Central Line

Episode Number: 129

Episode Title: Inside the Monitor: Updates in Medical Education

Recorded: April 2024

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Welcome to ASA’s Central Line, the official podcast series of the American Society of Anesthesiologists, edited by Dr. Adam Striker.

DR. ZACH DEUTCH:

Welcome back to Central Line. I'm your guest host, Dr. Zach Deutch. Today I'm joined by Dr. Shobana Rajan for our discussion of anesthesia education and the many ways it is evolving, which is the topic of June's ASA Monitor. Dr. Rajan happened to be guest editor for this issue. I'm very pleased to welcome her to Central Line to talk about this topic, which is one that many of us have interest in, whether we're in academic medicine or not. Welcome to the show, Dr. Rajan.

DR. SHOBANA RAJAN:

Thank you so much for this kind invitation to take part in this podcast.

DR. DEUTCH:

We're glad to have you. Getting us started off, can you tell us a little bit about yourself, your career path and how you got interested in medical education and what your role in education is right now?

DR. RAJAN:

Sure. I did my first residency in anesthesiology at one of the premier institutions for education and research in India, and I worked for a few years before I came to the United States and then did my second residency in anesthesiology. Now, the most valuable lesson that I learned during my initial years of training in India was to think and learn reflectively. The whys, the whats and the hows, and to continuously build on foundational concepts. And this has become my philosophy of education as I subsequently transition to the United States. So when I trained the second time, this gave me the opportunity to look at education with a fresh perspective, which is through the eyes of my co-residents in the United States. And I was struck with the realization that there was this growing divide between the millennials and the faculty, because the faculty were trained with traditional lectures, whereas the millennials at that time, when more into digital learning and, you know, if you gave them a traditional lecture, it's possible that many of them would zone out. So I realized at that point that there needs to be some drastic reforms in education, and I've been working on it since then, and I feel that we need to have what is called as active learning, where the trainees are actively engaged and empowered after the learning. So this has been my philosophy and vision for education.

After this, I've held multiple leadership positions in education on the national and international scene. I'm currently program director for the Neuro Anesthesiology Fellowship at the Cleveland Clinic, where I work as staff anesthesiologist, and my vision for this position is opening minds and eyes to the fascinating field of neuro anesthesiology for the trainees. I'm also the current chair for the International Council for Perioperative Neuroscience Training, which deals with global standardization of neuro anesthesiology fellowships and accreditation of training. At the ASA, I am on the editorial board of the ASA monitor and also chair of the Abstract Review Committee of Clinical Neurosciences. I've had the honor to obtain the Distinguished Educator Award, the ASA, and the SNACC Lifetime Educator Award, and I am really extremely happy, and I feel it's an honor to be in this career where I'm completely dedicated to teaching and mentoring.

DR. DEUTCH:

Thank you for that excellent summation.

Let's move on to talk about the role of education as it affects the future of our specialty. So we all know that there's a shortage of anesthesiologists. And many believe that this will get worse. So one of the solutions, of course, is to try to recruit more and more medical students into our field. But we also know that our field is not necessarily high profile within the role of basic medical student education. And they're not aware often of the role that we play, whether we're working in the OR out of the OR, all the things that anesthesiologists do. Can you talk about this challenge of visibility and recruitability, and what's being done to ensure that medical students are exposed to our specialty? And are you aware, in your travels as an educator and on the national and international scene, of any institutions that have solved this problem, and in what ways have they done so?

DR. RAJAN:

Sure. I think attracting interested medical students into our specialty is the need of the hour, and possibly the way forward for the growth of our speciality. I think medical students choose their specialty based on a number of factors. Their interest in a particular area, their exposure to a particular specialty, their personal fit, and then important factor is when they have some role models or mentors who can influence them, as well as peers who are in a particular specialty and doing well and are successful in that specialty. So when some of the criteria are not met, medical students end up choosing a career that they're not particularly happy with and then have to change to a different specialty of choice.

If you look at some surveys from the AAMC in 2020, it suggests that medical students have not been choosing anesthesiology as their first choice. But later they get into anesthesiology as an alternate option. It's possible that these medical students had some pre-made bias about the specialty, or it could have been a lack of exposure to anesthesiology early enough during medical school, or even lack of appropriate mentorship.

So because of this, there have been a number of initiatives by different universities to try and improve interest in anesthesiology. Some universities have created programs where they get medical students to do some simulation sessions, procedural skill sessions, and this possibly could improve familiarity with anesthesiology. Other institutions have had career discussions with medical students and mentorship models. Recently, there was a program that Brown University introduced, and this is called anesthesia - much more than putting you to sleep, and they've been able to attract some of the brightest medical students into our speciality. At Stanford, they have a near peer mentoring process where residents in anesthesiology mentor medical students as well as high school students. And apparently this has resulted in a threefold increase in interest in anesthesiology. Hence, one has to have a multi-pronged approach which includes curriculum reform, innovative educational efforts, advocacy, and mentorship programs in order to attract the future generation and get them interested and engaged in our speciality early enough in their medical school. I think that's where we need to go.

DR. DEUTCH:

So we have leaders on the East Coast, Providence, Rhode Island, leaders on the West Coast, Palo Alto, California, according to your travels.

DR. RAJAN:

Yes. That's absolutely correct. Yes.

DR. DEUTCH:

So what we can say is our private groups that may not necessarily be trading, these people can thank practices like these for reeling in the best and brightest into our specialty, and providing people that can work with them in their practices. So it really benefits everyone in the end, is the hope.

DR. RAJAN:

Absolutely. And I think we do need to continue recruiting these medical students so that our speciality is going to grow from here.

DR. DEUTCH:

Yeah, that makes logical sense. One of the things you touched on, which is also a hot topic in medicine, on this podcast, in our specialty and in professional life as a whole is mentorship. There's also the concept of sponsorship. Can you talk about the specific difference between these two things, mentorship and sponsorship, and share your thoughts kind of on how both these concepts are evolving in the sense of young professionals being exposed to any field, be it medical or otherwise?

DR. RAJAN:

Definitely. Um, I think mentorship, sponsorship, and coaching are some buzzwords in academia, and it appears as if they blend into each other. But yes, there are some subtle differences between them.

Mentorship is quite a time-tested intervention. A mentor is a person who acts as a guide and advisor to another person, especially someone who is less experienced and younger. So this can be a senior faculty mentoring a junior faculty or a junior faculty mentoring a trainee or a senior resident mentoring a junior resident. And there are a number of advantages of having an effective mentor, because this leads to a positive impact on the trainee as well as mentor satisfaction. And many studies have been done, and research has shown that mentorship is associated with enhanced faculty retention rates, heightened productivity in the department, greater diversity, and reduced recruitment costs. So it's definitely a promising strategy for optimizing your return on investment in your organization. In spite of many of the proven benefits of having effective mentorship in one's department, I think it's still elusive to many of the growing junior faculty, and therefore, every department needs to possibly formalize mentorship in order for it to be effective. And an important point to ponder is how much does the institution value mentoring, and how much would you need to spend to hire the correct people to mentor the faculty? Initially, our department could potentially have a scheme of one is to one mentorship, and then one is to many mentorship. And then as they grow and develop in the mentorship program, it can become a one is to one. And generally they say you need a 20 hour approach to have a proper relationship between a mentor and a mentee. As this mentorship program grows, then one can start identifying if some of these mentors can actually become sponsors.

Now there is a subtle difference between mentorship and sponsorship, because sponsors use their connections to leverage their position to expand the mentees visibility and help open doors for them for high impact opportunities. A sponsor is someone who could amplify the mentees achievements, talk highly of the mentee in, say, a specific speciality or organization that they are involved in. They might be able to strategize and connect them to different other experts in the country and boost the person that they sponsor. So while mentorship helps the trainee or the mentee to achieve their goals, the sponsorship goes one step further and actually opens up doors.

And there's one more buzzword which is called coaching, where the coach increases the self-awareness of an individual through active listening and curiosity. Now, coaches do not have to be anesthesiology fellowship, and they guide the coachee towards improving specific skills or goals for a predetermined time.

So, as you can see, there are some differences between mentoring, coaching and sponsorship. But I think that ultimately the goal is for the faculty to be satisfied and happy and have a good relationship with the learner.

DR. DEUTCH:

So in your professional life right now, obviously you're exposed to learners at a variety of levels. Do you find yourself serving most often as a mentor, coach, or sponsor?

DR. RAJAN:

I've served as a mentor as well as a sponsor. I have not served as a coach, but definitely mentorship and sponsorship, and I've also been a mentee, and therefore I do really understand both sides of the coin, and I feel very grateful to have had such excellent mentors and sponsors, which have given my career such a boost.

DR. DEUTCH:

We know that the specific environment, the learning climate is another term for it, is very important for learners and trainees. And this is especially true for those from groups like underrepresented minorities, that may feel uncomfortable in certain situations for a variety of reasons. In your opinion and role as an educator, what kinds of interventions help to create understanding, mutually beneficial discussions, and proper self-reflection. And given that, what steps can we take as on an organizational basis and as individual educators to ensure that our trainees and that our learners feel comfortable and valued and can be productive in their specific environment.

DR. RAJAN:

The issue of the underrepresented minorities is something very near and dear to my heart. For a seamless and effective learning experience, there should be a strong relationship between the learner and the educator. However, there have been some previous surveys that that have indicated that the underrepresented learners have felt isolated and have felt invisible, and this kind of culture could be associated with self-doubt in the learners and ultimately could result in burnout. And the same thing can happen even to the underrepresented faculty who may feel that they are not being valued in a department. And because of this, there have been instances where many of them have left academic medicine, and this could definitely be a big loss for a department.

So many departments have come up with innovative ways to improve the experiences for some of these learners. In 2022, the Medical College of Wisconsin Pediatric Residency Program created an anonymous survey for residents to report if they experienced any microaggressions. And they even tracked these incidents and interventions, and they had mentors and offered some intervention as well. They offered support for the victims and also offered more education regarding this. And this improved the rate at which the underrepresented minorities spoke up and they felt heard and they appreciated this.

So some of the strategies could be that every department could have some policies and enforce it and promote DEI within the department. And I think this could help change culture and make those who are underrepresented feel more comfortable and protected. Some departments actually have committees for DEI, and they have their they have their own small group discussions in addition to grand rounds. And this can help to increase awareness in the department. These committees explore topics like advocacy, the role of social determinants and disease, cultural wealth, and professional identity development. A third strategy could be to engage alumni from these underrepresented groups to participate in mentoring the current trainees, and I think all these strategies could overall help with improving relationship between the learner and the educator.

DR. DEUTCH:

Thank you. It’s very clear that in order for our specialty to be successful, our education process has to be optimal and everyone has to feel comfortable and valued within whatever structure they're in. So I think it's a very pertinent topic. And your answer was excellent.

I want to talk a little bit about technology. Things like the internet, student engagement, dealing with a generation, which is is very virtual in their own ways. But first we need to take a patient safety break. Please stick with us and we'll see you right afterwards.

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DR. SCOTT WATKIN:

Hi this is Dr. Scott Watkins with the ASA Patient Safety Editorial Board.

Medication and medical supply shortages threaten the safety and quality of patient care.

Clinicians and clinical practices should be proactive and develop a plan for dealing with shortages before they occur. Establishing a direct line of communication with supply chain personnel, considering an emergency stockpile, and staying informed of impending shortages using FDA resources are all good places to start.

During times of medication or supply shortages, clinics need processes and protocols for managing scarce resources and reducing waste, and tracking and reporting any complications that result from substitute medications/supplies. It is important that clinicians receive education whenever substitute or unfamiliar medications/supplies are introduced into clinical practice to reduce the possibility of errors.

Clinicians can ensure that they continue to provide the right care to the right patient at the right time regardless of limitations imposed by the supply chain by taking a proactive approach to medication and supply shortages.

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For more patient safety content, visit asahq.org/patientsafety

DR. DEUTCH:

We're back. Technology has really changed how many learn. We're well aware of this whether we work in medicine or not. We see technology everywhere, and certainly as we age, we see or feel the gap between us and those beneath us in terms of how they use technology for everything and our own facility with it is really quite poignant. So we have online learning, educational apps, podcasts, all sorts of things, including virtual reality. We can't go into depth on all these topics, but let's talk about online learning and specifically the idea of the validity of these endeavors. We have lots of truth, half-truth and untruth on the internet. Is there a danger in the sense of medical education, of having unincorporated, unverified content creep into the curriculum? Looking at this as a possible danger, how would we guard against it?

DR. RAJAN:

Sure. I do agree with you that over the past decade, there's been a big divide between the educators and the learners. Traditionally, the educators were accustomed to reading textbooks and attending lectures, but today's learners have embraced the digital platforms, and they prefer online resources, apps and podcasts for their educational needs. So a critical challenge, as you mentioned, is ensuring the credibility and evidence based nature of these online resources. And as you mentioned, podcasts have also become extremely popular these days because it allows the listener to multitask. They can listen during a road trip or while you're waiting at an airport. And the only problem is, since podcasts and many other online resources operate under the free open access medical education, there does exist this inherent risk of inaccurate content or misinterpretation of what was said.

So to bridge this gap, one solution could be for rotation directors to develop online curricula with links to high quality, verifiable reading materials. In particular, one could choose resources which are endorsed by professional societies because these are more likely to be peer reviewed and reliable. Another significant issue with online resources is that while they can contribute toward engaging and interactive learning, the students interpretation may not be accurate. And therefore, while these digital tools are valuable, they should definitely be used with careful supervision. They could serve as preparatory reading, for example, in a flipped classroom model, and then the core concepts could be later discussed and reflected upon in face-to-face lectures. And that, I think, might ensure that there is a comprehensive and effective learning experience. So there could be different ways in which one could approach this problem and make sure that the learners are actually getting the maximum out of these so-called online or hybrid resources.

DR. DEUTCH:

So let's talk about one specific aspect of technology, which is immediate: virtual reality. A big technological advancement. How do you see the role of that in our field, and what are the pros and cons of of incorporating it or its usage in general?

DR. RAJAN:

I'm really glad that you brought virtual reality up, because it's an exciting breakthrough and it's poised to significantly transform the landscape of education. It offers an immersive virtual digital learning environment, and the learners have to use these Oculus glasses or a head mounted display to visualize the virtual scenario, which obviously appears real and life like. For example, when the trainee performs a central line insertion with the Oculus glasses, the experience feels very authentic and three dimensional, and this closely mirrors a real life scenario. Obviously, the advantages it allows for an active engagement of the trainee and an interactive environment as well. So when they do an actual central line on a real patient, it might be more stressful, and it's prone to complications, obviously. But when you do it in a simulated environment such as this, this can produce some discomfort just enough for adequate learning to occur without really the undue stress or any complication for a patient. Additionally, if they make a wrong movement with their hands, it's possible that you can configure the system to create an audible alarm or a loud sound, and this would alert the learner that they're doing something wrong, and then that can steer them in the right direction. So it actually gives audible feedback. Another advantage of virtual reality is that the faculty is able to assess each trainee’s proficiency level, because the VR, or the virtual reality, dynamically assesses trainee performance.

And as with everything else, there are some downsides as well. For example, you can have unforeseen things in real patient scenarios, but actually recreating them in a simulated environment is much more difficult. And the tactile feedback that you get may also not be as accurate as when you're inserting in a real patient. So many people are able to use fiber optic. They learn, and they're able to intubate a mannequin fiber optically. But when they actually do this in a real patient, it's definitely harder, right? So it's something similar to that. But I think with technological advances you can overcome these disadvantages possibly in the future.

And then there's something, a further advance, called augmented reality and extended reality, which are emerging technologies where these technologies actually overlays information onto the real world. And they enhance but not replace the user's real environment. So while virtual reality, everything is virtual. In augmented reality, apparently you actually are able to see it on a real patient. There was a recent article about extended reality, where they elaborated on how it can be used to teach crisis management. They can create avatars or have a collaborative learning with the people from different countries. For example, if you want to teach or learn regional blocs, then there's collaborative learning possible with the use of extended reality. So there's a lot of growth in this area. And now whether it's all going to be just a gimmick or whether it is going to come in in the future, we still have to see.

DR. DEUTCH:

Are you currently using this technology at Cleveland Clinic?

DR. RAJAN:

At Cleveland Clinic, we've been discussing it, but we haven't really started using it. We have simulations, but not virtual reality yet. And I do know about some other institutions, such as University of Michigan at Ann Arbor. I think they are collaborating with some other departments to try and implement virtual reality. And they have done some pilots, and I'm pretty sure they're going to collaborate with more departments and so people would be trying this out.

DR. DEUTCH:

And what will be interesting will be the interface between the classic simulation that we've done with the control room behind the the one way glass and this because I do know that, I recently went to my 25th medical school reunion at George Washington University, and they had a simulation lab that had those standard aspects of simulation that we’re kind of aware of, you know--the mannequin, the control room. But there was also virtual reality aspect in other rooms that were kind of separate. But over time, I think these things are kind of kind of merge over time and create that type of experience, it seems to me.

DR. RAJAN:

Yeah, I would completely agree with you on that. And I think we are yet to see how this evolves. But I think there's a lot of exciting times ahead.

DR. DEUTCH:

For sure. And we've been talking about technology. You know, obviously it goes pretty quick. And there's a lot of smart people driving this. It certainly makes our world smaller in that, things that used to be a major issue--communication, email, text--now, we're all joined instantaneously and constantly. So given this virtual world that we live in and this this interconnectivity that's global, how does it impact learners and educators in anesthesiology, from fellowship directors to program directors to regular attendings? What's the role of that interconnectivity and, uh, global awareness, if you will.

DR. RAJAN:

Again, I think this is an excellent question, and I'd like to discuss virtual borders in education by referencing the International Council for Perioperative Neuroscience Training. Now that there are so many advantages and advancements in technology and neurosurgical techniques, and because of increasing complexity of neurosurgical intervention, there has been a lot of push towards developing neuro anesthesiology fellowships, which initially were not standardized. But now the thinking is that one needs to have standardized neuro anesthesiology fellowships, and instead of just making it national, the Society for Neuroscience and Anesthesiology and Critical Care went ahead to try to make it a global standardization of neuro anesthesiology fellowships, that is, neuro anesthesiology, having just virtual borders, like you mentioned. So the ICPNT, which is the International Council for Perioperative Neuroscience Training, currently has about 30 programs under it from different countries -- North America, South America, United Kingdom, Europe, Asia, Australia and the Middle East. And it's also growing. And now these different programs from different countries are able to collaborate virtually. They have monthly webinars where their trainees present. And so it is extremely beneficial because the way each department or each setup handles a case is completely different from the other. And so there's a lot of learning and training involved. And I think that this organization is not just a simple accreditation body, but it also focuses on collaborative education and research. And it has this infrastructure and a platform which is capable of doing this. I think in the future, they're going to have a tele mentoring programs where they can have experts to provide guidance and remote support. And although these initiatives are not yet extensively employed, I think they are expected to be particularly valuable for enhancing skills for health care providers in resource limited settings. And I think patient outcomes are going to dramatically improve because of international collaboration. So I know that all specialties have not gone global, and many of them are national, but since neuro anesthesiology has grown in this global fashion, I expect that it's going to grow very rapidly in the near future.

DR. DEUTCH:

It'll be interesting to see, given the spread of technology, whether it be in medicine or just the news feeds, everything is instantaneous now. So certainly whatever we do will impact immediately somewhere else. We're coming to the end of our time here. And I just wanted to ask you, as the guest editor of our June issue of The Monitor, I'm just wondering if you have any parting words or thoughts that putting this issue together brought to mind or things that you want to communicate to our readers before we go?

DR. RAJAN:

Sure. I just want to say that I'm extremely grateful for the opportunity to put this issue together, because after all my experience in the area of education, I was constantly trying to visualize how I could tie everything together. So it makes sense and wanted to give it some shape and life. And I'm really grateful that this issue of the ASA monitor gave me that opportunity. And I do feel that we are gazing into a bright future with digitalization affording a very rapid, uh, speedy grasp of concepts to fit the fast pace of the current age. I must say, it was an amazing experience to identify important themes and putting all the articles together. I approached different experts in education in the field, and I think this is a consolidated issue which covers the breadth and depth of education. And I think all the articles complemented each other and they gelled together like pieces of a puzzle. But we do need to remember that at the heart and core of education is the important relationship between the mentor and the mentee, and the trainees need to feel valued and validated so that they can learn and give their best to their patients. As physicians, we see patients on some of their worst days in their lives, and we need to be fully capable as an empathetic, caring and a competent physician to be able to care for them. And I think we are gazing into a very bright future for education. Thank you so much.

DR. DEUTCH:

Thank you for joining us, Dr. Rajan, your your conscientiousness and commitment to medical education in the future of our specialty is noted and appreciated by myself and I'm sure by many other members and will be noted by our listeners. For those listeners who want to learn more or read more about the topics we touched on today, you can visit asamonitor, org. And, everyone, we look forward to seeing you again on the next episode of Central Line podcast series, and take care.

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