INTERNATIONAL

Impact of COVID-19 Pandemic on Teaching and Training in Neuroanesthesia and Neurocritical Care: An Indian Perspective

Padmaja Durga, MD, DNB, PDCC

Padmaja Durga, MD, DNB, PDCC
Professor and Head, Department of Anaesthesiology and Intensive Care
Nizam's Institute of Medical Sciences (NIMS), Hyderabad, India

Nidhi Panda, MD
Professor, Neuroanaesthesia, Department of Anaesthesia and Intensive Care
Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India

Manikandan Sethuraman, MD, PDCC
Professor and Head, Division of Neuroanesthesiology
Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST), Trivandrum, India

Girija P. Rath, MD, DM
Professor, Department of Neuroanesthesiology and Critical Care
Neurosciences Center, All India Institute of Medical Sciences (AIIMS), New Delhi, India

Ponniah Vanamoorthy, MD, DM
Associate Director & Senior Consultant, Department of Neuroanaesthesia and Neurocritical Care
MGM Health Care, Chennai, India

Rajiv Chawla, MD
Director, Anesthesiology
Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India

There will be no other year like 2020. The COVID-19 pandemic has created a severe disruption to several aspects of life. Education was also adversely affected. Medical education in general and neuroanesthesia and neurocritical care in particular requires intense direct and indirect training. As the curve of the pandemic seemed to flatten and life was slowly returning to normalcy, a second surge seems to have started. It’s time to ponder over how the pandemic affected the training of neuroanesthesia and to learn from the experience as to how the quality of training can be maintained even during the adversity through the ’out of the box thinking’and tweaking the delivery of teaching.

Impact on COVID-19 Neuroanesthesia Services
The emergence of severe acute respiratory syndrome coronavirus-2 resulted in an overwhelming health crisis, particularly in the ’hotspots’ of India. Incidentally, in these hot spots, the majority of the institutions involved in training the anesthesiologists in neuroanesthesia and neurocritical care are also located. All the hospitals in cities such as Mumbai, Delhi, Bangalore, Lucknow, Chennai, Hyderabad, Chandigarh, and Trivandrum were overwhelmed with COVID-19 patients during the peak of the pandemic. The pandemic brought in complete restructuring of clinical workflows in most medical centers, which has affected the educational experience for trainees. The cancellation of elective neurosurgical procedures and the need to redeploy personnel to support ICUs to manage the surge of patients admitted with severe COVID-19 was done in many institutions, thus affecting the training of neuroanesthesiology. Some tertiary care and university hospitals, especially those with exclusive neuro-care facilities such as All India Institute of Medical Sciences (AIIMS), New Delhi, Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST), Trivandrum, National Institute of Mental Health, and Neurosciences (NIMHANS), Bangalore, had paradoxically experienced a surge in the neurosurgical patients as the other units had shut down their neurosurgical units.

Impact on Training in Neuroanesthesia
A panel discussion was conducted during the 22nd Annual Conference of the Indian Society of Neuroanesthesiology and Critical Care (ISNACC-2021 Virtual). The participants (authors) included the program directors, faculty from institutions exclusively dedicated to neurosurgery and training for DM neuroanesthesia like the Neuroscience Center of AIIMS, SCIMST, institutions that offered postgraduation in anesthesiology (MD) with neuroanesthesiology as a part of the curriculum and MD along with DM (Doctorate of Medicine) in neuroanesthesiology like the Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh and faculty from private hospitals offering fellowship courses in neuroanesthesia. Representatives of the trainees were also included to share their point of view during the discussion.

The Faculty Perspective
All the educators expressed concerns about the effect of the pandemic on training. With only days to prepare, faculty and staff shifted all didactics, discussion groups, and assessments to remote platforms after a brief pause. Efforts made to contribute to educational advancement by active curricular innovation and transformation by the faculty were seminal. While the COVID-19 pandemic was a source of disruption in several ways, it was also a catalyst for the transformation of medical education brewing for the past decade. Educators across the country have now recognized that they also must embrace new competencies that are better suited to addressing the challenges. According to many neuroanesthesiology training program directors, the pandemic has led to a paradigm shift in clinical and educational endeavors. The educators said that though they were familiar with computers, they did require some learning to upgrade their computer competencies during the pandemic to rapidly and adequately digitize their teaching approaches.

The Trainee Perspective
The pandemic also presented with practical and logistical challenges. In addition to concerns for patient safety, recognizing that students may potentially spread the virus when asymptomatic, there was also a fear that they may acquire the virus within the course of training. The educators, too, suffered from similar apprehensions. A particularly challenging aspect of education during the pandemic was the substantial restriction of clinical learning experiences for medical students. Given the shortage of personal protective equipment (PPE), limited COVID-19 testing abilities, and uncertainty about how easily the virus could be spread, medical schools were reluctant to engage learners in the care of patients with or suspected of having COVID-19. Further complicating the issue was the decline in the numbers of patients seeking care for conditions other than COVID-19. Faculty and residents, coping with patient surges and novel care delivery methods, had limited bandwidth for supervising medical students. There was a concern whether the fear would douse the fire for learning. The trainees, on the contrary, said that the fear did not interfere with the enthusiasm to learn, but it was the restrictions imposed by the PPE that were bogging them down. However, some institutions faced an increase in the volume of emergency and urgent cases, which was a cause of great stress due to uncertainty.

Impact on Curriculum
Across the country, institutions and organizations have embarked on the curricular redesign to ensure that the neuroanesthesia training continues despite the constraints and concerns about balancing curricular time while supporting COVID care and maintaining traditional courses and content. The training's main objective is to develop competence, which is a combination of knowledge, skills, and behavior used to improve performance. The knowledge component was not significantly affected. The educators had utilized the time to increase the didactic lectures and case-based discussions. In centers that trained for DM (3-year course), there was no significant compromise in the basic skill training as the trainees already processed some basic training of skills such as arterial line, central venous access, and difficult intubation.  Trainees whose tenure was ending were given priority over those whose training was to be done later. Departments were allowed by institutions to define senior students as essential so that they could complete their rotations and graduate on time. In the short-term programs such as Post-Doctoral Certificate/ Fellowship Course (1 year), ISNACC Post-Doctoral Fellowship (1 year), and postgraduate training, the effect was much more significant. The duration of training was compromised. Most postgraduate training programs (3 year-MD/DNB) incorporate a minimum of four months rotation through neuroanesthesia during the second year. This clinical rotation was reduced in many neuroanesthesiology fellowship programs and this caused disruption to curricula. Several institutions reduced the use of fiber optic intubation in cervical spine pathology. The intubations were performed by modifications of more experienced personnel, thus depriving the residents of their training.

What was affected the most was the behavior, the non-technical skill training, especially during crisis management. However, the educators noted that there was no increase in critical events. Longer times were spent on timeout and preparing for the case both by the surgeons and the anesthesiologists with an attempt to improve planning for the procedures and minimize the critical events. This was one of the collateral benefits of operating room (OR) management achieved during the COVID-19 pandemic.

Impact on Neurocritical Care Training
The pandemic had an impact on neurocritical care training, too. The training acquired in the COVID critical care also enhanced the performance of residents in neurocritical care. The training was done to inculcate safe behavior. It was essential to train residents and fellows on safety issues related to caring for patients with COVID-19, particularly those who require aerosol-generating procedures. Learning and practicing proper techniques for donning and doffing PPE were critical safety training components, conducted via video and simulation training sessions. However, there was an impact on the ICU management as invasive procedures and monitoring were limited. The imaging of these patients in neurocritical was also restricted. Clinical assessment played a vital role in the management.

Neuroanesthesia Research and Publications During COVID
Research and publications had temporarily taken a back seat. The cancellation of elective neurosurgical procedures and other changes in work patterns as hospitals prepared to manage a surge in COVID-19 patients halted some ongoing projects. The thesis projects of students were also adversely affected. However, some institutions have utilized this lull in the clinical work to conceptualize new projects, write grant proposals and complete unfinished tasks. There was also excellent scope for innovations during COVID like the development of aerosol protection box intubation, indigenous low-cost ventilators, anti-fog devices for headgears, indigenous development, new designs and new materials for PPE, ventilated headboards and swab collection booths are just a few to name. New protocols and practice guidelines published for anesthetic management of neurological patients undergoing surgical and interventional management were developed. The residents were provided special training on these for them to be effective.

Impact on Trainee Wellbeing
Trainee wellbeing was an important responsibility for the faculty as well as for organizations. The pandemic has strained the educational and emotional wellbeing of physicians in training.  There was a feeling of loss of control because of the disruption of daily schedules. There were fears about PPE and safety. The organizations extended unprecedented support in all aspects to the trainees, including food and stay. The departments ensured that they were coping with the challenges they faced during the pandemic. The pandemic has also created unforeseen anxiety and fears for future practice as a subspecialist because of the impact of the pandemic on education and training. There were apprehensions about truncated training. Rapid changes were happening in the corporate practice as well. There were reduced workloads in neuroanesthesia. This heightened concerns that managers could be downsizing teams leading to loss of jobs or decreased monetary compensation because of a reduction in the number of shifts undertaken by trainees. There was also a perception that there could be reduced job opportunities for outgoing residents. Though there were financial repercussions for some period, there were no reported trainee job losses. This ensured the minimal impact of the pandemic on neuroanesthesia as a career choice and admissions to the courses.

Turning Adversity into Opportunity
ISNACC had already explored the possibility of online teaching platforms even before the pandemic and invested in them. Hence, it was possible to graduate the batch of well-trained neuroanesthesiologists on time and without lowering the standards. The training was conducted by various methods using various online platforms by many institutions. For our rescue, the trial access/free version of various online streaming/conferencing tools and free/less costly internet data packages from telecom companies has made it possible to reach the students in such a complex situation. ISNACC members also reaped the benefits of virtual training. The world had shrunk; there was a global exchange of ideas; students had access to worldwide teachers who could inspire the next generation.

Conclusion
The neuroanesthesiologists in India can proudly say that they were not on the sidelines but rather a part of the response when the medical profession proved its worth to a struggling country and learned so much about raising and reaching new levels of caring. The educators used innovative ways to maintain clinical training and educational activity. The trainees were found to have confidence that adequate attention was being paid on their overall well-being.