your host Sol Flores. I'm a cardiac intensivist at Texas Children's Hospital and associate professor of pediatrics at Baylor College of Medicine. I'm also the treasurer of the in-training section steering committee for the Society of Critical Care Medicine. Today we'll be talking about the effect of the COVID-19 pandemic on the medical education. Is virtual education here to stay? And I have the pleasure to be with two experts on this topic. First I have Dr. Lane Silver. She's a second year pediatric critical care medicine fellow at Cohen Children's Medical Center of Health in New High Park, New York. She received her bachelor of science degree at Cornell University in biometry and statistics and her medical degree from Renaissance School of Medicine at Stony Brook University. She completed her pediatric residency training at the Icahn School of Medicine at Mount Sinai. She's the first author on the recently published article The Effect of the Coronavirus 2019 Pandemic on Pediatric Critical Care Fellowship Training and is very interested in medical education, specifically focusing on virtual learning and simulation. Her other current research interest includes pediatric acute respiratory distress syndrome. Welcome Dr. Silver. And I also have Dr. Cheryl Tarasi. She's a pediatric critical care attending at Cohen Children's Medical Center of Norwell Health in New High Park, New York and an assistant professor at Donald and Barbara Zucker School of Medicine at Hofstra Norwell. Her academic interests lie in medical education. She's the program director of the Pediatric Critical Care Fellowship and the associate program director of the pediatric residency at Cohen Children's Hospital. She has a master's in health professional and leadership and she serves on various local regional and national medical education committees. For example, she sits at the Norwell Health System GME Well-Being Executive Committee and the Association of Pediatric Program Directors. Chief resident executive committee. She has been a mentor of multiple trainees in medical education projects, including Dr. Silver's survey of the effect of the pandemic on the Pediatric Critical Care Fellowship Training. Welcome Dr. Tarasi. And I really appreciate you guys' presence. I think this is one of my favorite topics to discuss about and I think it's so timely to go over some of the details of your survey. Since the onset of the pandemic back in March 11, 2020, the lives of everybody suddenly changed and went upside down. Thousands of patients getting infected, mortality on the rise, hospitals at the brink of collapse. Along those lines, healthcare providers are stretched to the fullest, medical schools have to suspend activities, and training programs were left with unclear paths. Quickly, leaders like yourself have to take action and modify curriculums to keep up with the current environment and virtual education solidifying itself as a plausible educational option. So Dr. Silver, can you give us a background on your experience as a trainee during the COVID-19 pandemic? Sure. Thank you so much for talking about this with us today. So I was a senior resident during the beginning of the pandemic at a hospital in New York City and then a junior fellow during the rest of that first year at a different hospital in New York City. And so my role during this time was mainly as a learner or a trainee with some minimal responsibility as a supervisor, educator for more junior residents and medical students. And at these two institutions, we experienced emergency mode in March of 2020 where ACGME requirements were paused for 30 days. I was redeployed to adult ICUs two different times during that first year of the pandemic, once in March and April of 2020, and then again in January of 2021. And I was interested in how other programs in the country were fending during this time as different locations were having very different experiences at different times during that first year of the pandemic. And so that kind of what piqued my interest to see what are other pediatric critical care fellowship programs doing during this time to provide the education that's necessary. And that's what motivated us to do the national survey to learn more about that topic and for me to do some more investigation on my own to kind of get a better sense at the scope of virtual education and critical care. Thank you for sharing that. Dr. Taurasi, what are your views of that? Hi, thank you. I wanted to also say thank you for talking with us today. So I was on the educator side. We were part of Common Children's, which is in Queens, New York. We were part of the first wave of the pandemic. And the experience that I had on all different levels was really fascinating. As a critical care provider, I was redeployed myself. I was on the front lines in the adult units. I was with my fellows who were also redeployed. We stopped all education briefly. And from the residency perspective, we had some residents redeployed and then other residents who were sitting at home doing nothing. And we briefly stopped new conferences, as Dr. Silver mentioned, based on ECG going into stage three pandemic emergency status. We then quickly moved to, well, we have to do something and what can we do? And we'll talk about this a little bit later of the evolution of the difference between moving emergently to online learning and then changing your curriculum to satisfy the normal learning needs of your residency and your fellowship. And again, there were also other things we'll get into about different kinds of, you know, prep for COVID versus actually learning your ECG requirements of your specific field. Those are really interesting points. Moving on. Dr. Silver, would you mind sharing the findings from your survey, please? Sure. So we conducted a survey of all PICU fellowship programs during February of 2021 and received about a 50% response rate from program directors. And we learned that nobody was doing fully in-person education at that time. About half were doing fully remote and the other half were doing some sort of blended curriculum. And about half of the program directors reported that learner engagement was lower than baseline. And the fellow responses we received were even worse in terms of learner engagement. Another thing that we looked at was different didactic types. So ironically, when we asked program directors, how did your didactic schedule change due to COVID, the large majority said there was no change. But when we asked about specific didactic types that are important for PICU training, we saw that nearly three quarters of program directors reported less simulation training and about half reported less procedural skills training and less ultrasound training, which was not that surprising as these are more hands-on modalities. About two-thirds of program directors reported that their fellows were doing less procedures than typical year and nearly half had less confidence in their fellows' ability to perform those procedures because of that. That was also associated with having less number of procedural skills didactic sessions. So this was interesting because it's something that's modifiable in that if program directors are seeing that their fellows are performing less procedures, there are other ways that they can compensate for that, either through mannequins, simulation, or having their fellows rotate outside of the unit to get those important skills. We also saw that during that first year of the pandemic, that inpatient pediatric ICU census was down pretty much nationally and in lots of places has since recovered, but program directors were reporting less confidence in their fellows' medical knowledge, management skills, and procedural skills when they saw those drops in their normal patient census, with bigger drops in census associated with bigger decreases in program director confidence. This is more of a perspective as we know different size programs have different patient censuses at baseline, but it's important for program directors to keep in mind because if they're seeing times either during the pandemic or post pandemic when their census is down, that might be a time where they have to supplement education in other ways. So overall in our survey, we really wanted to highlight the deficiencies in education and pediatric critical care to stimulate discussion on what we can do better moving forward to compensate for the parts of education that have changed due to the pandemic. That's a really good summary, but let me ask you a question. What do you think were some of the early on setbacks on education? So Dr. Trausty and I were both in New York City during this time, so we went from everything being programming as normal to in the course of a couple of days going into complete emergency mode, and emergency remote learning is very different than what a virtual online curriculum should be. So what happened was we did no education, and then at some point educators took their pre-existing curriculum and just put it onto the online platform. And I think it's naive to think that taking your curriculum from before and just moving it onto the computer is going to be just as effective, and so that was a big setback early on. There was not really time to prepare and there was really no background for how to make this new education effective, and there was no clear time. Each location was on a different scale in terms of what was going on in the pandemic, and so in New York we started hard and fast and in other places maybe it was a little bit different. But there was also really no time when that crisis mode became a more stable mode. You didn't realize you were in a more stable pandemic time until that time had already passed and you're on to the next crisis. So there was not really a time where we learned about a new normal of how we can conduct our education, and so I think that was kind of a setback from the beginning and played into low learner and low educator buy-in. So as a learner I didn't think that this type of education was here to stay, and I was very much focused on learning all I could learn about COVID and much less focused on learning about my general pediatric board topics, and so I'm sure that was true in other specialties as well. And as critical care providers we really had to shift our focus to clinical work, which I think is another setback in this transition to virtual learning is that in graduate medical education, especially in critical care, medical education is secondary to the clinician's job of being a doctor, being a clinician, or being a researcher. So the medical schools did a much better job at this. They were able to just focus on how to provide education while our educators were focusing on how to be clinicians and secondarily how to provide education, and so Dr. Trost, you can talk more on this about how medical education is not really protected time or funded time for a clinician, and so it makes it very difficult to just create something out of nothing for a virtual education during a pandemic. So there were, there's been some research done on different ways that this would, that different specialties were able to provide virtual education early on and how some of them were successful and others less so, and so the National Surgery Resident Lecture Series was created by Virginia Commonwealth University, and this was a group of surgeons who had low surgical volume at this time, were doing daily sessions to teach surgical residents around the country about core learning topics, but after about a month they weren't able to keep up with this because they didn't have volunteers for the lectures, they didn't have funding, and their learners were now starting to get back to the surgical volumes they were used to and not able to log into these live webinars, and so problems like that I think were really common in the beginning and hard to overcome. The last, oh I'm sorry, go ahead. Okay, the last thing I wanted to mention was that the expectation in medical education is that everything that's publicly available online is going to be evidence-based, peer-reviewed, up-to-date, and fully accurate, and this requires an enormous amount of time on the part of the educator to provide. Those are really good insights into how you experienced all of this in the heart of it all, and you know I'm very appreciative of you sharing all of that, but I want to hear Dr. Terrasi's point on that, specifically how do you think virtual education has evolved over the last two years? So I think like Dr. Silver mentioned, we started with emergency online learning, which was essentially everybody just taking their usual curriculum and moving it online, which didn't really work, we quickly discovered. Also, the early literature was not great literature, it was more like the equivalent of education case reports of this is something we're trying, we don't have any data, whether it works or not, but here you go, this is an idea, and that was just as the ways COVID And that was just as the ways COVID articles were coming out very quickly, the whole process of being approved for publication was sped up, it was the same in medical education, that usual standards were kind of put to the side, and it was here's an idea, let's publish it and see if other people want to try it. One of the other things people were using online learning for was related to COVID, like debriefing and prepping for redeployment, and that stuff was all necessary at the time, but not necessarily done in the best ways with the most sound pedagogical principles. But over this time now that we've had different waves and maybe breaks in clinical emergencies, we are now taking some pause and looking at how adult learning theories and other educational principles can now apply to virtual education. And this is really on both sides, the faculty is adjusting as well as the learners who now have to learn a different way, like they're learning on Zoom, which is obviously new for them also. Like Dr. Silver mentioned, UME, undergraduate medical education, really took the lead on this, and GME has lagged a little bit behind but is now using these lessons. Also learning lessons from other kinds of educators that have been doing online learning for maybe a longer time. And so for example, there are frameworks that are related, that are education frameworks related to using technology, there's a framework called TPAC, I'm not going to bore people with it, but it looks, it's basically a Venn diagram of how you take content and technology and knowledge and put that all together, and that that's how you can make a session. There's also a really great video that you can find on YouTube called Pedagogy in the Age of Zoom, which Neil Mehta, who's a well-known medical educator, talks about things that you have to think about when you are teaching online, when you are teaching remotely, things like something called cognitive load, which means you cannot put too much on your slides, because it is hard to pay attention to a lot of things on a slide as well as what somebody's saying to you. And so trying to understand these different theories, which will make you a better educator online, are starting to be put into literature, be put into frameworks that will be easier for people to understand. So I think the summary is we went from emergency online learning to making this something that works with sound educational principles behind it. These are really great points, and I think they're going to be welcomed by our community, because like you said, we weren't really trained in developing high-quality educational material virtual. We had to kind of learn this on the go, and it's amazing how much you guys have been able to learn with this survey. But here comes a question, and this is the meat of our talk. Do you think that pediatric critical care education virtually is here to stay? So I think that it is probably in a hybrid mode. I think that Dr. Silver has touched on that there's things that we all know are better done in person, especially procedural type of education simulation. Although it can be done virtually, it takes a lot to learn how to do that remotely, so that tends to be better in person. But really, a lot of the other kinds of didactics can be moved virtually, and there are some benefits to it. So if you think about Generation Z, who is the generation born in 1997, which is our medical students now, they are really poised for this kind of learning. They grew up with technology. They want to use technology. They're comfortable with technology. They are learning in their middle school and high school a lot of active problem solving, a lot of self-directed learning. So this is really the generation who will do well in this environment. There's also a certain amount, which as faculty, I think we understand this. There's a certain amount of flexibility to having lectures done remotely. My fellows now, when they're on academic time, they can be at home, and they don't miss, they work at home, they do their research, and they don't miss any conferences because we are doing them remotely. So I do think that we're kind of set up for this to stay, but in order to do it, we have to, to go back to what I said before, we have to do it the right way. We have to learn how to do it. So faculty development is going to be a huge part of this. So that, like you mentioned, Dr. Flores, like we did not learn how to write. We don't know how to do this. I know how to take a whiteboard and write on a whiteboard, and that's how I've taught. So we have to learn almost a new identity as teachers to incorporate this technology and to teach this way, but it can be done. I think that's the important thing, is it can be learned. It doesn't have to be that complicated, and you don't have to be a master educator to learn how to teach virtually. I feel the same way. I think that really summarizes the way we, a lot of us in a faculty role, feel about this environment. I think that hybrid is probably going to be the way to go in the future, but I do want to hear Dr. Silver comments. You're going to be devil's advocate here. You're going to tell us the pros and cons. As a trainee, the pros and cons of virtual education, what do you think should stay? What do you think should go? So I think, like Dr. Trause mentioned, there are some components of learning that are great to be done online, and this is mostly knowledge-based content, and so you can have an online learning platform where you have a mix of synchronous and asynchronous sessions. So asynchronous sessions are material that the learner does on their own time, and as a learner, this is something that's great if you're self-motivated and like to take the time to learn things on your own schedule. So maybe there's pre-recorded videos or somebody's PowerPoint or an article or chapter posted on a topic, and on your own time you can look at it. You can pause in the middle of the video to look up something you're unsure about. You can refer to other resources, and then you have a synchronous session where you go through kind of the problem-solving part of it, the teamwork part of it, learning from your peers, asking questions, and that's something that can be done really well, especially with knowledge-based content that doesn't necessarily change from day to day. So something like cardiopulmonary interactions where maybe you need to see it, hear it, read it, do it 10 different times to understand, but it's not necessarily going to be different next year or the year after. That's something that's great for an online learning platform, and I think if educators and learners have buy-in and engagement in it, it's something that could last for years of the same content, and it could be really effective. Something that we've already talked about that's not effective virtually is these hand-on experiences, and it seems like most programs actually just didn't have them all together, but from my experience when we've tried to do some of these sessions as virtual, they don't go as well, so this is like simulation, procedural skills, ultrasound. Obviously, we're losing that bedside teaching that we've all done since medical school where you see pathology firsthand, you watch someone else elicit physical exam findings, and you mimic it yourself, so that for sure is going to suffer during virtual time, and I think especially for younger trainees, I know for me, you know, when I was a medical student in the VICU, I examined every patient like five times a day because what else are you doing, and so our younger trainees aren't doing that because they're trying to mimic, like, have less patient interaction, but I do think what Dr. Trosty's saying about a hybrid model is really where things are moving for the future, and as someone who was in medical school at a time when there were some online learning and some in-person learning, I saw more and more that classmates no longer went in person when it was available to view online. That is really where the trend is going, and the AMA did a survey a few years ago where less than 50% of medical students were going to all of their lectures in person at that time, and I'm sure in the years following, it was even less, so I think that's kind of my thoughts on that hybrid model. I don't know if Dr. Trost, you had anything else you wanted to add about it? So I think, as I was preparing for this, I was actually thinking that if there could be another word for hybrid result that means three things. I think some things being in person, like you were talking about, Dr. Silver, the procedural skills, simulation, as I mentioned before, like, these are the kind of things that I think really are good to be in person, but then there's also the remote. We can do synchronous and asynchronous, and asynchronous has a lot of different ways. In general, the teaching for asynchronous has been that's the passive learning. They can watch a pre-recorded video. You can do reading ahead of time, but asynchronous doesn't have to be passive. It can be active. You can be giving projects, group projects, individual projects for people to do asynchronously, and again, going back to adult learning theory, this fosters intrinsic motivation, which adult learners, they are not, external motivation means like your teacher's telling you to do something, your parent's doing something. Intrinsic motivation is really what drives adult learners, so that's what you want to foster, and asynchronous learning can actually foster that, and they also like things that are self-directed. That's also part of adult learning theory, so these can be things that can be done on trainees' own time, and then you have synchronous sessions to now you do the problem solving, like another theory called constructivism, which is when you take knowledge, and then you have to synthesize and construct. That's where the name of the theory comes from, and that's really where the meat of learning is, so combining all three of these in-person things, asynchronous learning, synchronous learning, I think is the real future of the hybrid model for GME. And I think those are really key points that I hope our audience is able to rescue, because we're taking a deeper dive into educational conceptual frameworks here, and adult learning, as Dr. Terrasi is sharing with us. I'm sure there's going to be way more down the pike in terms of methods to be able to substitute, for the time being at least, traditional learning. One of the things that I'm particularly interested in is on the virtual education of ultrasound. As you said, it's very challenging, because it's one of those hand-eye coordination, hand skills, and having an instructor right over you holding your hand, it's one of those things that is really helpful. But I do hear that there are virtual simulators coming down the pike that may be something that may be able to bridge some of those challenges. So now, here's the final question for both of you guys, and it's kind of like a two-for-one type of question. So one is, what do you think professional societies should do with regards to virtual education, in terms of implementing them into their curriculum? And B is, do you think national, international meetings should be virtual, in-person, or hybrid? So I think societies really should, like SCCM, should have a role in this move to virtual curriculum. Things like video, like everything we're talking about takes a lot of preparation. Everybody, I'm sure most of the faculty listening, have PowerPoints that they made several years ago that they only have to tweak a little bit before they give it, and this involves changing everything you've been doing, and it takes a lot of time. So we should collaborate and make some of that easier. So some of these asynchronous projects, pre-recorded videos, that can be done nationally, and we can share with each other. So societies having like video libraries of these kind of asynchronous learning, and Dr. Silva was mentioning, you can watch it, you can pause it, you can, you know, really do it in the time of day that works the best for you. I think societies have a big role in that, that's number one. Number two, and I mentioned this before, we do, you need faculty development. My health system, I was part of a faculty development webinar for the Northwell health system, where we went through all the different kinds of technology available, and our whole point, meaning like different kinds of platforms that people can use, and the whole point of this was don't learn all of these things, pick one or maybe two that you learn really well, like don't try to make it complicated, try to make it as simple as possible, and faculty really loved it, but I think that's something that the national societies can really help with, making webinars that people can watch and learn some of the, just like the simple tips of how can I make this work. You don't necessarily have to understand all the theories behind it to be a good virtual teacher. I think you just need some strategies, and I think that's where the societies can be really helpful for, is collaborating and making that, those kind of resources available. What are your thoughts, Dr. Silver? So I was thinking along the lines of what you were saying about virtual ultrasound, that some of the professional societies nationally could help vet some of these online programs that can be used so that we know that the education is what we're expecting of it, so whether that's virtual ultrasound, there's other virtual reality and gaming systems that surgeons use with robotic surgeries for procedural skills, there's one for endoscopy as well as bronchoscopy virtual reality and gaming, and I think that is the future of online education, and if the professional societies are able to vet these private companies or these online resources so that we know they're up to the standards of education, then we can all share in these resources and know that the learners and the educators are all kind of on the same playing field and getting the most up-to-date and accurate information, but in terms about national societies kind of dictating when we're virtual versus when we're in person, I think it's going to be really difficult, as we've seen during this pandemic, that different parts of the country are on totally different pages at different times, and so when we might be in crisis mode in New York, somebody in another part of the country might be in more stable pandemic mode, and so I think that there's going to always be that changing environment, and for your second question about conferences, I think Dr. Trosty and I were, of course, very much looking forward to doing this in person and would love to do this in person in the future, but I do think that there's something great about being able to log into conferences remotely, and as a trainee who, you know, is on service all the time, I have been able to log into some remote conferences that I would never have been able to go to if they were in person, and so I think a hybrid model for conferences is also going to be what continues, but we just have to keep in mind that having a certain number of users doesn't mean that number of people is necessarily engaged and listening, and so it doesn't necessarily make it the same experience, so if you're going to be giving a conference to a group of people and also have it be recorded for online, you might have to change how you're teaching and how you're speaking, just like what Dr. Trosty was talking about before. So, the gist of it is that the professional society should reach deep into the into the toolbox of educational conceptual frameworks, trying to implement things that are efficient. I do like the what Dr. Taurasi was saying with regards to faculty development, not only that means academic promotion, but also learning new skills that could be deployed for education, and then in terms of our conferences, particularly for the ones that are national and international, being able to have a hybrid model I think is going to be here to stay for the most part. Yes, I mean interviewing is probably here to stay for, you know, maybe for faculty recruitment also, but for residents and fellowships, I think that's it, like we are going to stay virtual. It just, it showed deficiencies that I think we maybe didn't even realize were there. Residents who didn't have the means to travel or with their, maybe at a smaller program where they couldn't get as much time off than at a bigger program, and I think it's the same for these conferences. This allows, a hybrid model allows many more people to attend, but we are going to obviously have to work on how best to deliver these conferences if we are going to make them hybrid. I agree. Well, during this time, we've been able to summarize some quantifiable effects of the pandemic on pediatric critical care fellowship training. We went over the challenges and successes of virtual learning and the role of professional societies in the transition from virtual to in-person learning. I'd like to thank you both for your time. I look forward to meeting you in person, hopefully in 2023. On behalf of the in-training section steering committee and the Society of Critical Care Medicine, I'd like to thank you for your attention.

COVID-19 pandemic

medical education

virtual education

pediatric critical care fellowship training

blended curriculum

learner engagement

hybrid model