INTRODUCTION
AO (Arbeitsgemeinschaft für Osteosynthesefragen) was founded in Switzerland in 1959 by a group of 13 visionary surgeons. Their achievements soon defied sceptics with the immediate, active, post-operative rehabilitation of patients through new methods of fracture care by operative fixation, or osteosynthesis. The “AO principles” have since then become a worldwide standard in fracture treatment and an important cornerstone of surgeons education. To ensure this worldwide leadership would continue, AO’s founders created the AO Foundation in 1984. The AO Foundation is a medically-guided non-profit organization led by an international group of surgeons, specialized in the treatment of trauma and disorders of the musculoskeletal system. It offers global networking opportunities and a knowledge service operating on internet and through standard training courses to affiliated surgeons and operating room personnel (ORP). AO surgeons, ORPs and staff members are dedicated to achieve more effective patient care by fostering and expanding an interdisciplinary network worldwide, which now accounts more than 5000 healthcare professionals involved in research projects, developments, clinical investigations and education. An ongoing worldwide collaboration with industrial and non-profit partners has been one of the keys to the AO’s success. Such partnership guarantees that knowledge is not only implemented but also complemented with implants and instruments for surgeons and ORPs for the ultimate benefit of the patients. Today, AO is present in more than 100 countries. Through the resources of its head office, AO Foundation makes sure that all regional activity occurs within the scope of its global framework, while working in synergy across the entire network. Through its Socio-economic Committee, AO also has presence in lesser-developed regions of the world, where it invests in sustainable healthcare programs and education of local surgeons and ORP. AO offers seminars and courses for general trauma, spine disorders, craniomaxillofacial (CMF) and veterinary specialities. The courses provide in-depth knowledge of the AO concepts and techniques in addition to more specialized know-how. AO courses combine multiple methods including practical exercises and group discussions. The annual courses of the Foundation take place in Davos (Switzerland) and attract around 1500 surgeons and ORPs from many countries of the world. Over the past 45 years, AO has educated more than 350.000 healthcare professionals. Advocating more effective patient care, AO thrives on sharing knowledge with a growing global community of surgeon and operating room personnel. AO also offers more than 200 fellowships lasting several weeks or months to young surgeons and ORPs in more than 100 hospitals around the world. The fellow learns new concepts and techniques under the mentorship of senior AO surgeons, and often forges professional and personal friendships that last a lifetime. Inspired by their own learning experience, many surgeons opt to become local or international faculty members and pass their knowledge to next generation surgeons.¹ AO supports them with educational materials and in-depth faculty training, as their teaching skills are a key factor in successfully disseminating the AO  knowledge worldwide.

The AO Foundation in Italy
In Italy, we have founded the AO Alumni Association, and some years later an Educational Board with the goal of coordinating all the activities of the AO Foundation in our country. The AO Italian Educational Board organizes every year: three AO courses in Davos (an AO Principle Course, an AO Advanced Course and an AO Comprehensive Course) for a total of about 200 surgeons; the AO Alumni Association Meeting for about 200 surgeons and one AO Course for 150 operating room personnel. In Italy we have more than 200 surgeons in the Alumni Association and this Trauma Society if sinked to the National Association of Orthopaedic and Traumatology. Every member has an active role and discusses together with the other members clinical cases brought up by our AO Alumni Association using website dedicated tools. The site is linked to the International website so that it is possible to discuss cases or receive remarks and suggestions on demand on specific cases from the International Faculty members. Recently, we have collaborated in building on a new interactive web site: the “AO surgery reference”. This instrument, at the beginning, was provided to university and research-dedicated (IRCCS) hospitals or to Orthopaedic Schools, to help the decisionmaking process in fracture care. In more recent years the “AO surgery reference” was opened to totally free access, and it now represents the most used medical website, for the number of connections. The AO Foundation website was awarded in 2008 as Best Care/Disease Management website, with almost 200,000 pages viewed by more than 12,000 surgeons for months. Clinical case discussion is one of the cornerstones in AO education. Talking about cases is an important part of AO courses and the educational mission of AO. Every course participant or member of the AO Alumni Association has always been free to share and discuss his/her own patient/case reports. To be of educational value, discussion must rely on the provision of arguments supported by evidence and proven criteria. Case discussion are useful for supporting one’s preformed opinions and can elicit new thoughts on a difficult clinical case. Case discussion also allows course participants to test their new knowledge gained at lectures and the opportunity for a friendly additional clarification of learning points from the faculty. Clinical cases help the participant to translate the new information into personal clinical practice. We are convinced that only internationally- validated clinical experience educates, and evidencebased case discussion is the best tool for applying the learned principle in daily practice. The practical element of the courses has been one of the defining characteristics of AO education, starting from the earliest courses in the 1960s. One of the most powerful effects in the instructional process is the “practice with feedback”, and it is estimated that up to 50% of the course time should be spent in practice with feed-back. Teaching practical skills, using plastic bone models, allows hand-on demonstrations of the procedures and practice, particularly suited to the teaching of surgical skills that can be learned effectively by emonstrations from experts followed by practice. The success or failure of the learning experience will be largely determined by interaction between the table instructors and the course participants. In Italy, the possibility of direct surgery interventions on cadavers does not exist, so a large number of young and senior surgeons every year leave Italy and go to other European countries to practice in a cadaver-lab or attend courses on surgical anatomy. Starting with this important clinical need, Pietro Regazzoni and Antonio Pace four years ago planned a new AO course. The comprehensive course is a special course, extending the theoretical-practical teaching of fracture fixation to also include anatomy and surgical approaches on cadavers, bi-and tridimensional imaging based on the latest technologies, endoscopic visualization, as well as the prosthetic treatment in the trauma field. The choice of Davos as the venue of the courses comes from the need to use the logistics and the equipments already tested in many years of activity, from the difficulty to use cadavers in Italy, and from the fact that the Davos courses have always been a reference point for their excellence in the trauma field for the Italian surgeons.

Final remarks
Clinicians and educators, experienced in the continuing professional development of physicians, postulate that many changing forces will direct developments in continuing medical education (CME) over the next decades. There are important new trends for the medical professions, such as: self-assessment programs, problem-based learning, continuous quality improvement and educational technologies.² Enthusiasm has been found to correlate with student learning gains in several studies and many papers in literature focus on talking and on learning. It is important to realise that learners cannot be considered as spectators of this process, but they should have an active role.³ We believe that the medical education system can be positively affected by those who actually grasp the truth of reality through its symbols. Information in itself can never generate a culture; only a person can generate culture. If education does not direct one toward a onstant self-development, it is not merely useless but harmful to the person. We try to improve standard cares for patients, in a worldwide perspective. When we plan our courses, we know that theory without practice is sterile; practice without theory is blind, because frequently learners come back to their clinical practice in the hospitals but they do not have the possibility to change anything in practice. But learning implies changing in practice: as a result of learned experience, people change in what they do, in what they think, in the way they choose. In our profession there are three major areas of changes: knowledge, skills and attitude. It’s really a major challenge to try to improve these three competencies in a learner. To learn from personal attitude and culture of the participants are the basis for understanding how to more easily change the other competencies. Self-assessment in professional learning is an important requirement, because self-perception of improvements in professional abilities, performance and competencies are important learning objectives to meet defined educational needs or to fill in clinical gaps. As learners we first need to understand our professional needs, which is not easy for many standard courses participants. So every time the faculty members have to approach new teaching methods, they have to ask themselves first and then the trainees, how clearly the educational needs are expressed, and subsequently change step by step the educational plan of the course to respond to problems that arise. Sometimes the learner needs someone who waits for him, someone who is there to show the right way to do something that he has always done differently. Problem-based learning may be defined as learning through discussing and interacting on cases or patient materials, either simulated or real. Many methods for problem-based learning are based on simple case discussion from published scientific papers or just using specific case reports, often considering complicated surgical situations.^4,5 This method of teaching is persuasive and effective in practice. We learned that only real professional conditions educate. In addition, it is a very common perception among our trainees that they can learn more from seeing what the teachers do than from what they say. In conclusion, the goals of the AO Foundation is to change the practices of the learner through a better care of patient’s needs. This results in an improvement of the quality of care delivered to patients on a regular basis, which is clearly a primary goal for health care practitioners.⁶ Another new trend in education is a new process, called technology-enabled knowledge translation, which implies the use of a wide variety of technical aids to assist the practitioners or the health care system in acquiring knowledge and applying it in the appropriate manner. There are many forces that lead to the use of simulation technologies for skills training for assessment purposes.⁷ But beyond improvements in knowledge, skills and attitude, it is more important to transmit to the learner, doctors or surgeons, the sense of responsibility. Every good surgeon or physician has to stand in front of his patient, and try to provide him or her with the best care for his or her illness. This alliance between the physician and the patient helps to develop responsibility in both parties.

Acknowledgements. I want to thank Luigi Giussani, from which I learned education principles which I find true in all fields of my life.

Riassunto – La Fondazione AO è stata fondata 50 anni fa in Svizzera da un gruppo di 13 pionieri della chirurgia e dell’insegnamento. La Fondazione AO è un organizzazione non-profit guidata da un gruppo di chirurghi specializzati nel trattamento delle lesioni traumatiche e nelle malattie del sistema muscolo-scheletrico. Offre a chirurghi e infermieri professionali di sala operatoria affiliati, un network mondiale con diverse opportunità di consultazione ed un servizio di informazioni scientifiche attraverso un sito web, finalizzate a poter raggiungere una effettiva cura del paziente, riconosciuta a livello internazionale. La Fondazione attualmente conta più di 5000 professionisti impegnati nella cura, nella ricerca, nello sviluppo, nella ricerca clinica e nella formazione. Quello che abbiamo imparato dall’esperienza della Fondazione AO in ambito di insegnamento è che imparare significa cambiare nella pratica clinica come risultato di un’esperienza fatta. La conoscenza, le abilità e la predisposizione attitudinale sono le tre aree di questo cambiamento. Si può insegnare solo qualche cosa di pratico, quello che apprendiamo in sala operatoria e la pratica clinica. Questo diventa contenuto di un reale insegnamento, perché verificabile a sua volta dal discente. Si può insegnare qualcosa che funziona nella pratica, e quindi riproducibile in modi differenti, da persone diverse in tutto il mondo.

REFERENCES

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