There is a well-known legend about ancient Sanskrit scholar, Kalidasa. Before evolving into an acclaimed literary giant, he was supposedly a dimwit as depicted by him sawing the tree branch on which he was sitting . However, there can be an alternate interpretation to the legend. Instead of sawing it, Kalidasa might have been just sitting on the dying branch to demonstrate how badly the tree had already been damaged so as to caution others about how unsafe the damaged tree had become for climbing. This ancient legend may be relevant for modern times as well. Without further ado, we may need more scholars like Kalidasa to recognize and demonstrate the dying branches even if, for the time-being, they are sitting on them in need of temporary support.
Times are evolving rapidly wherein it will warrant more than just fight or flight responses because competing or ignoring virtuality may not avoid eventuality. While accepting the dawn for growing dominance of virtuality and lurking irrelevance of humanity, the existential question arises that whether long drawn tenures of medical schools, residencies and fellowships can remain economically viable to acquire credentials and privileges in overspecialized medicine considering that the exclusivity to practice in medical specialties and sub-specialties is likely to be easily breached by skilled workers who all may cost-effectively acquire the minimum required practicable knowledge through open source and open access virtual interfaces.
Medicine may no longer remain the realm of institutionalized education to attain degrees because for how long sharpening of skills and acquisition of experience can be controlled and limited by regulations safeguarding the privileges for dying world of old-school wisdom in the wake of booming world of new-age virtuality. It is not clear how many specialties and sub-specialties will survive this onslaught of virtuality . Therefore, it may be an intelligent decision for current practitioners of medicine to caution medical students and residents about those specialties and sub-specialties which may seem more likely to surrender first. Though this may hasten the withering away of dying specialties and sub-specialties, the practice of medicine itself may become healthier and more viable for the contracted workforce after overspecialization has been downsized because the economy strapped down by burdensome overlapping redundancies may finally be able to break free while reshaping a relevant future invested in underexplored futuristic avenues.
Basically, practitioners, administrators and regulators of specialties and sub-specialties may have to magnanimously decide on their own about which residencies and fellowships are redundant and bound to become irrelevant when virtuality as an all-knowing singularity will primarily need the skilled trainable workers to efficiently fulfill its worldly needs unlike the educated brainy learned tirelessly questioning its needs in the world. While it may remain difficult for oblivious newbies born into conflict zones and congenitally inheriting unresolvable disputes, newbies enlightened by Kalidasa-like prophecies may intelligently seek births into indisputable zones possessing untapped potential for excellence. Ironically, disputes may soon resurrect within originally indisputable zones secondary to far too many staking claims on the prizes offered inside the newly-established zones thereby forcing the intelligent insatiable ones to move away from stagnating establishments once again in search for newer horizons to establish in the world ruled by the all-knowing virtuality.
Herein, irrespective of its political undertones and ramifications, U.S. President Trump’s “Executive Order on Modernizing and Reforming the Assessment and Hiring of Federal Job Candidates” issued on June 26, 2020  may ironically come in handy by being too futuristic because, even though it is aimed at creating, sustaining and protecting jobs for the vocationally “skilled” humans over the institutionally “educated” humans, it may turn out to be the stepping stone as an example for the future of humanity when robotics will be taking charge over our lives and humans will have to rapidly adapt, learn and acquire newer “skills” with little or no time at all for semester/term/tenure based “education”. Although this “dystopic” future has been foreseen and documented by Yuval Noah Harari in his non-fiction literary works namely “Homo Deus: A Brief History of Tomorrow”  and “21 Lessons for the 21st Century” , the question is whether this “inadvertently farsighted” executive order foresees national and even global reshaping of safer, economical and sustainable healthcare provisions for the ever-growing national and global populations with their escalating “essential” healthcare needs.
At least for the time-being, the global outcry over healthcare costs may seem irrelevant  once gauged through the eyes of healthcare economy and corresponding gross world product creating jobs and food globally especially when (a) patients as end-users may not be wondering  about costs as long as third-party payers are paying on their behalves; (b) third-party payers may not be freely negotiating costs with healthcare providers and facilities so as to avoid being ostracized for their reluctance to pay for "essential" healthcare needs; and (c) healthcare providers as prescribers may not be actively seeking awareness about costs incurred as long as their patients are responding to their treatments and their bills are being cleared by third-party payers.
Concurrently, the often reported shortage of healthcare workers within the society may be keeping societal economy overall healthy because while the overrated/overestimated shortages may be fueling more enrollments into training programs allowing the expansion of healthcare workforce to match the expansion in the created "essential" healthcare needs for sustaining healthcare economy's boom, even the underrated/underestimated shortages, while fueling restrictions to healthcare access and thus restricting the expansion of "essential" healthcare needs inadvertently feeding on dwindling non-healthcare economy, may allow gross world product some freedom from its current overdependence on healthcare economy to sustain jobs (and ensure food) for global populations.
However, to better combat against or adapt to the evolving era of inescapable robotics, the professional societies may have to understand and resolve the core issues of contention between physician-providers and non-physician-providers because (a) if it is about patient safety, the patients embracing robotics may not be facing the dilemma whether to choose their healthcare providers based on their institutional “education” or their vocational “skills”; (b) if it is about healthcare reimbursements, the third-party payers embracing robotics may not be facing the dilemma whether to reimburse healthcare providers based on their comprehensive “education” incurred debts or their focused “skills” limited costs; and (c) if it is about healthcare jobs, the educational institutions embracing robotics may not be facing the dilemma whether to teach and train the future healthcare workers over costly marathon cycles to inculcate “education” or over timely sprinting runs to impart “skills”.
Essentially, the futuristic workers should start looking beyond their human competitors by actually negotiating smarter and farsighted collaborations among them so that when the global economy is reshaped/ruled/owned by robotics and growing number of job avenues starts becoming redundant, the innate and acquired vigor of flexible humans to acquire faster “skills” without waiting for slower “education” may allow them to not only outlive their historical human competitors but also coexist with the robotics ruling the global economy as its future masters.
engorge neck veins for cannulation, proceduralists (a) turn patients into Trendelenburg position and/or (b) ask patients to hold breath and/or (c) passively raise patients’ leg and/or (d) ask assistants to apply supraclavicular occlusive digital pressure just proximal to – towards heart – site of venous cannulation [1-3]. However, these maneuvers may not be feasible during emergent cannulation of neck veins intraoperatively. Therefore, on the lines of circumferential hand tourniquets replacing assistants circumferentially constricting extremities to engorge veins for cannulation, we suggest a non-circumferential tourniquet as an alternative to supraclavicular occlusive digital pressure by an assistant. Peck had objectively demonstrated application of stethoscope’s pressure to engorge external jugular vein and thereafter with Foster patented its improvised version as an apparatus to be utilized for external jugular vein cannulation [4-5]. Analogously, there may be two options. Per option A (Figure 1 (A)), proceduralists may curve their non-dominant hands into a C-shape with their four fingers pressing supraclavicular tissues posteriorly while their thumbs stretching the skin cranially to allow access of the engorged veins by their dominant hands. If proceduralists are concerned about inadvertent needlestick injuries to their non-dominant hands while accessing the engorged veins as per option A, they may consider using option B (Figure 1(B)) wherein 1-inch-by-18-inch latex-free blue-colored rolled tourniquet which routinely comes in sterile IV start kits may be adhered to 1-inch tape and thereafter applied at supraclavicular site to occlude external jugular vein proximally and visibly engorge it distally for cannulation. However, while cannulating internal jugular vein, appropriate position of option A or B may have to be judged per ultrasonographically visible changes in internal jugular vein’s caliber.
Per our self-investigation on ourselves, as compared to normal ultrasonographic antero-posterior caliber of external jugular vein of co-author (MG) in supine position (Figure 1(C)), the C-shaped non-dominant hand of co-author (DG) increased MG’s external jugular vein’s ultrasonographic caliber from 0.16 cm to 0.34 cm (Figure 1(D)) while blue-colored rolled tourniquet only increased it to 0.23 cm (Figure 1(E)). Although the contact pressure of ultrasound probe itself can change the caliber of superficial veins being visualized, the antero-posterior caliber of MG’s internal jugular vein did not vary much between the three visualizations (Figure 1(C-E)). Moreover, as compared to applied blue-colored rolled tourniquet’s constant pressure, DG’s non-dominant hand might have generated more pressure into MG’s supraclavicular space thus engorging MG’s external jugular vein more as similar to overzealous application of circumferential pressure on extremities improving the engorgement of peripheral veins for cannulation.
A word of caution may be warranted. As analogous to patients’ tolerance for ultrasound probe-generated pressure, patients’ tolerance for proceduralists’ hand-generated or rolled tourniquet-generated supraclavicular pressure might have to be taken into consideration. Moreover, although this assembly may visibly engorge external jugular vein even in upright position, neck vein cannulation may have to be always attempted in supine position keeping access site at least below the level of heart because occlusive pressure of this assembly may be neither complete nor continuous thus exposing risk of air embolism during cannulation of partially engorged/full neck veins in upright patients.
Demonstration on mask-wearing MG’s neck veins: DG’s non-dominant hand in a C-shape (A) and blue-colored rolled tourniquet (B) engorging external jugular vein (blue arrows) with its ultrasonographic antero-posterior caliber in supine position at 0.16 cm (C) increasing to 0.34 cm (D) due to DG’s non-dominant hand and to 0.23 cm (E) due to blue-colored rolled tourniquet; internal jugular vein (IJV) is also visible in all ultrasonographic frames (C-E) for comparison