|Year : 2020 | Volume
| Issue : 2 | Page : 38-41
Nephrology teaching during the Coronavirus Disease 2019 pandemic
S Arunkumar1, Dipankar Bhowmik2
1 Assistant Professor, Department of Nephrology, All India Institute of Medical Sciences, New Delhi, India
2 Professor, Department of Nephrology, All India Institute of Medical Sciences, New Delhi, India
|Date of Submission||10-Aug-2020|
|Date of Acceptance||13-Aug-2020|
|Date of Web Publication||01-Sep-2020|
Dr. Dipankar Bhowmik
Department of Nephrology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
The rapid spread of coronavirus disease 2019 (COVID-19) to pandemic proportions since March 2020 has placed enormous pressure on health-care workers worldwide. India was placed on a nationwide lockdown from March to May 2020 and is gradually opening up with regard to travel and businesses. India is the third worst-hit country in the world after the United States and Brazil with 2.1 million documented cases. Coronavirus 2 infection is commonly associated with acute kidney injury in severe cases. The rapid spread of coronavirus has strained and stretched our health-care system, in particular, nephrology service to previously unknown dimensions. This has affected the normal routine of clinical training and necessitated a change in the approach to medical education. Apart from the training perspective, the stress on account of changes in clinical rotation, fear of contracting COVID-19, and uncertainty about the future course of disease and job prospects affects mental health of residents. This brief review explores the impact of such curtailed clinical activities and teaching and the possible approaches to nephrology teaching during the pandemic.
Keywords: Coronavirus 2, dialysis modalities, free open-access medical education, nephrology teaching
|How to cite this article:|
Arunkumar S, Bhowmik D. Nephrology teaching during the Coronavirus Disease 2019 pandemic. J Renal Nutr Metab 2020;6:38-41
|How to cite this URL:|
Arunkumar S, Bhowmik D. Nephrology teaching during the Coronavirus Disease 2019 pandemic. J Renal Nutr Metab [serial online] 2020 [cited 2020 Dec 3];6:38-41. Available from: http://www.jrnm.in/text.asp?2020/6/2/38/294184
| Introduction|| |
The rapid spread of coronavirus disease 2019 (COVID-19) to pandemic proportions since March 2020 has placed enormous pressure on health-care workers worldwide. India was placed on a nationwide lockdown from March to May 2020 and is gradually opening up with regard to travel and businesses. However, the number of cases of COVID-19 is still significantly high and increasing daily. We are the third worst-hit country in the world after the United States and Brazil with 2.1 million documented cases.
Coronavirus 2 infection is commonly associated with acute kidney injury in severe cases. Furthermore, patients with kidney disease and renal transplant recipients are more commonly affected, thereby overburdening the clinical nephrology service in all centers. This rapid spread has strained and stretched our health-care system, in particular, nephrology service to previously unknown dimensions. Residents and trainees are a major part of the workforce and have been taking care of COVID patients. The combination of “social distancing” and the unprecedented challenge posed by this pandemic has a deleterious effect on the residency training programs worldwide. This has affected the normal routine of clinical training and necessitated a change in the approach to medical education. Apart from the training perspective, the stress on account of changes in clinical rotation, fear of contracting COVID-19, and uncertainty about the future course of disease and job prospects affects mental health of residents. We shall explore the impact of such curtailed clinical activity and teaching and the possible approaches to nephrology teaching during the pandemic in this brief review.
| Nephrology Training Program in India|| |
COVID-19 is poised for a prolonged course and has crippled health-care delivery across the globe. The normal schedule of all nephrology training programs in India, be it the DM Nephrology course (DM) or the Diplomate of National Board course, is derailed due to this crisis. Although the sequence of training varies in different centers, a nephrology trainee is expected to learn the following during the course of his training of 3 years:
- Competence and skill in managing patients with regard to nephrology and aware of the latest developments in nephrology
- Procedural skills in nephrology – Perform kidney biopsy, dialysis catheter placement (tunneled and nontunneled), peritoneal dialysis catheter placement, and creation of arteriovenous fistula
- Training in various dialysis modalities – hemodialysis, plasmapheresis, hemofiltration, and continuous renal replacement therapy
- Renal transplant care – Workup and postoperative management of renal transplant recipients with appropriate titration of immunosuppressive therapy to improve outcomes
- Basic knowledge in research with completion of at least one research project as a thesis/dissertation.
As enlisted above, nephrology training entails a combination of clinical work which includes bedside teaching and procedural training and a teaching program to impart theoretical knowledge to the nephrology trainees. This teaching is accomplished by bedside clinical sessions with discussions, journal clubs, seminars, and clinical rounds. Nephrology trainees are expected to present a fixed number of seminars/symposia which would ensure a thorough theoretical training and is a regular academic exercise.
| Coronavirus Disease 2019 and Nephrology Training Program|| |
COVID-19 has modified patient care and the entire nephrology training curriculum this academic year. A number of nephrology admission beds have been curtailed to accommodate “COVID suspect” patients coming to the hospital. The various components of clinical nephrology training affected by this pandemic are listed in [Table 1]. Almost all components of clinical training are adversely affected. Apart from this disruption of teaching schedule, the nephrology trainees are subjected to more stress owing to their close contact and management of COVID-19 patients. Apprehension about risks of contracting infection while treating the patients, availability and quality of personal protective equipment, risk of transmission of infection to close contacts and family members, lack of social life, and social support all add to heightened anxiety and work stress-related disorders among residents and trainees.
|Table 1: Nephrology training activities affected by coronavirus disease 2019|
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The overall impact of such disruption of training will depend on the total duration of such cessation and the timing with regard to residency training. We have already lost nearly 5 months to this pandemic, and those in the final year of training are more affected than those who have started their courses this year. Although training is important, ensuring resident safety is of foremost importance. Once safety is ensured, the training deficit can be partially offset by developing strategies to train residents remotely by employing technology for continuing medical education.
| Medical Education during COVID-19 – Technology|| |
Social distancing is the only known preventive strategy against COVID-19, and in-person physical teaching sessions are impractical in the immediate future. Social media with its various technological advances have shown immense potential in health-care and medical education. Free open-access medical education (FOAMed) is the primary web-based learning facility and includes discussions on Twitter, blog posts, podcasts (audio), and live streaming of conferences. Teaching faculties have equipped themselves with technological developments to restart the teaching sessions in an online format. A earlier systematic review on utilizing social media for medical education identified technical issues, variable learner participation, and privacy concerns as the limiting issues. It has been a decade since this review was published, and with change in perception and availability of technology, this would be different if a similar assessment is done now. The acceptance of online formats by residents and the influence of such training on resident's knowledge have to be assessed in order to promote such endeavors in the future.
| Smart Devices – messenger Applications|| |
The speed of dissemination of information has grown exponentially with advances in technology. The extensive penetration of smart devices (smartphones, tablets, etc.) has made the spread of information fast and widespread. This also provides a unique opportunity for knowledge transfer. Almost all smart devices have access to messaging platforms such as WhatsApp ®, Telegram ®, Slack ®, WeChat ®, and many more. These services allow the creation of closed groups wherein dissemination of all and any information is possible. With the availability of end-to-end transcription, privacy is also taken care of by most messaging services. Real-time discussion about patient cases and exchange of study materials including scientific articles and images are highly useful features of such applications. Furthermore, the data exchanged are available for review later at any convenient time.
India has been at the forefront of utilizing WhatsApp ® for clinical practice. In review of such practices including 32 papers, over 12 were from India, and this paper noted the convenience of the use of the application. Another recent study on the utility of WhatsApp ® in medical education noted the efficiency and versatility of such media in educating students both with a predefined curriculum and also without a curriculum. Many such studies in postgraduate medical education, using other media like Facebook ®, have shown promise for this modality of teaching. In nephrology, a pilot study in the Nephrology Fellowship Program of Northwell Health, USA, reported a positive experience among both fellows and faculty for a WhatsApp ®-based teaching–learning program. The comfort and variety were other noteworthy advantages of this medium.
Apart from a learning advantage, such instant messaging platforms facilitate communication among faculty and students improving patient care and satisfaction. A continuing nephrology education (CNE) initiative through WhatsApp group chats among hemodialysis nurses in East Africa proved to be a valuable method for informal education. Similar programs for dialysis technicians, medical students, and nephrology residents are bound to be successful.
| Online Video Sessions|| |
Nephrology residents manage COVID-19 patients on a rotation basis, and the duration of each shift is usually limited to 6 h. The varying schedule combined with the need for social distancing has led to a resurgence of digital platforms to conduct online teaching sessions. Popular platforms which are available for free include Google Meet ® and Jitsi ®, while others such as Zoom ® and Cisco Webex ® provide free services only for a limited period of time with subscription options for online sessions of longer durations.
Digital platforms help conduct the routine seminar/symposia, journal clubs, and case discussions as scheduled during the pre-COVID period. The universal availability of cheap, fast Internet with personal computers has enabled teaching programs to continue the teaching schedule without any hiccoughs. Collaborative sessions involving pathologists for nephron-pathology discussions and radiology for nephron-radiology discussions help patient care and also train residents.
Major educational conferences including the European Renal Association-European Dialysis and Transplant Association Annual Congress 2020 were streamed alive with multiple sessions available for free access for nephrology enthusiasts all over the world. This has, in fact, increased the coverage and dissemination of conference material when compared to the normal physical meeting. The American Society of Nephrology annual meeting (kidney week) has also been scheduled to be held virtually. Although the lack of networking is a restricting factor, the ease of learning the latest advances in the field from the best researchers in the luxury of one's home and the privilege of scheduling the sessions at one's own convenience is expected to make virtual conferences popular. A survey conducted by Nature after the American Physics Conference revealed that over 80% of respondents favored an online conference. Furthermore, the webinars conducted by various regional, national, and international organizations have ensured that the learning has not stopped during the COVID-19 pandemic. The immense popularity of virtual conferences has prompted conference organizers to plan for hybrid meetings, wherein in addition to the physical component, a virtual mode will also be available.
| Free Open-Access Medical Education|| |
There has been a tremendous growth of FOAMed over the last decade. Nephrology societies have been focusing on social media to improve the reach of nephrologists all over the world. Among the various social media platforms, Twitter has been the most popular choice among doctors, especially nephrologists, to disseminate knowledge. An important drawback with twitter was the character limit (280 characters) for a tweet. This has been offset using tweetorials, which are a series of connected tweets on a common topic. The various FOAMed resources available for nephrologists are listed in [Table 2].
The FOAMed resources are free, easily accessible, and retrievable, making it convenient for trainees to access it at any time. Moreover, they provide ample scope for the trainees to interact directly with leaders in nephrology, journal authors, and scientists. This improves their understanding and also stimulates the trainees to clear all their doubts online. Case-based teaching resources like NephSIM have shown to have a global reach due to the ease in usage and user satisfaction.
COVID-19 pandemic, by curtailing the standard physical teaching sessions, has provided the trainees ample time to utilize these FOAMed resources to improve their training and provides possibility of CNE in these trying times.
| Challenges Ahead|| |
COVID-19 has stimulated a growth of “teletraining” in medical education, and it may become the new normal if it shows success in sustaining resident interest and knowledge in the long term. A basic prerequisite would be the universal availability of smart devices – mobile phones, tablets, and computer devices in addition to a stable Internet connection. This has to be ensured for all trainees and faculty for this approach to be successful. The online platform requires training for the teaching faculty to adequately use the resources available on the Internet. Apart from issues due to unfamiliarity, implications of social media use are of concern. Studies evaluating the acceptance, difficulties, and success of these newer modalities of teaching and learning are required to better understand the need and remove any lacunae in medical education.
| Conclusion|| |
Although the pandemic was an unprecedented setback in academics and educational development in nephrology, it did provide a once in a lifetime opportunity for medical trainees to understand about pandemic response. Furthermore, in the light of resource allocation, it develops team ethos and flexibility in resident attitude and an opportunity for cross-training. The ultimate goal of a residency program is to deliver a competent nephrologist for the society, and online teaching tools combined with a planned schedule should do the same without compromising resident health and safety. Social media provides a dynamic platform to facilitate teaching residents and fellows and, when well utilized, may supplant the standard didactic teaching schedule being followed in medical education at present.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest
| References|| |
Gabarre P, Dumas G, Dupont T, Darmon M, Azoulay E, Zafrani L. Acute kidney injury in critically ill patients with COVID-19. Intensive Care Med 2020;46:1339-48.
Rose S. Medical student education in the time of COVID-19. JAMA. 2020;323:2131-2.
Cheston CC, Flickinger TE, Chisolm MS. Social media use in medical education: A systematic review. Acad Med 2013;88:893-901.
Coleman E, O'Connor E. The role of WhatsApp® in medical education; a scoping review and instructional design model. BMC Med Educ 2019;19:279.
Sterling M, Leung P, Wright D, Bishop TF. The use of social media in graduate medical education: A systematic review. Acad Med 2017;92:1043-56.
Jhaveri KD, Pascarelli B, Hasan A, Kozikowski A, Fishbane S, Pekmezaris R. 'WhatsApp®'ening in nephrology training. Clin Kidney J 2020;13:8-13.
Makwabe EF, Pereira-Kamath N, Vincent L, Mngumi J, Kelly H, Pichan F, et al
. SAT-489 audit of a WhatsApp based continuing education platform to facilitate on the job formal learning to improve quality of care delivered among haemodialysis nurses. Kidney Int Rep 2020;5:S204.
Woolston C. Learning to love virtual conferences in the coronavirus era. Nature 2020;582:135-6.
Desai T, Sridharan S, Parada X, Claure-Del Granado R, Orantes C, Madariaga H, et al
. Exploring the uncharted territory of social media: The next frontier of medical education in nephrology. Clin Kidney J 2018;11:156-61.
Breu AC. From Tweetstorm to Tweetorials: Threaded tweets as a tool for medical education and knowledge dissemination. Semin Nephrol 2020;40:273-8.
Colbert GB, Topf J, Jhaveri KD, Oates T, Rheault MN, Shah S, et al
. The social media revolution in nephrology education. Kidney Int Rep 2018;3:519-29.
Farouk SS, Hilburg R, Sparks MA. Design, dissemination, and assessment of NephSIM: A mobile-optimized nephrology teaching tool. J Grad Med Educ 2019;11:708-12.
[Table 1], [Table 2]