REVIEW

CURRENT
OPINION Education and training in ultrasound-guided
regional anaesthesia and pain medicine
Alwin Chuan

Purpose of review
Effective and safe regional anaesthesia and pain medicine procedures require clinicians to learn and
master complex theoretical knowledge and motor skills. This review aims to summarize articles relevant to
education and training in these skill sets in the previous 2 years.
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Recent findings
Twenty-two articles were identified, investigating nine out of the 13 top-ranked research topics in education
and training in regional anaesthesia. Research topics addressed by these articles included prerotation
simulation, deliberate practice combined with formative assessment tools, validation of assessment tools,
three-dimensional-printed models, and knowledge translation from simulation to clinical practice. Emerging
concepts investigated for their applications in regional anaesthesia included eye-tracking as a surrogate
metric when evaluating proficiency, and elastography aiding visual salience to distinguish appropriate
perineural and inappropriate intraneural injections.
Summary
Research into education and training in regional anaesthesia covered multiple and diverse topics.
Methodological limitations were noted in several articles, reflecting the difficulties in designing and
conducting medical education studies. Nonetheless, the evidence-base continues to mature and innovations
provide exciting future possibilities.
Keywords
medical education, regional anaesthesia, simulation, training, ultrasound

INTRODUCTION education and training, whereas more recently a

The use of ultrasound in regional anaesthesia focus has been on simulation-based education in
&

(UGRA) procedures is relatively recent, but has argu-
ably become the standard of care for regional anaes-
thesia when performed by anaesthesiologists and
pain medicine physicians. Evidence-based reviews
of clinical outcomes for UGRA peripheral and neu-
raxial blocks have concluded that ultrasound-guid-
ance provides benefit of increased block success
rates, faster block onset, shorter block performance
times, reduction in needle passes, and is at least
noninferior to other nerve localizing modalities
with respect to neurological complications [1–4].
Gaining proficiency in the technical and non-
technical skill sets required for efficacious and safe
UGRA performance is thus necessary. This has
prompted a search for evidence-based medical edu-
cation to inform all aspects of curriculum develop-
ment, motor skills training, design of in-vitro
models, teaching methodology, and competency
assessment. The first review was performed in
2013 by Nix et al. [5] on the evidence-base for UGRA
regional anaesthesia [6,7,8 ] as well as in broader
anaesthesia training [9]. This has merit as several
previous meta-analyses have shown that a curricu-
lum that incorporates simulation-based medical
education, especially with deliberate practice, con-
fers multiple advantages beyond didactic teaching
and traditional experiential clinical placements
[10,11]. Other reviews relevant to regional anaesthe-
sia training have focused on the role of competency-
based assessment and its impact on how physicians
gain knowledge and skills [12,13].
South West Sydney Clinical School and the Ingham Institute of Applied
Medical Research, UNSW Australia, Liverpool Hospital, Sydney, New
South Wales, Australia
Correspondence to Alwin Chuan, MBBS, PhD, FANZCA, Department of
Anaesthesia, Liverpool Hospital, Liverpool, Sydney 2170, NSW,
Australia. Tel: +61 2 8738 3173; e-mail: a.chuan@unsw.edu.au
Curr Opin Anesthesiol 2020, 33:674–684
DOI:10.1097/ACO.0000000000000908

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


KEY POINTS
 Previous evidence supports the use of simulation in
regional anaesthesia training. Further studies have
supported the benefit of prerotation simulation in
enhancing learning and skill uptake when trainees
commence clinical exposure.
 Previous work on expertise supports the use of
deliberate practice as an effective form of faculty
teaching. Using an assessment tool to guide feedback
during deliberate practice was found to be useful.
 While individual components of the regional
anaesthesia curriculum such as core blocks and
assessment tools were investigated, a standardized
regional anaesthesia curriculum is not yet finalized.
 Eye-tracking technology may be useful as an objective
metric in assessing aspects of regional anaesthesia
procedural skills. Further validation studies are required
to determine appropriate endpoints.
 The extent of knowledge transition from simulation to
improved clinical outcomes, as well as duration of skills
retention after simulation, is not well defined.
This narrative review provides an update of
regional anaesthesia education and training articles
in literature from 2018 to 2020. To organize the
discussion, studies will be categorized by themes
previously defined in an international Delphi con-
sensus survey of research priorities in regional anaes-
&
thesia education and training [14 ]. These are
curriculum design; equipment and benchtop part-
task trainer models; regional anaesthesia assessment;
knowledge translation from training to clinical prac-
tice; methodology and conduct of regional anaesthe-
sia education research; and motor skills training.
Methods
The following search parameter was used to identify
potential articles of interest in PubMed and via
Google search: ‘regional anaesthesia’ or ‘regional
anesthesia’ or ‘nerve block’, and ‘simulation’ or
‘training’ or ‘education’. Limits were placed on year
of publication, full text available, and English lan-
guage. References were hand searched to identify
other articles meeting the above criteria.
Results
The PRISMA flow diagram is in Fig. 1. Twenty-two
articles were identified. Seventeen articles were clin-
ical studies (Table 1), with five articles on curriculum
or equipment; three articles on knowledge transla-
tion, assessment, or methodology; and two articles
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Training in regional anaesthesia and pain medicine Chuan
on motor skills (articles may have more than one
theme). Five articles were review articles and edito-
rials (Table 2), of which three were on curriculum
and one each on research methodology and equip-
ment. Table 3 reorganizes the articles by aligning
study aims against the top-ranked topics by research
&
priority. Of the 13 top-ranked topics [14 ], only four
topics were not specifically investigated by the 22
articles in this review.
Curriculum design
Two small, proof-of-concept randomized control
trials (RCTs) investigated traditional versus simula-
tion teaching. In Nixon et al. [15], 12 anaesthesiol-
ogy residents underwent prerotation training in
obstetric epidural blocks using an online multime-
dia package. Photos and videos augmented didactic
information on patient assessment, medications,
procedural tasks, and postblock follow-up. In Mla-
&
denovic et al. [16 ], 22 dental students received
training in inferior alveolar nerve blockade with
the assistance of augmented reality goggles. These
goggles superimpose computer generated imagery
onto the visual field view of the wearer. In both
instances, simulation training was beneficial with
faster and higher quality of performance of regional
anaesthesia. Another study that used an online
multimedia learning package was by Muriel-Fernan-
dez et al. [17] of 53 different peripheral and truncal
blocks, and pain procedures. This study was how-
ever primarily descriptive, and evaluation of learn-
ing outcomes was not performed.
The impact of an ultrasound teaching curricu-
lum was examined by Matyal et al. [18] in their
institution. All cardiothoracic point of care applica-
tions including echocardiography were included,
with a smaller UGRA component. The curriculum
was based on elements of proficiency-based progres-
sion, such as regular self-assessments and an
observed structured clinical examination at the con-
clusion of knowledge training. In the next phase,
expert faculty provided feedback to trainees in a
clinical setting. However, these assessments were
done only for cardiothoracic ultrasound applica-
tions, and not specifically for UGRA knowledge
and clinical skills.
&
Kim and Tsui’s [8 ] review article on simulation-
based UGRA teaching summarized important topics
of knowledge and motor skills training, and compe-
tency-based assessment. Importantly, the authors
addressed nontechnical skills in UGRA competency
such as teamwork and management of complica-
tions. Of interest is the concept of gamification,
which aims to reward friendly competitive behav-
iour through conceits such as earning of points and
www.co-anesthesiology.com 675
Regional anaesthesia
FIGURE 1. PRISMA flow diagram. RA, regional anaesthesia.
proficiency leaderboards. However, no studies have
yet been reported in the context of regional
anaesthesia simulation.
Two editorials addressed broader curriculum
&
issues. Turbitt et al. [19 ] argued that better patient
care is achieved if anaesthesiologists adopted ‘wide-
spread competence in performing a small number of
nerve blocks which cover the vast majority of surgi-
cal procedures’. This would mean identifying those
blocks of greatest value on evidence-base of efficacy
and safety. Based on anatomical locations, a simpler
range of basic ‘Plan A’ blocks complemented with
backup ‘Plan B’ advanced blocks was proposed. A
flow-on benefit of a standardized curriculum is eas-
ier national implementation and simplified simula-
tion training. However, follow-up correspondence
has highlighted that the numbers and expertise of
current teaching faculty is currently insufficient
even for Plan A blocks [20]. Mariano and Rosenquist
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[21] described the background and process of
regional anaesthesia and pain medicine fellowships
gaining accreditation from the Accreditation Coun-
cil for Graduate Medical Education in 2017. Success-
ful accreditation brings benefits in training quality
and promotes standards in education.
Equipment used for education and training
O’Donnell and Loughnane [22] reviewed features of
ultrasound machines and needle enhancement
technology that have improved sonographic image
quality and real-time visualization of needles. Other
advances including magnetized needles, ultra-high-
frequency transducers, and three-dimensional/four-
dimensional ultrasound were also reviewed but
uptake is currently limited. The authors noted
that the risk of intraneural injection is clinically
important, and described the possibility of using
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 Training in regional anaesthesia and pain medicine Chuan
Table 1. Summary of clinical research articles, organized by year of publication
Reference Themes Study characteristics
McLeod Equipment Evaluation of a tip-tracking
et al. [24] (piezo element) block
needle on soft embalmed
cadavers. Crossover trial
of 8 novices and assessed
over 160 videos of
ultrasound-guided sciatic
nerve block performance
McLeod Assessment Formulation of a 30-item
et al. [34] methodology checklist (15 items each
for success and errors)
using methodological
framework analysis.
Validation used 12
anaesthesiologists (6
novice, 6 expert)
performing an ultrasound-
guided interscalene block
on a soft embalmed
cadaver
Nixon et al. [15] Knowledge RCT comparing traditional
translation (textbooks and journal
curriculum articles) versus computer-
enhanced visual learning
program for obstetric
combined spinal epidural
blocks. 12 Novice
anaesthesiology residents
per group
Matyal et al. [18] Curriculum Observational study of
impact of an ultrasound
teaching curriculum
(including UGRA) at a
single centre. Initial
6 weeks of didactic and
hands-on teaching with
regular knowledge
assessments and ending
with an OSCE session.
Next phase-introduced
benchtop simulation and
then clinical procedures
under supervision from
expert faculty
Mladenovic Curriculum Initial RCT comparing
et al. [16 ] traditional (textbooks and
&
low fidelity benchtop
model) versus augmented
reality simulator for inferior
alveolar blocks performed
by 41 dental students
Muriel-Fernandez Curriculum Description of an online
et al. [17] UGRA simulator. 53
Different blocks
(peripheral, truncal, and
pain procedures) were
available for training.
Surface anatomy,
sonoanatomy, and
projected needle trajectory
can be reviewed
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Results
5 Out of 15 success
endpoints, and 1 out of
15 error endpoints,
improved with use of the
tracker needle.
Secondary outcomes
using eye-tracking
metrics were
predominantly not
different
Reliability assessed for the
checklist. Secondary
outcomes using eye-
tracking metrics were
associated with level of
UGRA expertise
Resident’s first combined
spinal epidural attempt
was assessed using a
49-item checklist.
Residents in the
computerized learning
program were faster,
more proficient and
scored higher on
knowledge testing than
traditional teaching
8 Anaesthesiologists
completed both initial
and clinical phases of
UGRA teaching. OSCE
did not examine UGRA
knowledge. No
workplace-based
assessment was
performed for clinical
UGRA procedures
Students with augmented
reality training were
faster, more successful in
finding the location for
blockade, and had more
controlled motor skills
than students with
traditional training. Block
success was not different
between groups
27 Anaesthesiologists used
the simulator for 1 year.
On average, each
student attempted each
block procedure 7.3
times
www.co-anesthesiology.com
Summary of article
Using the tip-tracking needle
improved needletip
localization and needletip
visibility on the high-fidelity
cadaver model, but overall
success and error rates were
not statistically different
Initial confirmation of content,
construct, and discriminate
validity of a new checklist
for interscalene brachial
plexus blocks. External
reliability confirmed
A prerotation electronic
learning package for
obstetric neuraxial UGRA
was found to be beneficial.
Core elements of the
package include multimedia
video clips, task
deconstruction, and self-
directed learning, within the
context of a flipped
classroom approach
Teaching curriculum-introduced
elements of proficiency-
based progression in the
initial phase. Deliberate
practice feedback from
expert faculty complemented
the next phase of teaching,
blending mixture of
benchtop, and clinical
procedures
Augmented reality was of
benefit in teaching a dental
RA technique. Further
evidence is required with
respect to objective
measures of proficiency,
and delineating how best to
integrate augmented reality
training into the curriculum
Further research is needed to
determine if clinical
outcomes are favourably
affected by the use of the
online simulator
677
Regional anaesthesia

Table 1 (Continued)
Reference Themes Study characteristics Results Summary of article

Naraghi et al. [25] Equipment Descriptive article on the use
of transglutaminase
(powdered meat glue) to
bind disparate pieces
together when creating
benchtop meat part-
trainers. In addition, the
interface formed between
two meat pieces mimics a
hyperechoeic fascial plane
seen in UGRA procedures
Chuan and Methodology Structured electronic Delphi
Ramlogan [14 ] international survey of
&
Transglutaminase was used Using transglutaminase may
to create fascia iliaca, increase the realism of
interscalene, and benchtop meat models by
serratus anterior recreating fascial planes
anatomical models for a typically seen in clinical
workshop. All 14 UGRA procedures
delegates who
responded to the
postworkshop survey
agreed that the models
were helpful
82 Topics were identified Research in RA education and
and ranked. 13 Topics training is still relatively

experts in RA education were deemed to be underdeveloped. The

and training, to identify
and rank topics in order of
research priority over 3
rounds of consensus
Bortman et al. [27] Equipment curriculum Before-and-after study
knowledge examining the effect of
translation introducing a 3D-printed
spine model (covered with
silicon of varying tensile
strength to mimic tissue
planes) for training in
thoracic epidural RA.
Before training was
traditional didactic and
passive observation of
procedure. After group
included the spine model
as a benchtop part-trainer
Shafqat et al. [35] Assessment Validation study of a
previously published
workplace-based
assessment tool for UGRA
procedures, consisting of a
22-item checklist and 9-
item global rating scale
Shaylor et al. [33] Knowledge t 3 and 6-Month follow-up of
ranslation skills retention after
attending a neuraxial
UGRA workshop. 19
Physicians agreed for
follow-up assessment of
skills using a 7-item global
rating scale
Ahmed et al. [30] Motor skills RCT of benefit of deliberate
practice from expert
faculty versus self-directed
learning when learning an
ultrasound-guided needling
task on a benchtop model.
15-Item checklist and 9-
item error assessment tool
was used during training
Mustafa Equipment Observational study of
et al. [23 ] anaesthesiologists’ ability
&&
essential research generated prioritization list
priority assists in targeting research
towards topics thought to be
of highest impact
14 Anaesthesiology Introduction of a 3D-printed
residents recruited in thoracic spine model into
before group (control) resident training may assist
and 12 residents in in improving clinical
intervention group. First performance of thoracic
attempt at clinical epidural blocks
thoracic epidural block
was more successful in
residents receiving spine
model training
Trained assessors observed Construct validity and
21 anaesthesiologists reliability of the tool was
performing their next confirmed. The tool could be
clinical UGRA peripheral used as formative feedback
nerve block. between assessor and the
Anaesthesiologists were assessed, enhancing the
divided into experience teaching aspect of
cohorts workplace-based assessment
There was a decline in Performance curves after
performance scores at workshops are nonlinear.
the 3-month follow-up, Other factors may contribute
but scores improved by to consolidation of
6 months knowledge and retention of
motor skills
18 Novices assessed. Feedback and deliberate
Novices in the deliberate practice may be enhanced if
practice group were an assessment tool metric is
more successful and had concurrently used for
less errors performing formative assessment
the needling task
22 Anaesthesiologists Elastography may be useful to
viewed 48 pairs of B- improve detection of

to detect appropriate mode and fused- inappropriate perineural

(target) and distractor
perineural spread, using B-
mode ultrasound and
fused-elastography. Videos
were of femoral and
interscalene UGRA blocks
performed on soft
embalmed cadavers
elastography videos.
Visual perceptive ability
was improved with
fusion-elastography, and
with greater injection
volumes
spread (such as accidental
intraneural injection), and
reduce the learning curve of
UGRA motor skills by
novices

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 Training in regional anaesthesia and pain medicine Chuan

Table 1 (Continued)
Reference Themes Study characteristics Results Summary of article

de Oliveira Filho Motor skills RCT of deliberate practice
and Mettrau [32] (termed high-frequency
feedback in the study)
versus self-directed
learning and feedback
only at end of training
session (control group) on
UGRA needling task
learning curve. Formative
feedback was anchored
with concurrent use of a
success and error checklist
Neice and Equipment Evaluation of a 3D-printed
Forton [28] needle guide (retracting-
stop needle guide) for out-
of-plane needle
trajectories. A benchtop
meat model with
embedded targets was
used to simulate a UGRA
needling task
Borg et al. [38] Methodology Construct validation study on
the use of eye tracking
technology in UGRA.
Novices were compared
against expert
anaesthesiologists on
visual processing metrics,
when asked to identify
relevant structures on static
sonoanatomy images
Johnson et al. [26] Equipment Descriptive correspondence
on the creation of a
thoracic epidural part task
trainer. Bony structures
were 3D-printed on the
basis of computed
tomography scans. Layers
of silicon and ballistic gel
were used to create fascial
planes that provide haptic
feedback during epidural
insertion practice
52 Novices were
randomized to control
and intervention.
Endpoint was image
quality during the
needling task. Novices
with deliberate feedback
6 Novices performed out-
of-plane UGRA needling
approaches. Time taken
to insert the needle to an
embedded target was
faster without loss of
accuracy using the
needle guide, versus
free-hand
10 Participants in total.
Experts in UGRA were
faster to identify the
relevant structure, and
less prone to be
distracted, when
measured with eye
tracking
A low cost, open-sourced
3D-printed thoracic spine
benchtop model was
produced
Deliberate practice, provided
to novices after each
needling attempt, improved
performance and
accelerated learning of the
needling task
Validation of a new needle
guide for out-of-plane needle
trajectories that may be
used during UGRA blocks
Potential use of eye tracking
as another metric to
determine expertise and
improved proficiency in
UGRA motor skills
The use of 3D printing
technology could reduce the
cost for departments to
provide models to practice
RA. Other uses include
creation of models with
difficult anatomy (e.g.,
scoliosis) for more
challenging practice

3D, three-dimensional; OSCE, objective structured clinical examination; RA, regional anaesthesia; RCT, randomized control trial; UGRA, ultrasound-guided
regional anaesthesia.

elastography and optical pressure sensors to detect
inadvertent intraneural needle placement.
These emerging technologies were investigated
by the research group in the University of Dundee,
UK, with two studies using fusion-elastography
&&
[23 ] and piezoelectric crystals embedded in the
needletip [24]. In the former study, the visual per-
ceptive ability of anaesthesiologists was greater
using elastography, allowing easier detection of
inappropriate perineural spread as well as recogniz-
ing intraneural injection when compared with B-
mode ultrasound. In the latter study, while there
were statistical improvements on some metrics, the
use of a tip-tracking needle did not change the
overall success and error rates when novices per-
formed sciatic nerve blocks on soft embalmed
cadavers. Further studies to explore their utility
are warranted.
While cadavers provide the highest fidelity in-
vitro model, animal-based benchtop models provide
a lower cost and more accessible alternative. Naraghi
et al. described the use of transglutaminase (meat
glue) to allow different pieces of meat to be assem-
bled together to mimic muscle groups seen with
ultrasonography. This have the interesting side-
effect of recreating hyperechoic fascial planes
observed in vivo, and allows an expanding space
when performing hydrolocation [25].
Three-dimensional printing allows clinicians to
create relatively low cost, bespoke, and easily shared
equipment useful for regional anaesthesia. Johnson
et al. [26] and Bortman et al. [27] both produced

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Regional anaesthesia

Table 2. Summary of review articles and editorials, organized by year of publication

Reference Themes Study characteristics Results Summary of article

Turbitt et al. [19 ] Curriculum Editorial arguing against a bias Three components are A possible basic block
&

towards development of novel necessary to shift RA into curriculum was described,

blocks with less evidence-base
than established blocks. While
not to be discouraged, better
patient outcomes may be
gained by widespread
adoption of RA techniques into
anaesthesia practice,
rationalize the number of blocks
being taught, and testing
anaesthesiologists for
competency in RA performance
O’Donnell and Equipment Review article summarizing three
Loughnane [22] recent equipment and
technological advances in
UGRA. This includes ultrasound
machines, needle technology,
and minimizing accidental
intraneural injection
Kim and Tsui [8 ] Curriculum Review article summarizing the
&
mainstream clinical practice:
a basic block curriculum;
demonstrable competency in
these blocks; integration of
RA into clinical pathways
Ultrasound machines have
better signal processing and
high-frequency transducers
are now commonly
available. Design changes
to block needles have
improved their visibility
using ultrasound.
Magnetized needles are
available that allows indirect
visualization
Simulators have been used in
but broader consensus is
required. Evidence-based
education is necessary to
improve training in
theoretical and motor skills
relevant in RA. Research
required into quality
parameters of different
blocks and patient-centred
outcomes
Research into uses of 3D/4D
transducers is ongoing.
Tissue elastography and
optical pressure sensors
have been investigated as
different modalities to help
detect intraneural contact
with an advancing needle
Avenues for future research

use of simulators for UGRA all aspects of UGRA include incorporating

training
Mariano and Curriculum A narrative review of RA and
Rosenquist [21] pain medicine fellowship
programs given accreditation
by the Accreditation Council for
Graduate Medical Education in
2017
Chuan et al. [39] Methodology Review of competency-based
assessment tools used in RA
and UGRA, including multiple
choice questions, cumulative
sum, hand-motion analysis,
visuospatial and psychomotor
screening, checklists, and
global rating scales
training, including
theoretical knowledge,
sonoanatomy, motor skills,
and nontechnical skills
12 Programs were successful
in gaining accreditation
within the first year
28 Original studies were
identified that validated
assessment tools used for RA
procedures. Statistical tests
of validation and reliability
was reviewed
elements of gamification to
improve willingness to learn
and retain new skills and
knowledge
Acceptance as an accredited
fellowship entails regular
review of the curriculum and
focuses on quality of
training in RA
Psychometric evaluation of
assessment tools is critical to
provide evidence of
credibility and acceptance
by all stakeholders

3D, three-dimensional; 4D, four-dimensional; RA, regional anaesthesia; UGRA, ultrasound-guided regional anaesthesia.

three-dimensional-printed neuraxial spine part-task
trainers to teach thoracic epidurals. Neice and
Forton [28] used three-dimensional additive
manufacturing to create a needle guide to assist in
out-of-plane approaches for UGRA.
Motor skills in regional anaesthesia and pain
medicine
There were two RCTs comparing deliberate practice
versus self-directed learning. Deliberate practice is a
teaching method that emphasizes individualized
training with concrete learning goals achieved
through a cycle of repetition and feedback [29]. In
the first study by Ahmed et al. [30] novices in the
deliberate practice group received feedback based
around a 15-item checklist and nine-item error
assessment tool. They found that novices with this
intervention were more successful and had less
errors performing a needling task. This is an example
of formative assessment, also termed ‘assessment for
learning’, a process by which an expert trainer can
provide feedback of both strengths and deficiencies
of a trainee’s skill set [31]. de Oliveira Filho and

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 Training in regional anaesthesia and pain medicine Chuan

Table 3. Research topics by priority as ranked in an international Delphi consensus survey [14 ], and articles in this review
&

addressing each topic

Research priority Articles in current review addressing
ranking Topics the research topic

1 What endpoints/milestones should be achieved on a Borg et al. [38]

simulator prior to clinical performance of UGRA?
2 Does simulation training show an improvement in clinical Nixon et al. [15], Bortman et al. [27],
outcomes such as improved efficacy, time taken, and less Shaylor et al. [33]
errors?
3 Which RA blocks should be considered as a core minimum Turbitt et al. [19 ]
&

set for all trainees? Are there benefits in teaching a subset

of blocks to competency versus broader exposure to all
blocks?
4 Is UGRA knowledge and technical skill generalizable: when Not applicable
does proficiency in one block type transfer to other blocks?
5 Does a rotation through a ‘block room’ provide better Not applicable
learning than programs without a block room?
6 Is there a minimum number of blocks to attain proficiency for Not applicable
each block or are the skills transferable?
7 Does simulation training bestow a safety advantage Nixon et al. [15], Bortman et al. [27]
compared with proceeding directly to supervised practice
in real patients?
8 What criteria should be used to evaluate the success of an Not applicable
UGRA residency training curriculum?
9 What are the necessary components of a formal structured Turbitt et al. [19 ], Matyal et al. [18],
&

training programme? Kim and Tsui [8 ], Mariano and

&

Rosenquist [21]
10 What should be consensus assessment tools to standardize McLeod et al. [34], Shafqat et al. [35],
RA education research? Chuan et al. [39]
11 What are the most efficacious means for practicing Shaylor et al. [33]
anaesthesiologists (consultants) to learn blocks?
12 Does deliberate practice in simulation improve RA Ahmed et al. [30], de Oliveira Filho and
proficiency? Mettrau [32]
13 How can trainees retain proficiency of knowledge and skills Shaylor et al. [33]
learnt after attending focused training (e.g., RA rotation,
simulation session, workshop)?

RA, regional anaesthesia; UGRA, ultrasound-guided regional anaesthesia.

Mettrau [32] similarly used deliberate practice
(which the authors termed as high-frequency feed-
back in their study) anchored by a checklist, finding
benefits of accelerated performance and steeper
learning curves in novices taught a UGRA
needling task.
Knowledge translation from simulation to
clinical practice
Linking simulation training to clinical performance
has been previously identified as the second highest
priority topic for regional anaesthesia education
&
research [14 ], and the following three studies are
to be commended for investigating this issue. As
previously described in the study by Nixon et al. [15]
the researchers taught residents obstetric epidurals
with a multimedia package and also assessed their
clinical performance with a 49-item checklist. Simi-
larly, Bortman et al. [27] taught thoracic epidurals
with a three-dimensional-printed model and
assessed residents’ success and need for supervision
in their clinical performance. A critical limitation of
both studies is that outcomes were measured only in
the resident’s first procedure, rather than over sev-
eral clinical interactions. Shaylor et al. [33]
attempted to follow-up at 3 and 6 months the extent
of skills retention by physicians who attended a
neuraxial UGRA workshop. This study has multiple
limitations including low response rates, confound-
ing with previous experiences, and skills decay was
variable between physicians as all had different
opportunities for training and clinical usage after
the workshop. It highlights difficulties in designing
feasible studies to measure skills retention and attri-
tion after simulation.

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Regional anaesthesia
Knowledge and skills assessment
Two studies performed psychometric evaluation of
assessment tools for UGRA. McLeod et al. [34] pro-
vided initial confirmation of content and construct
validity of a 30-item checklist, in turn designed
using a methodological framework analysis from
expert regional anaesthesiologists. Secondary out-
comes include eye-tracking metrics, which is cov-
ered in detail in the next section. A limitation of this
new tool is validation is currently restricted to
interscalene blocks.
A block-generic workplace-assessment tool was
investigated by Shafqat et al. [35]. This tool is a
combined checklist and global rating scale [36],
which is believed to be most appropriate when
assessing medical procedural skills [31]. This study
revalidated and confirmed reliability using 21 anaes-
thesiologists as they performed their next UGRA
procedure (peripheral nerve and truncal blocks). A
block-generic tool would improve feasibility and
help standardize assessment of procedural skills in
both clinical and research contexts. However, one
limitation of this tool is a focus on technical skills
only, instead of holistic patient-centred and team-
based care. Regional anaesthesiologists also require
competency in nontechnical skills such as pre and
postprocedure steps, communication, team work,
risk management, and insight into safe practices
[37].
Methodology of research
Eye-tracking (or eye-gaze) technology uses infrared
light from head-worn goggles to track the move-
ment of the wearer’s pupils and correlate direction
and duration of gaze with the wearer’s visual field.
This may provide data including which object draws
immediate visual attention, subsequent order of
visual attention, and duration of gazing. Practical
applications have included marketing surveys, aug-
mented reality, and electronic assisted control and
communication by individuals with severe physical
disabilities. When used in research, multiple objec-
tive endpoints may be defined such as areas of
interest as a ‘heatmap’ (direction or frequency of
gazing at a specific visual point), gaze time, time
taken to fixate, and number of glances.
Eye-tracking has only recently been investigated
for use in regional anaesthesia simulation, with the
majority of studies within the time period of this
review. Appropriately, these initial studies sought to
validate some endpoints provided by eye-tracking
software. A small study was performed by Borg et al.
[38] comparing five novices and five expert regional
anaesthesiologists on gaze time both in the area of
interest and outside the area of interest, and time
682 www.co-anesthesiology.com
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
taken to fixate. These endpoints were measured
when participants were shown static sonoanatomy
images and asked to identify relevant structures.
Some metrics were possibly useful, with experts
faster at correct fixation and less likely to be dis-
tracted away from the area of interest.
&&
The interesting study by Mustafa et al. [23 ]
compared the visual salience of novices versus
experts, using fusion-elastography to provide visual
clues of appropriate perineural spread of injectate.
Experts are known to have automated pattern rec-
ognition of relevant (target) and irrelevant (distrac-
tor) sonoanatomical structures, informed by their
greater knowledge and experience. An explicit ratio-
nale for this study was to build a body of work that
complements eye-tracking technology as a means to
objectively describe UGRA learning curves.
The same research group included eye-tracking
as secondary endpoints in their other studies; the
primary outcomes have been described earlier in
this review [24,34]. Of the data from eye-tracking,
McLeod et al. [24] did not find effective discrimina-
tion, whereas McLeod et al. [34] did find results
supporting its use to stratify proceduralists based
on expertise. Conclusions from the results of all
available studies are limited as methodologies are
dissimilar, the sample sizes are small, and validation
of eye-tracking was not the primary aim in the
majority of studies. A possible advantage of eye-
tracking is allowing longer term follow-up of knowl-
edge translation after simulation, as it provides an
objective tool to assess training outcomes in the
laboratory and later in clinical environments.
&
Chuan and Ramlogan [14 ] performed a struc-
tured prospective electronic Delphi international
survey of 38 experts in regional anaesthesia, to
identify and rank education and training topics in
order of research priority. Conducted over three
rounds, the expert panel ranked 82 topics. Based
on a-priori thresholds, a consensus was reached on
13 top-ranked topics (Table 3). The primary aim of
the study was to describe the breadth of research
activities in regional anaesthesia education, and to
inform researchers on which topics to target based
on importance to our subspecialty.
A review of competency-based assessment tools
used in regional anaesthesia was performed by
Chuan et al. [39]. This review provided a statistical
framework to evaluate the psychometric properties
of an assessment tool, or commonly called ‘assessing
the assessment tool’. These are dependent on mea-
suring the validity (content, construct, and face
validity) as well as the reliability (external and inter-
nal) of the tool. Having robust testing of psycho-
metric properties is required so that all stakeholders
have confidence in the results gained from
Volume 33  Number 5  October 2020

assessment. The review covered different types of
statistical tests, including commonly encountered
tests such as Cronbach’s alpha, Cohen’s kappa, and
intraclass correlation coefficient, as well as uncom-
mon but robust tests such as generalizability theory
and Rasch item-response theory.
CONCLUSION
The current review described the 22 recent articles
pertaining to education and training in regional
anaesthesia and pain medicine. The themes and
topics of these articles were varied. Performing
research in regional anaesthesia education is diffi-
cult due to diversity of topics, feasibility to recruit
and logistics, smaller sample sizes, linking interven-
tions to improved patient care, and large interindi-
vidual differences in learning. Encouragingly, the
majority of recent research output specifically
addressed nine of the top concerns identified in
our subspecialty, and continues to add information
to a maturing evidence-base.
Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
REFERENCES AND RECOMMENDED
READING
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& of special interest
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