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  Table of Contents 
SPECIAL ARTICLE
Year : 2020  |  Volume : 21  |  Issue : 2  |  Page : 81-84
 

Impact of COVID-19 pandemic on education and learning of trainee anesthesiologists, and measures to combat the losses


1 Department of Anaesthesiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
2 Department of Anaesthesiology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, Cambridge, UK

Date of Submission21-Aug-2020
Date of Decision23-Aug-2020
Date of Acceptance25-Aug-2020
Date of Web Publication19-Sep-2020

Correspondence Address:
Dr. Ghansham Biyani
Department of Anaesthesiology, Box 93, Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, Hills Road, Cambridge, CB2 0QQ
UK
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TheIAForum.TheIAForum_132_20

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  Abstract 


The COVID-19 pandemic has affected every facet of medicine, including anesthesiology. The purpose of this article is to enumerate the possible effects of global lockdown on the education, research, and training of postgraduates of different grades, and to discuss the measures which need to be enacted on to mitigate the impact. This includes innovating and adapting to newer modalities of teaching and training, modifications in research and conduct of examination, and other resources required in rebuilding the losses trainees had in their medical education.


Keywords: Anesthesiology, COVID-19, education, examinations, research, training


How to cite this article:
Bhatia P, Biyani G, Mohammed S, Lala P. Impact of COVID-19 pandemic on education and learning of trainee anesthesiologists, and measures to combat the losses. Indian Anaesth Forum 2020;21:81-4

How to cite this URL:
Bhatia P, Biyani G, Mohammed S, Lala P. Impact of COVID-19 pandemic on education and learning of trainee anesthesiologists, and measures to combat the losses. Indian Anaesth Forum [serial online] 2020 [cited 2020 Dec 4];21:81-4. Available from: http://www.theiaforum.org/text.asp?2020/21/2/81/295320




It is difficult to estimate the impact of COVID-19 pandemic on the curriculum of trainee anesthesiologists. However, we can presume that this pandemic is going to cause a major interruption in postgraduates' teaching, learning, training, research, and examinations.[1] Importantly, these interruptions will not just be causing short-term issues, but can also have long-term consequences for the affected cohorts. As the governments are lifting up the restrictions in a phased manner, many countries including India are preparing to reopen, but it is very likely that the numbers of elective surgeries will remain low in the near future for an undefined duration. Hence, trainees are likely to have fewer patient encounters and thereby lesser opportunities for learning. In this article, we have discussed the possible consequences, and potential ways to combat this impact. This involves innovation and adaptation to newer ways of teaching and training, relocation (redeployment) of trainees, modifications in the conduct of examinations and research, and producing job opportunities in these unprecedented times.

Unlike previous pandemics, the COVID-19 has posed newer challenges. We need to think as a specialty, how can we ensure that residents are trained adequately and efficiently in a shorter period of time? Recently, few articles have been published in the literature describing the changes made by various departments and institutes to their training program including restructuring, newer ways of teaching, redeployment of trainees, and rotational policies to mitigate the losses trainees had to their curriculum during this global pandemic.[1],[2],[3],[4],[5]


  Possible Consequences and Potential Solutions Top


Education/teaching

The education program directors and other faculty members are faced with challenges of delivering regular teaching classes to trainees, as both the face-to-face and group training are abandoned due to social distancing measures. The clinical leads need to rethink what needs to be taught in an effective way so that the students' education is least affected. With respect to the curriculum, the Medical Council of India (MCI) recommends that every institution undertaking a postgraduate training program shall set-up an academic cell or a curriculum committee, under the chairmanship of a senior faculty member, which shall work out the details of the training program in each specialty. The training programs shall be updated as and when required.[6] A few reports had recommended relooking at the anesthesia curriculum even before this pandemic time.[7],[8] COVID-19 pandemic provided an opportunity for reemphasizing this long-standing issue.

Fortunately, technology is helping us to conduct online teaching by the use of web-based audio and video conferencing platforms with recording capabilities. There has been a paradigm shift toward video-based teaching, and trainees are coping well with this new format of learning.[1] Topics such as the management of critically ill patients, airway management, pharmacology of emergency medications, acute respiratory distress syndrome, deep vein thrombosis, and pulmonary embolism, sepsis and multiorgan dysfunction, mechanical ventilation, regional anaesthesia, among others must be focused on. This will not only cover a few of the core topics, but also enable the residents to work comfortably and efficiently in theaters and critical care units. However, the “pandemic of Covid-19” has resulted in the “epidemic of webinars.” Students may start losing interest after a period of time due to increasing loneliness, as socialization is an essential need for human beings. Moreover, virtual teaching requires computers and internet access, which may not be accessible to everyone at all the time. The other disadvantages include difficult interaction, lack of real-time teaching experience, and issues related to technology.

Training/practice

Trainees particularly those who are just starting their profession as anesthesiologists, are likely to have fewer patient encounters, and thereby lesser opportunities to learn, and perform various essential procedures. The effect is likely to be even more drastic on the candidates doing their 1-year fellowship and Postdoctoral Certificate Courses programs, or 2 year diploma course. For instance, fellowships in pediatrics, and transplant anesthesia are likely to be significantly affected. However, the residents including the freshers are still expected to function and be effective in delivering high-quality care despite limited opportunities for learning.

Restructuring of the workforce can be an effective way of dividing the work.[1] Undoubtedly, the focus at this point should be to safely deploy the necessary volume of the resident workforce to support the pandemic efforts, but this phase also provides an opportunity for the candidates to complete their modules and training in areas such as critical care, trauma/orthopedics, and obstetrics. The registrars should be divided into different groups consisting of the critical care team, theater team, obstetric team, and peripheral team. The teams should be rotated at regular intervals to give equal opportunities for learning to all the residents. The critical care team can learn key concepts such as management of sicker patients, insertions of invasive lines, and the principles of mechanical ventilation. The theater team registrars should utilize this time to learn and perform neuraxial and peripheral nerve blocks to provide anaesthesia to the patients, as this will not only avoid performing aerosol-generating procedures, but also plays a key role to reopen the elective surgeries. Labor analgesia is less frequently practiced in India. The obstetric team can take up this challenge and effectively learn the art of performing continuous epidural, and combined spinal-epidural techniques to hone their skills. The peripheral team can look after the hospital-wide calls to perform intubations, and for the placement of central venous catheters, arterial catheters, temporary vascular access, or nasogastric tubes. Extensive planning is also required to make sure that all residents get equal exposure to different subspecialties, once the theater work resumes normal working conditions. Logbooks shall be maintained and checked by the faculty members at regular intervals.

Simulation is a highly effective modality of teaching and training. Mannequin-based simulation in nonpatient care settings can be used to learn essential skills such as management of difficult airway, cardiorespiratory resuscitation, management of anaphylaxis, and also to replicate rare events like malignant hyperthermia, and local anesthetic systemic toxicity.[9] For this purpose, the provision of skill laboratories in medical colleges is mandatory. Live models can be used to demonstrate the sonoanatomy of regional blocks and point-of-care ultrasound. The major drawback of simulation is that ultimately the participants know that they are working within fabricated scenarios. Furthermore, the myriad of additional challenges posed when operating on a real patient in theater is almost impossible to simulate.[10],[11]

It is a common practice across many of the state government, and private medical colleges, to ask their residents to do on-call shifts just after completing their first 6–12 months of training, under distant consultant cover. We believe such a practice may jeopardize a patient's safety. Postgraduates should be allowed to take their own time to learn and must feel confident in managing sicker patients before they are asked to do on-call shifts. The consultants must work on floor along with the trainees for the first few shifts to guide them on how to deal with the life-threatening emergencies of routine hours.

Examinations

We are well-versed with the recommendations put forward by the MCI with respect to the conduct and structure of the examinations. However, we are of the opinion that the conduct of examinations also needs modifications. They can be conducted virtually using the video conferencing. In place of allotting the patients, the examiners need to prepare long and short case scenarios and provide investigations, imaging, and other relevant information to the students before the discussion. Such a pattern is being used for many years now by the European Society, Royal College (United Kingdom), and other boards to test the knowledge of the candidates. Examiners also need to create, and store images of better quality (of the anesthesia machine, circuits, drugs, equipment, X-rays, electrocardiogram, blood gas, capnography, and others) in a database which can be shared with the students during the viva voce. Objective structured clinical examinations are also uniquely designed to provide both formative and summative assessment of all core competency areas including professionalism, communication skills, and practice-based assessment.[12] Simulators can also be used for examination purposes to assess the practical knowledge of the students.[10]

The MCI recommends that the structured training program shall be written up and strictly followed, to enable the examiners to determine the training undergone by the candidates.[6] However, we believe the examiners should take into consideration whether the candidate appearing for the examinations had any case deficiencies as they relate to this pandemic. The fellowship program directors should also determine whether the candidate is ready to graduate, or needs an extension by a few months to get the minimum required number of procedures to successfully complete the program.

Research

Conduct of randomized controlled trials may be difficult due to the less density of elective cases. However, COVID-19 can be considered as a primetime for conducting research in the fields of critical care, obstetrics, regional, and trauma anesthesia, as these specialties are least affected. Performing meta-analysis and writing up of systemic and nonsystemic reviews should also be considered by the research enthusiasts.

Jobs

Junior anesthesiologists who have just passed out their postgraduate examinations are likely to meet with the challenges of employment, for various reasons. Traditional in-person interviews may be substituted with virtual meetings (using apps such as Skype, Zoom meeting, and Google hangouts) in light of travel restrictions. The junior doctors can be employed in the emergency departments, critical care, labor wards, and trauma centers to deliver their services. We welcome the initiative taken up by many of the organizations to retain their employees and pay to their fullest salary in these difficult times.


  Conclusion Top


The COVID-19 pandemic has presented a multitude of challenges to the clinical leads in maintaining effective postgraduate medical education. By adopting newer ways of teaching and training, by redeployment and rotation of trainees, and modifications to the conduct of examinations and research may enable the residency programs to function smoothly during this crisis. These changes may well prepare us to withstand a second wave if arises, or to other similar pandemics in the future. These adoptions also mean that our future generation colleagues carry with them the confidence of anaesthetizing the patients safely.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Zhang AS, Myers M, Kee CJ, McClary KN, Barton RS, Massey PA. Adapting Orthopaedic Surgery Training Programs During the COVID-19 pandemic and future directions [published online ahead of print, 2020 Jun 25]. Arthrosc Sports Med Rehabil. 2020;10.1016/j.asmr.2020.06.008. doi:10.1016/j.asmr.2020.06.008.  Back to cited text no. 1
    
2.
Nassar AH, Zern NK, McIntyre LK, et al. Emergency Restructuring of a General Surgery Residency Program During the Coronavirus Disease 2019 Pandemic: The University of Washington Experience. JAMA Surg. 2020;155:624-7. doi:10.1001/jamasurg.2020.1219.  Back to cited text no. 2
    
3.
Juprasert JM, Gray KD, Moore MD, Obeid L, Peters AW, Fehling G et al. Restructuring of a General Surgery Residency Program in an Epicenter of the Coronavirus Disease 2019 Pandemic: Lessons from New York City. JAMA Surg. Published online July 07, 2020. doi:10.1001/jamasurg.2020.3107.  Back to cited text no. 3
    
4.
Sabharwal S, Ficke JR, LaPorte DM. How We Do It: Modified Residency Programming and Adoption of Remote Didactic Curriculum During the COVID-19 Pandemic. J Surg Educ 2020;77:1033-6. doi: 10.1016/j.jsurg.2020.05.026.  Back to cited text no. 4
    
5.
Chhabra S, Kamal M, Chhabra D, Agha M. Sustaining academics during the COVID-19 pandemic. Indian Anaesth Forum 2020;21.170-1.  Back to cited text no. 5
    
6.
Guidelines for Competency-Based Postgraduate Training Program for a Diploma in Anaesthesiology. The postgraduate medical education regulations 2000. medical council of india. Available from: http:// www.mciindia.org. [Last assessed on July, 15 2020].  Back to cited text no. 6
    
7.
Wong A. Review article: Teaching, learning, and the pursuit of excellence in anesthesia education. Can J Anaesth 2012;59:171-81.  Back to cited text no. 7
    
8.
Bould MD, Naik VN, Hamstra SJ. New directions in medical education related to anaesthesiology and perioperative medicine. Can J Anesth 2012; 59: 136-50.  Back to cited text no. 8
    
9.
Van Zundert AA, Gatt SP, Mahajan RP. Continuing to excel in anaesthesia through the 'big five': Teaching, training, testing, quality, and research. Br J Anaesth 2016;117:276-9.  Back to cited text no. 9
    
10.
Komasawa N, Berg BW. Simulation-based airway management training for anesthesiologists-A brief review of its essential role in skills training for clinical competency. J Educ Perioper Med 2017;19:E612.  Back to cited text no. 10
    
11.
Martinelli SM, Isaak RS, Schell RM, Mitchell JD, McEvoy MD, Chen F. Learners and luddites in the twenty- first century: Bringing evidence-based education to anesthesiology. Anesthesiology 2019;131:908-28.  Back to cited text no. 11
    
12.
Hastie MJ, Spellman JL, Pagano PP, Hastie J, Egan BJ. Designing and implementing the objective structured clinical examination in anesthesiology. Anesthesiology 2014;120:196-203.  Back to cited text no. 12
    




 

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