Successful Are Those Who Adapt; Innovative Teaching Methodologies in Pain Fellowship Training During COVID-19 Pandemic in a Developing Country

Aliya Ahmed, Robyna Irshad Khan, Shemila Abbasi, Ali Sarfraz Siddiqui, Azhar Rehman, Ausaf Khan, Tanveer Baig, Gauhar Afshan
Department of Anaesthesiology, Aga Khan University, Karachi, Pakistan

Corresponding Author
Aliya Ahmed
Department of Anaesthesiology, Aga Khan University, P.O. Box 3500, Stadium Road, Karachi 74800, Pakistan.

COVID-19 pandemic caught the entire world blindsided causing dramatic changes to most, including medical teachers and learners. After the initial shock, world has accepted the ‘new normal’ making it imperative to focus on continuity of quality education, while staying safe .Department of Anaesthesiology at our university is a robust academic unit offering residency and fellowship training programs. Pain fellowship is a one-year program, which is unique in selecting candidates from across the country with a vision of developing country-wide pain services. Present fellow is an employee of a public hospital in a northeastern town and plans to return to her parent institution after completing fellowship training. With the start of lockdown, elective work was suspended leading to a holdup on out-patient services and interventional pain procedures. In this backdrop, pain faculty decided to reorganize the pedagogy and teaching modalities to ensure completion of curriculum within the stipulated year.

How We Conventionally Deliver the Curriculum
Pain curriculum is delivered in two six-monthly modules. Fellow’s weekly duties include two on-call duties, three pain clinics, five in-patient rounds, and two interventional procedure lists. There is a weekly session for interactive teaching, simulation-based hands-on workshops, and external rotations to radiology and physical rehabilitation. One elective external rotation is offered to indigenous candidates for wider exposure. The fellow is also required to complete a research project/clinical audit. Assessment consists of continuous clinical assessment, workplace-based assessment and six monthly written and oral examinations.

How We Modified Our Curriculum Delivery During the Pandemic
With the pandemic, number of patients and procedures decreased overnight, and training program came to a halt. After registering that Coronavirus is here to stay, a meeting of the pain faculty was organized to find solutions. A review of the available literature showed that most specialty training programs were switching to web-based technology to maintain teaching and learning. Each aspect of the fellowship program was discussed to find practical and innovative solutions.

From Conventional to Virtual Classroom
Monday morning Pain Grand Rounds are a regular feature of the fellowship program and include faculty tutorials, guest lectures, journal clubs, research presentations, critical incidents and case discussions. These one-hour slots at the beginning of the week give pain team an opportunity to regroup and are a valued source of positive energy. They were resumed immediately on a virtual format, utilizing Zoom Cloud app and Microsoft Teams. We had no prior experience of virtual classroom, so we all learned on the go, with fellow leading the way. Initially, there were some concerns but in this day of technological ease and a bit of help from IT department, all issues were sorted out easily.
From Real Patients to Manikins
Normally our patient workload is sufficient for the fellow to get hands-on training. Simulation-based training provided a backup when number of patients decreased. Simulation based workshops are planned for procedural skills including ultrasound guided regional anesthesia (UGRA), fluoroscopy-guided procedures, radiofrequency ablation, etc. ensuring skills training.

From Face to Face to Telehealth Clinics
Chronic pain clinics were on halt for a month following the lockdown. Shifting to teleclinics required installation of proper equipment. Our patient population usually does not use computers, however calling via applications on smartphones is common. WhatsApp video call service and Zoom cloud are functioning smoothly after a few initial glitches. Restarting clinics helped in triaging patients requiring urgent interventional procedures. The fellow is assigned to all the clinics to enable her to observe/treat maximum patients.

Combining Services for Better Exposure
Acute and chronic pain rounds have been combined for the fellow to get adequate exposure. Appropriate protective equipment is mandatory. Since pain intervention lists are shortened, fellow is assigned to orthopedic list once a week to learn UGRA. The recommended safety precautions are strictly followed , .
Rescheduling Rotations
Realizing that radiologists use Picture Archiving and Communication System (PACS) to report and teach images and there is no direct contact with patients, this rotation was preponed, ensuring that pre-defined curriculum is delivered. For fellow’s introduction to neuro-functional tests, two half-day sessions were preponed as well.

Reflection and Conclusion
Unpredictabilities of life, both good and bad, keeps it interesting. Successful are those who adapt quickly. COVID-19 pandemic is a disaster affecting the entire world, but life must go on. Initial inertia had to be shrugged off quickly to ensure that an ambitious, diligent, hard-working trainee, who took a non-expandable leave of absence from her full time job, left her family, and travelled 800 kilometers to enroll in a training program, timely completes it. Our experience with web-based teaching showed us the associated benefits and we plan to incorporate the new teaching modalities in future. The ready acceptance of advanced technology in a traditional teaching program of a developing country makes one wonder: is COVID-19 a blessing in disguise for the enhancement of postgraduate medical education in developing countries?

Declaration of Interests
The authors have no financial or non-financial conflicts of interest to declare.

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