REVIEW

CURRENT
OPINION Advances in anesthesia education: increasing
access and collaboration in medical education,
from E-learning to telesimulation
Brenna R. Nelsen a, Yun-Yun K. Chen b, Morana Lasic a,b,
Angela M. Bader a,b,c, and Alexander F. Arriaga a,b,c,d

Purpose of review
Downloaded from http://journals.lww.com/co-anesthesiology by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 12/07/2020

The landscape of medical education continues to evolve. Educators and learners must stay informed on
current medical literature, in addition to focusing efforts on current educational trends and evidence-based
methods. The present review summarizes recent advancements in anesthesiology education, specifically
highlighting trends in e-learning and telesimulation, and identifies possible future directions for the field.
Recent findings
Websites and online platforms continue to be a primary source of educational content; top websites are
more likely to utilize standardized editorial processes. Podcasts and videocasts are important tools desired
by learners for asynchronous education. Social media has been utilized to enhance the reach and visibility
of journal articles, and less often as a primary educational venue; its efficacy in comparison with other e-
learning platforms has not been adequately evaluated. Telesimulation can effectively disseminate practical
techniques and clinical knowledge sharing, extending the capabilities of simulation beyond previous
restrictions in geography, space, and available expertise.
Summary
E-learning has changed the way anesthesiology learners acquire knowledge, expanding content and
curricula available and promoting international collaboration. More work should be done to expand the
principles of accessible and collaborative education to psychomotor and cognitive learning via
telesimulation.
Keywords
adult learning, e-learning, medical education, teledebriefing, telesimulation

INTRODUCTION These trends towards collaborative and accessible

Anesthesiology learners are called upon to demon-
strate mastery across the broad competencies of
clinical knowledge, technical skills, and profession-
&&
alism [1 ]. Current educators should seek to under-
stand best practices in current medical education, so
they may best utilize tools and methods at their
disposal. Learners need to be well informed of the
most useful resources for their self-directed educa-
tion, especially amongst competing demands of
clinical duties.
One of the most striking changes in the medical
education landscape over the last decade has been
the continued rise of e-learning, defined as educa-
tional modalities that utilize electronic connections
&&
to access internet-based resources [1 ,2]. E-learning
has shifted the focus of medical education away
from the traditional classroom and increasingly
towards the use of digital and online media content.
educational material have encouraged new methods
of skills and procedural instruction, and there is an
increasing need to expand procedural and simula-
tion instruction globally. The present review sum-
marizes recent advancements in anesthesiology
education, specifically highlighting trends in
e-learning and telesimulation education, and iden-
tifies potential future directions for the field.
a
Harvard Medical School, bDepartment of Anesthesiology, Perioperative
and Pain Medicine, Brigham and Women’s Hospital, cCenter for Surgery
and Public Health and dAriadne Labs, Boston, Massachusetts, USA
Correspondence to Brenna R. Nelsen, Harvard Medical School, Boston,
MA, USA. Tel: +1 617 732 8922;
e-mail: Brenna_Nelsen@hms.harvard.edu
Curr Opin Anesthesiol 2020, 33:800–807
DOI:10.1097/ACO.0000000000000931

www.co-anesthesiology.com Volume 33  Number 6  December 2020

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.


KEY POINTS
 E-learning has changed the way anesthesiology
learners acquire knowledge, expanding content and
curricula available and promoting
international collaboration.
 Podcasts and videocasts are viewed as desirable by
learners and help facilitate learner-directed,
asynchronous education.
 Social media platforms such as Twitter have been
utilized to enhance the reach and visibility of journal
articles; its use as a primary educational venue is still
early, and its efficacy in comparison with other e-
learning platforms has not been adequately evaluated.
 Telesimulation can effectively disseminate practical
techniques and clinical knowledge sharing, extending
the capabilities of simulation beyond previous
restrictions in geography, space, and
available expertise.
 Early research shows teledebriefing is rated as effective
by learners, though more studies are needed to assess
educational gains.
APPLICATIONS OF ADULT LEARNING
THEORY
A discussion of e-learning should be grounded in the
theory of adult learning. Five assumptions of adult
learners are that they: are independent and self-
directing, have accumulated past experiences, value
learning and integrating it into the demands of their
daily life, learn by problem solving, and are highly
motivated [3]. Understanding these specific attrib-
utes characterizing an adult learner is necessary to
recognize their influence on undergraduate and
graduate medical education in the field of anesthe-
siology gravitating towards these newer educational
modalities.
The assumption that adult learners are both self-
directing and highly motivated helps illustrate why
learners may be more inclined to seek information
outside a traditional classroom structure. Residents
and fellows have limited time for educational
endeavors outside clinical duties, and they may be
more motivated to engage with content that allows
them to easily navigate to relevant topics pertinent
to their clinical encounters. Trainees have clinical
experience that allows them to build off prior
knowledge in their continued learning.
New educational tools strive to make learning
relevant, applicable, and as active as possible, with a
focus on dynamic problem solving. One model
that has been increasingly employed is the flipped
classroom model, where learners acquire content
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Advances in anesthesia education Nelsen et al.
knowledge independently, then use focused class-
room time to engage in active problem solving with
application of material. One study found that
flipped classroom models improve knowledge reten-
tion and are preferred by anesthesiology residents
[4]. However, some evidence suggests that similar
educational gains can be afforded via other modes of
active learning. For instance, one study found no
difference in knowledge retention or learner prefer-
ences between flipped and nonflipped classroom
settings when both utilized active learning meth-
ods; the results led the study authors to suggest
active learning may be the backbone for educational
gains that are typically ascribed to flipped classroom
models [5]. These results encourage consideration of
other types of active learning methodologies that
can be utilized individually by learners on their own
time, outside a traditional classroom environment,
as time for such learning activities is often limited.
E-LEARNING TO IMPROVE LEARNER
KNOWLEDGE
Applying the attributes of an adult learner to anes-
thesiology trainee education, it should come as no
surprise that the education landscape has shifted
away from traditional in-person didactic structures
and increasingly towards accessible and engaging
content that allows learners to be self-directed in
their educational pursuits. One of the most striking
changes in the medical education landscape over the
last decade has been the continued rise of e-learning
&&
technologies. In their review, Martinelli et al. [1 ]
highlight the pivotal role that e-learning educational
tools play in the learning and development of anes-
thesiology trainees, citing specific examples of new e-
learning platforms – such as websites, web-based
simulations, question banks, and podcasts – that
target the anesthesiology learner. E-learning, and
the associated virtual and digital content, have been
an integral part of the Free Open Access Med(ical
Ed)ucation (FOAM) movement, which has helped to
democratize educational resources and increase
access to this content [6].
Websites and online modules
Websites and online modules were among the first
e-learning platforms and continue to be a main-
stream source of educational content for anesthesi-
ology learners, with a recent focus on curation and
dissemination of quality, reviewed content. In their
review of websites for critical care education, Wol-
brink et al. identified nearly one hundred websites
relevant for critical care medical education. Among
these various platforms, the top ten websites often
www.co-anesthesiology.com 801
Technology, education and safety
utilized a peer review editorial processes, suggesting
a higher standard for reviewed content [6]. Many of
these websites incorporated other forms of digital
and media content including podcasts and videos,
and top websites were more likely to incorporate
interactive learning elements such as quizzes [6].
Other websites focus on providing the critical ele-
ments of active learning via web-based simulations,
allowing learners to apply knowledge and concepts
in a well tolerated, virtual learning environment. A
study of web-based simulation for medical students
in an anesthesiology clerkship found that students
significantly preferred online simulation to tradi-
tional lecture didactics for instruction on the clini-
cal use of pulmonary artery catheters [7].
Podcasts and videocasts
With more and more learning occurring outside
traditional classroom structures, educators have
sought to reach learners in new and innovative ways.
Podcasts and videocasts are important tools that have
expanded the reach of modern educational content
and facilitate asynchronous education. One critical
analysis of anesthesiology podcasts identified 22
anesthesiology-related podcasts, 90% of which had
been developed since 2010. Two thirds of these pod-
casts demonstrated evidence of peer review, support-
ing the notion that podcasts can be a rigorous
supplement to medical education [8]. Podcasts can
be an accessible form of education for all learners but
especially residents and fellows, whose time for sup-
plemental learning is often constrained by clinical
duties. One analysis surveying listeners of Anesthesia
and Critical Care Reviews and Commentary
(ACCRAC), a popular anesthesia and critical care
podcast, found that learners’ ability to listen while
engaging in other activities was the primary reason
for preferring podcasts to other modes of education
&
[9 ]. A majority of respondents stated they preferred
to look up podcast episodes by topic of interests,
suggesting that learners are particularly appreciative
of their ability to engage in asynchronous education
&
of pertinent areas of interest [9 ]. Podcasts and videos
can be an effective adjunct to traditional curriculum
structures. One study found that medical students
who received additional podcast video lectures per-
formed better than students who only had a hands-
on training session during a mask ventilation and
&
intubation clinical examination [10 ].
Social media
Social media is another emerging forum for anes-
thesiology medical education, though at present
less literature exists on the topic specific to
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anesthesiology. Social media has enhanced the
reach and visibility of journal articles in the field,
as highly tweeted articles have been shown to be
cited more frequently [11,12]. Social media outlets
can also be utilized as a primary educational venue,
replacing traditional didactic curriculums with
tweetorials or other collaborative threads. Using
Twitter and other social media to augment or even
replace curriculum content is a relatively new area of
exploration in the field but has promising potential.
One analysis of a Twitter-augmented journal club
for anesthesia residents found that residents spent
more time engaging with the educational content in
a Twitter journal club than in a traditional journal
club structure [13]. The authors posited that Twit-
ter’s seamless adoption, 24/7 connectivity to experts
and peers worldwide, and creation of virtual com-
munities with hashtags confer significant educa-
tional benefits for the resident learners [13].
However, at present, the efficacy and accuracy of
social media education in comparison to other e-
learning medical education modalities has not been
adequately evaluated.
E-learning
E-learning platforms have many distinct educa-
tional advantages that make these resources highly
valuable to the modern anesthesiology learner. The
speed and accessibility of these platforms allow
learners to connect with content, peers, and educa-
tors from around the globe. While traditional lec-
tures assume a one-size-fits-all approach, e-learning
curricula allow individuals to source material on
topics relevant to the learners’ specific educational
needs. Evidence comparing the efficacy of e-learn-
ing curricula with traditional classroom structures is
promising. One such study compared results of
anesthesiology residents and fellows who learned
the fundamentals of point-of-care ultrasonography
via traditional didactics to those with a tailored e-
learning curriculum; the study found no difference
in knowledge acquired during the didactics (as mea-
sured by change in pre and postsession assessment
scores), nor any difference in learner satisfaction
with these sessions, supporting the notion that
independent e-learning can be a noninferior alter-
&
native to traditional classroom settings [14 ].
E-learning has in many ways changed the way
anesthesiology learners acquire knowledge, expand-
ing content and curricula available and promoting
international collaboration. However, educators
must recognize the inherent limits of e-learning
platforms for anesthesiology learners. Many e-learn-
ing modalities are fundamentally geared towards
disseminating information and assessing the
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 Advances in anesthesia education Nelsen et al.

FIGURE 1. Integration of anesthesiology e-learning and telesimulation into traditional learning and its relation to Miller’s
Pyramid of Assessment [1 ,2] and Bloom’s Taxonomy of Learning [3]. Asterisk () denotes the use of telemedicine in chronic
&&

pain, preoperative, and postoperative office or hospital visits. For examples of educational tools specific to anesthesiology, see
Martinelli et al. [1 ]. ITE, in-training examination; OSCE, Objective Structured Clinical Examination; PBLD, Problem-Based
&&

Learning Discussion; PEARLS, Promoting Excellence and Reflective Learning in Simulation. Citations for Figure 1: 1. Martinelli
SM, Isaak RS, Schell RM, et al. Learners and luddites in the twenty-first century: bringing evidence-based education to
anesthesiology. Anesthesiology. 2019;131(4):908–28. 2. Miller GE. The assessment of clinical skills/competence/
performance. Acad Med 1990; 65(9 suppl): S63–7. 3. Davidson M. The taxonomy of learning. Int Anesthesiol Clin
2008;46(4):1–15.

‘knows’ level of Miller’s pyramid (Fig. 1). Acquisition
of factual knowledge is just the first piece of the
puzzle; while it is vital for learners to have a concep-
tual understanding of topics and procedures, anes-
thesiology trainees must demonstrate competence
in ‘Showing’ and ‘Doing’. For a procedurally-
oriented specialty such as anesthesiology, demon-
strating mastery of execution on the knowledge and
skills learners have gained is of the utmost impor-
tance in assessing trainee competence.
TELESIMULATION TO IMPROVE LEARNER
TRAINING AND SKILLS
Simulation has been shown to be a highly valuable
tool for anesthesiology education, incorporating
active learning and problem solving in a low-stakes,
safe learning environment [15,16]. It has also
proven to be an effective method to teach proce-
dural skills of anesthesiology, and evaluate trainee
performance and identify gaps in performance
[16,17]. However, an insufficient number of simu-
lation educators has been cited as a limitation to the
expansion of simulation, particularly in resource-
limited settings [16]. Screen-based simulations have
been employed as a means of distributing educa-
tional content, overcoming hurdles of time and
educator costs [18]. Although screen-based simula-
tions succeed in expanding accessibility, some
(but not all) studies suggest they are inferior to
in-person clinical instruction. Such studies have
found that in comparison to mannequin-based sim-
ulation, screen-based simulation is less effective
in improving learners’ skills [19,20]. With screen-

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Technology, education and safety
based simulations perhaps an inferior alternative,
there is a clear need to expand the use of in-person
simulation to areas for which space and simulation
expertise may be constrained.
Telesimulation is an emerging educational
modality that combines the utility of simulation
with recent advancements in distance and virtual
learning education. Although telecommunications
and simulation resources have been utilized in the
past, the concept of telesimulation has only recently
been described in medical literature, originating as a
term in literature largely within the last decade. In
their review, McCoy et al. [21] define telesimulation
as the process by which telecommunication and
simulation resources are utilized to provide educa-
tion, training, and/or assessments to learners at an
off-site location.
Much like the underpinnings of the e-learning
movement, the goal of many telesimulation initia-
tives is to improve learner access to valuable educa-
tion content, while also facilitating collaboration
and democratization in medical education. Among
the initial motivations for telesimulation was the
desire to expand the use of simulation to resource-
restricted settings [22,23]. Telesimulation utilizes an
internet connection to link instructors and learners
at disparate locations. Both instructors and learners
require access to simulators, computers, basic vid-
eoconferencing software and two screens, enabling
the participants to interact simultaneously [23,24].
Initial studies highlighted the value of telesimula-
tion in teaching laparoscopic surgeons in low-
resource settings, requiring only the use of two
simulators, two computers, a webcam, and SkypeTM
[23]. Thus, with relatively little infrastructure invest-
ment, telesimulation was shown to be an effective
method to connect learners with educators across
institutions. Telesimulation has demonstrated util-
ity in educational initiatives across a wide array of
fields and in teaching diverse procedural tasks
including surgical techniques, needles and line
placements, and ultrasound [23,25,26].
Telesimulation has recently shown promising
potential as a tool in anesthesiology for improving
psychomotor and cognitive domains of learning.
Telesimulation was shown to be an effective means
of teaching ultrasound-guided regional anesthesia
to learners with off-site faculty in a multihospital
pilot program [24]. In the study, participants across
four hospital sites reported significantly higher post-
training scores versus pretraining scores following
telesimulation training sessions; however, the
extent of the educational benefits specific to tele-
simulation could not be ascertained in absence of a
control group [24]. One randomized study compar-
ing the effectiveness of telesimulation (TeleSIM) and
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standard simulation (SIM) in teaching fourth year
medical students management of critically ill
patients found no significant difference in evalua-
tion scores or favorability rating between the Tele-
SIM and SIM groups, providing early evidence that
telesimulation may be an equally effective modality
for teaching clinical skills [27]. Few other studies at
present have provided a direct comparison of edu-
cational gains from telesimulation to standard
simulation.
Telesimulation has the potential to be used as a
low-cost method of improving the clinical skills and
training of critical care physicians around the world.
Even in the absence of simulation sessions, use of
video conferencing interfaces to connect remote
institutions has shown to be an effective method
of sharing clinical skills and improving quality of
care among critical care practitioners [28]. Recent
trials using telesimulation as a means of interna-
tional knowledge sharing have shown its effective-
ness in teaching approaches to the evaluation and
management of critical care patients amongst
&&
diverse international cohorts [29 ]. Another benefit
of telesimulation is the ability to promote cross-
cultural interaction and knowledge sharing across
institutions. One study demonstrated the feasibility
of telesimulation in teaching difficult airway man-
agement and local anesthetic toxicity in an interna-
tional collaboration among anesthesiology
residents in the United States and France [30]. These
sessions may be a valuable adjunct to traditional
education centered around home institutions and
might better prepare anesthesiologists intending to
work abroad or across cultural barriers [30].
Teledebriefing
Another critical learning opportunity afforded by
the rise of telesimulation is the expansion of tele-
debriefing. Teledebriefing describes the process in
which learners undergo poststimulation debriefing
with a facilitator at an off-site location [31]. In
simulation exercises, debriefing is widely considered
to be a critical time for learner knowledge consoli-
dation [31]. Frameworks such as the PEARLS
approach [Promoting Excellence and Reflective
Learning in Simulation] have been employed in
simulation education to better facilitate debriefing
discussions and promote learner self-assessment
[32] (Fig. 2). Similar to telesimuation, teledebriefing
is thought to confer benefits to the learner while
requiring only minimal investment in basic equip-
ment, such as smartphones and television [33]. Early
trials comparing teledebriefing with other modali-
ties have been limited. One study comparing
teledebriefing with on-site debriefing found that
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 Advances in anesthesia education Nelsen et al.

FIGURE 2. Promoting Excellence and Reflective Learning in Simulation (PEARLS) debriefing framework. Permission obtained:
Current Opinion in Anesthesiology for Figure 1 from Eppich and Chang 2015. Citation for Figure 2: Eppich W, Cheng A.
Promoting Excellence and Reflective Learning in Simulation (PEARLS): development and rationale for a blended approach to
healthcare simulation debriefing. Simul Healthc. 2015;10(2):106–115.

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Technology, education and safety
in-person sessions were rated more favorably by
learners, however both in-person debriefing and
teledebriefing sessions were regarded as highly effec-
tive [34]. In the study, teledebriefings were rated
overall quite favorably by residents, suggesting that
learners may still derive significant benefit from
teledebriefing sessions particularly in the absence
of an in-person alternative, though more studies are
necessary to fully ascertain the educational benefit
of teledebriefing [34]. Another potential benefit of
teledebriefing is learners’ ability to be evaluated by
educators outside their home institution, allowing
them to have valuable feedback with an educator
who has no direct connection with the learner’s
performance and assessment in-house. In thinking
about the future of teledebriefing, additional work is
necessary to understand if frameworks for tradi-
tional debriefing sessions (such as PEARLS) are effi-
cacious in the setting of teledebriefing, or if other
frameworks should be constructed and adopted for
virtual debriefing sessions.
Telesimulation is an effective modality in the
dissemination of practical techniques and clinical
knowledge sharing, utilizing telecommunications
advancements to extend the capabilities of simula-
tion beyond previous restrictions in geography,
space, and available expertise. Initially used to share
simulation education to resource-limited settings,
telesimulation has also been shown to be of benefit
in the education and assessment of learners at off-
site locations and knowledge sharing of best prac-
tices. In the future, telesimulation should continue
to expand as an important tool to connect learners
and educators around the world, sharing best prac-
tices and knowledge while fostering international
collaboration. Additionally, asynchronous models
of telesimulation could be explored to alleviate the
potential limitations inherent to scheduling ses-
sions across international time zones. Finally, the
use of telesimulation may necessitate investment in
physical simulation equipment such as mannequin
models. While telesimulation may be a low-cost
investment for the educational gains afforded by
these sessions, further expansion of other types of
virtual and screen-based simulations may be able to
still provide educational benefits in the absence of
physical simulation equipment.
CONCLUSION
E-learning has continued to shift the focus of medi-
cal education away from the traditional classroom
and increasingly towards the use of peer reviewed
and online media content. Recent evidence sup-
ports the use of podcasts, videocasts, and social
media as additional educational tools that can be
806 www.co-anesthesiology.com
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further be explored. Educators must also recognize
the limits inherent to e-learning technologies, and
specifically pay close attention to how teaching and
dissemination of skills instruction is occurring,
while still maintaining high regard for the goal of
accessible content. Advancements in telesimulation
and teledebriefing illustrate how the benefits of
simulation can be extended beyond previous restric-
tions in geography, space, and available expertise,
with the potential to be a powerful adjunct to anes-
thesia education and to foster international collab-
oration. More work is necessary to elucidate the
benefits of telesimulation and to grow its scope.
Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
A.F.A. is the recipient of a mentored research training
grant from the Anesthesia Patient Safety Foundation and
the Foundation for Anesthesia Education and Research.
He is the recipient of a Career Development Award from
the Center for Diversity and Inclusion of the Brigham and
Women’s Hospital. He is a member of the Patient Safety
Editorial Board for the American Society of Anesthesiol-
ogists and Question Editor for the American Board of
Anesthesiology, where he receives a stipend for work that
is otherwise done in a volunteer capacity. The authors
otherwise declare no conflicts or competing interests in
the preparation of this paper.
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&&
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Advances in anesthesia education Nelsen et al.
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