Adapting Curricula for Endoscopy Training During COVID-19
Simulation and Other Educational Approaches
June 16, 2020
The novel COVID-19 pandemic presents a unique challenge for Gastroenterology residency programs globally, many of which are adjusting their endoscopy training curricula to adapt to the rapidly changing clinical landscape. Since endoscopic procedures pose a risk of generating aerosols and increasing transmission, special consideration will be required to ensure ongoing educational development for trainees, while minimizing risks to their safety, maintaining social distancing, and preserving essential resources such as personal protective equipment (PPE).
Practice guidelines released by the Canadian Association of Gastroenterology, American Society for Gastrointestinal Endoscopy and the American College of Surgeons (ACS) recommend the delay of non-essential endoscopic activities and elective surgeries, and are limiting the number of personnel involved in patient operations. As such, patient-based training opportunities for residents and fellows will likely be impacted for an extended period of time.
In-person academic activities, such as teaching conferences, and rotations between different hospital sites are also recommended against by the Centers for Disease Control and Prevention (CDC), in accordance with group size restrictions.
Leveraging Simulation for Endoscopic Skills
“For a procedure-focused specialty such as gastroenterology, attaining and maintaining competency in endoscopic skills has become a concern for fellows during this pandemic. The concern is augmented by the indefinite time period we will be away from the endoscopy suite. Because this is uncharted territory, there is fear of whether this will pose a detriment to our acquisition of procedural skills.” – Shah, R. et al. (2020)
Reduced numbers of routine endoscopic procedures and withdrawal of trainees from operations at many institutions has significantly impacted hands-on endoscopy training in operating rooms. Given that Gastroenterology is a procedure-focused specialty, practicing and maintaining endoscopic skills is critical for the development of a trainee in the field. To address this, simulation has been emphasized as an approach to augment resident learning during the COVID-19 period.
Simulation offers the opportunity to rehearse technical skills and preserve dexterity through deliberate, repeated practice of techniques in the absence of patient cases. Particularly, virtual reality (VR) simulation—especially those with representative endoscopes—can closely replicate aspects of the surgical experience in upper and lower endoscopy, as well as advanced procedures such as ERCP, to minimize skill decay.
Shah, R., et al (2020) at the Case Western Reserve University School of Medicine in Ohio, USA propose the creation of an endoscopy simulation-based training (SBT) curriculum as a solution to meet educational objectives during the pandemic. Similarly, educators at the University of California in San Francisco, USA discuss the use of simulation to supplement procedural experience during this crisis period but noted the challenges with accessing hospital-based simulation centres as a barrier. Coe, T.M., et al (2020) suggest the provision of written or verbal faculty feedback through remote mediums such as Zoom video calls during simulation sessions for guidance.
Innovative Solutions to Adapt the Curriculum
In addition to hands-on training with simulation, residency program directors and educators are implementing other techniques to continue providing high quality endoscopy training. These include:
This mode of learning can be adapted for operative case preparation in light of reduced case volumes. Depending on the endoscopy site’s equipment, procedures can be live-streamed or recorded (with patient confidentiality measures in place) and discussed in real-time via the use of microphones or reviewed at a later time through archives.
Siddiqui, U., & Aslanian, H.R. (2020) successfully implemented virtual endoscopy rounds, which involved videos of patient cases presented by attendings or fellows with discussions about important aspects of the endoscopic procedure, didactic teaching, and Q&A through chat functions. Shah, R., et al. (2020) reported the use of the journal, VideoGIE, for endoscopy video resources.
Internet and social media platforms for group discussion
Major gastrointestinal (GI) societies and journals, podcasts, apps (ASGE GI Leap), online channels (YouTube), and social media platforms (Twitter, LinkedIn, etc.) provide users with a space to host interactive discussions, share content such as video clips of procedures with commentary, and foster a sense of community. Shah, R., et al. (2020) suggests the use of social media for journal clubs. However, content posted on some platforms may lack peer review and level of scrutiny, therefore may have the challenge of propagation of inaccurate information or improper techniques.
Telemedicine for complete clinical encounters
Telemedicine plays an increasingly important role in healthcare accessibility and can allow triaging for patients who need in-person office v.s. virtual visits. However, as an emerging technology, its implementation may be complicated with technical issues, such as connection disruptions, that may impede the use of the system.
In these unprecedented times, collaboration between programs and sharing of knowledge is encouraged to ensure the successful training of residents and fellows. If your institution has a novel approach to adapting simulation into the curriculum, please share with the community.