feel compared to watching a screen. Trainees and practicing surgeons should be able to watch live surgeries with VR and interact with the surgical team.

VR overcomes some of the challenges of simulator-based training previously mentioned making this technology more portable and more easily accessible. Several of the existing arthroplasty companies already have adapted virtual reality into orthopaedic surgery training and are being trialed. We await the results to better understand how to integrate VR into traditional teaching models.

Mobile-based apps are also a great source for education 4 . One of the primary advantages of a mobile device is quick access to educational materials such as journals, e-books, and surgical videos.

Mobile apps are also already widely in use to aid the surgeon in navigating conferences and tailoring the event to one's specific educational needs. Industry has also adopted these technologies allowing surgeons to virtually tour their exhibit booth or to help surgeons familiarize themselves with a myriad of surgical equipment and techniques.

Surgical planning apps are a great tool for the surgeon to minimize errors and confusion in the operating room. The surgeon can share the plan and instrument details with the entire surgical team.

Using the mobile device with social media has become an integral part of daily medical life. Patient privacy should always be kept in mind while using blogs and social media. Social media may someday help young practitioners to solve problems for difficult cases as well as create long term meaningful contacts with experienced surgeons.

As we continue to watch meetings from around the world be cancelled or rescheduled, we must wonder what our annual meetings might look like in the future. The annual meeting is one of the pillars of our great societies. It provides the society the opportunity to show yearly progress, to recognize women and men leaders in research and clinical accomplishments, to reconnect with industry and each other. The mission of AANA and similar educational organizationsis to advance the art and science of arthroscopy and minimally invasive surgery through education, skills assessment and advocacy. Can all this be done over a computer screen?

Before we answer what we need, we must consider the current situation. The recommendations to maintain a safe meeting might range from taking participants' temperatures on-site, answering questionnaires, checking vaccination documents to social distancing and wearing masks and gloves and possibly much more. When or if the immediate threat is gone, many will agree it might be time to assemble again, but with caution. Will convention centers have temperature scanners like airport metal detectors for everyone to walk through or will we be required a health/vaccination record to board a plane? It is interesting to note that animals such as cows and horses, when crossing state lines, are required to have health certificates. If testing can be successful, with a low false negative rate, might it be required at all meetings greater than 5 individuals?

One of the special parts of our annual meeting is the opportunity to interact and network. Social distancing is not part of our meeting. Can we really give up the person-to-person meetings, where we get to talk to manufacturers to develop new equipment, talk to the old guard and bring the new guard along? Taking away the casual meeting over a cup of coffee seems like a deadly blow; but will it be necessary to be safe and might we never have these simple things ever again?

We look toward to the future for new technology which may help the online annual meeting look more appealing. Virtual reality with the use of holograms is one-way surgical demonstrations can move forward, as already discussed. Imagine placing your personal VR mask on your head and literally walking down the hall to register when you run into the President of AANA. You can then go to the exhibit area and talk to vendors, no different than the way it used to be. This convenience can all be done from the comfort of your own home. The future might have the solutions for a contact-free annual meeting utilizing virtual 3D environments but we again must ask at what cost.

The unsettling question is how or if our great society wants to gather its members. Medicine and the care of patients has always been based on human interaction. The subtleties of a smile, the interpretation of anxiety, all this may be lost if we can't meet face-to-face. One must hope that we will figure out a way to meet this goal of gathering once again and improve on the process of teaching each other so that our patients benefit in our profession of selfless service.

The future of orthopaedic training is rapidly evolving. Technology is and will be an integral part of this evolution. New innovations are being made every day. With increasing pressure on the surgeon to deliver high quality patient care, it is important to find novel avenues to educate and train surgeons nationwide while maintaining efficient and safe patient care. It is the responsibility of the surgeon to keep himself updated with newer developments and technology. National and international orthopaedic societies and teaching institutions world-wide should consider utilizing the abovementioned methodologies and more to enhance education and training.

In the end some of us may remember 2019 as the last real meeting. Some may say 2021 will be the new era with perhaps a hybrid meeting. Now is the opportunity to decide how and what we must change in this new era. Let's make sure that however we move forward, we do with safety in mind for all of us and keep the traditions and mission of our society alive.

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