Introduction The global pandemic of COVID-19 had strong repercussions in healthcare education around the world. Different adaptations to imposed restraints such as quarantine and social distancing forced different adaptations to conduct educational programs, such as video conferencing software, social media platforms, and Free Open Access Medical education tools.¹

Web-based solutions are increasingly helpful in supporting clinical and academic activities during the COVID-19 pandemic. Moreover, most of these educational methods emphasize the cognitive area of Bloom’s Taxonomy, as psychomotor and attitudinal training becomes harder via remote education, with multiple barriers to deliver personalized feedback.

Definitions - Distance education: Also known as distance learning, refers to any education provided without the teacher and students being physically present together.

- Distance simulation: Simulation performed with either the facilitator, learners or both in an offsite location separate from other members to complete educational or assessment activities. Facilitation and assessment can be performed either synchronously or asynchronously using video or web conferencing tools.²

- Applications or apps: Software programs designed to run on a computer/tablet/mobile phone to accomplish a particular purpose. Today, mobile applications play an integral role in medical education, as healthcare professionals and students use these emerging technologies during their training and practice.³

- Web resource: A web resource is any identifiable resource (digital, physical, or abstract) present on or connected to the World Wide Web. Web-based instructional methods are often categorized as e-learning, or the use of Internet technologies to enhance knowledge and performance.⁴

- E-learning: Methods of e-learning include self-paced tutorials, webcasts, podcasts, and interactive learning modules. e-learning has advanced from textbooks in electronic format to a highly interactive medium to enhance education for students and postgraduate learners.⁴

- Educational outcome levels: Based on the Kirkpatrick hierarchy, there are 4 outcome levels. The reaction level determines the level of satisfaction; the learning level measures the level of knowledge, skills, and values acquired by the participants from the program; the behavior level ascertains the changes in the participants’ behaviors in the work environment because of the program; and the impact level examines the institutional outcomes that demonstrate a good return on investment and can be attributed to the training program.⁵

State of distance healthcare education:

Studies suggest that more than 85% of healthcare professionals and medical students use a smartphone, and 30–50% use medical apps for learning and collecting information. In a survey done recently, most respondents (70%) reported that their simulation center was conducting distance simulation. Significantly more respondents indicated long-term plans for maintaining a hybrid format (82%), relative to going back to in-person simulation.⁶

Web-based resources. What level of learning can we reach?

They have become inevitable in clinical educational settings, particularly as they are accessible for learning anywhere. Integrating web-based learning resources in medical education can enhance interactivity and has been demonstrated to improve satisfaction as well as facilitate learning efficiency.⁴

A good example is the implementation of distance-based procedural skills training through a computer platform (https://c1do1.ai/) with asynchronous feedback for suturing, paracentesis, thoracocentesis, endotracheal intubation and other procedural skills.^{1 7} Participants logged into the platform, reviewed material, practiced while recording the session, and uploaded the video through the training platform. The expert tutor remotely delivered asynchronous feedback. Participants trained remotely until achieving course approval.

Regarding evidence, the effectiveness of smartphone applications in improving knowledge and skills in healthcare professionals and students, have been shown recently in a systematic review and meta-analysis (Level 2). The pooled effect of 15 studies with 962 participants showed that the knowledge score improved significantly in the group using mobile apps, compared to the group who did not use mobile applications. Regarding skills, 19 studies (11 RCTs, 3 quasi-experimental and 5 interventional cohort studies) reported that mobile applications were effective in improving skills among the participants.³

Comparisons with traditional face-to-face education:

The COVID-19 pandemic caused an increase of different procedural skills training at distance and generated an opportunity to include technology and computer platforms in training. The effectiveness of this modality and comparisons with traditional face-to-face teaching with direct feedback have not been deeply evaluated.

We have developed a prospective randomized study to compare two different training modalities for peripherally inserted central catheters (PICC) under ultrasound guidance: traditional face to face training with synchronous direct feedback versus distance training through an online platform with asynchronous distance feedback. We chose installation of PICCs as the standard procedure for this study because this critical skill is in high demand. It also has a high level of difficulty because the current standard of care includes mandatory use of real-time ultrasound during catheter insertion. This procedure is comparable with a continues peripheral nerve block under ultrasound. This simulation-based training program significantly improves residents PICC placement skills with both modalities (traditional training and online platform with asynchronous feedback). The asynchronous feedback training modality seems to be a comparable alternative to traditional face-to-face training methodologies, opening a new and innovative possibility for teaching procedural skills in healthcare.⁸

Evidence in RA The University of Toronto is developing a research project: Online Regional Anesthesia Resources – Are They Effective? They hypothesize that the use of those online educational materials will give medical students non inferior ability and knowledge for image acquisition and anatomical interpretation of ultrasound image for supraclavicular brachial plexus block, when compared to conventional in person teaching.

Despite the evidence shows the acquisition of skills through applications is possible, and even though learning could be in some specific procedures comparable to traditional face-to-face training, the evidence in regional anesthesia is scarce.

Future research can be oriented towards clarifying whether both methodologies are comparable in specific regional anesthesia procedures.

Another innovative idea could be piloting crisis management and non-technical skills training (LAST for example) through web applications, and later to compare this training with traditional training.

References

1. Vera M, Kattan E, Cerda T, Niklitshek J, Montaña R, Varas J, Corvetto MA. Implementation of Distance-Based Simulation Training Programs for Healthcare Professionals: Breaking Barriers During COVID-19 Pandemic. Simul Healthc. 2021 Dec 1;16(6):401-406.

2. Lioce L, ed. Healthcare Simulation Dictionary [Internet]. 2nd ed.Washington, DC: Agency for Healthcare Research and Quality; 2020.

3. Chandran VP, Balakrishnan A, Rashid M, Pai Kulyadi G, Khan S, Devi ES, Nair S, Thunga G. Mobile applications in medical education: A systematic review and meta-analysis. PLoS One 2022 Mar 24;17(3):e0265927.

4. Kleinpell R, Ely EW, Williams G, Liolios A, Ward N, Tisherman SA. Web-based resources for critical care education. Crit Care Med. 2011 Mar;39(3):541-53

5. Yardley S, Dornan T. Kirkpatrick’s levels and education ‘evidence’. Med Educ 2012;46(1):97–106.

6. Buléon C, Caton J, Park YS, et al. The state of distance healthcare simulation during the COVID-19 pandemic: results of an international survey. Adv Simul 2022;7, 10.

7. Corvetto MA, Kattan E, Varas J, Caro I, Altermatt FR. Designing Sustainable Solutions to Implement a Distance-Based Simulation Basic Life Support Training Program During COVID-19 Pandemic in Low-Income Countries. Simul Healthc. 2022 Oct 1;17(5):351-352.

8. Corvetto M. Simulation-based training program for peripherally inserted central venous catheter insertion: Randomized comparative study of synchronous direct feedback versus asynchronous distance feedback. Best Abstract, SESAM Lisbon Congress 2023.