Ergonomic evaluation of a mechanical anastomotic

ORIGINAL ARTICLE

Ergonomic evaluation of a mechanical anastomotic stapler used by Japanese surgeons

Emiko Kono ?Mitsunori Tada ?Makiko Kouchi ?Yui Endo ?Yasuko Tomizawa ?Tomoko Matsuo ?Sachiyo Nomura

Received:12December 2012/Accepted:13May 2013/Published online:27July 2013óThe Author(s)2013.This article is published with open access at https://www.wendangku.net/doc/5a4045872.html,

Abstract

Purpose The satisfaction rating of currently available mechanical staplers for Japanese surgeons with small hands is low.To identify the issue,we examined the relationship of hand dimensions and grip force with the operation force of a mechanical circular stapler.

Methods Hand dimensions and grip force were measured in 113Japanese surgeons (52men and 61women).We then evaluated the relationship between grip width and the operation force required to push the lever of the stapler,at three points on the lever,using a digital force gauge.

Results The optimal grip width of the dominant hand was 62.5±8.5mm for men and 55.5±5.9mm for women (p \0.001).The maximum grip force of the dominant

hand was 44.2±6.1kg for men and 29.7±4.5kg for women (p \0.001)and the maximum operation force required to push the lever 7.0,45.0,and 73.0mm from the end of the lever was 21.8,28.6,and 42.4kg,respectively.Conclusions To our knowledge,this is the ?rst ergo-nomic study of a surgical stapler to be conducted in Asia.Firing the stapler by gripping the proximal side of the lever is physically impossible for most Japanese women sur-geons since the required operation force exceeds the maximum grip force,which probably accounts for the stress perceived by these women.

Keywords Ergonometric áMechanical anastomotic stapler áWomen Surgeons áMaximum grip force áHand length

Introduction

In 1958,Professor Mine [1]developed and introduced the concept of a mechanical circular stapler in Japan.This stapler was used https://www.wendangku.net/doc/5a4045872.html,ter,Androsovn [2]in Russia simpli?ed the mechanism of the stapler and developed the ‘‘PSK-25’’,known as the ‘‘Suture Gun’’.Most currently available mechanical anastomotic staplers are made in the United States and Europe.Among the mechanical anasto-motic staplers,DST-EEA (Covidien,Mans?eld,MA,USA)and CDH (Ethicon Co.Ethicon Endo-Surgery,Cincinnati,Ohio,USA)do not have handle size variation.This creates an ergonomic issue for Japanese surgeons who have relatively smaller hand dimensions and weaker grip force than surgeons from North American and European countries.

A survey on the ergonomic satisfaction of the currently available mechanical staplers among members of the

E.Kono

Department of Surgery,Osaka Kosei-Nenkin Hospital,Osaka,Japan

E.Kono áY.Tomizawa áT.Matsuo áS.Nomura Japan Association of Women Surgeons,Tokyo,Japan M.Tada áM.Kouchi áY.Endo

Digital Human Research Center,National Institute of Advanced Industrial Science and Technology,Tokyo,Japan Y.Tomizawa (&)

Department of Cardiovascular Surgery,Tokyo Women’s Medical University,8-1Kawada Shinjuku,Tokyo 162-8666,Japan

e-mail:4CRNRY@hij.twmu.ac.jp

T.Matsuo

Sales Planning and Project Management,Surgical Solutions,Covidien Japan,Tokyo,Japan

S.Nomura

Department of Gastrointestinal Surgery,Graduate School of Medicine,The University of Tokyo,Tokyo,Japan

Surg Today (2014)44:1040–1047DOI 10.1007/s00595-013-0666-6

Japanese Society of Gastroenterological Surgery(JSGS) clearly demonstrated that Japanese surgeons with small hands experience dif?culties with using the staplers[3].To identify the problems,we examined the relationship of hand dimensions and grip force with the operation force required to operate the mechanical stapler.

Materials and methods

Subjects

During the2days of the66th General Meeting of the Japa-nese Society of Gastroenterological Surgery held in July2011 in Nagoya,all the men and women surgeons who were in the conference hall were asked to participate in this study.The volunteers who agreed to participate were given a brief explanation of the objectives and procedures and all signed an informed consent form prior to the experiment.A total of113 volunteers(52men and61women)participated in this study.

Background information on the subjects,including gen-der,age,height,weight,and dominant hand,was collected by a self-report questionnaire.The average ages of the men and the women were38.9±9.3and33.4±6.0years,respec-tively.Means of the self-reported height and weight were

173.3cm and70.5kg for the men and159.3cm and52.8kg for the women,respectively.Ethical approval for this study was obtained from the ethics committee of the Japanese Society of Gastroenterological Surgery on July5,2011.

Measurement of hand dimensions

We measured the hand length from the wrist crease in95 subjects,using a digital caliper(CDC-P20PMX,Mitutoyo Co.,Kanagawa)with the tips of the jaws modi?ed for measuring living people.The hand length of the remaining 18men was measured from an image of the right palm scanned with a?atbed scanner(GT7300U,Seiko Epson Corp.,Nagano)and in-house image processing software (Hand Matrix,Digital Human Research Center,Tokyo) retrieved the hand dimensions from the palmar image.The distance from the center of the most distal wrist crease to the tip of the middle?nger was measured as the hand length for the present study(Fig.1a).

The signi?cance of gender differences in hand dimen-sions was tested using a t test with a signi?cance level of5%.Statistical software(StatView Ver.5.0,Abacus Corporation,California)was used for this purpose. Measurement of grip force

Five grip dynamometers(T.K.K5401;Takei Scienti?c Instruments Co.,Ltd.Tokyo)were used for measuring the grip force at various grip widths.The grip widths of the dynamometers were set at40.0,47.5,55.0,62.5,and 70.0mm.For women,the grip force was measured from the narrowest grip width in ascending order.For men,the grip force was measured in the reverse order,from the widest to the narrowest.For both women and men,we measured the right hand?rst,and then the left hand.The optimal grip width and the maximum grip force were computed from these measurements.

Measurement of operation force

The operation force was measured at the Digital Human Research Center,National Institute of Advanced Industrial Science and Technology,Japan,using a digital force gauge (FGPX-50,Nidec-Shimpo Co.,Kyoto)and a vertical-type motorized test stand(FGS-100VC,Nidec-Shimpo Co., Kyoto;Fig.2a).The gripper of a mechanical anastomotic circular stapler(DST-EEA28,Covidien,Mans?eld,MA, USA)was clamped in two vices and?xed to the base of the stand so that the longitudinal axis of the gripper was parallel and the working plane of the lever was perpen-dicular to the base.Although the lever normally faces downward during surgery,the stapler was positioned with the lever facing upward in this measurement in order to simplify the experimental setup.

A cylindrical indenter,10.0mm in diameter and

20.0mm in height,was attached to the detector of

the

force gauge.The indenter was made of engineering plastic(Delrin,Du Pont,DE,USA)and a?llet,5.0mm in radius,was introduced in the bottom face of the indenter to minimize friction between the lever and the indenter.The indenter pushed the lever at three different points:at both ends of the anti-slip rubber(approxi-mately7.0and73.0mm from the end of the lever)and at the mid-point of the anti-slip rubber(approximately 45.0mm from the end of the lever),at100.0mm/min until the lever reached the full stroke position.Since the lever turned around at the axis of rotation,the contact point between the indenter and the lever slid closer to the axis as the indentation depth increased(Fig.2b).The sliding distances were approximately25.0,20.0,and 15.0mm when the initial contact point was7.0,45.0, and73.0mm,respectively,from the end of the lever. The initial grip width was wider when the pushing point was closer to the end of the lever,while the full stroke grip width was wider when the pushing point was closer to the pivot of the lever(Fig.2b).

To test the operation force with or without staples,two transparent silicone rubber sheets,1.0-mm thick,were used as a test sample for measurement,since it is a homoge-neous solid material with good reproducibility,and for visual con?rmation of successful staple?ring and fastening by the staples.After the initial measurement,additional measurements were repeated?ve times using the same device without staples and sheets(blank shot),to test for reproducibility.The indentation depth of the indenter and corresponding pushing force(operation force)were sam-pled at50Hz and transferred to an Excel sheet running on a host computer(Let’s Note CF-Y2DW1AXR,Panasonic Co.,Osaka)through the USB port using an Excel plug-in (FGT-VC,Nidec-Shimpo Co.,Kyoto).

Optimal grip width and maximum grip force

The optimal grip width was de?ned as the grip width at which the maximum grip force was achieved.From the grip force measured under?ve different grip width con-ditions,the optimal grip width and the maximum grip force of each individual were calculated using a method pro-posed by Ruiz et al.[4–6].For this purpose,a second-order polynomial regression curve was computed for each indi-vidual using the grip width as the independent variable and the grip force as the dependent variable.

If the second-order polynomial curve was a convex upward function and the local maximum was within the range of40.0–70.0mm,the maximum grip force was taken as the local maximum of the regression curve,and the optimal grip width as the grip width at maximum grip force.If either the local maximum was out of the above range or the regression curve was a convex downward function,then the maximum grip force was taken as the highest value of the?ve grip force measurements and the optimal grip width,as the corresponding grip width.

The signi?cance of gender and laterality differences in optimal grip width and maximum grip force was tested using a t test at a signi?cance level of5%.Statistical software(SciPy Ver.0.10,Enthought Inc.,TX,USA)was used for this purpose.

Mean and95%con?dence interval of the grip force The mean and standard deviation of the grip force for each grip width were computed from the measured grip force of the dominant hand of the men and women surgeons.The95% con?dence intervals were then obtained from the computed mean and standard deviation for each grip width.To examine the relationship between grip width and grip force,second-order polynomial regression curves were computed for the lower and upper limits of the95%con?dence interval for

a

b

Fig.2View of the system for measurement of the operation force (a)and schematic presentation of the pushing points on the lever(b). a1digital force gauge,2vertical-type motorized test stand, 3mechanical anastomotic stapler,4host PC for recording,5indenter.

b Three different pushing points(7.0,45.0and73.0mm from the end of the lever)on the lever,and positions of the lever in the initial and full stroke conditions

both genders,using the grip width as the independent variable and the grip force as the dependent variable.

Grip width and operation force of the mechanical anastomotic stapler

The relationship between grip width and the operation force required for operating the mechanical anastomotic stapler at each pushing point was evaluated by subtracting the measured indentation depth at each time step from the initial grip width.To evaluate the possible relationship between grip width and the operation force required,the lower and upper limits of the operation force were com-puted from the curves representing the relationship between the grip width and the operation force.

Results

Hand dimensions

All subjects completed the questionnaire and measurements satisfactorily.The self-reported heights(mean±SD)and weights were173.0±5.3and159.3±4.8cm and 69.8±7.1and52.8±7.6kg for the men and women, respectively(both p\0.001).The hand length was 184.1±7.0mm for the men and169.5±6.4mm for the women(p\0.001).There was a signi?cant correlation between hand length and height for the combined data of the men and women(r=0.86,p\0.001;Fig.3).

Optimal grip width,maximum grip force,and95%

con?dence interval of grip force

Measurements were completed satisfactorily for all the subjects.The optimal grip width(mean±SD)was

62.5±8.5mm for the dominant hand of the men,

63.5±6.9mm for the non-dominant hand of the men,

55.5±5.9mm for the dominant hand of the women,and 54.1±5.9mm for the non-dominant hand of the women (Fig.4).The men had wider optimal grip width than the women for both the dominant and non-dominant hands (p\0.001).

The maximum grip force(mean±SD)was 44.2±6.1kg for the dominant hand of the men, 41.8±5.7kg for the non-dominant hand of the men, 29.7±4.5kg for the dominant hand of the women,and 27.2±4.8kg for the non-dominant hand of the women (Fig.5).The men had greater maximum grip force than the women,for both the dominant and non-dominant hands (p\0.001).Furthermore,the dominant hand had greater maximum grip force than the non-dominant hand for both the men(p\0.05)and the women(p\0.01).

Figure6shows the95%con?dence intervals of the grip force for the men and women at different grip widths.Grip forces were greater in the men than in the women for all grip widths(p\0.001;data not shown).For each grip width,the average grip force for the men was greater than the upper limit of the95%con?dence interval of the grip force for the women.

Operation force

At all pushing points,the silicone sheets were successfully punched and stapled by the mechanical anastomotic sta-pler,as con?rmed by visual inspection.Figure7shows the relationship between the displacement of the indenter and operation force at three different pushing points.

With

staples,the curves of the operation force showed three signi?cant peaks from mechanical interactions among the staples,punch,and the anvil head.However,under (blank shot),no peaks were observed.The magnitudes (operation force)and the horizontal positions (displacement distance)of the peaks differed depending on the pushing points.As the pushing point approached the axis,the initial grip width became narrower (119.0,104.0,and 93.0mm for the 7.0-,45.0-,and 73.0-mm pushing points,respectively),while the grip width at full stroke became wider (38.6,40.9,and 46.6mm,respectively;Fig.2b).Also,as the pushing point approached the axis,both the maximum and full stroke operation forces increased.The line connecting the peaks was de?ned as the maximum line (Fig.8,

triangles),being 21.8,28.6,and 42.4kg for the 7.0-,45.0-,and 73.0-mm pushing points.The differences in magnitude of the operation force as shown by the shaded area enclosed by the curves provide the upper and lower limits of the operation force (Fig.8).

When an anastomotic device is used clinically,the hand comes in contact with the surface of the lever;however,when the hand exerts pressure on the lever,the center of pressure distribution can be regarded as the center of the operation force.The relationship between the grip width and operation force is thus approximated by a trajectory within the shaded area,starting from a point on the

initial

Fig.8Relationship between the grip width and the operation force at the three different pushing points (7.0,45.0and 73.0mm from the end of the lever)

line(broken line),passing a point on the maximum line (dash line),then ending at a point on the full stroke line (solid line;Fig.8).

Discussion

Problems and possible solutions

To our knowledge,this is the?rst Asian ergonomic study on a disposable mechanical anastomotic stapler imported from the United States.During gastroenterological surgery, surgeons are required to perform anastomosis successfully and securely,but this procedure is perceived to be stressful for surgeons with small hands,especially women[3].This study is signi?cant because the number of women surgeons in Japan is increasing[7,8]and the physical characteristics of the hands of men and women differ:women have shorter hand length,narrower optimal grip width,and lower maximum grip force than men.

The operation force required to push the lever to full stroke position differs according on the pushing point, since the lever has a rotation axis,and the length of the arm

(distance from the rotation axis to the pushing point)helps to reduce the operation force required;however,it increases the total distance to move from the initial posi-tion to the full stroke position.A combination of these factors yields high and low limits of the operation force. The relationship between the grip force of the subjects and the operation force required to push the lever shows why there is ergonomic incongruity between the hand capability of Japanese women surgeons and the device properties (Fig.9).For men surgeons,only the upper half of the maximum lies within the95%con?dence interval of the grip force for men,and the lower half of the maximum line is below the lower limit of grip force.Men even with the weakest grip force are able to?re the anastomotic device because the trajectories of operation force when the lever is pushed in the middle(trajectory1in Fig.9)and at the distal end of the lever(trajectory3in Fig.9)are below the lower limit of their grip force.Conversely,for women, the upper part of the maximum line extends beyond the upper limit of the95%con?dence interval of the grip force for women,and the lowest point of the maximum line is greater than the lower limit of their grip force.

Some women surgeons have learned from experience to grip the proximal end of the lever with the non-dominant hand during the?rst half of the operation(trajectory2in Fig.9)and then gradually move the dominant hand to grip the distal end of the lever(trajectory3in Fig.9)in the latter half of the operation.These maneuvers effectively result in a trajectory following the lower limit of the operation force.The most important implication from Fig.9is that women surgeons with the lowest grip force are not capable of operating the mechanical anastomotic device with only their dominant hand even with this strategy,since the lowest operation force is greater than the lower limit of the95%con?dence interval from around the maximum point to the full stroke point.Moreover, since the95%con?dence interval of the grip force is lower in women than in men,the safety margin of the grip force against the operation force is lower in women,lim-iting their con?dence in operating mechanical anastomotic devices.This may be the main reason for the stress felt by women surgeons when operating the mechanical stapler.

Global variations in hand size

The statistics of hand length are listed in ISO7250-2 (2010)[9].In this document,hand length is de?ned as the distance from a line connecting the radial stylion(the most distal point of the styloid process of the radius)and the ulnar stylion(the most distal point of the styloid process of the ulna)on the palmar side to the tip of the middle?nger (Fig.1b).The average hand length was189.6mm for Japanese men and175.4mm for Japanese women vs. 202.0mm for American men and181.7mm for American women[9].The mean hand length for the Japanese people documented in ISO7250-2is longer than that in the present study,due to the difference in de?nition of hand length as the line connecting the stylion and ulnar stylion is more proximal than the most distal wrist crease used in this

study.

The coef?cient of correlation between hand length and height is in?uenced by the de?nition of hand length,body height,and the study population.According to Japanese data on young adults,based on measurements by experts, the coef?cients of correlation ranged from0.70to0.75.In the present paper,correlation was computed from the measured hand length and self-reported height,with resulting coef?cients of correlation ranging from0.64to 0.69.Khanapurkar and Radke[10]reported that the coef-?cient of correlations for young Indian people aged19-to 22-year old were0.62for men and0.65for women.All these data show relatively high positive correlations; therefore,we speculate that this tendency holds at least for Asian populations.The hand length of Japanese people is shorter than that of American people.According to the investigation of Berguer and Hreljac[11],the glove size is 7.5or larger for23.5%of men surgeons,and7or larger for19%of women surgeons in the United States.On the other hand,only1%of women surgeons in Japan wear gloves of size7or larger,whereas99%wear gloves of size6.5or smaller[3].The average grip force was reported to be62.2kg for the dominant hand and58.5kg for the non-dominant hand of American men surgeons,and 36.7kg for the dominant hand and34.4kg for the non-dominant hand of women surgeons[12].The hand sizes in other Asian countries are close to those in Japan.The mean hand length is185.8and174.7mm in South Korean men and women[9],respectively,and183and171mm in Chinese men and women,respectively[13].Considering the similarity in hand dimensions,the problems in handling anastomotic staplers experienced by Japanese surgeons are also likely to be experienced by surgeons in other Asian countries.Ultimately,all surgeons should be able to operate these surgical devices easily and comfortably regardless of hand dimension and grip force.Thus,surgical devices should be developed based on the guidelines of ergonomics[14–17].

Limitations of the study

This study has some limitations:?rst,the ratio of the male and female subjects was not identical to the actual gender ratio in the Japanese clinical situation,since we inten-tionally recruited women surgeons;second,the maximum grip force may have been over-evaluated because the hand dynamometer was easier to grasp than the stapler in the clinical setting;third,the?ring force of the mechanical anastomotic stapler may have been under-or over-esti-mated using silicone sheets as test material because of the difference in resistance between silicone sheets and fresh gut tissues;and fourth,only one product from one company was examined.A similar experiment is necessary to examine multiple devices from other companies.Conclusions

Women surgeons have shorter hand length and weaker grip force than men surgeons in Japan.Thus,?ring the circular stapler by gripping the proximal side of the lever is phys-ically impossible for most of Japanese women surgeons since the required operation force exceeds the maximum grip force for a given grip width.

Acknowledgments We are grateful to Professor Shu-ichi Miya-gawa,President of the66th General Meeting of the Japanese Society of Gastroenterological Surgery,for his help.We also thank Dr.Teresa Nakatani for her useful discussions.This study was supported by a Grant-in-Aid for Scienti?c Research(C)No.23510353from the Japan Society for the Promotion of Science.

Con?ict of interest E.Kono,M.Tada,M.Kouchi,Y.Endo, S.Nomura and Y.Tomizawa have no con?icts of interest to declare. T.Matsuo is an employee of Covidien Japan,Inc.

Open Access This article is distributed under the terms of the Creative Commons Attribution License which permits any use,dis-tribution,and reproduction in any medium,provided the original author(s)and the source are credited.

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从实践的角度探讨在日语教学中多媒体课件的应用

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第10课 日本的季节 日本的一年有春、夏、秋、冬四个季节。 3月、4月和5月这三个月是春季。春季是个暖和的好季节。桃花、樱花等花儿开得很美。人们在4月去赏花。 6月到8月是夏季。夏季非常闷热。人们去北海道旅游。7月和8月是暑假，年轻人去海边或山上。也有很多人去攀登富士山。富士山是日本最高的山。 9月、10月和11月这3个月是秋季。秋季很凉爽，晴朗的日子较多。苹果、桔子等许多水果在这个季节成熟。 12月到2月是冬季。日本的南部冬天不太冷。北部非常冷，下很多雪。去年冬天东京也很冷。今年大概不会那么冷吧。如果冷的话，人们就使用暖气炉。 第12课 乡下 我爷爷住哎乡下。今天，我要去爷爷家。早上天很阴，但中午天空开始变亮，天转好了。我急急忙忙吃完午饭，坐上了电车。 现在，电车正行驶在原野上。窗外，水田、旱地连成一片。汽车在公路上奔驰。 这时，电车正行驶在大桥上。下面河水在流动。河水很清澈，可以清澈地看见河底。可以看见鱼在游动。远处，一个小孩在挥手。他身旁，牛、马在吃草。 到了爷爷居住的村子。爷爷和奶奶来到门口等着我。爷爷的房子是旧房子，但是很大。登上二楼，大海就在眼前。海岸上，很多人正在全力拉缆绳。渐渐地可以看见网了。网里有很多鱼。和城市不同，乡下的大自然真是很美。 第13课 暑假 大概没有什么比暑假更令学生感到高兴的了。大学在7月初，其他学校在二十四日左右进入暑假。暑假大约1个半月。 很多人利用这个假期去海边、山上，或者去旅行。学生中，也有人去打工。学生由于路费等只要半价，所以在学期间去各地旅行。因此，临近暑假时，去北海道的列车上就挤满了这样的人。从炎热的地方逃避到凉爽的地方去，这是很自然的事。一般在1月、最迟在2月底之前就要预定旅馆。不然的话可能会没有地方住。 暑假里，山上、海边、湖里、河里会出现死人的事，这种事故都是由于不注意引起的。大概只能每个人自己多加注意了。 在东京附近，镰仓等地的海面不起浪，因此挤满了游泳的人。也有人家只在夏季把海边的房子租下来。 暑假里，学校的老师给学生布置作业，但是有的学生叫哥哥或姐姐帮忙。 第14课 各式各样的学生 我就读的大学都有各种各样的学生入学。学生有的是中国人，有的是美国人，有的是英国人。既有年轻的，也有不年轻的。有胖的学生，也有瘦的学生。学生大多边工作边学习。因此，大家看上去都很忙。经常有人边听课边打盹。 我为了学习日本先进的科学技术和日本文化来到日本。预定在这所大学学习3年。既然特意来了日本，所以每天都很努力学习。即便如此，考试之前还是很紧张。其他学生也是这

新视野大学英语5课文翻译(全)

教育界的科技革命 如果让生活在年的人来到我们这个时代，他会辨认出我们当前课堂里发生的许多事情——那盛行的讲座、对操练的强调、从基础读本到每周的拼写测试在内的教学材料和教学活动。可能除了教堂以外，很少有机构像主管下一代正规教育的学校那样缺乏变化了。 让我们把上述一贯性与校园外孩子们的经历作一番比较吧。在现代社会，孩子们有机会接触广泛的媒体，而在早些年代这些媒体简直就是奇迹。来自过去的参观者一眼就能辨认出现在的课堂，但很难适应现今一个岁孩子的校外世界。 学校——如果不是一般意义上的教育界——天生是保守的机构。我会在很大程度上为这种保守的趋势辩护。但变化在我们的世界中是如此迅速而明确，学校不可能维持现状或仅仅做一些表面的改善而生存下去。的确，如果学校不迅速、彻底地变革，就有可能被其他较灵活的机构取代。 计算机的变革力 当今时代最重要的科技事件要数计算机的崛起。计算机已渗透到我们生活的诸多方面，从交通、电讯到娱乐等等。许多学校当然不能漠视这种趋势，于是也配备了计算机和网络。在某种程度上，这些科技辅助设施已被吸纳到校园生活中，尽管他们往往只是用一种更方便、更有效的模式教授旧课程。 然而，未来将以计算机为基础组织教学。计算机将在一定程度上允许针对个人的授课，这种授课形式以往只向有钱人提供。所有的学生都会得到符合自身需要的、适合自己学习方法和进度的课程设置，以及对先前所学材料、课程的成绩记录。 毫不夸张地说，计算机科技可将世界上所有的信息置于人们的指尖。这既是幸事又是灾难。我们再也无须花费很长时间查找某个出处或某个人——现在，信息的传递是瞬时的。不久，我们甚至无须键入指令，只需大声提出问题，计算机就会打印或说出答案，这样，人们就可实现即时的"文化脱盲"。 美中不足的是，因特网没有质量控制手段；"任何人都可以拨弄"。信息和虚假信息往往混杂在一起，现在还没有将网上十分普遍的被歪曲的事实和一派胡言与真实含义区分开来的可靠手段。要识别出真的、美的、好的信息，并挑出其中那些值得知晓的, 这对人们构成巨大的挑战。 对此也许有人会说，这个世界一直充斥着错误的信息。的确如此，但以前教育当局至少能选择他们中意的课本。而今天的形势则是每个人都拥有瞬时可得的数以百万计的信息源，这种情况是史无前例的。 教育的客户化 与以往的趋势不同，从授权机构获取证书可能会变得不再重要。每个人都能在模拟的环境中自学并展示个人才能。如果一个人能像早些时候那样"读法律"，然后通过计算机模拟的实践考试展现自己的全部法律技能，为什么还要花万美元去上法学院呢？用类似的方法学开飞机或学做外科手术不同样可行吗？ 在过去，大部分教育基本是职业性的：目的是确保个人在其年富力强的整个成人阶段能可靠地从事某项工作。现在，这种设想有了缺陷。很少有人会一生只从事一种职业；许多人都会频繁地从一个职位、公司或经济部门跳到另一个。 在经济中，这些新的、迅速变换的角色的激增使教育变得大为复杂。大部分老成持重的教师和家长对帮助青年一代应对这个会经常变换工作的世界缺乏经验。由于没有先例，青少年们只有自己为快速变化的"事业之路"和生活状况作准备。