Teaching in the Era of the Pandemic

*  This piece was written prior to the September 2021 Final FRCA CRQ examination, this was an incredibly difficult time for trainees, made more difficult by the errors that took place during the exam period. My blog does praise the use of technology to deliver exams and all things considered, I do think that being able to deliver exams, share resources and teach remotely is still a wonderful achievement, but I want to acknowledge that no system or delivery method is perfect. When there are errors, these must be corrected. I hope my blog highlights the amazing teaching and knowledge sharing that took place, showing the good that has been and will continue to be accomplished despite COVID-19, because I believe that is an achievement we should celebrate.

How it started

The COVID-19 pandemic has had significant and mostly devastating effects on many aspects of life in general and on healthcare services in particular. As healthcare professionals, we had received the news originating in China, initially with intrigue and curiosity, but soon with the news coming closer to home in Europe, reality started to sink in and the intrigue was soon replaced by worry and concern.

The intensive care community was probably the first clinical group to be concerned about the potential impact of a highly contagious acute respiratory illness on critical care units around the country. Naturally, most of these concerns were around service provision and critical care capacity on a national level. Plans to manage potential extreme surges, needed to be drawn quickly to make sure we were prepared as clinicians to manage the extreme demand. Many of these plans were drawn mainly on local levels in the initial phase, obviously with national support and guidance. Soon enough, however, knowledge sharing became the norm and national guidelines covering many areas of clinical care of COVID-19 patients were disseminated. Alongside being prepared to care for patients with COVID-19, plans were needed to manage patients with long term conditions and those with other acute presentations, within the limitations and pressure of hospitals and critical care units being potentially overwhelmed with COVID-19 patients. This was further complicated with the need to maintain healthcare facilities “COVID secure”, or at least as close to that as possible.

Staffing

Executing all these plans successfully presented many challenges: increased demand on equipment, drugs, bed spaces to name a few. Yet the most difficult challenge to manage was staffing.

It became quite clear early on, that adequate staffing will be a significant challenge. Not only because certain clinical areas either suffer from absolute staffing problems or relative problems because of the increased demand, but also because of the risks posed by the pandemic itself on the more vulnerable staff. That meant that areas like critical care units, perceived to be associated with increased risk of exposure, faced even tougher staffing challenges with the added burden, of working to mitigate the risks imposed on their vulnerable staff.

Staff redeployment, surge rotas, returning retirees, were all examples of innovative ways to manage critical staff shortages. These strategies were needed and mostly applied (in many cases as voluntary initiatives) from medical and nursing staff, across the spectrum, from junior staff in training to permanent senior members of staff.

Special emphasis has to be made on mentioning that the levels of anxiety related mainly to working in unfamiliar clinical areas, or when staff felt that they may work beyond their levels of competency, were quite high. National regulatory bodies and Royal Colleges were quick to reassure staff that adequate support and guidance will be made available as soon as possible and to ensure that safe good quality care continues to be offered in the NHS alongside ensuring staff wellbeing and sustainability. 

Amongst the different staff members that needed redeployment or restructuring of their work patterns to maintain safe service provision were junior medical trainees across all specialties – medical, surgical, anaesthetic and more relevant intensive care medicine trainees.

Dilemmas and compromise

Those trainees faced many challenges and anxieties – firstly there was the fear of working in unfamiliar clinical areas or out of their competencies, secondly came the worry about the impact of spending considerable part of their training on “COVID wards” thus missing on training opportunities, but more importantly came the concerns regarding training progression and examinations.

Regulatory bodies and Royal Colleges recognised these concerns, however, they were faced with the dilemmas of needing to support service provision in a time of unprecedented demand (which included ensuring ongoing supply of CCT holders) while maintaining the integrity and quality of the United Kingdom’s medical training. They were also faced with the need to maintain the safety of the trainees as much as possible within the constraints imposed by the highly contagious respiratory disease. Compromises needed to be made and quick decisions were taken to cancel national postgraduate examinations (that were due to be held during the first COVID-19 wave) thus at least guaranteeing trainees’ safety and ensuring that the NHS can continue to provide an un-interrupted service, for what was hoped to be a short temporary period of time.

Knowledge sharing

The pandemic period, however, was not all doom and gloom – the medical community quickly embraced knowledge sharing on such a scale, that I (for one), have never seen before. Resources were made available both nationally and internationally at a very rapid pace – whether in the form of statistics (The value of data gathering, analysis and sharing should probably be the most celebrated outcome of this unfortunate pandemic), or rapidly evolving guidelines or research results.

Trainees in intensive care medicine were hungry for education on the new disease, its potential therapies, as well as updates or refinement of existing therapies in critically ill patients particularly with severe respiratory failure. This hunger was also palpable from trainees outside the intensive care community or those early on in their training journey. Anaesthetic trainees were instrumental team players on intensive care units.

The pressures arising from the rapidly escalating service demands meant that time was precious. The need to maintain social distancing and safety of trainees and educators was another ongoing challenge.

If data management were a major player in managing COVID-19; then telecommunication technology was the real goal scorer.

Telecommunication provided the needed means to maintain an agile, adaptable and flexible medium for education and training. Quickly enough, the intensive care clinicians and educationalists were at the forefront of using the available technology to develop innovative answers to the challenges posed on training.

Creating a network of information

The Faculty of Intensive Care Medicine (FICM), Intensive Care Society (ICS), Association of Anaesthetists and Royal College of Anaesthetists (RCoA) collaborated in developing a website (freely accessible) which hosts up to date clinical guidelines, national guidance, links to patient information webpages and much more. The https://icmanaesthesiacovid-19.org/ content was updated regularly throughout the pandemic with the accumulation of research output informing best practice, mainly in relation to the management of COVID-19. The website hosts more than clinical guidance – wellbeing resources, advice on shielding, infection control, restarting planned activities. These resources were readily accessible and followed different formats from podcasts to webinars to PDF documents.

More relevant the website provided link to the COVID-19 learning program developed by Health Education England e-Learning for Healthcare (HEE e-LfH), in response to the pandemic. This program was made freely available to all health and care workers in the UK. This program was quite wide reaching offering all levels of education from basic care to invasive ventilation guidance, with users being able to choose material that is relevant to their clinical roles.

It is worth noting, that the e-LfH in collaboration with the FICM, hosts a program of 10 e-learning modules of particular interest to trainees undertaking the first stage of their ICM training. Again, these resources are freely available to any NHS trainee.

Other Royal Colleges and Clinical societies provided (mostly) free access to online webinars and podcasts, related mainly to the management of the COVID-19 and its various complications – most of these activities were directed at healthcare professionals at executive or senior stages as opposed to trainees, nevertheless they still offered the opportunity for trainees to access latest evidence.

With the first wave subsiding, the FICM (alongside other Royal Colleges) needed to decide on the resumption of examinations mainly to ensure that career progression is not halted any further.

Technology and innovation

Again, technology and innovation were instrumental. The written component of the FFICM examination was delivered via online remote invigilation, where the RCoA engaged the services of https://www.testreach.com/. This enabled the college to continue offering the FFICM, the FRCA and the FFPM without further cancellations or delays.

The FFICM Final SOE & OSCE components were also delivered remotely. On this occasion the Zoom video conferencing software was employed to facilitate the remote examination in conditions that aimed to replicate the face to face experience as much as possible.

Certainly this innovation was a welcome news. Dr Victoria Robinson, the Chair of the Examiners very helpfully presented a webinar still accessible explaining the anticipated changes with the remote examinations. The trainees sitting the first diets, experienced some technical glitches, which in my opinion were inevitable, given the novelty of the whole process.

The deployment of online technology to the conduct of these examinations entailed an extra cost for the RCOA, however, it was not passed on to the trainees taking the exams. Furthermore, the FICM, following the General Medical Council (GMC) guidance, advised that first remote (online) attempt at any component of the FFICM examination, would not count towards the overall six attempts a trainee is allowed to take before being awarded the FFICM – it is worth noting that this is a temporary change applicable from August 2020 to July 2021.

Innovation was also required when it came to exam preparation courses. Again, technology came to the rescue. The FICM annual exam preparation course was offered digitally – over 3 tiers of engagement, ranging from pre-recorded lectures to a large number of candidates to more focussed exam practice, to a smaller number.

Generally, there are a few final FFICM exam preparation courses on offer in the United Kingdom annually. The need for social distancing unfortunately led to many of these courses being cancelled. One of the courses however, was still being run from Stoke-on-Trent, with the organisers delivering a full day of exam practice, conducted remotely alongside pre-recorded lectures being made available beforehand.

Some technical glitches were experienced in the two preparatory courses, particularly in the first run – nevertheless the feedback from trainees (either received directly or through social media) was overwhelmingly positive. Trainees felt that they were well prepared (not only academically) but more importantly, they felt that they were better prepared to be examined remotely.

These successes, which may perhaps be perceived as small, were actually down to monumental efforts (mostly entirely voluntary) from clinical and educational leaders across the intensive care community in the UK, the FICM and the wider NHS, working closely with the regulators and partner Royal Colleges. To date, two dates of the Final FFICM SOE and OSCE examinations (as well as preparatory courses) have been provided successfully and the third in October 2021.

Postgraduate Training

Clarity and planning were needed with other aspects of postgraduate training especially for trainees where programs were disrupted significantly by the pandemic, whether because of the need for redeployment or because of missed training opportunities. A lot of anxiety was felt, especially among anaesthetic trainees with regards to disruption of modular training, lack of theatre opportunity and potential problems related to recognition of prolonged times spent supporting intensive care units. The RCoA working with GMC has very helpfully provided trainees with updated guidance regards derogation of clinical and exam milestones, that is to continue until at least September 2021. The RCoA newsletter is available here Anaesthetic Training Update January 2021 | The Royal College of Anaesthetists (RCoA.ac.uk) Updates to the ARCP requirements were approved by the GMC in collaboration with the different Royal Colleges and again this was communicated to trainees, quite extensively.

Many of the intensive care units in the United Kingdom offer, clinical placements to medical students, particularly in their final years. Again, the COVID-19 pandemic placed significant disruption to undergraduate education in the UK. The need for limitations on gathering, meant that almost all education, was offered remotely, for as long as possible. Again innovative solutions were needed to deliver practical components of certain courses.

Undergraduate medical education

The situation with undergraduate medical education was more challenging – there needed to be a balance between delivering good quality medical education and maintaining safety within the constraints of the pandemic. Medical schools, flexibly employed the use of technology to deliver much needed theoretical education, remotely, via different online platforms. Many of the assessments were also conducted online.

Nevertheless, there is no alternative to hands-on bedside clinical teaching especially for final year medical students. Also, shadowing and participating in the clinical care of patients, is one of the best ways to ensure final year medical students, are prepared to take on their Foundation Year 1 responsibilities.

On my ICU

On my intensive care unit (University Hospital of North Midlands), we welcomed our Year 5 Keele medical students on the unit, from August 2020. We utilised the resources of our colleagues in infection prevention teams, to ensure all our students are offered suitable PPE. The clinical skills team helped train our students on following the PHE guidance with regards to the use of PPE both on the ICU and also on the wards. With the start of the COVID-19 vaccination program, our students were among the first to receive their vaccines. With the start of the second wave and with our students made as safe as possible, we employed further innovation – medical student assistantships. Our year 5 students, quickly assimilated in teams tasked to help as part of “proning teams” and also support some of our nursing colleagues. The practice development team on the ICU, were tasked with the induction and training of our student-heroes to enable them to fulfil these roles. We at UHNM, are at the fortunate position of having a team of enthusiastic clinical educators – our students, received bedside teaching at every opportunity. We were very proud to receive the news that 99% of Keele Year 5 students had passed their course. We were also quite proud to receive very good feedback from the Year 5 lead, as to how supported the students felt on the ICU and how useful they found their clinical placements to be – especially during the busy surge weeks. We did not stop there – we continued to offer our regular Year 3 Student Selected Components, and all our slots were fully utilised.

Team work 

None of this work was undertaken with the aim of achieving individual success nor was the colossal accomplishment down to any single individual’s effort; it was rather a testament to the appreciation of the role of maintaining good quality education, not just to ensure the sustainability of the healthcare service for the future, but to continue to be true to the spirit and ethical core of medical training.  

Now with the great success of the vaccination program, we should hopefully start to see, a more sustainable course with the pandemic contained, and further significant surges avoided. There will be chances to learn many lessons from how we all dealt with this crisis.

I am confident that the accomplishments in the field of education and maintenance of training during this pandemic have paved the way for ample opportunities for future potential development and will continue to influence the way we deliver medical education by combining the use of the latest advances in communication technology with face to face teaching and given the particular flexibility and agility that the UK has demonstrated in this field, what it has to offer is most certainly bound to have a significant worldwide impact.