International training and outreach in the pandemic era

Robert Morgan

As we start to emerge from the strictures imposed by the COVID-19 pandemic, it is timely to reflect on the delivery of education and training to interventional radiologists (IRs) around the world, especially those living in countries with limited access to the educational opportunities that are generally available to interventionists in the more developed world, writes Robert Morgan (St George’s University Hospitals NHS Foundation Trust, London, UK).

Before COVID-19

Before the COVID-19 pandemic affected populations worldwide, several major international interventional radiology societies (Cardiovascular and Interventional Radiological Society of Europe [CIRSE], Society of Interventional Radiology [SIR] and Asia Pacific Society of Cardiovascular and Interventional Radiology [APSCVIR]) had spearheaded programmes to deliver education and training in several countries around the world. Some medical device companies had also begun their own initiatives sponsoring senior IRs to visit countries to participate in the training of the local IRs. The concept of training IRs travelling to less well-developed countries and systems—i.e. outreach training—had been going on for some years from the start of this millennium. In the last decade, we saw a significant increase in this practice with ever-larger delegations of training IRs visiting a wider number of countries.

These outreach training programmes usually offered exposure to hands-on device training, and in some cases procedural training in addition to more formal teaching through lectures and small group tutorials. Where possible, the local outreach training experience was designed to complement standard training delivered by local senior IRs and online education and attendance at live educational events, where feasible, depending on the financial and political constraints of each country.

Although quality education can be delivered remotely, in-person training such as can be provided by outreach training enables valuable interactions and discussions between training faculty and trainees that are difficult to replicate online. My recent experiences as an outreach training faculty in Myanmar serve to illustrate the benefits of in- person outreach training.

Outreach training pre-COVID-19

In both January 2019 and 2020, I travelled to Myanmar as a member of an intersociety collaborative endeavour to provide training and education in two IR outreach workshops. The workshops were organised by senior members of the Asia Pacific Society of Interventional Radiology (APSCVIR) with participating members from CIRSE and the SIR in collaboration with senior Myanmar IRs.

In each programme, workshops were held in Yangon and in Mandalay General Hospitals. Both hospitals are of moderately large size with over 500 beds each. Each of the radiology departments are well equipped with two or more computed tomography (CT) scanners, at least one magnetic resonance imaging (MRI) scanner, one angiographic machine and general radiographic equipment.

The vast majority of the interventional radiology staff at these hospitals had never had the opportunity to attend a major congress, such as APSCVIR, CIRSE or SIR. All visiting international faculty members were impressed by the enthusiasm of the local staff and trainees to learn about interventional radiology. It was very evident that they were highly appreciative of receiving training from the visiting faculty.

A comprehensive scientific programme was delivered at both workshops covering a wide range of interventional radiology procedures including transarterial chemoembolization (TACE), radiofrequency ablation (RFA) of liver tumours, uterine fibroid embolization (UFE), haemodialysis interventions, central venous access, lower limb arterial interventions, urological interventions, hepatobiliary interventions and abscess drainage. The workshop programme involved lectures, small group teaching and hands-on device training. In addition, there were several live cases performed by the faculty, including myself. Live case topics included TACE, RFA, lower limb arterial angioplasty and stenting, and haemodialysis access angioplasty and stenting.

One less obvious benefit of in-person training was that local IRs strongly encouraged clinicians from other specialties to attend the workshop, particularly specific lectures and live cases that were relevant to their practice. This meant that during each lecture or tutorial, aspects of procedures were highlighted to increase the attractiveness of interventional radiology to these referring clinicians with specific emphasis put on the favourable comparison of interventional radiology procedures with the competing alternative treatments. The desired result of such an interaction would be to increase the number of referrals to interventional radiology by these local clinicians, which in my opinion, was an effective method—and one that is less translatable to an online educational format.

In summary, the main benefits of outreach training included: enabling local IRs without the financial resources to attend in-person congresses to receive a programme of tailored education to their specific requirements and surroundings; and raising the awareness of the potential of interventional radiology among other clinical specialties, which may result in increased referrals of patients for these minimally invasive, typically outpatient procedures.

Where are we now?

Inevitably, as a result of the effect of the COVID-19 pandemic worldwide and the severe restrictions on international travel, these outreach training programmes have come to a halt. In a similar manner to international congresses, which have currently moved almost exclusively to an online/virtual format, some societies have endeavoured to provide outreach training online through webinars and live discussion forums. This method of education has similar drawbacks for the delivery of outreach educational workshops as it does for international meetings. These are relatively obvious but are worth stating nevertheless: reduced impact of online lectures compared with live lectures; a lack of interpersonal interactions for educational and networking purposes; reduced opportunity for small group discussions; and the complete absence of hands-on device or procedural training. Finally, a specific disadvantage of online teaching for less well-developed countries is the dependence on the local information technology (IT) structures and ability of the local IRs and trainees to access the internet adequately for online teaching, which may be demanding in terms of the bandwidth required.

Where do we go from here?

The experiences of the past 18 months have reminded us that the internet is an effective method to deliver education and training. However, the majority of doctors, both trainees and trainers, are firmly of the opinion that virtual methods do not, and must not, completely replace in-person educational methods.

However, the pandemic is a worldwide phenomenon. Although vaccination programmes in many countries, particularly in Europe and North America are well advanced, this is not the case in Asia, South America or Africa where a significant proportion of outreach programmes take place. It is likely that international congresses will return as live educational events in 2022, but they will be restricted by COVID-19 testing and impacted by the country of origin of delegates. Unfortunately, it may be longer before IRs are able to travel to countries with lower vaccination rates to deliver outreach training. However, this is not to say that this form of training must be abandoned or forgotten. International societies such as CIRSE, SIR, and APSCVIR must continue to commit to the concept of outreach training and to make plans for the day when this valuable training format once again becomes feasible to deliver.

In summary, international societies have the ability and an obligation to deliver local education and training to IRs in lower- and middle-income countries. Local in-person outreach training has significant benefits that cannot be provided by the virtual format. Although a return to outreach training workshops may not be feasible for a year or more, this important method of training must not be forgotten and interventional radiology societies must continue to devise schedules for outreach training as soon as this becomes possible again.

Robert Morgan is a consultant and reader in interventional and diagnostic radiology. He is deputy editor-in-chief CVIR Endovascular and a past president of CIRSE. He has reported no disclosures relevant to this article.


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