Cite as: Carter W, Yalamuru B, Newmark J, et al. Tele-Simulation during the COVID-19 pandemic- a blueprint forinnovation in medical education . ASRA Pain Medicine News 2023;48. https://doi.org/10.52211/asra050123.007.

An important pillar of medical education is simulation. Simulation is “a generic term related to an artificial representation of a real-world process to achieve educational goals through experiential learning.”¹ In medical education, simulation is the utilization of any device or environment that represents clinical care² and, for years, has been recognized as an effective teaching modality. Simulation has been used in pain medicine fellowship programs to provide education in communication, professionalism, and responses to critical, adverse clinical events¹.

Prior to the COVID-19 pandemic, simulation sessions would often occur in-person with standardized patients (SPs) in a simulated examination or procedure room, awaiting a fellow or resident trainee to knock and enter the room to begin. Instructors and observers could view these sessions as they occurred, individually in real time (via one-way glass), individually, or by viewing live recorded videos of multiple rooms simultaneously. After each session, the trainees would return to the conference room for debriefing.³ However, the pandemic has presented educational institutions with new barriers (such as suspending clinical rotations and in-person skill-based practice) to overcome⁴ to allow for social distancing and staffing efficiency. A solution to this is the use of tele-simulation in the learning environment to provide high-quality sessions to pain fellows and residents during the pandemic. Similarly, real-world patient care has shifted to the use of tele-medicine. This article will address the impact of the pandemic on education and the application of tele-simulation.

A solution to this is the use of tele-simulation in the learning environment to provide high-quality sessions to pain fellows and residents during the pandemic.

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Since most pain fellowships are only one year, the shutdowns during the pandemic led to many pain fellows losing vital training time. Many hospitals called in physicians and medical students from various specialties to help with “emergency and acute hospital services.”⁵ This resulted in the redeployment of medical students, residents, fellows, and attending physicians into critical care. Several practices were put on hold due to COVID-19, leading to delays in their education⁶ as well. A survey conducted by Lee and Deer was sent to various fellowships programs (anesthesiology, physical medicine and rehabilitation, neurology, and other subspecialties) regarding their training during COVID-19. Out of the 60 surveys collected, an overwhelming 44 respondents answered either “yes” or “somewhat” to the question of whether they felt that their “educational training has been negatively affected by COVID-19.”⁵ A perceived lack of opportunities for training is detrimental to trainees’ educational experience and confidence. However, tele-simulation could provide a way to continue teaching medical practices to future pain physicians during the pandemic.

A collaborative research study was conducted by the University of Virginia, Stanford University, and Massachusetts General Hospital/Harvard Medical School to explore the benefits of tele-simulation by surveying fellows after they experienced two different tele-simulation scenarios. The first tele-simulation experience involved six pain medicine fellows participating in three encounters with SPs focused on difficult topics like increased pain after a transforaminal epidural injection, failed spinal cord stimulator and intrathecal pump trials, opioid misuse, and failed urine drug screen, which all took place via the Zoom³ digital platform. The second tele-simulation experience took place at the Stanford University Center for Immersive and Simulation-based Learning (CISL) via Zoom³ and involved a single encounter in which all participants led a difficult conversation surrounding opioid use disorder. The first simulation showed that an overwhelming 83% of the fellows found the pain simulation format very believable, and about 67% of the fellows found the simulation extremely useful for current practice.³ Additionally, about 33% of the fellows found the simulation experience to be extremely useful for future practice, and the remaining participants found the simulation to be very useful. The second simulation data suggests that 100% of the fellows found the entire pain simulation experience extremely believable and useful for practice.³ Overall, the study suggests that most of the fellows had a positive learning experience and found that the tele-simulation was believable and beneficial.

Other studies support the findings that tele-simulation is viewed favorably by trainees. A research study conducted by several hospitals in Toronto, Ontario, Canada aimed to determine if pediatricians could use tele-simulation to teach intraosseous (IO) insertion techniques to physicians in Africa. A tele-simulation lab was set up at Princess Marina Hospital in Gaborone, Botswana, and at the Toronto Western Hospital surgical simulation lab.⁷ The results of the study showed that “all physicians reported that tele-simulation teaching was a worthwhile experience, and about 95% felt more prepared to manage pediatric resuscitation.” ⁷ Overall, the study concluded that the “session improved physicians’ knowledge, self-reported confidence, and comfort level in inserting an IO needle.”⁷ Another study performed by researchers of the University of California San Diego School of Medicine aimed to assess the impact of tele-simulation vs in-person simulation that focused on treating patients with illnesses such as hyperkalemia, chronic obstructive pulmonary disease exacerbation, upper gastrointestinal bleed, and seizures. The results of the survey showed that “there was a trend toward improvement” in their skills to identify critically ill patients, interpret chest x-rays, communication skills, and escalation of care after the tele-simulation.⁸ At the end of the study, trainees were asked to score whether simulation was a good way to learn critical care skills. The students strongly agreed that in-person learning was “5.0 out of 5.0.” and remote learning was “4.9 out of 5.0^.”⁸ Given the positive findings that tele-simulation is viewed as favorably as in-person experiences, training programs can consider incorporating tele-simulation into their curriculums when needed.

Other forms of tele-simulation include the use of virtual reality (VR). Several types of VR systems can potentially be used to teach and advance the technical and procedural skills of trainees. Organizations worldwide are working with pain educators to develop these novel systems. One such program incorporates attendings demonstrating newer pain medicine procedures on a virtual platform.⁹ Specifically, the program involves 3-hour events consisting of six, 30-minute segments. During each segment, an attending physician teaches a procedure/technique and reviews data, which is displayed on a virtual platform. There are virtual attendings available for both students and attendings to ask/answer questions as well.

In addition, other VR programs allow students and educators to use their VR headsets and computers to simulate scenarios focused on nursing, military-medical, and EMS training. This program offers trainees the chance to take each course individually or combined. It allows trainees to track their progress over time and provides quality debriefing tools and even multiplayer capabilities. There is a multiplayer capability that allows educators and trainees from around the globe to join the same scenarios and patient cases for diverse collaboration.¹⁰ These studies suggest that VR simulation may also be incorporated into post-graduate medical education to enhance learning opportunities.

Conclusion

Despite the numerous challenges medical practices faced during the COVID-19 pandemic, including the need to implement social distancing and function with alternative (lean) staffing models, medical education has evolved and adapted to overcome these obstacles. Tele-simulation is an important educational tool and can be used effectively in pain medicine fellowships to provide high-quality learning opportunities via multiple scenarios and skills-building sessions.

Whitney Carter, BS, is a scribe, in the pain division at the University of Virginia in Charlottesville.

Bhavana Yalamuru, MBBS, is an assistant professor in the pain division at the University of Virgina in Charlottesville. 

Jordan Newmark, MD, is the president & CEO of E&S Newmark Consulting and an adjunct clinical associate professor at Stanford University School of Medicine in Stanford, CA.

Taylor Purvis, MD, is a resident in the Department of Anesthesia, Critical Care and Pain Medicine, at Massachusetts General Hospital in Boston.

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Gary Brenner, MD, PhD, is the program director of the pain medicine fellowship at Massachusetts General Hospital and an associate professor at Harvard Medical School in Boston, MA.

David Brodnik is a medical student at Eastern Virginia Medical School in Norfolk.

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Lynn R. Kohan, MD, is a professor, division chief of pain, and program director of the pain medicine fellowship in the Department of Anesthesiology at the University of Virginia in Charlottesville. 

References

1. Al-Elq AH. Simulation-based medical teaching and learning. J Family Community Med 2010;17(1):35-40.
2. Lame G, Dixon-Woods M. Using clinical simulation to study how to improve quality and safety in healthcare. BMJ Simul Technol Enhanc Learn 2020;6(2):87-94. https://doi.org/10.1136/bmjstel-2018-000370.
3. Purvis T, Newmark J, Brenner GJ, et al. Pain education innovations during a global pandemic. Pain Med 2021;22(9):1891-96. https://doi.org/10.1093/pm/pnab254.
4. Papapanou M, Routsi E, Tsamakis K, et al. Medical education challenges and innovations during COVID-19 pandemic. Postgrad Med J 2022;98(1159):321-27. https://doi.org/10.1136/postgradmedj-2021-140032.
5. Lee DW, Deer T. Pain fellows survey: COVID-19 impact on the training and job market. Pain Med 2021;22(12):3106-09. https://doi.org/10.1093/pm/pnab165.
6. Prem A, Anand S, Chandrashekar A. Impact of COVID-19 on an academic pain fellowship program. Pain Physician 2020;23(4S):S433-38.
7. Mikrogianakis, A, Kam, A, Silver, S, et al. Telesimulation: an innovative and effective tool for teaching novel intraosseous insertion techniques in developing countries. Acad Emerg Med 2011;18(4):420–27. https://doi.org/10.1111/j.1553-2712.2011.01038.x
8. Lin E, You AX, Wardi G. Comparison of in-person and telesimulation for critical care training during the COVID-19 pandemic. ATS Sch 2021;2(4):581-94. https://doi.org/10.34197/ats-scholar.2021-0053OC
9. New Orleans, LA: MedE Combine, LLC. Available at: https://mededcombine.com. Accessed July 20, 2022.
10. Virtual Reality Medical Simulation. Mountain View, CA: SimX. Available at: https://www.simxvr.com. Accessed August 1, 2022.