Perspectives on the New Curriculum

The Training Program Experience

By Mara B. Antonoff, M.D., Resident Medical Editor

The new thoracic surgery curriculum has arrived. Debuting this past summer, the curriculum resulted as a joint endeavor of several key organizations heavily vested in thoracic surgical education, with the aim of providing a web-based, multimedia repository of educational materials, accompanied by a formal structure and schedule of weekly topic coverage. Conceptually, the new curriculum has much to offer, with immense theoretical benefits to both the teacher and the student. But what about in practice? Now several months after its launch, the materials provided via the Moodle site and WebBrain have been accessed by the majority of training programs in this country.

How are these tools being utilized by the various programs, and what feedback do they have based on their experiences? The goal of this article will be to explore the various usage patterns of several institutions and their strategies for implementing the materials and integrating them with on-the-ground educational activities. Both the strengths and drawbacks from a programmatic standpoint will be addressed. As you read this article, perhaps you will be motivated to take another look at the curriculum, with new ideas as to how it might best suit your program’s needs.

At Oregon Health and Science University (OHSU), the new curriculum was officially introduced to the trainees and faculty members in a very formal and organized manner, heavily employing the provided instructional videos to become quickly oriented to the new system ("How-To: Utilizing the Thoracic Surgery Brain WebBrain," by Dr. Craig Baker; "How-To: Navigating Moodle," by Dr. Ara Vaporciyan; and "Overview of Teaching Cardiothoracic Surgery" – all available from the Moodle site, http:// jctse.mrooms.net, under Resources on the right hand column). OHSU Program Coordinator Jill Rose reports that she also received helpful information about accessing the curriculum when she attended the "Educate the Educators" course in June, sponsored by the Joint Council on Thoracic Surgery Education (JCTSE). Ms. Rose states, "Faculty and learners enthusiastically adopted this new curriculum and immediately put it to use at least twice a week." When the weekly emails come out, the relevant articles and videos are sent to the trainees and faculty members in the form of a reminder email, including links to the online videos and all related PDF’s as attachments. The residents and fellows then engage in formal curriculum review sessions with faculty, students, and mid-level practitioners – covering the cardiac topics on Monday mornings and thoracic topics on Friday mornings.

At Loma Linda University Health, the residents meet with a faculty moderator on a weekly basis to cover the materials related to the weekly Thoracic Surgery Curriculum topics. The style of presentation is left to the discretion of the attending surgeon, with the majority of the didactic sessions following an oral-board, case-based scenario format. Rather than directly accessing the Moodle pages and WebBrain site, the majority of the faculty and trainees have found that they prefer to have the materials provided to them as hard copies. Consequently, these materials are downloaded and distributed by the program coordinator on a weekly basis.

As with any new educational program, there may be a need for adjustments in initial plans and utilization based on early experiences. For the first few months following release of the curriculum, the Loma Linda group aimed to cover two topics per week – cardiac on Monday mornings and thoracic on Thursday mornings. However, with a tremendous amount of material available for each topic, they ultimately decided to transition to a single weekly session.

While the Loma Linda program has attempted to adhere to the schedule according to the weekly curriculum emails, other programs have chosen to utilize the available materials within the framework of alternative curricular schedules. Rose Haselden, the program coordinator at the Medical University of South Carolina (MUSC), explains that they created their own timeline for covering the materials, based on their specific needs and objectives.

Dr. John Ikonomidis, program director at MUSC, recalls being quick to adopt the new thoracic surgery curriculum. He states, "We were very impressed with its scope and current referencing. When it became available, we went through its entire corpus and divided it into sections which could be covered in 30 minutes. Then we developed a schedule where two topics (one adult or pediatric cardiac and one thoracic) would be covered in our weekly one-hour didactic sessions." Dr. Ikonomidis continues, "The residents are expected to read the material beforehand and faculty are assigned to quiz the residents during the session." In this way, the MUSC program has found a way to use the full breadth of materials, but tailoring the exact learning objectives for their trainees.

While some programs have taken to re-organizing the materials and producing hard copies of the resources for the residents, others have chosen to use the curriculum in its native structure, as a freestanding means of educational supplementation. At Washington University in St. Louis, the trainees are taught how to access the materials and encouraged to both follow the weekly thoracic surgery curriculum emails for independent reading and to utilize the immense resources available for investigating topics relevant to specific cases, conferences, and research interests. Dr. Marc Moon, program director at Washington University, explains that "we have not utilized the materials in any formal, assigned manner; rather, we choose to use the curriculum as a resource for independent study, encouraging our residents to access the multimedia materials both for at-home study and point-of-care reference." Dr. Moon expresses gratitude for the new curriculum, reporting that the faculty members "are grateful that our trainees are able to access these curricular materials through the WebBrain and Moodle, as they serve as an outstanding educational supplement to a high volume operative experience." Dr. Moon further emphasizes, "We find that the new curriculum functions as an excellent adjunct to our clinical teaching."

There are a number of proposed strengths to the new curriculum – its breadth, its ease of access, its correlation with the educational objectives of the American Board of Thoracic Surgery. But what are the benefits being identified from the level of the training program? Dr. Paul Schipper, program director at OHSU, expresses appreciation for the greater volume of material accessible by the trainees, as compared with the older curriculum previously sponsored by the Thoracic Surgery Directors Association (TSDA). States Dr. Schipper, "We’ve been using the TSDA emailed curriculum for several years. With the release of WebBrain, we’ve switched over and been very pleased. Residents are accessing the material and digging deeper into it than previously. In our teaching sessions, we are spending more time on applying the material and less time on explaining it, and I think this is good." Appreciation for the breadth and depth of the material was also noted by Dr. Moon, who identifies the program’s strengths as its ease of access, its large volume, and its applicability to a wide range of educational needs.

Despite the generally laudatory praise, there have been a few issues identified by the training programs that could benefit from some improvement.

Certainly, this is not surprising, as with any educational program, practice and feedback are necessary to optimize the execution for the users. Further, with a resource collection of such enormity, minor tweaks will likely continue in the background at all times in order to ensure ongoing quality-control.

In considering further revision, Dr. Wallen raises some concerns regarding format. He states that "all the moving around on the links makes people crazy," and, for this reason, at Loma Linda, all of the materials are distributed from the WebBrain to the faculty and trainees by the program coordinator. "Otherwise, we would have a revolt," Dr. Jason Wallen explains, This distaste for accessing the materials via the WebBrain is not shared by all users, but it provides feedback, suggesting that changes could be made to optimize formatting to increase ease of use.

Certainly, the leaders in the TSDA, JCTSE, and Thoracic Surgery Residents Association (TSRA) who contributed to the development of the new curriculum are eager for this kind of feedback, welcoming all users to provide constructive criticism. Dr. Ara Vaporciyan, program director at the University of Texas MD Anderson Cancer Center, co-chair of the TSDA/JCTSE Curriculum Committee, and one of the 4 section editors for the curriculum itself, has been a key player in the development of the new curriculum.

States Dr. Vaporciyan, "I never expected this to be perfect on the first try and this is exactly the feedback we need. If we can start an honest conversation about the flaws in the system we can better allocate resources to fixing the most pervasive issues."

Despite the challenges that have been identified, Dr. Wallen remains positive about the curriculum, stating, "We are excited to have an electronic curriculum that our residents can access from anywhere that includes readings and multimedia content. We anticipate that following the curriculum will enhance our residents’ performance on future inservice exams and pave the path to certification."

Dr. Ikonomidis shares Dr. Wallen’s enthusiasm, summarizing that his "residents are constantly engaged and we believe that their learning efficiency has increased." Notes Dr. Schipper, "I am hopeful that this system will stay current and realize and appreciate the effort this has and will take to do so."

Certainly, the new curriculum has already been heavily utilized and appreciated by a number of training programs. While there will always be minor adjustments to be made, the innovators behind the Thoracic Surgery WebBrain and Moodle site are receptive to feedback and clearly dedicated to its ongoing growth.

Perhaps this article has encouraged those of you that aren’t using the curriculum regularly to incorporate it into your institution’s educational structure. For those of you already heavily engaged, perhaps you’ve been inspired to try some new strategies of implementation. Moreover, for all users of the system – trainees, educators, and coordinators – regardless of your program’s current level of use, the take-home message from the creators of the curriculum is that you are encouraged to provide feedback to allow evolution and improvement of the program.

The Trainee Experience

By Sanford M. Zeigler, M.D., Resident Medical Editor

Dr. Antonoff has detailed how different programs have chosen to implement the new curriculum. Of course, in order for the curriculum to work in any setting, people have to actually sit down, access the material, and learn from it. The modules need to be easily accessible, logically organized, and appropriate for the audience for which they are intended. To that end, the folks behind the new curriculum worked diligently to organize all the material into the WebBrain format, which attempts to organize the content by the logic of the human brain, using mind maps, and Moodle, which compartmentalizes the readings into individual curricular assignments that are served up on each resident’s personal Moodle page.

The overall architecture of the WebBrain is very organic; the "Brain" is split into four main branches, comprised of Foundations of Surgery, Cardiovascular, Thoracic, and Congenital headings. From these, the subject matter continues to divide and subdivide again until you reach a terminal branch, where the reader can open a number of different sources, both primary and secondary, on a given subject. The brains’ power lies in the connections that can be made across these fluid boundaries. An example can be seen with one reference that discusses MRI imaging of pericardial disease and cardiac masses. When this is selected, the thought leads the reader back to both the pericardial disease heading and the cardiac tumors heading. The subject selection feature allows the reader to wander throughout the entire WebBrain in a free-flowing but logical manner. Connections across different subjects are, at this point, still rarely utilized. The cross-referencing feature could be a boon for more junior integrated residents and general surgery residents if more of the basic concepts section were connected to cardiac and thoracic subjects, and could allow more self-directed reading to residents that find the time to do so. The WebBrain has some basic search functionality embedded in it that could be used to help understand specific clinical scenarios as they are encountered. Layered upon all of the subject matter are tags, which correspond to the weekly curricular readings. If trainees search for the tag "CV08," for example, they will be directed to each source with that tag, bringing the weekly source matter right to the front. Thus, the WebBrain can be used as a guide for casual reading, as a reference for a particular question or clinical scenario encountered in practice, and also as the source for material covered in didactic session.

The Moodle interface is the gateway to the WebBrain. While it may sound easier to deliver the contents of the WebBrain to each resident rather than go through Moodle, this interface serves two functions. In order to license the content for the curriculum, publishers of many of the textbooks require tight security to prevent unauthorized duplication of the materials. Moodle, by requiring a unique login to access the single WebBrain, provides that security and also allows the WebBrain to be modified in the Cloud, rather than at the level of the end-user. Moodle also provides other testing and tracking tools that have not been completely rolled out. Over the coming months, its full architecture will be used to incorporate quizzes, collaborative message boards, and personal tracking to help residents and their program directors ensure that the material is being covered adequately.

Nearly every resident and faculty member I asked about the new curriculum agreed that the update in content and delivery was badly needed. As an intern in an integrated cardiothoracic surgery program, I remember feeling very jealous of my general surgery colleagues’ access to the SCORE portal, which gave them an easily navigable curriculum accessible from anywhere, with instruction in everything from basic science and physiology to advanced surgical diagnosis and technique. The rollout of the Moodle interface and Web Brain content is the first step to a similar, comprehensive compendium of the necessary knowledge to master cardiac and thoracic surgery.

Response to the rollout has been generally positive from the residents. Most residents agree that the content provides a great sample of landmark papers, lecture videos, book chapters, and consensus statements. A fellow Stanford resident, George Dimeling, wrote: "I like the weekly focus and the topic organization. The content is good, but tough to access." The articles and chapters are often more up to date than printed textbooks, and, once the reader accesses the Brain, are instantly viewable with no further log ins or downloads.

Of course, for a busy resident, it may not always be possible to cover a long book chapter quickly, and the primary literature sometimes fails to cover an entire topic. Justin Schaffer, another Stanford resident, offered this thought: "There’s either a short paper or a 40-page book chapter – there is no solid review of the subject matter. They need something like the Doty lecture series and the TSRA publications to get you warmed up if you don’t have all that time." In fact, the WebBrain incorporates many chapters of the TSRA Cardiothoracic Review book, and the TSRA Clinical Scenarios were added to Moodle on Dec. 12.

One of the more common complaints had little to do with the content but more to do with delivery. At my own institution, most of our hospital computers run an outdated copy of Internet Explorer and have restricted access to update or install a new browser. The out-of-date or restricted software packages that are pervasive in institutional machines nullify many of the advantages of the WebBrain/Moodle format, as the majority of computers at Stanford Hospital cannot access the WebBrain. Furthermore, the WebBrain interface can be laggy and slow even with compatible software.

Others have complained that it is not always easy to find the readings, especially if a program does not follow one of the standardized curricula included with the rollout. First, one must find which content they are responsible for via departmental website or reference to the curricula. Next, the resident logs into the Moodle room, and the proper WebBrain course is launched, then each article for the week is selected and downloaded. Only after that can the content be read, saved, or printed. Using the tag function is helpful, but each time a tagged article is selected, the resident is taken away from the search and to the specific content area, away from the other material assigned for the week. Though it isn’t very difficult to navigate back to the search, all of the steps above make it a bit more of a process to access the material than is convenient for a resident trying to fit in readings between cases or while waiting to round. The new software is a definite improvement, yet still has not reached its full potential.

As Dr. Antonoff pointed out, one residency program has easily overcome this obstacle by consolidating and emailing the appropriate material every week. While the Moodle portion of the curriculum still sees limited functionality, this is probably the best solution to all of the problems. If the articles are in your mailbox, they are accessible anywhere, without the bother of logging in and navigating the Brain.

I discussed this with Dr. Jim Fann, who has been very involved in developing the curriculum, and he explained that direct delivery of the content to each resident had been part of the original goal. As mentioned before, however, publishers require that the delivery of the material is secure from unauthorized duplication. Within the context of an individual institution, those issues are less confining. While individual programs work to integrate the material into their own traditions, it may be worthwhile to designate a resident or office staff member to be in charge of distributing the week’s reading. One little-recognized feature of Moodle is the ability to upload calendars. Perhaps this area could be used by each program to keep the curricular and departmental calendars adjacent to the WebBrain link for easier access.

The recent changes in cardiothoracic surgical education have been myriad, and the rollout of the new curriculum is one of the most pervasive and visible signs of that change. The new curriculum has been designed and updated to reflect not only updates in medical knowledge and consensus, but also changes in the demographic of the cardiothoracic surgery resident and new paradigms in surgical education. The content and delivery systems, while not perfect, remain an ever improving work in progress, which aims to bring cardiothoracic surgical education into the collaborative, cloud based learning era while broadening its reach to both green cardiothoracic surgery interns and traditional fellows with a full general surgery residency behind them. All things considered, the rollout has been very successful, and as more functionality is added and bugs are worked out, things can only improve.

The Training Program Experience

By Mara B. Antonoff, M.D., Resident Medical Editor

The new thoracic surgery curriculum has arrived. Debuting this past summer, the curriculum resulted as a joint endeavor of several key organizations heavily vested in thoracic surgical education, with the aim of providing a web-based, multimedia repository of educational materials, accompanied by a formal structure and schedule of weekly topic coverage. Conceptually, the new curriculum has much to offer, with immense theoretical benefits to both the teacher and the student. But what about in practice? Now several months after its launch, the materials provided via the Moodle site and WebBrain have been accessed by the majority of training programs in this country.

How are these tools being utilized by the various programs, and what feedback do they have based on their experiences? The goal of this article will be to explore the various usage patterns of several institutions and their strategies for implementing the materials and integrating them with on-the-ground educational activities. Both the strengths and drawbacks from a programmatic standpoint will be addressed. As you read this article, perhaps you will be motivated to take another look at the curriculum, with new ideas as to how it might best suit your program’s needs.

At Oregon Health and Science University (OHSU), the new curriculum was officially introduced to the trainees and faculty members in a very formal and organized manner, heavily employing the provided instructional videos to become quickly oriented to the new system ("How-To: Utilizing the Thoracic Surgery Brain WebBrain," by Dr. Craig Baker; "How-To: Navigating Moodle," by Dr. Ara Vaporciyan; and "Overview of Teaching Cardiothoracic Surgery" – all available from the Moodle site, http:// jctse.mrooms.net, under Resources on the right hand column). OHSU Program Coordinator Jill Rose reports that she also received helpful information about accessing the curriculum when she attended the "Educate the Educators" course in June, sponsored by the Joint Council on Thoracic Surgery Education (JCTSE). Ms. Rose states, "Faculty and learners enthusiastically adopted this new curriculum and immediately put it to use at least twice a week." When the weekly emails come out, the relevant articles and videos are sent to the trainees and faculty members in the form of a reminder email, including links to the online videos and all related PDF’s as attachments. The residents and fellows then engage in formal curriculum review sessions with faculty, students, and mid-level practitioners – covering the cardiac topics on Monday mornings and thoracic topics on Friday mornings.

At Loma Linda University Health, the residents meet with a faculty moderator on a weekly basis to cover the materials related to the weekly Thoracic Surgery Curriculum topics. The style of presentation is left to the discretion of the attending surgeon, with the majority of the didactic sessions following an oral-board, case-based scenario format. Rather than directly accessing the Moodle pages and WebBrain site, the majority of the faculty and trainees have found that they prefer to have the materials provided to them as hard copies. Consequently, these materials are downloaded and distributed by the program coordinator on a weekly basis.

As with any new educational program, there may be a need for adjustments in initial plans and utilization based on early experiences. For the first few months following release of the curriculum, the Loma Linda group aimed to cover two topics per week – cardiac on Monday mornings and thoracic on Thursday mornings. However, with a tremendous amount of material available for each topic, they ultimately decided to transition to a single weekly session.

While the Loma Linda program has attempted to adhere to the schedule according to the weekly curriculum emails, other programs have chosen to utilize the available materials within the framework of alternative curricular schedules. Rose Haselden, the program coordinator at the Medical University of South Carolina (MUSC), explains that they created their own timeline for covering the materials, based on their specific needs and objectives.

Dr. John Ikonomidis, program director at MUSC, recalls being quick to adopt the new thoracic surgery curriculum. He states, "We were very impressed with its scope and current referencing. When it became available, we went through its entire corpus and divided it into sections which could be covered in 30 minutes. Then we developed a schedule where two topics (one adult or pediatric cardiac and one thoracic) would be covered in our weekly one-hour didactic sessions." Dr. Ikonomidis continues, "The residents are expected to read the material beforehand and faculty are assigned to quiz the residents during the session." In this way, the MUSC program has found a way to use the full breadth of materials, but tailoring the exact learning objectives for their trainees.

While some programs have taken to re-organizing the materials and producing hard copies of the resources for the residents, others have chosen to use the curriculum in its native structure, as a freestanding means of educational supplementation. At Washington University in St. Louis, the trainees are taught how to access the materials and encouraged to both follow the weekly thoracic surgery curriculum emails for independent reading and to utilize the immense resources available for investigating topics relevant to specific cases, conferences, and research interests. Dr. Marc Moon, program director at Washington University, explains that "we have not utilized the materials in any formal, assigned manner; rather, we choose to use the curriculum as a resource for independent study, encouraging our residents to access the multimedia materials both for at-home study and point-of-care reference." Dr. Moon expresses gratitude for the new curriculum, reporting that the faculty members "are grateful that our trainees are able to access these curricular materials through the WebBrain and Moodle, as they serve as an outstanding educational supplement to a high volume operative experience." Dr. Moon further emphasizes, "We find that the new curriculum functions as an excellent adjunct to our clinical teaching."

There are a number of proposed strengths to the new curriculum – its breadth, its ease of access, its correlation with the educational objectives of the American Board of Thoracic Surgery. But what are the benefits being identified from the level of the training program? Dr. Paul Schipper, program director at OHSU, expresses appreciation for the greater volume of material accessible by the trainees, as compared with the older curriculum previously sponsored by the Thoracic Surgery Directors Association (TSDA). States Dr. Schipper, "We’ve been using the TSDA emailed curriculum for several years. With the release of WebBrain, we’ve switched over and been very pleased. Residents are accessing the material and digging deeper into it than previously. In our teaching sessions, we are spending more time on applying the material and less time on explaining it, and I think this is good." Appreciation for the breadth and depth of the material was also noted by Dr. Moon, who identifies the program’s strengths as its ease of access, its large volume, and its applicability to a wide range of educational needs.

Despite the generally laudatory praise, there have been a few issues identified by the training programs that could benefit from some improvement.

Certainly, this is not surprising, as with any educational program, practice and feedback are necessary to optimize the execution for the users. Further, with a resource collection of such enormity, minor tweaks will likely continue in the background at all times in order to ensure ongoing quality-control.

In considering further revision, Dr. Wallen raises some concerns regarding format. He states that "all the moving around on the links makes people crazy," and, for this reason, at Loma Linda, all of the materials are distributed from the WebBrain to the faculty and trainees by the program coordinator. "Otherwise, we would have a revolt," Dr. Jason Wallen explains, This distaste for accessing the materials via the WebBrain is not shared by all users, but it provides feedback, suggesting that changes could be made to optimize formatting to increase ease of use.

Certainly, the leaders in the TSDA, JCTSE, and Thoracic Surgery Residents Association (TSRA) who contributed to the development of the new curriculum are eager for this kind of feedback, welcoming all users to provide constructive criticism. Dr. Ara Vaporciyan, program director at the University of Texas MD Anderson Cancer Center, co-chair of the TSDA/JCTSE Curriculum Committee, and one of the 4 section editors for the curriculum itself, has been a key player in the development of the new curriculum.

States Dr. Vaporciyan, "I never expected this to be perfect on the first try and this is exactly the feedback we need. If we can start an honest conversation about the flaws in the system we can better allocate resources to fixing the most pervasive issues."

Despite the challenges that have been identified, Dr. Wallen remains positive about the curriculum, stating, "We are excited to have an electronic curriculum that our residents can access from anywhere that includes readings and multimedia content. We anticipate that following the curriculum will enhance our residents’ performance on future inservice exams and pave the path to certification."

Dr. Ikonomidis shares Dr. Wallen’s enthusiasm, summarizing that his "residents are constantly engaged and we believe that their learning efficiency has increased." Notes Dr. Schipper, "I am hopeful that this system will stay current and realize and appreciate the effort this has and will take to do so."

Certainly, the new curriculum has already been heavily utilized and appreciated by a number of training programs. While there will always be minor adjustments to be made, the innovators behind the Thoracic Surgery WebBrain and Moodle site are receptive to feedback and clearly dedicated to its ongoing growth.

Perhaps this article has encouraged those of you that aren’t using the curriculum regularly to incorporate it into your institution’s educational structure. For those of you already heavily engaged, perhaps you’ve been inspired to try some new strategies of implementation. Moreover, for all users of the system – trainees, educators, and coordinators – regardless of your program’s current level of use, the take-home message from the creators of the curriculum is that you are encouraged to provide feedback to allow evolution and improvement of the program.

The Trainee Experience

By Sanford M. Zeigler, M.D., Resident Medical Editor

Dr. Antonoff has detailed how different programs have chosen to implement the new curriculum. Of course, in order for the curriculum to work in any setting, people have to actually sit down, access the material, and learn from it. The modules need to be easily accessible, logically organized, and appropriate for the audience for which they are intended. To that end, the folks behind the new curriculum worked diligently to organize all the material into the WebBrain format, which attempts to organize the content by the logic of the human brain, using mind maps, and Moodle, which compartmentalizes the readings into individual curricular assignments that are served up on each resident’s personal Moodle page.

The overall architecture of the WebBrain is very organic; the "Brain" is split into four main branches, comprised of Foundations of Surgery, Cardiovascular, Thoracic, and Congenital headings. From these, the subject matter continues to divide and subdivide again until you reach a terminal branch, where the reader can open a number of different sources, both primary and secondary, on a given subject. The brains’ power lies in the connections that can be made across these fluid boundaries. An example can be seen with one reference that discusses MRI imaging of pericardial disease and cardiac masses. When this is selected, the thought leads the reader back to both the pericardial disease heading and the cardiac tumors heading. The subject selection feature allows the reader to wander throughout the entire WebBrain in a free-flowing but logical manner. Connections across different subjects are, at this point, still rarely utilized. The cross-referencing feature could be a boon for more junior integrated residents and general surgery residents if more of the basic concepts section were connected to cardiac and thoracic subjects, and could allow more self-directed reading to residents that find the time to do so. The WebBrain has some basic search functionality embedded in it that could be used to help understand specific clinical scenarios as they are encountered. Layered upon all of the subject matter are tags, which correspond to the weekly curricular readings. If trainees search for the tag "CV08," for example, they will be directed to each source with that tag, bringing the weekly source matter right to the front. Thus, the WebBrain can be used as a guide for casual reading, as a reference for a particular question or clinical scenario encountered in practice, and also as the source for material covered in didactic session.

The Moodle interface is the gateway to the WebBrain. While it may sound easier to deliver the contents of the WebBrain to each resident rather than go through Moodle, this interface serves two functions. In order to license the content for the curriculum, publishers of many of the textbooks require tight security to prevent unauthorized duplication of the materials. Moodle, by requiring a unique login to access the single WebBrain, provides that security and also allows the WebBrain to be modified in the Cloud, rather than at the level of the end-user. Moodle also provides other testing and tracking tools that have not been completely rolled out. Over the coming months, its full architecture will be used to incorporate quizzes, collaborative message boards, and personal tracking to help residents and their program directors ensure that the material is being covered adequately.

Nearly every resident and faculty member I asked about the new curriculum agreed that the update in content and delivery was badly needed. As an intern in an integrated cardiothoracic surgery program, I remember feeling very jealous of my general surgery colleagues’ access to the SCORE portal, which gave them an easily navigable curriculum accessible from anywhere, with instruction in everything from basic science and physiology to advanced surgical diagnosis and technique. The rollout of the Moodle interface and Web Brain content is the first step to a similar, comprehensive compendium of the necessary knowledge to master cardiac and thoracic surgery.

Response to the rollout has been generally positive from the residents. Most residents agree that the content provides a great sample of landmark papers, lecture videos, book chapters, and consensus statements. A fellow Stanford resident, George Dimeling, wrote: "I like the weekly focus and the topic organization. The content is good, but tough to access." The articles and chapters are often more up to date than printed textbooks, and, once the reader accesses the Brain, are instantly viewable with no further log ins or downloads.

Of course, for a busy resident, it may not always be possible to cover a long book chapter quickly, and the primary literature sometimes fails to cover an entire topic. Justin Schaffer, another Stanford resident, offered this thought: "There’s either a short paper or a 40-page book chapter – there is no solid review of the subject matter. They need something like the Doty lecture series and the TSRA publications to get you warmed up if you don’t have all that time." In fact, the WebBrain incorporates many chapters of the TSRA Cardiothoracic Review book, and the TSRA Clinical Scenarios were added to Moodle on Dec. 12.

One of the more common complaints had little to do with the content but more to do with delivery. At my own institution, most of our hospital computers run an outdated copy of Internet Explorer and have restricted access to update or install a new browser. The out-of-date or restricted software packages that are pervasive in institutional machines nullify many of the advantages of the WebBrain/Moodle format, as the majority of computers at Stanford Hospital cannot access the WebBrain. Furthermore, the WebBrain interface can be laggy and slow even with compatible software.

Others have complained that it is not always easy to find the readings, especially if a program does not follow one of the standardized curricula included with the rollout. First, one must find which content they are responsible for via departmental website or reference to the curricula. Next, the resident logs into the Moodle room, and the proper WebBrain course is launched, then each article for the week is selected and downloaded. Only after that can the content be read, saved, or printed. Using the tag function is helpful, but each time a tagged article is selected, the resident is taken away from the search and to the specific content area, away from the other material assigned for the week. Though it isn’t very difficult to navigate back to the search, all of the steps above make it a bit more of a process to access the material than is convenient for a resident trying to fit in readings between cases or while waiting to round. The new software is a definite improvement, yet still has not reached its full potential.

As Dr. Antonoff pointed out, one residency program has easily overcome this obstacle by consolidating and emailing the appropriate material every week. While the Moodle portion of the curriculum still sees limited functionality, this is probably the best solution to all of the problems. If the articles are in your mailbox, they are accessible anywhere, without the bother of logging in and navigating the Brain.

I discussed this with Dr. Jim Fann, who has been very involved in developing the curriculum, and he explained that direct delivery of the content to each resident had been part of the original goal. As mentioned before, however, publishers require that the delivery of the material is secure from unauthorized duplication. Within the context of an individual institution, those issues are less confining. While individual programs work to integrate the material into their own traditions, it may be worthwhile to designate a resident or office staff member to be in charge of distributing the week’s reading. One little-recognized feature of Moodle is the ability to upload calendars. Perhaps this area could be used by each program to keep the curricular and departmental calendars adjacent to the WebBrain link for easier access.

The recent changes in cardiothoracic surgical education have been myriad, and the rollout of the new curriculum is one of the most pervasive and visible signs of that change. The new curriculum has been designed and updated to reflect not only updates in medical knowledge and consensus, but also changes in the demographic of the cardiothoracic surgery resident and new paradigms in surgical education. The content and delivery systems, while not perfect, remain an ever improving work in progress, which aims to bring cardiothoracic surgical education into the collaborative, cloud based learning era while broadening its reach to both green cardiothoracic surgery interns and traditional fellows with a full general surgery residency behind them. All things considered, the rollout has been very successful, and as more functionality is added and bugs are worked out, things can only improve.

The Training Program Experience

By Mara B. Antonoff, M.D., Resident Medical Editor

The new thoracic surgery curriculum has arrived. Debuting this past summer, the curriculum resulted as a joint endeavor of several key organizations heavily vested in thoracic surgical education, with the aim of providing a web-based, multimedia repository of educational materials, accompanied by a formal structure and schedule of weekly topic coverage. Conceptually, the new curriculum has much to offer, with immense theoretical benefits to both the teacher and the student. But what about in practice? Now several months after its launch, the materials provided via the Moodle site and WebBrain have been accessed by the majority of training programs in this country.

How are these tools being utilized by the various programs, and what feedback do they have based on their experiences? The goal of this article will be to explore the various usage patterns of several institutions and their strategies for implementing the materials and integrating them with on-the-ground educational activities. Both the strengths and drawbacks from a programmatic standpoint will be addressed. As you read this article, perhaps you will be motivated to take another look at the curriculum, with new ideas as to how it might best suit your program’s needs.

At Oregon Health and Science University (OHSU), the new curriculum was officially introduced to the trainees and faculty members in a very formal and organized manner, heavily employing the provided instructional videos to become quickly oriented to the new system ("How-To: Utilizing the Thoracic Surgery Brain WebBrain," by Dr. Craig Baker; "How-To: Navigating Moodle," by Dr. Ara Vaporciyan; and "Overview of Teaching Cardiothoracic Surgery" – all available from the Moodle site, http:// jctse.mrooms.net, under Resources on the right hand column). OHSU Program Coordinator Jill Rose reports that she also received helpful information about accessing the curriculum when she attended the "Educate the Educators" course in June, sponsored by the Joint Council on Thoracic Surgery Education (JCTSE). Ms. Rose states, "Faculty and learners enthusiastically adopted this new curriculum and immediately put it to use at least twice a week." When the weekly emails come out, the relevant articles and videos are sent to the trainees and faculty members in the form of a reminder email, including links to the online videos and all related PDF’s as attachments. The residents and fellows then engage in formal curriculum review sessions with faculty, students, and mid-level practitioners – covering the cardiac topics on Monday mornings and thoracic topics on Friday mornings.

At Loma Linda University Health, the residents meet with a faculty moderator on a weekly basis to cover the materials related to the weekly Thoracic Surgery Curriculum topics. The style of presentation is left to the discretion of the attending surgeon, with the majority of the didactic sessions following an oral-board, case-based scenario format. Rather than directly accessing the Moodle pages and WebBrain site, the majority of the faculty and trainees have found that they prefer to have the materials provided to them as hard copies. Consequently, these materials are downloaded and distributed by the program coordinator on a weekly basis.

As with any new educational program, there may be a need for adjustments in initial plans and utilization based on early experiences. For the first few months following release of the curriculum, the Loma Linda group aimed to cover two topics per week – cardiac on Monday mornings and thoracic on Thursday mornings. However, with a tremendous amount of material available for each topic, they ultimately decided to transition to a single weekly session.

While the Loma Linda program has attempted to adhere to the schedule according to the weekly curriculum emails, other programs have chosen to utilize the available materials within the framework of alternative curricular schedules. Rose Haselden, the program coordinator at the Medical University of South Carolina (MUSC), explains that they created their own timeline for covering the materials, based on their specific needs and objectives.

Dr. John Ikonomidis, program director at MUSC, recalls being quick to adopt the new thoracic surgery curriculum. He states, "We were very impressed with its scope and current referencing. When it became available, we went through its entire corpus and divided it into sections which could be covered in 30 minutes. Then we developed a schedule where two topics (one adult or pediatric cardiac and one thoracic) would be covered in our weekly one-hour didactic sessions." Dr. Ikonomidis continues, "The residents are expected to read the material beforehand and faculty are assigned to quiz the residents during the session." In this way, the MUSC program has found a way to use the full breadth of materials, but tailoring the exact learning objectives for their trainees.

While some programs have taken to re-organizing the materials and producing hard copies of the resources for the residents, others have chosen to use the curriculum in its native structure, as a freestanding means of educational supplementation. At Washington University in St. Louis, the trainees are taught how to access the materials and encouraged to both follow the weekly thoracic surgery curriculum emails for independent reading and to utilize the immense resources available for investigating topics relevant to specific cases, conferences, and research interests. Dr. Marc Moon, program director at Washington University, explains that "we have not utilized the materials in any formal, assigned manner; rather, we choose to use the curriculum as a resource for independent study, encouraging our residents to access the multimedia materials both for at-home study and point-of-care reference." Dr. Moon expresses gratitude for the new curriculum, reporting that the faculty members "are grateful that our trainees are able to access these curricular materials through the WebBrain and Moodle, as they serve as an outstanding educational supplement to a high volume operative experience." Dr. Moon further emphasizes, "We find that the new curriculum functions as an excellent adjunct to our clinical teaching."

There are a number of proposed strengths to the new curriculum – its breadth, its ease of access, its correlation with the educational objectives of the American Board of Thoracic Surgery. But what are the benefits being identified from the level of the training program? Dr. Paul Schipper, program director at OHSU, expresses appreciation for the greater volume of material accessible by the trainees, as compared with the older curriculum previously sponsored by the Thoracic Surgery Directors Association (TSDA). States Dr. Schipper, "We’ve been using the TSDA emailed curriculum for several years. With the release of WebBrain, we’ve switched over and been very pleased. Residents are accessing the material and digging deeper into it than previously. In our teaching sessions, we are spending more time on applying the material and less time on explaining it, and I think this is good." Appreciation for the breadth and depth of the material was also noted by Dr. Moon, who identifies the program’s strengths as its ease of access, its large volume, and its applicability to a wide range of educational needs.

Despite the generally laudatory praise, there have been a few issues identified by the training programs that could benefit from some improvement.

Certainly, this is not surprising, as with any educational program, practice and feedback are necessary to optimize the execution for the users. Further, with a resource collection of such enormity, minor tweaks will likely continue in the background at all times in order to ensure ongoing quality-control.

In considering further revision, Dr. Wallen raises some concerns regarding format. He states that "all the moving around on the links makes people crazy," and, for this reason, at Loma Linda, all of the materials are distributed from the WebBrain to the faculty and trainees by the program coordinator. "Otherwise, we would have a revolt," Dr. Jason Wallen explains, This distaste for accessing the materials via the WebBrain is not shared by all users, but it provides feedback, suggesting that changes could be made to optimize formatting to increase ease of use.

Certainly, the leaders in the TSDA, JCTSE, and Thoracic Surgery Residents Association (TSRA) who contributed to the development of the new curriculum are eager for this kind of feedback, welcoming all users to provide constructive criticism. Dr. Ara Vaporciyan, program director at the University of Texas MD Anderson Cancer Center, co-chair of the TSDA/JCTSE Curriculum Committee, and one of the 4 section editors for the curriculum itself, has been a key player in the development of the new curriculum.

States Dr. Vaporciyan, "I never expected this to be perfect on the first try and this is exactly the feedback we need. If we can start an honest conversation about the flaws in the system we can better allocate resources to fixing the most pervasive issues."

Despite the challenges that have been identified, Dr. Wallen remains positive about the curriculum, stating, "We are excited to have an electronic curriculum that our residents can access from anywhere that includes readings and multimedia content. We anticipate that following the curriculum will enhance our residents’ performance on future inservice exams and pave the path to certification."

Dr. Ikonomidis shares Dr. Wallen’s enthusiasm, summarizing that his "residents are constantly engaged and we believe that their learning efficiency has increased." Notes Dr. Schipper, "I am hopeful that this system will stay current and realize and appreciate the effort this has and will take to do so."

Certainly, the new curriculum has already been heavily utilized and appreciated by a number of training programs. While there will always be minor adjustments to be made, the innovators behind the Thoracic Surgery WebBrain and Moodle site are receptive to feedback and clearly dedicated to its ongoing growth.

Perhaps this article has encouraged those of you that aren’t using the curriculum regularly to incorporate it into your institution’s educational structure. For those of you already heavily engaged, perhaps you’ve been inspired to try some new strategies of implementation. Moreover, for all users of the system – trainees, educators, and coordinators – regardless of your program’s current level of use, the take-home message from the creators of the curriculum is that you are encouraged to provide feedback to allow evolution and improvement of the program.

The Trainee Experience

By Sanford M. Zeigler, M.D., Resident Medical Editor

Dr. Antonoff has detailed how different programs have chosen to implement the new curriculum. Of course, in order for the curriculum to work in any setting, people have to actually sit down, access the material, and learn from it. The modules need to be easily accessible, logically organized, and appropriate for the audience for which they are intended. To that end, the folks behind the new curriculum worked diligently to organize all the material into the WebBrain format, which attempts to organize the content by the logic of the human brain, using mind maps, and Moodle, which compartmentalizes the readings into individual curricular assignments that are served up on each resident’s personal Moodle page.

The overall architecture of the WebBrain is very organic; the "Brain" is split into four main branches, comprised of Foundations of Surgery, Cardiovascular, Thoracic, and Congenital headings. From these, the subject matter continues to divide and subdivide again until you reach a terminal branch, where the reader can open a number of different sources, both primary and secondary, on a given subject. The brains’ power lies in the connections that can be made across these fluid boundaries. An example can be seen with one reference that discusses MRI imaging of pericardial disease and cardiac masses. When this is selected, the thought leads the reader back to both the pericardial disease heading and the cardiac tumors heading. The subject selection feature allows the reader to wander throughout the entire WebBrain in a free-flowing but logical manner. Connections across different subjects are, at this point, still rarely utilized. The cross-referencing feature could be a boon for more junior integrated residents and general surgery residents if more of the basic concepts section were connected to cardiac and thoracic subjects, and could allow more self-directed reading to residents that find the time to do so. The WebBrain has some basic search functionality embedded in it that could be used to help understand specific clinical scenarios as they are encountered. Layered upon all of the subject matter are tags, which correspond to the weekly curricular readings. If trainees search for the tag "CV08," for example, they will be directed to each source with that tag, bringing the weekly source matter right to the front. Thus, the WebBrain can be used as a guide for casual reading, as a reference for a particular question or clinical scenario encountered in practice, and also as the source for material covered in didactic session.

The Moodle interface is the gateway to the WebBrain. While it may sound easier to deliver the contents of the WebBrain to each resident rather than go through Moodle, this interface serves two functions. In order to license the content for the curriculum, publishers of many of the textbooks require tight security to prevent unauthorized duplication of the materials. Moodle, by requiring a unique login to access the single WebBrain, provides that security and also allows the WebBrain to be modified in the Cloud, rather than at the level of the end-user. Moodle also provides other testing and tracking tools that have not been completely rolled out. Over the coming months, its full architecture will be used to incorporate quizzes, collaborative message boards, and personal tracking to help residents and their program directors ensure that the material is being covered adequately.

Nearly every resident and faculty member I asked about the new curriculum agreed that the update in content and delivery was badly needed. As an intern in an integrated cardiothoracic surgery program, I remember feeling very jealous of my general surgery colleagues’ access to the SCORE portal, which gave them an easily navigable curriculum accessible from anywhere, with instruction in everything from basic science and physiology to advanced surgical diagnosis and technique. The rollout of the Moodle interface and Web Brain content is the first step to a similar, comprehensive compendium of the necessary knowledge to master cardiac and thoracic surgery.

Response to the rollout has been generally positive from the residents. Most residents agree that the content provides a great sample of landmark papers, lecture videos, book chapters, and consensus statements. A fellow Stanford resident, George Dimeling, wrote: "I like the weekly focus and the topic organization. The content is good, but tough to access." The articles and chapters are often more up to date than printed textbooks, and, once the reader accesses the Brain, are instantly viewable with no further log ins or downloads.

Of course, for a busy resident, it may not always be possible to cover a long book chapter quickly, and the primary literature sometimes fails to cover an entire topic. Justin Schaffer, another Stanford resident, offered this thought: "There’s either a short paper or a 40-page book chapter – there is no solid review of the subject matter. They need something like the Doty lecture series and the TSRA publications to get you warmed up if you don’t have all that time." In fact, the WebBrain incorporates many chapters of the TSRA Cardiothoracic Review book, and the TSRA Clinical Scenarios were added to Moodle on Dec. 12.

One of the more common complaints had little to do with the content but more to do with delivery. At my own institution, most of our hospital computers run an outdated copy of Internet Explorer and have restricted access to update or install a new browser. The out-of-date or restricted software packages that are pervasive in institutional machines nullify many of the advantages of the WebBrain/Moodle format, as the majority of computers at Stanford Hospital cannot access the WebBrain. Furthermore, the WebBrain interface can be laggy and slow even with compatible software.

Others have complained that it is not always easy to find the readings, especially if a program does not follow one of the standardized curricula included with the rollout. First, one must find which content they are responsible for via departmental website or reference to the curricula. Next, the resident logs into the Moodle room, and the proper WebBrain course is launched, then each article for the week is selected and downloaded. Only after that can the content be read, saved, or printed. Using the tag function is helpful, but each time a tagged article is selected, the resident is taken away from the search and to the specific content area, away from the other material assigned for the week. Though it isn’t very difficult to navigate back to the search, all of the steps above make it a bit more of a process to access the material than is convenient for a resident trying to fit in readings between cases or while waiting to round. The new software is a definite improvement, yet still has not reached its full potential.

As Dr. Antonoff pointed out, one residency program has easily overcome this obstacle by consolidating and emailing the appropriate material every week. While the Moodle portion of the curriculum still sees limited functionality, this is probably the best solution to all of the problems. If the articles are in your mailbox, they are accessible anywhere, without the bother of logging in and navigating the Brain.

I discussed this with Dr. Jim Fann, who has been very involved in developing the curriculum, and he explained that direct delivery of the content to each resident had been part of the original goal. As mentioned before, however, publishers require that the delivery of the material is secure from unauthorized duplication. Within the context of an individual institution, those issues are less confining. While individual programs work to integrate the material into their own traditions, it may be worthwhile to designate a resident or office staff member to be in charge of distributing the week’s reading. One little-recognized feature of Moodle is the ability to upload calendars. Perhaps this area could be used by each program to keep the curricular and departmental calendars adjacent to the WebBrain link for easier access.

The recent changes in cardiothoracic surgical education have been myriad, and the rollout of the new curriculum is one of the most pervasive and visible signs of that change. The new curriculum has been designed and updated to reflect not only updates in medical knowledge and consensus, but also changes in the demographic of the cardiothoracic surgery resident and new paradigms in surgical education. The content and delivery systems, while not perfect, remain an ever improving work in progress, which aims to bring cardiothoracic surgical education into the collaborative, cloud based learning era while broadening its reach to both green cardiothoracic surgery interns and traditional fellows with a full general surgery residency behind them. All things considered, the rollout has been very successful, and as more functionality is added and bugs are worked out, things can only improve.