Competence-Based Training and Immersion Virtual Reality: Paradigm-Shifting Advances in Medical Education

Abstract

See Article, page 223 and 230 Two Futuristic articles in this centenary issue of Anesthesia & Analgesia remind us that medical education is evolving at an accelerating pace. One article focuses on competence-based medical education and the other on immersive virtual reality (VR) as tools to enhance learning and provide real-time clinical support.1,2 These complementary approaches are designed to develop practical, experiential clinical skills that are coupled with effective decision-making. The purpose of this commentary is to highlight the strengths of these 2 paradigm-shifting educational strategies and to summarize several challenges that lie ahead. In the first article, Drs Kealey and Naik1 asked whether competence-based medical training in anesthesiology has delivered on its promise of better education. The authors provide a comprehensive overview of the literature and a summary of their individual perspectives as education leaders. These experts write with authority, with Dr Kealey having served as chair of the committee that oversees competencies in one of the largest anesthesia residency programs in North America, and Dr Naik being the director of assessments for the Royal College of Physicians and Surgeons of Canada. The authors remind us that the goal of medical training programs is to produce competent clinicians who can serve the needs of society. Competence has been defined as “the quality or state of having sufficient knowledge, judgment, skill, or strength.”3 The intent is to ensure that residents graduate with the technical and nontechnical skills needed to ensure safe and effective clinical practice. Scholarly or theoretical knowledge, while important, does not equate to clinical competence. This competence-based approach reflects the old adage, “Start with the end in mind,” as it focuses more on the outcome or product than traditional time-based training programs do. Certainly, competence is 1 of the 4 key “C traits” we seek in ourselves and in our colleagues—the other 3 being character, confidence, and commitment. Competence-based medical education has been adopted in the residency training programs of many jurisdictions, including the United States, Europe, and Canada.4–6 A comparison among programs in different countries revealed that 90% of the anesthesiology-related clinical skills identified as necessary were common across different regions.7 This high level of commonality in terms of clinical skills holds promise for the development of international competence standards that could facilitate greater reciprocity in training programs and portability of clinical practice. However, there are some divergences in nontechnical competencies, such as those related to professionalism and to cultural and behavioral practices. The key enablers of competence-based medical education are regular and numerous assessments of trainee performance, mapped to specific desired competencies. Quantitative performance ratings and qualitative narratives are collected and used to provide feedback. The assessments are designed as observable clinical encounters and are intended to guide the development of competencies. Compared to traditional approaches, these frequent assessments yield more feedback for trainees and more information to allow training programs to make summative decisions. Drs Kealey and Naik clearly outline the advantages of shifting to competence-based medical education but acknowledge the need to rigorously assess whether the changes do, in fact, lead to more competent graduates, more flexible performance-based training timelines, and improved clinical practices. They also recognize the need to identify and address the unintended consequences of competence-based medical education. Many educational institutions are well advanced in the adoption of competence-based residency programs; thus, as Drs Kealey and Naik suggest, it is now essential to evaluate the impact of these new curricula. Although the concept of basing clinical education on competence might seem simple, it entails numerous complexities, and the adoption of such programs may cause unintended problems, including disruptions in learning environments. At the same time, there may be unanticipated benefits. For example, physicians trained in this manner may be more accustomed to feedback and, thus, may be more open in their eventual careers to regular assessment focused on improvement. This approach may also improve the accuracy of self-assessment, encourage reflective learning styles, and support a commitment to lifelong learning. It is important to recognize, consider, and address several potential hurdles associated with competence-based medical education. The first challenge is to determine whether competence-based medical education programs do, in fact, “build a better product.” Studies of long-term outcomes are needed to determine whether this approach improves trainees’ clinical performance. Equipoise is required when developing research studies aimed at objectively determining whether the new programs are substantially better than traditional models. For now, the jury is still out regarding the value of competence-based residency programs. The second challenge is to measure the costs, both financial and nonfinancial, of a competence-based curriculum. Such costs could negatively affect funding-strapped departments and might also strain already weary trainees and faculty. One potential unintended consequence is the diversion of resources away from other established or emerging essential educational programs, such as the development of ultrasound-guided skills and simulation-based training. Given resource constraints, departments will need to balance these competing priorities. The third concern is that many competence-based medical education programs depend on large amounts of assessment data. Consequently, robust data management platforms need to be developed in parallel with the educational programs themselves. Previous experience in Canada provides a cautionary tale in this regard. When the Royal College of Physicians and Surgeons of Canada first implemented competence-based medical education, the electronic tools and software platforms required to capture and organize assessment data were unavailable to some educational programs. Thus, programs were left to develop home-grown assessment solutions. Apart from the need for systems to collect and summarize these assessment data, concerns related to data stewardship, ownership, security, and confidentiality must be addressed and approaches standardized. In particular, institutions must determine how they will protect the assessment data gathered and under what circumstances the results can be requested, accessed, and utilized by other fiduciary organizations and regulatory authorities. The fourth concern is the impact of the new curriculum on each learner’s experience and the learning environment more generally. For example, as noted by Drs Kealey and Naik, frequent assessments can foster tensions between trainees and faculty and may actually create barriers to offering a nonjudgmental and supportive learning environment.1 On the other hand, a shift to competence-based medical education will require all of us to develop a mindset of life-long coaching that can be embraced and emulated by trainees. Overall, the theoretical advantages of competence-based medical education are clear, and programs of this type have now been implemented in many countries. Thus, it is time to measure the financial and nonfinancial costs of these programs and determine whether the costs are justified and whether the programs are beneficial for learners, trainers, and the learning environment. The second article that we considered here is by Drs Fahad Alam and Clyde Matava, the 2 clinician investigators who founded the Collaborative Human Immersive Interaction Laboratory (CHISIL).8 This team has been at the cutting edge of studying and implementing immersive virtual environments and is now working with international colleagues to develop effective immersive experiences. The goal is to develop VR teaching tools that can be widely used in educating both health care providers and their patients. In their current article, Drs Alam and Matava offer an exciting glimpse into virtual environments, VR, and the future of immersive VR. Their report highlights how anesthesia education has evolved in parallel with computer technology over the decades since the advent of personal computer systems, as well as how our discipline has leveraged application of the technology as these systems have become more popular and affordable. This article is most timely, given how the coronavirus pandemic has broken down geographic barriers to medical education and promoted virtual interaction and learning. Also, the rapid evolution of VR technologies, driven primarily by the gaming industry, has made VR and augmented VR (AVR) tools readily available at a reasonable cost. The major strength of adopting immersion VR-based education is that it provides a realistic, dynamic, interactive learning environment that can be accessed at a distance. Interactive sessions can be led either in real time by in-person trainers or asynchronously by bots equipped with artificial intelligence-driven algorithms. There are no safety risks to patients (avatars), and the learners’ performance data can be readily analyzed for feedback and assessment. Consider the example of a synchronous immersion workshop in which anesthesiologists located on different continents gather to learn a specific technique such as management of a fractured larynx. They each don a headset and meet in a virtual simulation center, where they have access to an expert (real or virtual) who can help them meet their shared goal of acquiring new knowledge and developing “hands-on” technical skills. The real-time coach demonstrates management techniques and then invites the learners to participate. Through the use of AVR, the instructor’s hands appear in the learner’s field of view to help guide and reposition the learner’s hands to facilitate fiber-optic endobronchial intubation. This may sound futuristic, but such exciting learning sessions are already underway. The advantage of an immersive VR approach is that it offers medical education and real-time coaching without geographic barriers and limitations. In addition, it avoids the time, financial, and environmental costs of travel and eliminates the risks to patients associated with learning new techniques. Current challenges include the need to improve the immersion environment to ensure that it offers high structural fidelity (the visual realism of the simulator) and functional fidelity (what the simulator can actually do in response to actions by trainees). In addition, the learning curriculum needs to be well grounded in education theory and principles, and an optimum learning environment must be provided. Finally, considerations for future application include the customization of these systems to take into account local practice realities and the need to address equity and diversity concerns that exist globally. The potential applications are exciting. Overall, the competence-based education model and immersion VR, which represent 2 major advances in our medical education armamentarium, have the potential to improve clinical performance and increase patient safety. Anesthesiologists are well positioned to lead the development and adoption of these futuristic educational tools given our risk management mindset and technical affinity. DISCLOSURES Name: Beverley A. Orser, MD, PhD, FRCPC, FCAHS, FRSC. Contribution: This author helped write the manuscript. Conflicts of Interest: B. A. Orser serves on the board of trustees of the International Anesthesia Research Society (San Francisco, CA) and is a codirector of the Perioperative Brain Health Centre (Toronto, Ontario, Canada; http://www.perioperativebrainhealth.com). Dr Orser is a named inventor on a Canadian patent (2852,978) and 2 US patents (9517,265 and 10,981,954). These 3 patents, which are held by the University of Toronto, are for new methods to prevent and treat delirium and persistent neurocognitive deficits after anesthesia and surgery, as well as to treat mood disorders. Dr Orser collaborates on clinical studies that are supported by in-kind software donations from Cogstate Ltd (New Haven, CT). Name: Salvatore M. Spadafora, MD. Contribution: This author helped write the manuscript. Conflicts of Interest: None. This manuscript was handled by: Thomas R. Vetter, MD, MPH.

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