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 Table of Contents  
REVIEW ARTICLE
Year : 2022  |  Volume : 36  |  Issue : 1  |  Page : 1-5

Introducing telesimulation as an innovative tool in the delivery of medical education


1 Deputy Director – Academics, Sri Balaji Vidyapeeth – Deemed to be University, Medical Education Unit Coordinator and Member of the Institute Research Council, Department of Community Medicine, Shri Sathya Sai Medical College and Research Institute, Ammapettai, Nellikuppam, Chengalpet District, Tamil Nadu, India
2 Department of Community Medicine, Shri Sathya Sai Medical College and Research Institute, Sri Balaji Vidyapeeth – Deemed to be University, Ammapettai, Nellikuppam, Chengalpet District, Tamil Nadu, India

Date of Submission05-Mar-2022
Date of Decision13-Apr-2022
Date of Acceptance09-May-2022
Date of Web Publication02-Sep-2022

Correspondence Address:
Dr. Saurabh RamBihariLal Shrivastava
Department of Community Medicine, Shri Sathya Sai Medical College and Research Institute, Sri Balaji Vidyapeeth (SBV) – Deemed to be University, Thiruporur - Guduvancherry Main Road, Ammapettai, Nellikuppam, Chengalpet District - 603108, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jms.jms_19_22

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  Abstract 


A medical student is expected to acquire multiple learning competencies during the course of his/her training period. The present review was carried out to explore the scope, merits, and challenges attributed to telesimulation in medical education, and devise a plan to successfully implement the same in medical college settings. An extensive search of all materials related to the topic was carried out on the PubMed search engine and a total of 33 articles were selected based on their suitability with the current review objectives. Keywords used in the search include telesimulation and medical education in the title alone only. Telesimulation has emerged as an innovative approach in the last couple of decades to strengthen and facilitate education, training, and assessment processes in the field of medicine. Similar to any method, even telesimulation has its own limitations that need to be addressed for enhancing the overall effectiveness and benefit to the medical students. Telesimulation plays an important role in facilitating the acquisition of knowledge, kinesthetic, and procedural skills through real-time training and via the inputs given during feedback or debriefing sessions. To conclude, telesimulation is a new domain in medical education, which has the potential to offer an ample number of opportunities in application and research. The need of the hour is to explore the effectiveness of telesimulation in training different topics and the learning objectives that can be covered and accordingly integrate the same for the benefit of medical students or other health professionals.

Keywords: Medical education, simulation, telesimulation


How to cite this article:
Shrivastava SR, Shrivastava PS. Introducing telesimulation as an innovative tool in the delivery of medical education. J Med Soc 2022;36:1-5

How to cite this URL:
Shrivastava SR, Shrivastava PS. Introducing telesimulation as an innovative tool in the delivery of medical education. J Med Soc [serial online] 2022 [cited 2022 Dec 1];36:1-5. Available from: https://www.jmedsoc.org/text.asp?2022/36/1/1/355578




  Introduction Top


A medical student is expected to acquire multiple learning competencies during the course of his/her training period. We must acknowledge that these planned competencies do not restrict to only knowledge and skill domains, but encompasses a wide range of areas, such as teamwork, leadership, and professionalism.[1] Considering the wide range of competencies, the training period, which has been predefined in most of the medical institutions across the globe, it becomes crucial to utilize the same optimally. In addition, acknowledging the fact that each medical student differs from another, as teachers, we have to adopt a wide range of innovative teaching–learning methods and media to appeal to all kinds of learner, and thereby keep them motivated to pursue their learning goals.[1],[2] The present review was carried out to explore the scope, merits, and challenges attributed to telesimulation in medical education, and devise a plan to successfully implement the same in medical college settings.


  Methods Top


An extensive search of all materials related to the topic was carried out on the PubMed search engine. Relevant research articles focusing on telesimulation in medical education published in the period 2001–2021 were included in the review. A total of 37 studies similar to the current study objectives were identified initially, of which, four were excluded due to the unavailability of the complete version of the articles. Overall, 33 articles were selected based on their suitability with the current review objectives and analyzed. Keywords used in the search include values and medical education in the title alone only (viz. Telesimulation [ti] AND medical education [ti]; COVID-19 [ti] AND medical education [ti]; simulation [ti] AND medical education [ti]; telesimulation [ti] AND COVID-19 [ti]; tele-surgery [ti]; telesimulation [ti]). The articles published only in the English language were included in the review [Figure 1]. The collected information is presented under the following sub-headings, namely, coronavirus disease-2019 (COVID-19) pandemic and medical education, simulation in medical education, telesimulation, merits of telesimulation, potential constraints, applications of telesimulation, strategies for effective implementation, and implications for future.
Figure 1: Flowchart for selection of research articles

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  Coronavirus Disease-19 Pandemic and Medical Education Top


The emergence of the COVID-19 pandemic proved detrimental for the delivery of medical education to both undergraduate and postgraduate medical students.[3],[4] In fact, as a precautionary measure and to ensure physical distancing, medical institutions were closed, and the theory sessions were initiated on different online platforms depending on the medical institution.[3] However, the most affected aspect was clinical training as students were deprived of the conventional face-to-face clinical exposure. Moreover, amid the fear of acquisition of COVID-19 infection and the caseload of the disease, a significant proportion of patients preferred to stay at home instead of visiting hospitals and thereby delayed their follow-up or ailments.[3],[4],[5] Further, as most of the clinicians were managing COVID-19 patients, not many were available for clinical teaching and thus there was definitely an urgent need to bridge the existing gap.


  Simulation in Medical Education Top


A wide range of curricular innovations and paradigm shift has been reported in the field of medical education in different parts of the world.[6],[7] Simulation has been regarded as one of the essential and integral components of medical education, which creates an enabling environment for medical students to learn in a safe atmosphere. The simulation gives a platform for medical students to get exposed to common, uncommon, as well as emergency cases, and generally prepare the medical students to deal with all kinds of situations till they become competent (means a student can repeatedly participate till they are confident in the assigned task).[6],[7] The participation of students in simulation plays an important role in enhancing patient safety.


  Telesimulation Top


Telesimulation has emerged as an innovative approach in the last couple of decades to strengthen and facilitate education, training, and assessment processes in the field of medicine.[1],[2] Since its inception, it has been employed in different broad (such as surgery and anesthesia) and super-specialty (such as pediatric surgery), nursing, and emergency medicine streams.[8],[9],[10] Telesimulation refers to a distance learning method wherein telecommunication and simulation resources are joined together to strengthen the process of teaching–learning and assessment.[2],[8] Even though it was primarily employed to train participants in resource-constraint settings, realizing the scope and potential, it should be looked upon as a suitable option to replicate the real patient experiences amid the ongoing pandemic.[10],[11],[12],[13]

This teaching–learning method enables interaction between participants and simulators or between participants and teachers while they are located remotely from one another.[14] The various options could be a remote teacher and physically present students with high-fidelity simulators; or teacher being present with the high-fidelity simulators while students are in remote locations; or remote presence of a teacher, students, and the standardized patients; or the presence of low-fidelity simulators, while both teachers and students are in remote locations.[9],[10],[11],[15],[16] Obviously, with the presence of high-fidelity simulators, human responses can be mimicked in a realistic manner and thus the entire learning process becomes effective. However, even a low-fidelity simulator, which permits observation of vital parameters or physical examination can prove to be quite effective.[14],[15],[16] The training imparted to students can be passed on to them using a wide range of video teleconferencing platforms, such as Zoom, Microsoft Teams, Skype, or in the form of prerecorded audio or video clips.[14],[15]


  Merits of Telesimulation Top


Telesimuation has been linked with a number of merits, including the ability to train medical students and healthcare professionals in resource-constraint settings, and because these training sessions can be carried out regardless of geographical boundaries, it makes the overall concept very useful.[8],[9] Apart from training, the students can also be assessed for their performance or skills acquired and thereby improved subsequently based on the feedback received from the assessors.[17] The knowledge and skills acquired from these sessions can be applied in real patient settings and thus it facilitates the overall process of patient care. The training imparted via this novel method neutralized the time barrier and proved to be quite a convenient method to ensure delivery of the educational content.[16],[17],[18] In other words, telesimulation enabled us to continue the learning process beyond the four walls of the simulation center alone.

Amid the ongoing COVID-19 pandemic, telesimulation emerged as a vital approach to continue the learning process, as in-person training had its own risk.[19] It is quite a cost-effective method for the institutions and administrators, as the major investment is during the initial stages, and subsequently over the years' a significant amount of revenue can be generated. Further, this also enables educational networking between different institutions and they can collaborate with each other for the benefit of students.[16],[17],[18] Moreover, it also becomes a powerful tool to disseminate the new content in medical education to different learners at a rapid pace, so that all the involved personnel can integrate the same in patient care.[19],[20]

It is important to remember that as students are actively involved in the learning process, the knowledge and skill gained become long-term and the learning becomes deep.[11],[12] It plays its part in laying down the foundation of self-directed learning for medical students and thus becoming lifelong learners. Further, the use of the telesimulation plays a vital role in teaching procedural skills and emergency skills to medical students.[8],[9] In addition, students learn the importance of teamwork in the management of patients and grow professionally. The findings of studies have demonstrated that students who are trained using telesimulation tend to have beer confidence, which at times is comparable to in-person training.[9],[10],[11],[12] In-fact, realizing these wide ranges of benefits there has been a gradual rise in the demand for organizing similar kinds of sessions and targeting more learners in each of the planned sessions.[15],[16],[17]


  Potential Constraints Top


Similar to any method, even telesimulation has its own limitations that need to be addressed for enhancing the overall effectiveness and benefit to the medical students. The first and foremost challenge has to be with regard to the availability of adequate number of teachers/trainers who are competent enough to carry out such kind of sessions for the students.[20] Considering the fact that telesimulation got major a boost upon the emergence of the COVID-19 pandemic, it is a work in progress, wherein interested people are gradually getting trained in this specific skill.[11],[12] Obviously, as technology is involved, there are bound to be technical constraints, such as availability of a strong technical team, noise during sessions, poor hearing, and presence of specific computer equipment.[20]

The other major challenge is the readiness and preparedness of the medical students to learn via telesimulation, as everyone is used to the conventional on-site training. Moreover, the absence of physical interaction or availability of good quality simulators, significantly impacts the quality of training imparted.[21],[22] There is an immense need to keep a balance between the knowledge and the clinical skills imparted to the students to ensure better involvement of students.[2] Further, the absence of informing students prior to the training sessions, or giving breaks during sessions, or not having a debriefing session upon the completion of training can significantly minimize the effectiveness of the session, and thus should be always incorporated.[10],[11] Finally, the financial investment expected from institutions or administrators in the establishment stage can turn out to be a major challenge in the initial stages.[15],[23]


  Applications of Telesimulation Top


Telesimulation plays an important role in facilitating the acquisition of knowledge, kinesthetic, and procedural skills through real-time training and via the inputs given during feedback or debriefing sessions.[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34] It has been employed in different surgical streams (such as laparoscopy, robotic surgery, ophthalmology, etc.), regional anesthesia, ultrasound-guided procedures, or orthopedic procedures.[8],[9],[24],[25],[26],[27],[28],[29],[30] Most of these applications have been in resource-constrained settings with limited access to high fidelity simulators or trained instructors. It has also been employed in emergency procedures like neonatal resuscitation, administration of anesthesia to the pediatric population, and in emergency medicine.[31],[32],[33] In-fact, junior medical students have been trained in emergency medicine skills so that they can perform better and save lives in remote settings.[31] Further, to bridge the gap in curriculum delivery, telesimulation has been employed to design a specific curriculum for medical students to facilitate their clinical training in hospital settings.[13]


  Strategies for Effective Implementation Top


Considering the technical complexities and other attributes pertaining to the telesimulation, it is very important to adhere to basic steps to ensure seamless implementation of the same in the institution.[2],[32] It is very essential that before we implement telesimulation, we plan about the resources (which are already available and that are required). The potential resources include simulated patient monitors, videoconferencing applications, trained faculty, technician, computer equipment, the internet, etc. Further, it is preferable to not train more than five participants in such a session as the task becomes quite challenging.[23] The next thing is to acknowledge the limitations of telesimulation when compared with on-site training, and accordingly decide about the topic and content that will be covered.[27],[30]

The next important thing is to frame 2–3 specific learning objectives that are feasible to be accomplished using telesimulation in an effective manner.[2] The organizing department should look to add features to optimize the quality of audio and video materials to enhance the overall utilization and effectiveness of such sessions. It is always a good practice to pilot run the session with the trained faculty before the real session, which will aid in the identification of potential mistakes and things that can minimize the overall effectiveness of the program.[20],[23] Further, feedback obtained from the participants in the pilot sessions can also prove to be extremely beneficial. On the day of the organization of the session, the participants should be explained the basics of the program, the objectives, and expectations of the students, right at the start of the program.[19],[20]

As each student differs from others, it becomes quite essential that some form of breaks should be given during the sessions. These breaks should be utilized for the participants to clear their doubts and refocus their attention towards the proceedings.[27],[28] Another essential strategy to enhance the effectiveness of the training session is via assigning specific roles and responsibilities to different members, as that will minimize duplication and ensure clarity of instructions.[1],[2] As already stated, it is vital to keep a debriefing session and explain to the participants what went well and what could have been done better.[34] The best approach will be that participants come out themselves about the same, as it will encourage reflection.[34]

It is very much important that the students who are not actively participating should be encouraged for better engagement via asking them to unmute, respond to the raised questions, participate in the ongoing discussion, etc.[29],[31] In order to continue learning, the organizers should share learning resource materials after the session and motivate them to keep learning.[24],[25] Finally, no session will be considered complete unless we obtain feedback from the participants about the different aspects of the training program, and all the given feedback should be carefully considered and accordingly remedial measures should be taken to enhance the benefit to the participants in the future training sessions.[2],[20]


  Implications for Future Top


As telesimulation is still finding its feet in many medical institutions, it won't be wrong to state that a lot needs to be done to eventually optimize the benefit of this innovative teaching–learning and assessment approach.[26],[27] There is a definitive need to explore various options by which the initial cost of establishing telesimulation in a medical college or the simulation center can be minimized.[20],[23] At the same time, we have to explore the benefits of the organized sessions and compare their effectiveness with the training programs organized physically. In addition, there is a definite need to evaluate the effectiveness of the telesimulation sessions and take subsequent steps to benefit all the involved stakeholders.[27]


  Conclusion Top


To conclude, telesimulation is a new domain in medical education, which has the potential to offer an ample number of opportunities in application and research. The need of the hour is to explore the effectiveness of telesimulation in training different topics and the learning objectives that can be covered and accordingly integrate the same for the benefit of medical students or other health professionals.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Suzuki S, Suzuki N, Hattori A, Hayashibe M, Konishi K, Kakeji Y, et al. Tele-surgery simulation with a patient organ model for robotic surgery training. Int J Med Robot 2005;1:80-8.  Back to cited text no. 9
    
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Nelsen BR, Chen YK, Lasic M, Bader AM, Arriaga AF. Advances in anesthesia education: Increasing access and collaboration in medical education, from E-learning to telesimulation. Curr Opin Anaesthesiol 2020;33:800-7.  Back to cited text no. 14
    
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Hayden EM, Khatri A, Kelly HR, Yager PH, Salazar GM. Mannequin-based telesimulation: Increasing access to simulation-based education. Acad Emerg Med 2018;25:144-7.  Back to cited text no. 15
    
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Gutierrez-Barreto SE, Argueta-Muñoz FD, Ramirez-Arias JD, Scherer-Castanedo E, Hernández-Gutiérrez LS, Olvera-Cortés HE. Implementation barriers in telesimulation as an educational strategy: An interpretative description. Cureus 2021;13:e17852.  Back to cited text no. 20
    
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