Novel, Multimodal Approach for Basic Transesophageal Echocardiographic Teaching

Basic Transesophageal Echocardiography Education for Senior Anesthesiology Residents-Institutional Experience

OBJECTIVE

The use of basic transesophageal echocardiography (TEE) in critically ill and older surgical patients can change patient management and improve outcomes after noncardiac surgery. The authors hypothesized that educating the future generation on basic TEE skills by an intense two-month rotation will help them achieve basic TEE certification by the National Board of Echocardiography (NBE) and facilitate good use of their skills for patient care during their practice.

DESIGN

This is a descriptive report of graduating anesthesiology residents who completed two months basic TEE rotation at the authors' residency program between 2013 and 2019. The authors report the clinical training goals, NBE testamur and certification status, and a survey report on the use of basic TEE skills in their practice SETTINGS: University medical center.

PARTICIPANTS

Residents who completed two months basic TEE rotation during their Clinical Anesthesia (CA)-3 year.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of a total of 115 residents, 67 (58%) elected basic TEE rotation. The NBE basic TEE certification and testamur status were achieved by 12 (21%) and 14 (24%) eligible residents, respectively. Residents (n = 43) personally performed 73 ± 21 (mean ± standard deviation) and reviewed 72 ± 28 (mean ± standard deviation basic TEE studies before graduation. The survey indicated that 63.4% of residents trained in basic TEE did not use their skills in their practice.

CONCLUSIONS

Two months' basic TEE rotation was able to fulfill its educational goals (testamur status and clinical training) but fell short on achieving NBE certification rate and its ultimate impact on practice and patient care.

Simulation-based training following a theoretical lecture enhances the performance of medical students in the interpretation and short-term retention of 20 cross-sectional transesophageal echocardiographic views: a prospective, randomized, controlled trial

Background

Both simulation-based training and video-based training serve as educational adjuncts for learning TEE among medical students. In the present study, we hypothesized that simulation-based training would better enhance the performance of medical students in the interpretation of 20 cross-sectional views compared to video-based training.

Methods

A total of 120 4th-year undergraduate medical students were enrolled in the present study. The study began with a pre-test of all the participants, followed by a 90-min theoretical lecture and a post-test. Subsequently, the participants were randomly divided into the video-based group (Group V) and simulation-based group (Group S). Next, Group V received 60 min of TEE video learning, while Group S received 60 min of TEE simulator training. After the respective training, both the groups undertook the retention-test 1 and retention-test 2, 1 week and 1 month later, respectively. The performance for each test was evaluated by five views, which were selected randomly and, respectively, from a set of 20 cross-sectional views. The primary outcome was the performance of the retention-test 1. Secondary outcomes included: (1) comparison the performances of the pre-test, post-test, and retention-test 2 between two groups; (2) comparison the performances of pre-test and post-test in the same group; (3) comparison the performances of retention-test 1, and retention-test 2 in the same group.

Results

Better performances were observed in Group S in both retention-test 1 (Group V: 63.2 [52.6, 77.6] vs. Group S: 89.5 [68.4, 100.0], P < 0.001) and retention-test 2 (Group V: 58.0 [48.0, 72.0] vs. Group S: 74.0 [64.0, 80.0], P < 0.001) compared to Group V. No statistically significant differences were observed in the performances of pre-test (Group V: 8.3 [4.2, 12.5] vs. Group S: 8.3 [4.2, 12.5], P = 0.825) or post-test (Group V: 46.2 [38.5, 57.7] vs. Group S: 44.2 [38.5, 56.7], P = 0.694) between the two groups. The improvement had been observed in the post-test, compared with pre-test in the same group, respectively (Group V in post-test: 46.2 [38.5, 57.7] vs. Group V in pre-test: 8.3 [4.2, 12.5], P < 0.001; Group S in post-test: 44.2 [38.5, 56.7] vs. Group S in pre-test: 8.3 [4.2, 12.5], P < 0.001). However, the performance in retention-test 2 was significantly reduced, compared with retention-test 1 in the same group, respectively (Group V in retention-test 2: 58.0 [48.0, 72.0] vs. Group V in retention-test 1: 63.2 [52.6, 77.6] P = 0.005; Group S in retention-test 2: 74.0 [64.0, 80.0] vs. Group S in retention-test 1: 89.5 [68.4, 100.0], P < 0.001).

Conclusions

Following a 90-min theoretical lecture, simulation-based training better enhanced the performance of medical students in the interpretation and short-term retention of 20 cross-sectional views compared to video-based training.

Trial registration

http://www.chictr.org.cn (ChiCTR2000033519, 3/June/2020).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-021-02753-1.

Three-Dimensional Transesophageal Echocardiography Simulator: New Learning Tool for Advanced Imaging Techniques

The use of intraoperative three-dimensional (3D) transesophageal echocardiography (TEE) has grown exponentially in recent years. Three-dimensional TEE technology has evolved to allow for real-time display of 3D images and, thus, has become the standard of care for the evaluation of cardiac anatomy and function. Its use has provided a new dimension of clinical insight when managing patients for cardiac surgery or structural heart interventions. While the intraoperative utility of 3D TEE has expanded, there has been a slower advancement in the area of training and, specifically, simulator-based training in 3D TEE. This training is essential, as the skill set involved in acquiring 3D data sets differs from that of two-dimensional (2D) TEE and requires users to be able to appreciate how 3D anatomic display differs from that of tomographic cross-sectional 2D imaging. This added skill set requires mental reconstruction and spatial reorientation to appreciate the added elevational dimension in frustum-based imaging and is best achieved in a simulation environment rather than the busy operating room. In this review article, the authors evaluate the functionality of a 3D TEE simulator and how simulators such as this can establish preclinical proficiency in novices in the expanding area of advanced 3D TEE imaging.

Educating Anesthesiologists During the Coronavirus Disease 2019 Pandemic and Beyond

The coronavirus disease 2019 (COVID-19) pandemic has altered approaches to anesthesiology education by shifting educational paradigms. This vision article discusses pre-COVID-19 educational methodologies and best evidence, adaptations required under COVID-19, and evidence for these modifications, and suggests future directions for anesthesiology education. Learning management systems provide structure to online learning. They have been increasingly utilized to improve access to didactic materials asynchronously. Despite some historic reservations, the pandemic has necessitated a rapid uptake across programs. Commercially available systems offer a wide range of peer-reviewed curricular options. The flipped classroom promotes learning foundational knowledge before teaching sessions with a focus on application during structured didactics. There is growing evidence that this approach is preferred by learners and may increase knowledge gain. The flipped classroom works well with learning management systems to disseminate focused preclass work. Care must be taken to keep virtual sessions interactive. Simulation, already used in anesthesiology, has been critical in preparation for the care of COVID-19 patients. Multidisciplinary, in situ simulations allow for rapid dissemination of new team workflows. Physical distancing and reduced availability of providers have required more sessions. Early pandemic decreases in operating volumes have allowed for this; future planning will have to incorporate smaller groups, sanitizing of equipment, and attention to use of personal protective equipment. Effective technical skills training requires instruction to mastery levels, use of deliberate practice, and high-quality feedback. Reduced sizes of skill-training workshops and approaches for feedback that are not in-person will be required. Mock oral and objective structured clinical examination (OSCE) allow for training and assessment of competencies often not addressed otherwise. They provide formative and summative data and objective measurements of Accreditation Council for Graduate Medical Education (ACGME) milestones. They also allow for preparation for the American Board of Anesthesiology (ABA) APPLIED examination. Adaptations to teleconferencing or videoconferencing can allow for continued use. Benefits of teaching in this new era include enhanced availability of asynchronous learning and opportunities to apply universal, expert-driven curricula. Burdens include decreased social interactions and potential need for an increased amount of smaller, live sessions. Acquiring learning management systems and holding more frequent simulation and skills sessions with fewer learners may increase cost. With the increasing dependency on multimedia and technology support for teaching and learning, one important focus of educational research is on the development and evaluation of strategies that reduce extraneous processing and manage essential and generative processing in virtual learning environments. Collaboration to identify and implement best practices has the potential to improve education for all learners.

Simulation in Neonatal Echocardiography

There is a growing interest in neonatologists to train in echocardiography. Recommendations for training have been published by medical societies and working groups, but concerns exist on their feasibility in the face of limited resources. Simulators are increasingly used for training in medicine, including echocardiography. They have the potential to help overcome the shortage of training opportunities. We describe the currently available 2 echocardiography simulators designed for neonatology. Both systems are based on real 3-dimensional echocardiographic data and use an electromagnetic tracking system. Although limited data exist proving their effectiveness, deduction from other disciplines support this assumption.

Learners and Luddites in the Twenty-first Century: Bringing Evidence-based Education to Anesthesiology

Anesthesiologists are both teachers and learners and alternate between these roles throughout their careers. However, few anesthesiologists have formal training in the methodologies and theories of education. Many anesthesiology educators often teach as they were taught and may not be taking advantage of current evidence in education to guide and optimize the way they teach and learn. This review describes the most up-to-date evidence in education for teaching knowledge, procedural skills, and professionalism. Methods such as active learning, spaced learning, interleaving, retrieval practice, e-learning, experiential learning, and the use of cognitive aids will be described. We made an effort to illustrate the best available evidence supporting educational practices while recognizing the inherent challenges in medical education research. Similar to implementing evidence in clinical practice in an attempt to improve patient outcomes, implementing an evidence-based approach to anesthesiology education may improve learning outcomes.

Training Surgical Residents for Ultrasound-Guided Assessment and Management of Unstable Patients

OBJECTIVE

Proficiency in the use of ultrasound is presently not an ACGME required core competency for accredited surgical training. There should be a basic unified ultrasound curriculum for surgical trainees. We developed a multimodal ultrasound-training program to ensure baseline proficiency and readiness for clinical performance without impacting trainee duty hours.

DESIGN

We developed and implemented a multimodal curriculum for ultrasound education and its use as a supplement to clinical evaluation of unstable patients.

SETTING

A single-center study was completed in a hospital setting.

PARTICIPANTS

Post-graduate year-1 surgical residents at our institution were invited to participate in a multimodal perioperative course.

RESULTS

51 residents attended the course over the three sessions. The vignette exam as a whole demonstrated a Cronbach's alpha of 0.819 indicating good internal reliability of the entire test. There was significant improvement in their knowledge in clinical vignettes (55% ± 12.4 on pre-test vs. 83% ± 13.2% on post-test, p<0.001).

CONCLUSION

It is feasible to incorporate a focused ultrasound curriculum to assess clinically unstable patients. The multimodal nature of the course aid in the development of preclinical proficiency and decreased the orientation phase of ultrasound use.

Standard Setting for Clinical Performance of Basic Perioperative Transesophageal Echocardiography

Background

Credible methods for assessing competency in basic perioperative transesophageal echocardiography examinations have not been reported. The authors’ objective was to demonstrate the collection of real-world basic perioperative transesophageal examination performance data and establish passing scores for each component of the basic perioperative transesophageal examination, as well as a global passing score for clinical performance of the basic perioperative transesophageal examination using the Angoff method.

Methods

National Board of Echocardiography (Raleigh, North Carolina) advanced perioperative transesophageal echocardiography–certified anesthesiologists (n = 7) served as subject matter experts for two Angoff standard-setting sessions. The first session was held before data analysis, and the second session for calibration of passing scores was held 9 months later. The performance of 12 anesthesiology residents was assessed via the new passing score grading system.

Results

The first standard-setting procedure resulted in a global passing score of 63 ± 13% on a basic perioperative transesophageal examination. The global passing score from the second standard-setting session was 73 ± 9%. Three hundred seventy-one basic perioperative transesophageal examinations from 12 anesthesiology residents were included in the analysis and used to guide the second standard-setting session. All residents scored higher than the global passing score from both standard-setting sessions.

Conclusions

To the authors’ knowledge, this is the first demonstration that the collection of real-world anesthesia resident basic perioperative transesophageal examination clinical performance data is possible and that automated grading for competency assessment is feasible. The authors’ findings demonstrate at least minimal basic perioperative transesophageal examination clinical competency of the 12 residents.

Role of Simulation in Perioperative Echocardiography Training

Echocardiography plays a major role in the diagnosis and management of hemodynamic compromise during the perioperative period. Both transthoracic and transesophageal echocardiography have been shown to improve outcomes after cardiac and noncardiac surgery. Teaching basic echocardiographic skills to perioperative physicians remains a challenging task. Thus far, simulation-based medical education has been proven useful in teaching specific procedural skills and management of infrequent catastrophic events. Simulation-based echocardiography education has the potential to facilitate clinical training in echocardiography. Several small studies have shown the benefits of echocardiographic simulation on developing psychomotor and cognitive echocardiography skills. Future research should focus on the impact of simulation on actual clinical echocardiographic performance in the operating room and ultimately, patient outcomes.