Disrupting the Education Paradigm: An Opportunity to Advance Simulation Training in Radiology-Radiology In Training.

HomeRadiologyVol. 298, No. 2 PreviousNext Reviews and CommentaryFree AccessPerspectivesDisrupting the Education Paradigm: An Opportunity to Advance Simulation Training in Radiology—Radiology In TrainingAlex J. Solomon , Ryan W. England, Andrew R. Kolarich, Robert P. LiddellAlex J. Solomon , Ryan W. England, Andrew R. Kolarich, Robert P. LiddellAuthor AffiliationsFrom the Department of Radiology and Radiological Science, Division of Vascular and Interventional Radiology, Johns Hopkins School of Medicine, 1800 Orleans St, Zayed 7203, Baltimore, MD 21287.Address correspondence to A.J.S. (e-mail: [email protected]).Alex J. Solomon Ryan W. EnglandAndrew R. KolarichRobert P. LiddellPublished Online:Dec 1 2020https://doi.org/10.1148/radiol.2020203534MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In AbstractDownload as PowerPointDr Solomon is a 4th-year resident on the diagnostic and interventional radiology training pathway at the Johns Hopkins Hospital. His research interests include medical education, patient outcomes, and high-value care.Download as PowerPointOpen in Image Viewer SummaryRadiology has always been on the cutting edge of medical innovation; however, in simulation-based training, we are lagging compared with our procedure-based colleagues.IntroductionThe coronavirus disease 2019 (COVID-19) pandemic has disrupted the idea of a typical day. Radiology, along with almost every other aspect of health care and society, continues to adapt in a rapidly changing environment, altering academic and private practice workflow and volume. Resident education in the era of COVID-19 was, and often continues to be, disrupted by changes in patient volume, clinical redeployment, remote image interpretation, modifications to the traditional trainee read-out, and any combination thereof (1). Recent analysis demonstrates a decrease of 49%–76% for diagnostic examinations and a decrease of 43%–63% for interventional procedures (2). Radiology trainees are likely disproportionately affected by these changes and the unknown circumstances ahead. Seventy-one percent of residents already report a negative impact on their educational mission, while 45% of residents and 61% of program directors note a moderate or marked decline in morale (3). Distance learning, remote teaching, and online case compilations are helping fill the void for diagnostic image interpretation; however, the hands-on nature of interventional radiology and the direct patient-facing aspects of diagnostic radiology (eg, mammography; contrast-enhanced US; image-guided biopsies or interventions in musculoskeletal radiology, body radiology, and neuroradiology) present a unique set of obstacles, which the widespread integration of simulation-based training may mitigate.The traditional “see one, do one, teach one” apprenticeship model for medical education is evolving due to work hour restrictions, lack of uniformity in training, public perception of trainees, emphasis on value-based care, and rapid development of new techniques, procedures, and devices. Decreased case volumes in the era of COVID-19 exacerbate many of these problems. Simulation-based training, currently integrated into the training of many surgical residencies, provides valuable hands-on experience, with the aim of improving patient safety and outcomes (4–6).Procedural simulation-based training is currently used in a limited and variable fashion in radiology training programs around the country. Despite a 2007 Joint Medical Simulation Task Force representing the Radiology Society of North America, Society of Interventional Radiology, and Cardiovascular and Interventional Radiological Society of Europe designed to spur the implementation of widespread simulation training, there is no comprehensive and uniform simulation-based training curriculum in radiology (7). However, despite the many barriers to widespread integration into the current training paradigm, all radiology training programs must equip trainees to enter the workforce in a few short years. Simulation-based education may help ensure ongoing trainee development and uniform competence in the face of the COVID-19 pandemic and future obstacles to radiology training.Opportunities for SimulationSimulators can be broadly classified based on the degree to which they approximate a true clinical encounter (face validity). Low-fidelity trainers are generally inexpensive and are often homemade devices on which to practice task-specific procedural skills. Therefore, trainees can gain familiarity with devices and procedural steps while building both confidence and competence (5,8). Materials, such as gelatin, fiber, food coloring, gloves, rubber tubing, and food products, are available to build simulators for US- and CT-guided procedures in particular (eg, biopsy, nephrostomy tube insertion).High-fidelity simulators are more complex and use hardware and software, such as augmented reality, virtual reality, or both, that mimic the look and feel of a real-world clinical experience. By adjusting variant anatomy and “patient” physiology between and during the simulation while incorporating complications and unforeseen challenges, one can assess a broad range of trainee knowledge, skills, and management. Mannequin-based simulators, such as the SimMan (Laeral Medical, Stavanger, Norway), offer real-time clinical information for common radiologic scenarios, including adverse reactions to contrast material and acute care life support. Integration of patient-specific anatomy and disease can allow trainees to simulate an upcoming procedure. In interventional radiology, high-fidelity simulators focus on endovascular procedures. Examples include VIST-Laboratory (Mentice, Gothenburg, Sweden), ORCAMP (Orzone, Gothenburg, Sweden), and ANGIO Mentor (3D Systems [formerly Simbionix], Beit Golan, Israel).High-fidelity simulators are not inherently better than their low-fidelity counterparts. Simulations should be tailored to the trainee level of experience and the specific aims and outcome measures of the simulation (9).Three-dimensional printing represents a hybrid of low- and high-fidelity simulation. Three-dimensional printers are increasingly common and affordable and allow for patient-specific models with varying degrees of realism. As new three-dimensional printing techniques and materials become available, this technology may soon offer an affordable, realistic, patient-specific, and easily reproducible method with which to locally build simulators.Barriers to Simulation IntegrationBoth low- and high-fidelity simulators can improve technical skills, allow for independent learning, assess trainee knowledge, and identify trainee deficiencies while ensuring a uniform educational experience through both formative and summative assessments (5). As with any disruptive technology, cost, infrastructure, and time are barriers to the widespread implementation of simulators.CostHigh-fidelity simulators are often cost prohibitive (ranging in the tens to hundreds of thousands of dollars for initial purchase). Low-fidelity simulators, although more affordable, often need routine replacement, new materials, or both to recreate the simulation.InfrastructureDedicated simulation centers offer a safe location to store simulation materials and should be accessible to allow for independent practice. The environment can be modified according to the specific simulation goals and used to incorporate multidisciplinary training and simulated patient complications.TimeDevelopment of task-specific simulations with assessments requires substantial time, education, and simulation expertise. Trainees must have dedicated time for independent practice, assessment, and debriefing. Faculty must be able to step away from their clinical duties to serve as facilitators for simulation events.Curriculum and AssessmentDevelopment of a comprehensive national curriculum could distribute the workload while ensuring uniformity of training. The curriculum should incorporate common and critical procedural variations, variant anatomy, and complications, with clear goals and objective metrics for both cognitive and technical proficiency defined for each module. Moreover, each simulation should include a dedicated debriefing session to review and reflect on the simulation experience. Minimal competence must be clearly defined, along with indications and specific tasks needed for remediation. It is critical that the simulation experience be valuable and that it not be viewed as simply a “check-the-box” experience by trainees.TrainingFacilitators and trainees must have dedicated initial instruction to build a basic understanding of how to use the various low- and high-fidelity simulators. Faculty need dedicated training on their roles during formative and summative assessments and on how to offer constructive feedback during dedicated debriefing after the simulation. Uniform training and simulation-specific objective assessments can mitigate variability among facilitators.Evidence-based Outcomes and Simulator ValidityEvidence-based medicine is founded on the principle that the best available evidence should guide medical practice. Therefore, simulator validity, which can be defined as the effectiveness of a simulation to impart the intended knowledge and skills to the trainee, must be evaluated (10). Validity is multifaceted and should be continually assessed using both subjective and objective metrics (Table). Despite the promise of simulation in radiology, there is insufficient evidence demonstrating predictive and concurrent validity (2,5).Assessment of Simulator ValidityThe barriers to widespread simulation integration are deeply intertwined. How can research be conducted on simulator validity without funding to obtain the simulator or without a standardized assessment? How can grants be obtained to purchase a simulator without supporting evidence or an experienced simulation facilitator? Simulation-based training in radiology requires a concerted effort involving a financial investment to deploy simulators and promote research on their use, coupled with a national curriculum-development program led by education and simulation experts. Both diagnostic and interventional trainees will benefit from the increased hands-on exposure, while faculty can expand their pedagogical abilities, develop new simulations, and hone and develop new skills with a widespread availability of simulators.In conclusion, simulation-based training in radiology continues to gain momentum; however, many programs lack the necessary financial commitment, comprehensive curriculum development, and evidence for efficacy to justify widespread implementation. The COVID-19 pandemic and the resultant precipitous decline in clinical volumes highlight the need for supplemental and novel educational techniques to ensure ongoing trainee development and uniform competence upon residency and fellowship graduation. Simulation-based education can mitigate the effects of caseload variability among trainees and allow for ongoing professional development for experienced radiologists. Radiology has always been on the cutting edge of medical innovation; however, in simulation-based training, we are lagging compared with our procedure-based colleagues. Now is the time to push for a disruption in our educational paradigm and use the obstacles presented by the COVID-19 pandemic to advance the science of simulation-based training in radiology.Disclosures of Conflicts of Interest: A.J.S. disclosed no relevant relationships. R.W.E. disclosed no relevant relationships. A.R.K. disclosed no relevant relationships. R.P.L. disclosed no relevant relationships.References1. Alvin MD, George E, Deng F, Warhadpande S, Lee SI. The Impact of COVID-19 on Radiology Trainees. Radiology 2020;296(2):246–248. Link, Google Scholar2. Gabr AM, Li N, Schenning RC, et al. Diagnostic and Interventional Radiology Case Volume and Education in the Age of Pandemics: Impact Analysis and Potential Future Directions. Acad Radiol 2020;27(10):1481–1488. Crossref, Medline, Google Scholar3. Robbins JB, England E, Patel MD, et al. COVID-19 Impact on Well-Being and Education in Radiology Residencies: A Survey of the Association of Program Directors in Radiology. Acad Radiol 2020;27(8):1162–1172. Crossref, Medline, Google Scholar4. Badash I, Burtt K, Solorzano CA, Carey JN. Innovations in surgery simulation: a review of past, current and future techniques. Ann Transl Med 2016;4(23):453. Crossref, Medline, Google Scholar5. Patel R, Dennick R. Simulation based teaching in interventional radiology training: is it effective? Clin Radiol 2017;72(3):266.e7–266.e14. Crossref, Google Scholar6. Griswold-Theodorson S, Ponnuru S, Dong C, Szyld D, Reed T, McGaghie WC. Beyond the simulation laboratory: a realist synthesis review of clinical outcomes of simulation-based mastery learning. Acad Med 2015;90(11):1553–1560. Crossref, Medline, Google Scholar7. Gould D, Patel A, Becker G, et al. SIR/RSNA/CIRSE Joint Medical Simulation Task Force strategic plan executive summary. J Vasc Interv Radiol 2007;18(8):953–955. Crossref, Medline, Google Scholar8. May BJ, Khoury JK, Winokur RS. Tools for Simulation; Low Budget and No Budget. Tech Vasc Interv Radiol 2019;22(1):3–6. Crossref, Medline, Google Scholar9. Munshi F, Lababidi H, Alyousef S. Low- versus high-fidelity simulations in teaching and assessing clinical skills. J Taibah Univ Med Sci 2015;10(1):12–15. Google Scholar10. Miller ZA, Amin A, Tu J, Echenique A, Winokur RS. Simulation-based Training for Interventional Radiology and Opportunities for Improving the Educational Paradigm. Tech Vasc Interv Radiol 2019;22(1):35–40. Crossref, Medline, Google ScholarArticle HistoryReceived: Aug 24 2020Revision requested: Sept 3 2020Revision received: Sept 19 2020Accepted: Oct 6 2020Published online: Dec 01 2020Published in print: Feb 2021 FiguresReferencesRelatedDetailsCited ByUltrasound Simulation Training for Radiology Residents—Curriculum Design and ImplementationLauren F.Alexander, Barbara L.McComb, Andrew W.Bowman, Stephanie L.Bonnett, Samantha M.Ghazanfari, Melanie P.Caserta2023 | Journal of Ultrasound in Medicine, Vol. 42, No. 4Radiology In Training: The Inaugural Year Amidst a PandemicEric Kim, Anna Trofimova, Francis Deng, Susanna I. 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