SECTION II

EDUCATION PROVIDERS

This section describes the role of education providers in promoting lifelong learning. Education providers are not just schools; they are a wide range of organizations that offer direct instruction for learners seeking job preparation and enhancement training.

We begin the section with a discussion with Dr. Edward Verrier, the director of a medical residency program that leverages technology to ensure that doctors receive training in the most current science. The exchange highlights the following issues, which all types of education providers discussed in this section confront:

• How these institutions adapt to the changing demographics of their target populations and the shifting demands of the economy for new skills

• The need to work closely with employers and other stakeholders to ensure that content is relevant and current

• How current program delivery combines technology, hands-on practical experiences, and classroom activities to foster effective learning environments

Executive Perspective

Joint Council on Thoracic Surgery Education: e-Learning and Surgical Residency

Edward Verrier

Why an online program? Why is the old model no longer adequate?

There is a sense among surgeons that if the traditional residency was good enough for them, it’s good enough for the next generation. But the whole world has changed. We no longer allow residents to teach. We have more safety standards. There’s more transparency and more accountability.

The whole environment is different, so we had to change. Resident education is no longer the model of “see one, do one, teach one.” We are flipping the classroom with this online course: content is available online; residents can move at their own learning pace, when they have time to focus on the material. During weekly conferences, rather than a power-point lecture, the faculty can lead an interactive session. They can focus on what the residents don’t know and what they need to understand and how to apply knowledge to cases.

Education is evolving at all levels: from kindergarten to high school, as well as college and medical school. It’s much more learner-centric. It has to be internally driven by the learner, not just externally defined by the faculty. Online courses acknowledge the fact that everybody learns at his or her own rate.

What is a basic description of the online program? What are the goals for the program?

Our intention was to create a meaningful online approach to thoracic surgery resident education. We’ve created 88 weekly units, to match the number of weeks in the 2-year residency. Each unit includes learning objects, learning points, and teaching pearls.

For each unit there are required readings and clinical case scenarios, which are in-depth cases, of about six or seven pages, with extensive references. There are vivid images, each of which is linked to learning objectives, discussion points, learning points, and teaching pearls. At the end of the unit there is an online test. The content and assessments are aligned with the milestones laid out by the residency review committee, and residents meet some of those milestones by completing those online tests.

Ultimately, the resident’s goal is to pass the medical boards. The materials in the online course are aligned with the board exams. Half of the board exam is examining cases, and one third of residents struggle with that section of the exam. So, to address this issue, the online course was designed to teach them to apply information rather than just memorize it.

What was the design process? How did you develop the curriculum?

To start, we conducted a robust needs assessment. We went to the American Board for Thoracic Surgery and to the residency review committee. We gave presentations at national meetings about what competency-based medical education really means. We talked to faculty members in other surgical disciplines and learned from what they are doing to improve both resident education programs and continuing education. We used this information to better define the requirements to be a heart or lung surgeon in the United States. This process resulted in a 60-page detailed document, separated into the four categories associated with a cardiothoracic surgery: heart, lungs, esophagus, and other organs in the chest.

Next, we needed to find a good navigation system, one that was readily available and that could work on a variety of platforms (PC, tablet, smart-phone). It needed to be very fast in bringing up pertinent information. When you click open an article, the PDF comes up immediately. It’s seamless. The system also needed to be able to handle a lot of traffic. Even in the pilot program there were 1,400 users (including residents, program staff, and faculty).

Then, we negotiated with publishers to acquire the rights to the course content. In addition to journal article, we were able to get permission to use electronic versions of 11 textbooks.

We also realized we needed a content management system (CMS). We reviewed different systems and chose PersonalBrain (Softonic International, Barcelona, Spain). It’s a mind-map system, which we organized by each of the four categories of thoracic surgery, and residents can drill down by topic. The system provides access to appropriate chapters of the texts, journal articles, videos of procedures, and audios of lectures. In addition, each student has an electronic portfolio to document his or her progress through the course. Finally, all the content on the site was reviewed by a professional advisory board, similar to a journal’s peer review process.

The content management system functions as a database so we also needed a learning management system (LMS) to provide guidance to learners. The LMS allows us to organize the curriculum into weekly units. Initially, we used an open-source system, but we are now moving to a platform with an enhanced CMS and LMS. We needed better reporting mechanisms and multi-tendency capabilities that the open-source system could not provide. We needed better coordination between the CMS and LMS with fewer clicks to proceed through the content and to the LMS. We are partnering with Astute Technologies (Fairfax, VA) to enhance the platform.

What were the barriers to implementation?

Copyright issues. Creating good assessments. Oh, and getting people to accept an online program.

These were some of the issues we faced:

• We needed to be familiar with the copyright issues for course materials. In our field, most journal articles are open source after a few years, but some journals never make their materials publicly available. We are hoping to negotiate longer-term agreements so we don’t have to worry about copyright issues every few years. Or about developing our own materials.

• We found that the toughest part is writing the assessment questions to help student prepare for their boards. We have used some old board questions, but with all the tests embedded in the course, we have had to write a lot of new questions. It’s taking longer than anticipated to get good questions.

• Finally, we need to get the users to accept it. The faculty and the residents are still embedded in an antiquated system of learning, focused on memorization and lectures. But once we have results for our residents, I think they will begin to change their minds.

How was the work coordinated? Who supported this work?

Initially, the four thoracic surgery societies sponsored this work, but two had to pull out for financial reasons. Now most of our funding comes from the Society of Thoracic Surgeons and the American Board of Thoracic Surgery. We also raised some money from industry.

The Joint Council on Thoracic Surgery has a board with two members from each of the societies, and the board advises us. There are some subcommittees to focus on specific topics. I also have a kitchen cabinet of four surgeons at other medical schools. They each focus on a different area: working with PersonalBrain, general issues related to medical education, developing simulations, and outreach to medical school faculties.

How do you measure success?

The program is just finishing its inaugural year. Although the course was designed before the year started, we are rolling it out one feature at a time, one per month. We won’t have outcome data until the end of the school year, but the content management system was designed to track usage. Anytime users sign in, the system tracks what they access and how much time they spend in the system. We review usage data every week. In addition, the system allows access to the residents’ portfolios. Information can also be aggregated to the program level, to assess program effectiveness. Faculty not only can look at their residents’ progress but also can compare outcomes with the other programs around the country.

We have a lot of data to gauge how the program is working, but the big test will be how residents do on their medical boards.

What are the next steps? What changes do you anticipate?

We believe that this online course module has appeal way beyond the thoracic surgery residency. We showed it to colleagues in the cardiothoracic anesthesia community and to associates who develop cardiac devices, and they want to be part of this. They would love access to this kind of content and this type of CMS. When we presented at the Europe Society for Thoracic Surgery, we noted a lot of interest, but I expect this program will be more popular in countries that are developing their medical education system. It may take longer to catch on in the United States and Europe.

There is also potential to use online courses for continuing medical education (CME). Currently, physicians earn CME credits by attending conference. These conferences often present research studies and information about registries, but they have little to do with competency-based education. There is currently no accountability for professional learning, but ultimately, society is going to ask, “Did you learn anything? How do we know if you learned anything?” Without assessment, there is no way to know if the professional even attended the lecture, let alone learned anything. How do you make a curriculum accountable, how do you make developing technical skills accountable?

Online education is emerging as the way forward in medical education, particularly in a specialty like cardiothoracic surgery, in which new technology is introduced every week. We see this as a first step toward an accountable curriculum.