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The Brazilian Society of Neuroradiology – the First Medical Society to Implement a National INR Simulation-based Curriculum

We explore the journey of SBNR and its mission to improve interventional neuroradiology training in Brazil.

November 23, 2022
Rebecka Melin

The Brazilian Society of Neuroradiology (SBNR) is the first Medical Society in the world to build a national curriculum with interventional simulation implemented. We had the opportunity to speak with the founders of this initiative and the executives of the society:

To standardize interventional neuroradiology training in Brazil, SBNR has developed and implemented a simulation-based program consisting of hands-on training, remote proctoring, and online classes. The program became available to all society fellows in 2021.

Explore the key takeaways of the article:

  1. The Brazilian Society of Neuroradiology
    Introducing the SBNR and the background of the national initiative.
  2. A need for change – INR education in Brazil before standardization
    Differences in teaching methods among training centers and a heterogenous educational approach resulted in varying proficiency levels among fellows in Brazil. The situation motivated SBNR to drive change in the national educational system – for improved treatment quality and patient experience.
  3. The value of simulation for standardizing INR training, improving proficiency levels and patient experience
    Training conditions are now equal among the centers, heterogeneity is lower, and the proficiency assessment method has improved. The new training platform has united the twenty-two centers and enabled proficiency-based learning and a higher level of fellow training in Brazil.


The Brazilian Society of Neuroradiology

What is SBNR, and what are the society's mission and vision?

C: SBNR has two basic missions: Educating and supporting physicians in their daily practice. We are a society linked with the Brazilian College of Radiology. All SBNR members and fellows come from three different specialties: neurosurgery, neurology, and radiology.  

M: Since no other societies focus on interventions, SBNR represents most interventionalists. There are certain challenges between the different clinical specialties that we want to solve to ensure the best patient care. We are fighting in a good way to bring the majority of the interventionalists to this society.  

F: In Brazil, we have almost 270 interventional neuroradiologists, and 70% are certified by SBNR. To practice interventional neuroradiology in Brazil, you must be evaluated by our society and authorized to perform an intervention.

C: In 2019, we built a new educational platform and created a proficiency-based curriculum. Proficiency-based learning refers to systems of instruction, assessment, grading, and reporting and is based on students demonstrating that they have acquired the knowledge and skills they are expected to attain as they progress through their education. When developing a training program, combining theory with practical experience is essential. Simulation is great in this context, as it enables hands-on procedural training in a safe and patient-free environment. Our program is based on three pillars: knowledge, skill, and attitude.

You need access to cases to develop practical skills and get hands-on training. We started to implement our curriculum during the burden of the ongoing Covid-19 pandemic. Suddenly the hospitals had a high percentage of covid patients, and there was a lack of real patient cases for the traditional 'master-apprentice' training methodology within radiology. How can you implement a new curriculum without patient cases? We discussed potential solutions with Mentice Renan Cancissu (Sales Director LATAM), which resulted in us creating a remote course for different centers that was proctored online.

A need for change – INR education in Brazil before standardization

What did the learning environment for trainees look like in Brazil before simulation was implemented?

F: About sixteen training centers (University Teaching Hospitals) in Brazil oversaw the training of interventional neuroradiologists. We found that the procedural training volumes differed between all the training centers, and the education had a very heterogeneous structure. Not only from a pedagogical point but there was no homogenous theoretical program.  

Furthermore, we found that the structure of interventional neuroradiology training was a global issue. We began to question ourselves: how can we implement homogeneous training in Brazil? How can we ensure that the trainees graduate with a high level of proficiency in the essential areas of their interventional specialty?

To solve these educational challenges, we built a new curriculum with a lot of focus on hands-on skill training related to each competence. When we developed a structure for the practical part of the training program, we decided to involve Virtual Patient simulation. The old training model (still the standardized global practice) was "see one, do one, teach one." We wanted to develop a new model: "observe one, train on the simulator, then treat a patient," with the final goal of transforming the training model into "never treat a patient without having trained on the simulator."

The focus is specifically on virtual simulation, as it enables us to get more precise metrics. It can be used to define the proficiency of a trainee and provide valuable data on when that trainee is ready to perform a real patient procedure, assessed in accordance with Entrustable Professional Activities (EPAs).  

It is a challenge to determine when a trainee is ready to treat a real patient, especially since our judgment is, by nature - based on our professional experience and emotions. Instead, the trainee must be assessed rationally and fairly based on scientific evidence. The minimal level threshold validated and formulated to measure the trainee and to ensure high quality and proficiency of the interventional procedure is key. Simulation helps us solve the educational challenges for fellow training and allows us to get precise metrics in terms of the development of each trainee.  

C: We need to be able to measure the trainee's proficiency and knowledge to know when he or she is ready to perform a real procedure. From my experience, some trainees need more time to develop their skills. This provides an unfortunate burden on the trainee, the senior physicians, the team, and everyone involved in the fellowship programs. When we developed the curriculum, one of our main focuses was the assessment of proficiency. In the patient-free and safe learning environment of simulation, it is possible to quickly identify, improve, or even correct potential technical skillset limitations of the trainees.

Day 1 of SBNR's hands-on course in Porto Alegre 9-11 NOV: Virtual Simulation workshop using Mentice VIST simulators.

How do you ensure that all physicians have a high supply of patients that provide a natural increase in experience and, in turn, ensure optimal procedural outcomes?

C: It is challenging since these areas are an active part of our function as a society. We need to analyze all centers to see how many cases each fellow has done per year. The training volume of trainees must increase. It is impossible to proficiently treat, e.g., an aneurysm in the brain if you only get to treat one per year. If we add a simulator to each center, we could increase virtual patient training volumes and thus improve the level of proficiency among fellows.  

M: Several centers lack a proper training program for their fellows, and we cannot certify a center like this. We are trying to create connections between the centers and potentially move the fellows between them so they can train other procedural variances. Simulation allows us to teach the fellows all the procedural steps, equipment and devices needed, and everything essential to know before performing a real procedure.

Day 1 of SBNR's hands-on course in Porto Alegre 9-11 NOV: Hands-on training using Mentice physiological flow system SIM Agility.

What was the defining moment that made SBNR decide to take action for change in the national educational system?

C: It all began in 2019 when we analyzed the data we received from all sixteen training centers in Brazil (today, there are twenty-two centers). When we went through the data, we discovered the educational heterogeneity that existed in all these centers. Each center taught its fellows in its own way, meaning there were sixteen different approaches to teaching. As SBNR, we are responsible for certifying new interventional neuroradiologists in Brazil, and the government's minister of education signs the certificate.  

Imagine the situation when sixteen centers, each with its own educational strategy, sent its fellows to us for certification by the end of the fellowship. The fellows were evaluated with a three-step test, and the test results and proficiency levels varied greatly since they all received different types of training. The fellows were not to be blamed here. In 2019 we started receiving data, and more than thirty experts within education and interventional neuroradiology met in Sao Paulo for discussions. In 2020 we finished the curriculum, and in 2021 we began implementing the platform.  

The value of simulation for standardizing INR training, improving proficiency levels and patient experience

What has the main impact been of the implemented simulation training?

M: People have started to realize the importance of simulation as an educational tool.  

F: I would say that we can divide the impact of educational changes into three parts. First, we have the cultural aspect. We are all part of the same team now and working towards the same goal. We have realized that we face the same challenges, which is essential for a functioning society. The second aspect is that we can promote equal training in Brazil. The heterogeneity is now lower. Clearly, we are moving towards the same goal and communicating in the same language in terms of training. The third aspect is that we can now ensure a fairer evaluation of the fellows and that they are at the right proficiency level to pass. Using the simulator and measuring specific metrics, we can see improvements among the fellows.  

It is also important to mention that not all training aspects have improved: Why is that? We are testing some hypotheses right now. We must have a program in place to ensure that the simulator is used correctly and that the learning objectives are achieved. The course supervisor is vital in this setting.

C: Today we have another level of fellow training in Brazil. Twenty-two centers are now collaborating, and we have monthly meetings with all the fellows to discuss a chosen topic. We work as one group now, which is fairer for the fellows. The platform enables us to share knowledge and information effectively and increase the proficiency level among the centers. A uniform team allows us to offer a higher quality of treatment to the patients and ultimately improve the patient experience and outcome.

Day 2 of SBNR's hands-on course in Porto Alegre 9-11 NOV: simulated live case on Mentice SIM Agility.

What is the future of simulation and interventions?

M: I believe that the usage of simulation will increase a lot, together with artificial intelligence, in the future. We will learn with simulation, and when we upload a case in the simulator, all the treatment possibilities will be there because the system will have figured it out before us.

C: I see a benefit of using the simulator for adoption and continuous proficiency-based learning of vascular robots, as some centers in the world are transitioning into robotic-assisted interventions. For the upcoming year, the focus will be on increasing the usage of simulation training for complex procedures and complications, as these are the situations you learn most from.

F: In the future, it could be an advantage to implement simulation in daily clinical practice to support decision-making, case planning, and mission rehearsal by using real patient data sets in advanced software applications such as Mentice simulation.


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