The global SARS-CoV-2 pandemic accelerated the adoption of new technologies to provide remote patient care and also to address the curricular and educational needs of learners while sheltering from hospital exposure. Virtual learning has been a major issue in North America, particularly on procedural training for various surgical residencies [7–9]. These changes have threatened many of our existing patterns of knowledge delivery but have also provided novel opportunities to reduce financial and geographic barriers and potentially uncouple medical education from a fixed time-based paradigm [10]. The 2020 virtual PS-BC reviewed herein exemplifies many of these challenges and opportunities, albeit in the context of subspecialty training after residency - a niche educational category but one with significant concerns given decreasing case counts and exposure to ‘routine surgical practice’ in residency [11].
The virtual version of the PS-BC afforded several tangible advantages to incoming pediatric surgical trainees, including eliminating the need for travel, greatly decreasing institutional costs and reducing time away from service. Importantly, our data identified an increase in number of participants for the 2020 camp from prior years, both first year PS residents as well as other categories of PS learners who were only invited as a result of the virtual platform. This observation may have been a direct result of reducing said barriers to attendance but could also simply represent momentum and enthusiasm in the PS-BC regardless of delivery format. The virtual format also significantly reduced the financial burden of hosting the course for the Course Director institutions, and as well for the learners and participating faculty. Notably, the overall budget of the virtual Boot Camp was nearly halved, and the cost per learner was reduced by two-thirds. These cost-savings were substantial, especially given the economic challenges and uncertainties experienced during the peak pandemic months in the summer of 2020. Prior camps were able to maintain cost neutrality through industry sponsorship; it remains unclear whether future camps will be able to generate financial support from industry as has been traditional in the past. Notably, we did encounter less philanthropic contributions to the PS-BC likely due to economic challenges during the peak months of shelter at home mandates across North America. However, this 2020 PS-BC was generously sponsored through several Pediatric Surgical Associations, industry, and a nominal registration fee.
Certainly the virtual experience has major limitations with screen fatigue and only short intermissions between sessions as content had been condensed into one lengthy day. Consideration had been given to hosting the event across several days with shorter screen time/day, but course directors were concerned about the audience presence at other major meetings that had transitioned to virtual format; these meetings appeared to experience diminishing attendance over time. We believed it would be most reliable and consistent with the ‘knowledge bolus’ of past camps to host a single day event to ensure the greatest attendance; we did not detect any erosion of learner participation throughout the day.
Another major advantage with the virtual delivery of the PS-BC was the recording of educational content for later viewing, courtesy of GlobalCastMD. Digital archiving of this invaluable material has the potential to reduce the need for future content creation and time expended. Importantly, this material could also be made available to practicing and training Pediatric Surgeons from resource-constrained regions around the globe, who might otherwise not have the opportunity to experience such a boot camp. However, concerns were raised regarding content ownership, copyright laws, and the preferred storage platform for high yield educational material. These issues are just beginning to be framed by medical educators [12]: should content be stored by third party providers that assist in its creation (e.g., GlobalCastMD)? Should specialty organizations like the Canadian Association of Pediatric Surgeons (CAPS) or the APSTPD act as stewards of archived content; if so, how do they regulate access? Would content be available to learners and faculty alike, and at the cost of membership or at further cost to individuals or institutions? Is there a risk of further alienating the disadvantaged already? Is it fair to offer open access if others have paid a registration fee some time in advance?
Importantly, several program directors remain unconvinced of the merits of the PS-BC. Evidence in favor of the positive effects of short, intense educational boot camps exist across several specialties [1, 13, 14], although sceptics will reasonably point out that the durability, and practical applicability of educational content is largely unproven [15]. A small sampling of boot camp participants who completed the post-test showed that learners retained educational content and even enhanced their fund of knowledge. Notably, learner responses were pooled for both the pre- and post-tests, which revealed significantly improved correct answers and indicated a positive impact on learner fund of knowledge. The relatively low post-test completion rate of participants is an acknowledged limitation of the presented data. Indeed, the seven responders to the post-test were arguably more motivated to complete the post-test and therefore could have biased this improved response rate. To evaluate greatest efficacy of educational content, a pre-test should be administered immediately before the intervention and then a post-test upon its completion. The delay of 8 weeks was intentional to assess knowledge retention but certainly impacted lower participation. Further, the satisfaction survey data were incompletely anonymized (respondent identity was available only to the course co-directors), which may have reduced the potential to provide negative answers from junior learners. Given the abundance of constructive feedback from PDs, this lack on anonymity appeared to have not influenced their opinions.
We did not expect to observe such disparate participation between PS training programs from Canada (100%) and the United States (48%). These differences may be explained by the recent origins of the PS-BC in Canada as described above. More concrete evidence of the PS-BC benefits to learner education and transition to a pediatric hospital environment needs to be gathered to convince those PDs who have ongoing reluctance to register their learners for future PS-BCs. Nevertheless, we did observe an encouraging increase in participation of all level learners, which was novel to the virtual format, but also specifically first-year PS residents as well.
While opinions varied between learners and directors about the merits and weakness of the 2020 virtual PS-BC, relative unanimity emerged that all participants craved an in-person experience. The ability to participate in hands-on technical teaching during animal labs was lost, simulation activities could not be adequately transitioned to a virtual platform on short notice, and establishing social connections was clearly inferior in the virtual world than in person. And yet, nearly everyone reading this article will be doing so online. Seeing patients through HIPAA-approved virtual formats and holding high level administrative meetings without leaving an office is now the norm rather than the exception. Indeed, some authors of this manuscript have essentially only met virtually. Change is the only constant. Future course directors of the PS-BC, much like all medical educators, will need to carefully consider learner needs when weighing the potential of in-person versus virtual learning activities. Hybrid approaches that promote the relative advantages of in-person learning while leveraging the lessons of a virtual platform may prove to be the most appealing future option; as may case-based learning [16, 17]. While emerging sophisticated simulation opportunities in a virtual format hold significant promise, these tools are currently fledgling and were not available on short notice in the summer of 2020. It is ultimately hoped that these data will inform future curricular development for surgical bootcamps, whether hosted in-person, virtually or using a hybrid model depending on our capacity to gather.