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15 Articles in Volume 20, Issue #6
Using Photobiomodulation to Treat Trigeminal Neuralgia
20/20 with Mark Wallace: Where Cannabis Fits into Pain Practice
A Commentary on Opioid Stewardship: Fentanyl, Sufentanil, and Perioperative Pain
Adherence and Relapse – How to Maintain Long-Term Gains in Patients with Chronic Conditions
Advanced Practice Matters with Theresa & Jeremy: COVID, Pain, and Power
Analgesics of the Future: Janus Kinase Inhibitors
Case Report: Quadratus Lumborum Block for Managing Pathologic Pain to the Hip
Chronic Pain and the Short-term Effects of Medical Cannabis
Differential Diagnosis: Polymyalgia Rheumatica or Rheumatoid Arthritis
Genicular Nerve Blocks: Field Tips on Prognostic Value and Technical Considerations
Guideline Update: ACR Promotes Pharmacologic Treatment for Osteoarthritis
Navigating New York's Medical Marijuana Program: A Patient Handout
Person-Centered Care: Lessons from the VA’s Whole Health Model
Psychedelics for Chronic Pain: Is It Time?
Resident’s Corner: What Pain Medicine Education is Missing in the COVID Era

Resident’s Corner: What Pain Medicine Education is Missing in the COVID Era

How hybrid training models, virtual reality, and lessons learned from other fields are filling in the pandemic-caused gaps (sort of) for two PM&R residents.

With the COVID-19 pandemic continuing to rage around the world and additional waves of infection likely, education in pain medicine will have to change in different ways in the coming years to train future physicians. A recent JAMA article by Lucey and Johnston makes note of the transformational effects that the COVID-19 pandemic is having and will have on graduate medical education, and pain medicine training is no exception to this.1 Fellowship programs are taking varied approaches to education in this unprecedented time, some of them relying on the experience of other fields. Here’s what the authors – both PM&R residents – are finding most beneficial to date.  

To curb the spread of COVID among healthcare providers, medical educators have had to find new methods for disseminating information effectively. (Image: iStock)

Didactics, Professional Education, and Networking

To curb the spread of COVID among healthcare providers, medical educators have had to find new methods for disseminating information effectively. Pain medicine training is no exception to this. At many institutions and with many different specialties, we have seen a decrease in collaborative didactics and conferences. While on the interview trail, we witnessed first-hand how programs are adapting to comply with social distancing and mask ordinances.

Given the vast knowledge base required for pain physicians, from interventional techniques to pharmaceutical management to multidisciplinary team collaboration, strong training programs are vital. To overcome the lack of in-person sessions, many pain fellowships have turned to virtual didactics. Many programs and specialties have had good things to say regarding virtual didactics, suggesting that attendance has been higher than before and that trainees enjoy the lectures more.2 While the content of the lectures remains standard, the Zoom-like telecommunication platforms and pre-recordings have come with a variety of unforeseen challenges.

We had been using virtual didactics in our residency program prior to the pandemic when on offsite rotations. On a personal level, we agree with the feedback from other fellows and residents, that the “human element” of education is missing. We found that when educators were off-site, it resulted in less effective teaching. The options that most fellowships and residencies seem to be employing is a hybrid model, to bring back the most in-person elements for important education in hands-on topics or particularly challenging concepts.

Poorer results with videoconferencing education has been studied in other fields. The American Institutes for Research and the University of Chicago Consortium on School Research trialed assigning students randomly to an in-person or online remedial Algebra I course and found that the success rates were lower in the online setting compared to the in-person setting.3 Similar results have been found in studies out of New York University and in charter schools in Ohio comparing standardized testing in a variety of subjects and high school graduation rates.4

In the same regard, many annual professional and continuing education conferences have transitioned to a virtual platform as a result of the pandemic. Some are utilizing a reward system that grants points to those who present an abstract, those who ask a question, or to those who contribute to a discussion to improve engagement. In these settings, at the end of the conference those with the most points are rewarded with wine, conference fees for future conferences, and other rewards. But more could be done, such as incorporating small-group discussions to allow participants to review evidence-based medicine in pain medicine, a proven method to learn effectively.5 A recent virtual pain conference attempted to encourage small-group discussions by having an online forum section on their website with a specific pain topic listed as the title. Participants could post comments and recent literature to further their discussion about the topic.

We have been incorporating discussions, both virtual and in-person, in our residency program as well, holding small, high-yield topic conversations with our residents and encouraging open conversation with good results measured by resident self-assessment on practice questions. We have seen this as well in fellowship programs on the interview trail, participating in weekly phone or video conferences to discuss board relevant topics.

What residents are missing, however, is the ability to really network. While conferences are typically social events allowing residents to network with various faculty and programs, virtual conferences appear to take away the aspect of human interaction that is a vital component to meetings. We remember before the pandemic being able to interact with the coordinators and directors of pain fellowship programs at meeting booths, which directly led to future collaborations and fellowship interviews.

Unfortunately, in this pandemic world, we feel that this is a vital aspect lost to current residents hoping to enter the field. We have seen during this time that even the most technologically forward conferences seem to have difficulty in recreating a human interaction experience between attendees.


Interventional Pain Training

Interventional pain management as an approach to chronic pain care has risen significantly in the past two decades; some studies indicate a rise of interventional procedures of approximately 7% per year in recent years.6 Fellowship participants are in need of hands-on training when it comes to these techniques. Unfortunately, the months of March and April during the initial wave of the pandemic in the US saw decreased volume across the country in all settings, academic medical centers not being spared.

While many training programs have since increased interventional procedure volume after the initial pandemic wave resulted in a stark decrease, the number one complaint from my colleagues in pain fellowship programs last year still remains the lack of interventional procedure exposure. The importance of repetition and variation of procedures is well understood for those in interventional pain training in order to feel comfortable with independent practice, and cannot be downplayed.

Virtual reality (VR) may be one way to make this training happen. While VR alone may not be the most desirable option, haptic technology in conjunction with VR has been used to teach surgical and fine motor skills since the early 2000s.7,8 Studies have reinforced the benefit of haptic-enhanced simulators in procedural skill development.

One study out of the University of Toronto assessed VR training with haptic feedback for Veress needle placement for creating the pneumoperitoneum at the start of laparoscopic surgical procedure. Twenty-two surgeons participated, reporting that the device appeared and felt realistic and was a useful tool for training.9 While no studies have tested the application in pain procedures, VR with haptic technology could play a role in procedural training in the COVID era.

Another option may be to increase the utilization of cadaver and simulator training for interventional pain procedures. With staffing limitations that may limit a fellow’s exposure to procedural volume, the rise of simulator and cadaver usage may see an increase as a means of interventional exposure in the coming months and years. Recent studies have noted the effectiveness of cadavers in providing realistic simulation of procedures and a means to improve both in-training confidence in performance.10 Similarly, simulation-based training of procedural skills have been described in urology and will need future study in pain procedures.11

With the COVID-19 pandemic affecting all aspects of medical training, residency and fellowship programs across the country have had to accommodate the training of their fellows and residents. While each program has responded differently to the pandemic, there is a need for evidence-based study to further training as the pandemic shows no sign of slowing down here in the United States. Due to the especially challenging nature of this, we can look to other fields and retrospective studies on graduate medical education.

Given the multidisciplinary nature and large breadth of practice that pain physicians must have, extrapolating data from other fields of medicine and other professions may give training programs a way to adequately train fellows in this trying time. While this may be a daunting task, the field of pain medicine is no stranger to change. As conferences and other aspects of pain medicine education are already implementing changes to continue to provide quality education, we are optimistic that fellowship training in pain medicine will continue be robust. We look forward to joining the ranks of pain physicians everywhere through comprehensive training.

See our coronavirus and pain resource center

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Resident’s Corner: Climbing the Learning Curve in Pain Management
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