This week, there was quite the dustup on LinkedIn when a company announced a new “online” stem cell training course. Suffice it to say, most patients don’t want to contemplate that everything their doctor knows about how to perform a complicated procedure like a stem cell injection, the doctor learned on YouTube U. In the same way, you likely don’t want to hear that your doctor went to medical school at night at DeVry University. However, this trend is really part of a bigger one that encompasses a shift from nonprofit physician training to for-profit “training.” So let’s explore that this morning.
The Differences Between Nonprofit and For-Profit Training
Postgraduate physician training has long been the realm of nonprofits. There are any number of them, from physician-run medical societies to physician-run organizations. They all have one thing in common: the goal isn’t to make money that goes into one person’s or a few people’s pockets—the goal is to educate physicians in the latest and best ways possible that are based on the peer-reviewed research or extensive physician experience. Hence, while physician instructors may be paid, they’re paid reimbursement for their time away from their practices. In addition, these “honoraria” are usually less than they could earn if they stayed home and saw patients. When doctors train as students, they know that while different companies may have drugs or devices they would like them to use, this doesn’t enter into the training. The course is agnostic to any one device or drug. After all, no one wants to believe that their doctor was trained only using device A, which may be inferior to device B, because the manufacturer of device A was a sponsor of the conference.
However, these past few years, the physician-education world has shifted. This shift is very prevalent in the stem cell world. We’ve seen more and more for-profit stem cell training companies springing up. These companies are more about maximizing profit, so they encourage sponsors and are generally “pay for play.” This means that if a manufacturer pays for sponsorship, he or she will get a paid physician surrogate who will “teach” the physicians at the course. As you might imagine, in this type of course, what’s taught is merely how fantastic the manufacturer’s drug or device is and how to use it. So gone is the analysis of the best way to treat the patient—instead replaced by an infomercial.
Some Examples of For-Profit Stem Cell Education: YouTube U
My 13-year-old son is an avid YouTube watcher. In fact, he’s taught himself to cook on YouTube. He can now bake a mean Hawaiian bread and a beautiful cake from scratch. However, most patients would be horrified to learn that their doctor may be doing the same with complex surgical procedures. After all, if my 13-year-old screws up, he just throws it all in the trash and starts over. Regrettably, we physicians usually only get one shot at doing it right.
This past week, the big dustup occurred on LinkedIn when a colleague sent me a marketing e-mail he had received from a company selling equipment to process fat stem cells. That group was now offering an online stem cell course. In fact, you could get two modules free if you acted now! It looked a bit like a bad joke or something you might see in The Onion, but it turned out to be true. The company really did expect a physician to learn procedures like bone marrow aspiration or liposuction (procedures used to harvest stem cells) by watching a video. What could go wrong? Let me explain.
Many other physicians and I teach for the Interventional Orthopedics Foundation. Several months ago, while teaching a hands-on bone marrow aspiration course, it was evident to me that an orthopedic surgeon from India who was in my group was struggling. In this hands-on class setting (versus the online kind), I began with a didactic lecture and then advanced to practice on cadavers. I was responsible for ensuring that the doctor could safely perform the procedure in real patients.
This orthopedic surgeon was awful. He just couldn’t seem to translate a lifetime of blind injections and arthroscopy to using imaging guidance to understand where the needle was located. It didn’t really matter what he tried to learn (we were also learning the simplest level-1 knee and hip injections), he was clearly traumatizing tissue left and right (lucky these were cadavers). By the end of the day, I knew I had only once choice—I had to fail him. What happened next I would never have predicted.
A few weeks after the course, I got a frantic e-mail. The surgeon I had failed asked if a peritoneal bleed was typical after a bone marrow aspiration (BMA). At first, I was shocked that this guy had the cajones to try a BMA after I failed him. After the shock of it all wore off, I realized what he had done wrong. He had managed to place the trocar completely through the pelvic bone and into some unsuspecting patient’s abdominal cavity! In the 9,500 stem cell cases we’re tracking in our registry, I had never seen a complication like this. Also, a large UK study of BMA complications that included more than 23,000 cases had never reported this type of complication. My only solace was that I had failed him, but that didn’t help the poor woman he injured.
While this was an orthopedic surgeon, think about what will happen when any physician, whether he or she has ever performed a procedure before or knows how to guide a needle under X-ray or ultrasound, can watch an online video and then go and perform a BMA. After all, this orthopedic surgeon severely injured a patient after several days of hands-on training. These physicians will have far-less experience with the procedure. Also, this new online course is open to nurse practitioners, physician assistants, naturopaths, and anyone else who can convince a licensing board that these procedures are within his or her scope of practice.
When my kids were little, they loved Build-A-Bear. You can pick out your bear, the sound box to install, the clothes, and accessories. So many choices for little minds to consider! This week, a for-profit, pay-for-play stem cell education company decided that if Build-A-Bear was ideal for 6-year-olds, why not give doctors the same options for stem cell training? They began offering discounted courses where the doctor can “Build Your Own Stem Cell Course.” The physician can pick and choose which parts of the education experience he or she wants. What could go wrong?
Physician education is a process much like building a skyscraper. You need the foundation training that allows you to understand which end is up. For stem cells, that’s usually what not to do. For example, if you decide to keep using the same anesthetic you’ve been using in your pain practice, like Marcaine, and expose that to stem cells, all of the cells you’ll be injecting will quickly die. After the basics are mastered, good medical education adds pieces brick by brick, but those bricks, just like in a building, need to go in order. For example, a stem cell procedure where you’re injecting into the bone is far more complicated than a simple joint injection using ultrasound. A complex joint procedure isn’t appropriate to teach to someone who has never injected a joint. So the mix-and-match Build-A-Bear stem cell course is a big problem.
What Does Non-Profit Stem Cell Education Look Like?As I said, I teach for the IOF, a real nonprofit that educates doctors in this area. First, it only accepts physicians for training and turns away physician extenders and naturopaths. Second, it will only take doctors who have specific skill sets that would allow them to understand how to place needles using ultrasound and fluoroscopy. Third, the courses are all hands-on with cadaver training. Fourth, the classes are highly structured on the exact skills that must be mastered. This is procedure by procedure, and the courses cover almost 100 different minimally invasive stem cell and platelet skills by body part organized into three levels. The easy stuff comes first, and the skills get harder to master as the student progresses. Finally, there’s a real pass-fail system. So not only is there a written test but there’s also a check by the instructor, who is encouraged to fail any physician who doesn’t have the skills to safely perform the procedures being taught.
The upshot? Stem cell education is taking some dark and scary turns. As a patient, you need to protect yourself and ensure that the doctor who wants to take or place stem cells actually has the training to do so. This is more than a YouTube U or Build-A-Bear course! Caveat emptor!