Free-access open-source e-learning in comprehensive neurosurgery skills training
Correspondence Address: Source of Support: Research projects funded by extramural grants from- 1. Indian Council of Medical Research (ICMR), Ministry of Health and Family Welfare, Govt. of India. 2. Dept. of Biotechnology (DBT), Ministry of Science and Technology, Govt. of India and BMBF, Germany- Indo-German Collaboration 3. Dept. of Health Research (DHR), Indian Council of Medical Research (ICMR), Ministry of Health and Family Welfare, Govt. of India, Conflict of Interest: None DOI: 10.4103/0028-3886.141208
Source of Support: Research projects funded by extramural grants from- 1. Indian Council of Medical Research (ICMR), Ministry of Health and Family Welfare, Govt. of India. 2. Dept. of Biotechnology (DBT), Ministry of Science and Technology, Govt. of India and BMBF, Germany- Indo-German Collaboration 3. Dept. of Health Research (DHR), Indian Council of Medical Research (ICMR), Ministry of Health and Family Welfare, Govt. of India, Conflict of Interest: None
Background: Since the end of last century, technology has taken a front seat in dispersion of medical education. Advancements of technology in neurosurgery and traditional training methods are now being challenged by legal and ethical concerns of patient safety, resident work-hour restriction and cost of operating-room time. To supplement the existing neurosurgery education pattern, various e-learning platforms are introduced as structured, interactive learning system. Materials and Methods: This study focuses on the concept, formulation, development and impact of web based learning platforms dedicated to neurosurgery discipline to disseminate education, supplement surgical knowledge and improve skills of neurosurgeons. 'Neurosurgery Education and Training School (NETS), e-learning platform' has integration of web-based technologies like 'Content Management System' for organizing the education material and 'Learning Management System' for updating neurosurgeons. NETS discussion forum networks neurosurgeons, neuroscientists and neuro-technologists across the globe facilitating collaborative translational research. Results: Multi-authored neurosurgical e-learning material supplements the deficiencies of regular time-bound education. Interactive open-source, global, free-access e-learning platform of NETS has around 1) 425 visitors/month from 73 countries; ratio of new visitors to returning visitors 42.3; 57.7 (2); 64,380 views from 190 subscribers for surgical videos, 3-D animation, graphics based training modules (3); average 402 views per post. Conclusion: The e-Learning platforms provide updated educational content that make them "quick, surf, find and extract" resources. e-Learning tools like web-based education, social interactive platform and question-answer forum will save unnecessary expenditure of time and travel of neurosurgeons seeking knowledge. The need for free access platforms is more pronounced for the neurosurgeons and patients in developing nations.
Keywords: E-Learning, education, internet, neurosurgery, open-source, skills training
Traditional training in surgical branches is mainly based on the 'Halstedian apprenticeship method'. But now, teaching by this method seems inadequate due to lack of time for the students and the educators. Institutions in developing nations lack facilities for effectual education, standardized training curriculum and in-lab skills training. The utilization of rapidly growing web-based technology will tide over the time and place constraint. A holistic platform for the neurosurgeons (aspiring, practicing and experts) to interact and improve their knowledge with the help of web-based technologies is the need of the hour.
E-Learning is described as a learning method in which information technologies and learning processes are integrated using internet.  Developments in information and communication technologies have catalyzed fundamental changes in medical education.  Remote accessibility, sharing of information and communication has expanded our capabilities; almost everything is just a click away. The present day classrooms are transforming into "virtual learning environment" with less requirement of real time human interaction [Figure 1]. Such a change benefits itinerant rural and urban practitioners.  The greatest barriers in using web-based technology are self-discipline of the learner, effective time management and knowledge of basic computer skills. ,
In the present study, we highlight development and utility of multi-authored, interactive, global, free-access, open source e-learning platform in neurosurgery with integration of web-based technologies and tele-education. We also substantiate the benefits of involving allied medical (neuro-anatomy, neuro-pathology, forensic medicine etc.) and technology related specialties (computer science engineering, biomedical engineering, applied mechanics and mechanical engineering) to collaborate in education and translational research to make "Neuro-technology" deliverable. This also aims at effective use of technology to change neurosurgical education from a traditional apprenticeship based summative system to a formative evaluation based system with incorporation of skills training. The same could be very well replicated and adapted to other medical and surgical sub-specialties.
A simple search on internet for neurosurgery education and e-learning shows multiple platforms of various neurosurgical societies and universities. They have regularly updated content and educational material over these interactive platforms. Most of these sites are either paid subscription or provide a restricted access to the university members. This places a constraint for effective transfer of web-based knowledge to resource stricken developing nations where lack of availability of knowledge is contributing to deficiencies in training. This led to the foundation of "Neurosurgery Education and Training School (NETS)" e-learning platform by creating the 'Free-access, online, multi-authored, multi-institutional database' providing connectivity to neurosurgeons across the globe.
Integration of web-based technologies
The integration of web-based technologies provides collection of tools and functions, to support teaching and learning processes like course management, online group discussion, assignments and course evaluation. ,
'Content Management System (CMS)' is a web-based technology for organization and dynamic delivery of the contents and 'Learning Management System (LMS)' provide tools for administration and scheduling of learning activities. A common platform integrated with CMS and LMS along with dynamic interaction with peer communities (social interactive platform) and dealing with neurosurgical education based queries (question-answer forum) has been developed [Figure 1].
For the development and smooth management of e-learning platform, we have incorporated Joomla 3.2.x (Open Source Matters, Inc. New York States, USA) for CMS and Modular Object-Oriented Dynamic Learning Environment (Moodle) 2.5.x (Martin Dougiamas, Moodle Trust, Perth, Australia) for LMS. These are open-source systems with excellent support from backbone community. They provide frame-work for e-learning architecture, facilitate interoperability, content packaging, content management, learning object meta-data and course sequencing.
'Sharing Content Object Reference Model (SCORM)' is the nuts and bolts for the web-based learning that provides a collection of standards and specifications. It describes how contents communicate with backend LMS through 'SCORM Run Time', interoperable course packaging, course description in a consistent way and sequencing the course on the learner based interaction.  We have used Adobe Captivate (Adobe Systems Incorporated, LA, USA), 3D Max, Maya (Autodesk, inc. San Rafael, CA, USA) for creating interactive virtual medical simulations . Educational material is organized on the IIT-Delhi Domain (http://aiimsnets.cse.iitd.ac.in, http://www.aiimsnets.org) on the proposed modular approaches of 'Neurosurgery Skills Training Curriculum'. ,
Establishment of an e-learning platform is a team effort, which involves clinicians, content managers and network specialists. NETS e-learning platform is a composite effort of 'Department of Neurosurgery, AIIMS, New Delhi' and 'Department of Computer Science and Engineering, Indian Institute of Technology, Delhi (IIT-D). The human resources involved are the content providers, data operators, system managers, 3D animation and graphic designers and the supporting management staff. A team of neurosurgeons, technologists and application specialists integrate the contents at the "Neurosurgery Animation, Graphics and Video Editing Laboratory (NAGVEL) [Figure 2]. An advisory board of faculty comprising of neurosurgeons from India and Germany, and technologists from IIT-Delhi evaluate the contents for its quality and multimedia presentations.
Basic formulation and content description
NETS e-learning platform contains educational material useful for the neurosurgery residents and practitioners [Table 1] and [Figure 3]:
• Downloadable presentations: 344 seminars (.ppt and.pdf) for basic neurosurgery discipline and allied sub specialties (vascular, skull-base, pediatrics, neuro-oncology, functional, spine, peripheral nerve, neuro-trauma), and recent advances in the field
• Operative videos: 26 edited operative videos describing the standard microscopic and endoscopic procedures in neurosurgery for various pathologies illustrating the surgical steps
• Archived didactic lectures videos: 37 videos addressing various task based and procedure based sessions (addressing microsuturing skills training, neuroendoscopic procedures and high speed drilling under magnification with how I do it sessions and panel discussion)
• 3-Dimensional (3D) animation based videos (n = 72) addressing:
• Social networking: In order to provide interaction with peer community and masters in the field, there is a discussion forum at www.facebook.com/aiimsnets. It addresses queries related to neurosurgery, neuropathology, neuro-oncology, neuro-radiology and neuro-technology
• Question and answer (Q and A) Forum: e-Learning platform also facilitates provisions for open discussion on case based clinical scenarios, which are acquired from indoor and outdoor patients who present themselves to the neurosurgery department. Interesting cases are discussed with a brief overview of their history, examination findings and radiographic imaging. In the same way, it also facilitates case based learning in which a clinical situation is explained and visitors provide their opinion on diagnosis, intervention required and management of possible complications. Any visitor can post a query/case and NETS faculty and other visitors of the platform provide the answer. In order to maintain quality and authenticity of the data, all discussions are evaluated by the content organizers prior to uploading it on the website. Special attention is considered to maintain the privacy of the patient and relevant data [Figure 3] and [Table 1]
• Tele-education: NETS also conducts tele-education sessions for neurosurgeons in India and Germany. These sessions (lectures, cadaveric demonstrations, live surgery) allow trainees to enjoy all capabilities and convenience of a real classroom interaction in a cost-effective way.
The future prospects are development of open source Moodle-based restructuring of the e-learning system for incorporation of a database of 'Computer Based Tests (CBT)' and 'Internet Based Tests (iBT)', to facilitate self-evaluation modules. At present, it provides only asynchronous learning material. Furthermore, it also aims to provide synchronous learning by organizing webinars, assignments and online certifications with free access to the trainees across the globe.
The need for a global free access e-learning platform can be visualized from the results obtained on the analysis of our elementary website and discussion forum [Table 2]. The database containing materials dedicated to neurosurgery providing education, surgical know-how and nuances is prerequisite for neurosurgery-training curriculum. The essence of learning is well promulgated with the help of discussion forum that leads to interaction with peer community and experts.
Over a period of one year we had 5226 visitors with 57% of repeat visitors. As the ratio of neurosurgeons to the population is quiet less, the number of visits is comparatively high from the community. The acceptance and usefulness of the content is evident from the returning visits and 64,380 views from 190 subscribers for surgical videos, 3-D animation, graphics-based training modules. The discussion forum had 968 members from 45 nations proving its global access with majority of the users were from developing nations of Asia and Africa. [Table 2].
'Google Analytics' shows that most of the users used desktops and laptops as primary tool. About 10% of the visitors used tablets and cell phones for accessing the contents. Effective content management and user-friendly interface translates into effectual learning. So, it highlights the need for responsive design of the platform for better deliverability.
Medical fraternity has been confronting the challenge of keeping pace with advances in technology of last century. Internet has become an integral part of our lives completely revolutionizing our life style. Vast medical literature and its availability on web have led to creation of several democratizing tools such as online libraries, blogs and social networking forums etc.  At present, the query before us is to find the way for efficient use of web-based technology.
Potential of web-based education systems in enhancing neurosurgery training
E-Learning is regarded as a creative implementation for delivery of knowledge and skills in various disciplines to large number of scattered student communities.  These technologies offer learners' control over content, learning sequence, pace, time, and even media, making it a "quick surf, find and extract" platform, allowing them to meet their personal learning objectives. ,,, Neurosurgeons can collaborate, discuss and contribute to the process of learning, and educators become facilitators of learning process rather than deliverers, while students become participants rather than listeners. ,,,,
Existing neurosurgery-training curriculum is facing problems of having non-standardized course structures, lengthy course durations, large expenditure and observer biases. The e-learning should not be regarded as a replacement for traditional instructor-led/hands-on skills training but as a supplement to it, forming part of a blended-learning strategy. It has changed the concept of teaching to 'self-learning' to be precise. At the same time, we wish to gestate various research opportunities for faculty as well as students working in neurosurgery but also technologists inclined towards research in related areas.
Spectrum of online educational content
The educational content available to the students through e-learning is classified as synchronous and asynchronous education. The synchronous contents are virtual "traditional" teaching involving real time interaction of the knowledge imparters and seekers, thus working together at the same time from different places. The benefit of these sessions can be enhanced if they are for groups of students thus facilitating discussion and diversity in thought. In the more popular asynchronous learning, the teaching and learning takes place at different places and time.
Contents of synchronous educational system
Synchronous learning environment helps to motivate the learner, encourages cooperation and group recognition, real time interaction and pressure of pacing. The available formats are:
Contents of asynchronous educational system
Asynchronous education provides the advantages of desirable flexibility (time and place), learning environment and cost effectiveness. The real beneficiaries are the neurosurgery residents. This learning is associated with better cognition and good outcome. Unlike synchronous learning, the motivation is poor due to lack of "media naturalness". ,
Contemporary e-Learning platforms for neurosurgery education
Since the time Pareras  pointed out the potential of internet in neurosurgery learning and information dissemination, there have been many websites to cater to the knowledge quest of neurosurgeons worldwide [Table 3]. The websites aiming to enhance the training program need to have both synchronous and asynchronous learning content. Only a few websites have both types of contents. The Congress of Neurological Surgeons (CNS) University of Neurosurgery and American Association of Neurological Surgeons (AANS) educational websites lead by their comprehensive content. Their webinars are of benefit to residents and practicing neurosurgeons. Modular courses by AANS, is a necessary step that needs to be emulated by other sites with same aspirations. University of California, Los Angeles (UCLA) has a good video library covering many relevant topics.
Limitations of current format
Dividend Global Reach : User statistics proves the dominance of developed countries in utilizing these potential websites, whereas the developing countries have not fully benefitted from these tools.  Apart from resource limitations, there are other barriers as well, such as poor infrastructure, lack of interest in the governing bodies, irregular internet access, and language and cultural barriers to name a few.
Lack of organized content
Structured, formulated and validated modular courses are the need of the hour. The courses should be topic based to provide continuity and flow for effectual knowledge transfer. e-Learning platforms should not be looked upon as mere online libraries, but they need to be interactive, reward based websites with virtual classroom facilities. Few of such content are available for the society members of leading neurosurgical societies such as AANS, CNS and e-Brain etc., Their restricted access to knowledge seekers of developing nations proves to be a limiting factor. It would be encouraging if institutions of developed nations provide their educational resources in an accessible format for free use by others around the globe.
Quality of the content
Contemporary internet use has rapidly embraced open-source principles in which one group makes its work freely available for use by others. The inherent risk of this format is the unreliability of the content due to lack of peer review.
Need for lite versions for hand held devices
Modern e-learning tools are becoming smarter and more interactive. At the same time, they are also more data- and processor-demanding. With growing users of smartphone devices and tablets, the content should be easily downloadable to facilitate quick surfing of their content and good graphic design for appropriate visualization. Lite versions will be of great use to developing nations with weaker bandwidth. 
Establishment and maintenance of an e-learning platform demands a significant financial investment. This investment includes establishment of separate housing for 'Central Repository system', purchase of high-end computer software, regular purchase and upgradation of required software, salary of the data operators, 3D animation graphic designers, and supporting staff [Figure 2] and [Table 4]. Industrial support is desired for research purposes to provide required hardware and software at subsidized rates for training and education. Several funding agencies such as Indian Council of Medical Research (ICMR), Department of Science and Technology (DST), Department of Biotechnology (DBT) and Department of Health Resources (DHR) etc., may assist in establishment of e-learning platform.
We believe that web-based technology is the key to a profound revolution in learning. But, any technology is a tool and not a strategy. In such a scenario, it becomes important to provide a global platform to neurosurgeons, where they can refine their knowledge and learn about the latest technologies and techniques. As medical education is an ever-changing science, some concepts will become obsolete in the standard textbooks; but an e-learning platform does not suffer from stagnation, as it gets regularly updated. It is important to have such potent educational mode be "free access" to further their benefits to developing nations. The future of technological advancements is beyond our imagination, and we should be ready to acclimatize to them. The untapped potential of e-learning platforms is monitoring of effectualness of residency program by governing and sponsoring bodies by direct communication with students. These websites can also promote research discussions for students to bridge the gap among universities, countries and other disciplines. With this paper, we strongly advocate the adoption of dedicated e-based, learning management platform for supplementing training and education in all the branches of medicine and surgery.
We would like to acknowledge the efforts of technical and application specialists from Neurosurgery Skills Training Facility, Neurosurgery Education and Training School, All India Institute of Medical Sciences, New Delhi, India. We thank Mr. Subhas Bora, Mr. Ajab Singh, Mr. Ram Niwas, Mr. Shashi Shekhar Kumar, Mr. Trivendra Kumar Yadav, Mr. Aakash Sharma, Mr. Gaurav Bhardwaj, Mr. Suresh Kothari, Mr. Vikram Singh, Mr. Satish Kumar for their untiring valuable support. We thank the funding agencies Department of Science and Technology (DST), Department of Biotechnology (DBT) and Department of Health Resources (DHR) for the infrastructure of NSTF. We thank Indian Council of Medical Research (ICMR) for funding the development of e-learning platform (Task force project No: 5/4-5/Neuro/TF/2011-NCD-I (2012-2015)) and Department of Health Resources (DHR) for funding the development of 3D modules for e-learning platform: DHR/Plan Scheme/GIA/5/2012 (2012-2013).
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4]