Volume 7 no 4

Postgraduate medical education during the COVID-19 pandemic lessons learned and calls to action for medical education leaders

 

Leanna S. McKenzie, MD, and Amonpreet K. Sandhu, MD

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Postgraduate medical education during the COVID-19 pandemic: lessons learned and calls to action for medical education leaders

Leanna S. McKenzie, MD, and Amonpreet K. Sandhu, MD

https//doi.org/10.37964/cr24740

 

The COVID-19 pandemic has led to a rapid transformation in the delivery of postgraduate medical education, causing unexpected effects on the learning experiences of residents in training. Program directors, as educational leaders, are relied on to adapt an established curriculum and clinical experience into a virtual world while navigating the limitations imposed by the pandemic. In this article, we focus on the impact of the dramatic changes to medical education delivery on both learners and leaders and examine the challenges and successes of the new strategies employed. A reflection of the importance of leadership in medical education is discussed, along with a review of the strategies that have emerged as successful and worthy of integration into our new medical education paradigm.

 

KEYWORDS: medical education, COVID-19, pandemic, postgraduate, program directors

 

CITATION: McKenzie LS, Sandhu AK. Postgraduate medical education during the COVID-19 pandemic: lessons learned and calls to action for medical education leaders Can J Physician Leadsh 2021;7(4):145-152 https//doi.org/10.37964/cr24740

 

The global COVID-19 pandemic has significantly disrupted postgraduate residency medical education. After decades of minimal change to the basic structure of residency, a seismic shift in educational delivery occurred in a matter of weeks. The need to adhere to social distancing rules while learning and providing patient care has led to an emphasis on distance education, a delicate balancing of service and education, and the emergence of new and creative methods for medical teaching and learning. In Canada, educators and clinicians have been preparing for the advent of competency-based medical education for several years, unaware of a widespread societal change that was forthcoming.

 

Challenges of residency education during the pandemic

 

The initial months of the pandemic led to a variety of changes to residency education. In-person teaching sessions, such as academic half-days and procedural skills and simulation sessions, were cancelled; outpatient clinic experiences were diminished or cancelled outright; certifying high-stakes examinations were deferred and reinvented in a remote format, all leading to significant emotional upheaval for trainees. Residents were on leave from clinical duties because of isolation or illness, out-of-province electives were cancelled, and research projects were stalled. All aspects of residency were affected. As educational leaders, program directors (PDs) faced an insurmountable workload as they adapted their program administration to a virtual format while managing concerns about the wellness of their trainees. These duties weighed heavily on PDs as they faced parallel demands in clinical medicine and heightened personal responsibilities.

 

Further unanticipated challenges began to emerge as the COVID- 19 pandemic progressed. With elective procedures cancelled during high COVID-19 peaks, residents in surgical programs found procedural opportunities lacking.1-3 Outpatient experiences were dramatically reduced, and learners found it difficult to engage in virtual clinics. As educational experiences transitioned to electronic platforms, challenges in communication and interaction between resident physicians and staff became noticeable.

 

Although physician educators may have initially adapted to the transition to socially distanced education, a number of questions arose. Are the residents gaining adequate clinical experience? How has the pandemic affected their ability to learn team management skills? How has the significant decrease in outpatient interaction affected their training? How are residents coping in terms of emotional well-being?

 

As physician educators and leaders, we were curious about the impact the pandemic exerted on our residents and PDs. More specifically, we sought to identify how the changes in education delivery and clinical environments have affected learning and wellness for both residents and PDs.

 

Methods

 

To assess the educational and leadership impacts of the pandemic restrictions at our institution, a tertiary care pediatric hospital in Calgary, AB, Canada, we administered an informal, voluntary online survey (Survey Monkey; Momentive Global, San Mateo, Calif., USA) to pediatric residents, subspecialty residents, and PDs in September 2020. This survey was considered part of a rapid quality improvement project and, therefore, based on a Project Ethics Community Consensus Initiative (ARECCI) ethics screening tool; thus, formal ethics board approval was not sought.4 The survey was distributed online via the deputy department head of education, and participation was completely voluntary and anonymous. Top

 

The aim of the study was to examine current perceptions of changes in the residency training program made in response to the pandemic. At the time of the survey, there was a widespread feeling in our hospital that both residents and PDs had shouldered a large burden in transforming and adapting to ad-hoc pandemic-style medical education. The information from the survey was intended to inform leadership regarding priority areas that required further support or attention.

 

The survey questions were created after a review of the literature and edited for clarity and brevity. The survey consisted of 10 questions related to residency training and examined the perceived impact of COVID-19 pandemic on three themes: clinical exposure, academic half-days and well-being. Resident participants were asked to rate how the pandemic affected various aspects of their experience on a five-point Likert scale: 1 = significantly worsened, 2 = slightly worsened, 3 = no change, 4 = slightly improved, 5 = significantly improved. PD participants were asked to rate the same questions in terms of their perceptions of how residents have been impacted in their training and well-being; but, they were also asked to rate how the pandemic affected their own well-being. For each question, participants were able to add comments at their discretion. Minimal demographics were obtained; residents were asked to identify whether they were a general pediatrics or subspecialty resident.

 

Results

 

Of 81 residents, 43 responded for a response rate of 53%. Most trainees responding were general pediatric residents (n = 33, 77%), and a minority were subspecialty residents (n = 10, 23%). Of 16 pediatric general and subspecialty PDs, 12 (75%) responded to the survey. We report our results thematically along with corresponding figures.

 

Resident perspective

 

Resident training experience during the pandemic: Most residents stated that the pandemic had slightly worsened their training experience (Figure 1), in alignment with other studies in the medical literature.2,5 Pediatric inpatient care saw a significant decrease in numbers of patients, which in turn has led to limited exposure to common problems, particularly respiratory ailments, which ironically decreased with the advent of COVID-19. Restrictions on entering the rooms of possibly infected patients led to further reduced clinical opportunities. Residents reported that communication issues were particularly strained at this time. Cessation of patient bedside rounds, challenging interactions with patients and families wearing personal protective equipment (PPE), and lack of ability to connect with colleagues and health care providers through nonverbal cues were all identified as barriers to inpatient work. However, despite these challenges, residents found that the low-volume/high-complexity patient profile allowed them to focus on learning complex medicine and teaching junior residents.

 

Outpatient experience has also been profoundly affected by the pandemic, as reflected in resident feedback (Figure 2), and this is supported by other studies examining residency experience during the pandemic.2,3,5 Specialty and subspecialty clinics were cancelled, and only the sickest or highest priority patients were seen. This led to a significant reduction in exposure to non-urgent but common pediatric problems, leaving deficits in resident training.

 

Many clinics have transitioned to virtual or telephone clinics. Staff physicians, many of whom were unaccustomed to virtual care themselves, were asked to accommodate a resident learner on these electronic platforms. This could be challenging for both resident and staff physician, who had to simultaneously learn a new process while supporting education. PDs cited the adoption of this new practice while accommodating resident learning as a strain for faculty members. However, virtual visits did provide an interesting opportunity for direct resident observation. In our survey, residents indicated that they preferred virtual clinic visits where the staff physician could observe them throughout the entire appointment, from taking a history through to counseling the patient. The fact that residents welcomed being observed by a staff physician for an entire encounter was an unexpected advantage of this technique and a critical component of competency-based medical education.6

 

Impact of the pandemic on academic curriculum delivery: The effect of the pandemic on didactic learning, such as academic half-days and rounds, was one of the few areas that was not significantly negatively impacted, according to residents (Figure 3). Many enjoyed being able to attend academic half-days from home or watch it later if they were post-call. However, lack of team building and socialization amongst peers and less informal mentorship between residents and staff were frequently cited as negative impacts.

 

Impact of the pandemic on overall resident well-being: Not surprisingly, residents felt that overall, their well-being had suffered and was significantly worse because of the pandemic (Figure 4). The top pandemic-related factor cited as affecting mental health was social isolation, followed by lack of ability to participate in recreation and decision fatigue. Notably, fear of contracting COVID-19 was reported with less frequency, suggesting that social factors may weigh more heavily than medical factors. Most residents felt that friends and family were most helpful for emotional support during the pandemic, and many felt that peer support within the program was valuable. Top

 

Program director perspective

 

Resident training experience during the pandemic: Most PDs shared the view that overall residency training was slightly worsened as a result of the pandemic (Figure 5). Their responses were similar to those of residents, but perhaps slightly more pessimistic. Main themes in response to this sentiment were related to the reduction in ambulatory exposure, complexities of logistics for virtual clinics, and overall lower patient volumes in the pediatric setting.

 

However, PDs did note some unexpected “silver linings” in the altered clinical activity. As some staff mentioned, the direct observation of residents in virtual clinics has presented some excellent opportunities for feedback and coaching. Others feel that the pandemic is a once-in-a-lifetime opportunity to participate in an unprecedented public health event.

 

Impact of the pandemic on academic curriculum delivery: Most PDs felt the experience was neither better nor worse, mirroring the comments of the residents (Figure 6). Positive aspects of virtual learning cited were improved attendance and the chance to attend sessions from the comfort of home or out of town clinical placements, such as electives and rural rotations; lack of social interaction, loss of community, and “Zoom fatigue” were identified as negative aspects.

 

Impact of the pandemic on overall PD well-being: As educational leaders, PDs have shouldered a large load during the pandemic. Most felt that their personal overall well-being was slightly or significantly worsened during the pandemic (Figure 7). Reasons attributed to the decline in their overall well-being included staffing issues, physical and mental health concerns for both self and residents, decreased interaction with trainees, and decreased sense of community. The importance of clear and timely communication was cited as critical to establishing an overall feeling of stability during these difficult times.

 

PDs also pointed to an increased workload for themselves and program administrators with the sudden need to adopt and navigate new technology. As one PD remarked: “Nobody added an 8th day of the week. But, we are getting it done!”

 

Discussion

 

Recognizing the strain and challenges of providing quality residency education during the pandemic, adaptations brought forward by education leaders may be divided into the following categories: short-term wins, medium-term modifications, and long-term transformations.

 

Short-term wins

 

Short-term wins, implemented in the first few months of the pandemic, are reactive, quick to implement, and may be very effective. They include moving lectures, academic half-days, rounds and webinars onto online platforms with recording capabilities to enable distance learning. Pre-existing online resources may also be invaluable for exam preparation, video learning, and community building. Simulation labs have been essential in teaching residents the skills of resuscitation, PPE donning and doffing, procedural skills, and elements of teamwork/crisis resource management.

 

Virtual patient encounters have created new opportunities for direct observation and coaching for residents, although mastery of these skills takes time and experience. Effective and timely communication between educational leaders and residents has been essential to navigate changes and mitigate stress. Finally, consideration of resident wellness, as promoted and modeled by educational leaders, is critical in this trying time. Top

 

Medium-term modifications

 

As the pandemic has continued, more substantial modifications have been developed, many of which may be adopted on a permanent basis. Most high-stakes certifying exams have been transformed into new formats, including a digital written examination and a virtual applied examination. The use of virtual teaching sessions, meetings, and conferences, which increases convenience and facilitates attendance, is likely to continue with some frequency beyond this pandemic.

 

Resident wellness has emerged as a critical issue as the pandemic continues, and, although it is difficult to navigate during quarantines and social distancing, it cannot be ignored. Ongoing social isolation, long work hours, and lack of community negatively impacts mental health and, in turn, our residents’ academic and clinical performance. Education leaders must actively check-in to support the wellness of individual learners and help them thrive academically. This can be achieved through one-on-one meetings, wellness virtual town halls, and the introduction of a resident wellness leader to acknowledge and validate resident concerns surrounding pandemic-related issues.

 

Long-term transformations

 

Medical education has been forced to pivot in light of the COVID-19 crisis, and programs have appropriately adapted. However, this has also generated questions around our pre-existing medical education framework and the need for long-term transformation. As educational leaders, we must consider lessons learned during the pandemic. Has the pandemic forced educators to reimagine the ways in which we deliver medical education? Should we modify how we assess our trainees? Is there a need for formal curricula and training around virtual patient encounters? If the pandemic continues for several years, will we graduate undertrained physicians? Will virtual and remotely conducted applied certifying exams be a fair and just model for certification?

 

The call to leadership has resonated throughout the pandemic. Department leaders have been expected to negotiate difficult and often conflicting positions of courage, advocacy, and humility in the face of great uncertainty. As educational leaders, PDs have been drawn into a position of trust and responsibility like never before. The challenges for PDs and educational leaders are unparalleled: advocating resident safety measures, including PPE and vaccination; ensuring quality education during high acuity; enabling access to virtual clinics and academic sessions; transitioning essential learning experiences to simulation; and, finally, recruiting faculty to champion education in the midst of an all-consuming public health emergency. PDs are expected to model professionalism while tending to the well-being of themselves, their families, and residents. Chief residents, technically learners themselves, have also found themselves in a state of heightened responsibility during the pandemic. Resident leaders have responded through advocacy, communication, instilling community, and modeling courage in the face of uncertainty.7 Senior residents may find themselves learning critical leadership skills during the pandemic, which ultimately will give them confidence and experience when faced with future crises.1,7 Top

 

As education leaders, we have a duty to our trainees to ensure the best possible work and learning environment, despite challenging situations. Our surgery colleagues addressed these tenets at the onset of the COVID-19 pandemic as they pertains to their specialty; however, the themes are entirely transferrable to all areas of medicine, including pediatrics.3 They include the promise to (a) prioritize trainee wellness and safety; (b) harness opportunities to learn from the COVID-19 pandemic; (c) restructure learning; (d) adapt current educational milestones; and (e) prepare for post-COVID-19.

 

Based on this paradigm, certain adaptations will be adopted into the long-term transformation of medical education. Examples include the use of simulation-based learning, virtual education sessions allowing for collaboration and sharing between centres, virtual patient encounters, the importance of trainee safety including PPE, and the firm incorporation of resident wellness into the curriculum. Teamwork and crisis management, residents-as-teachers, and leadership development have also developed as emerging themes critical to resident education.

 

There are many questions, but limited clear answers. However, one message remains: a reflexive return to the previous status quo after the pandemic means ignoring the important lessons learned and novel opportunities for medical education. As Dr. Lee Goeddel from Johns Hopkins shared: “This is a crisis of a lifetime. If students can learn from it in appropriate ways, it’s going to make our future physician workforce better.”8 Educational leaders must reflect and learn from this crisis to continue to improve and advance the state of residency education. Top

 

Conclusion

 

The COVID-19 pandemic has presented a major challenge to the delivery, assessment, and administration of residency education. Despite the best intentions of educational leaders to provide a seamless transition to virtual and safe learning, there have been unexpected consequences, both positive and negative. Educational leaders have learned that excellent communication from leadership and attention to wellness for both residents and physician leaders is imperative. In addition, new areas for development in resident education have emerged.

 

All education leaders should reach out to their trainees to ensure well-being needs are being addressed and supported; reflect critically on local adaptations to the pandemic to identify initiatives that can and should be continued post-pandemic; and leverage this crisis as an opportunity to advocate funding and associated opportunities to build new curriculum and resources in the areas of wellness, teamwork, simulation, crisis management, and leadership development. As we move forward into control over the pandemic, it is clear that many educational strategies unexpectedly tested during this time in history will be integrated into our medical education framework for years to come.Top

 

References

1. Rana T, Hackett C, Quezada T, Chaturvedi A, Bakalov V, Leonardo J, et al. Medicine and surgery residents’ perspectives on the impact of COVID-19 on graduate medical education. Med Educ Online 2020;25(1):1818429. https://doi.org/10.1080/10872981.2020.1818439

2. Aziz H, James T, Remulla D, Sher L, Genyk Y, Sullivan ME, et al. Effect of COVID-19 on surgical training across the United States: a national survey of general surgery residents. J Surg Educ 2021;78(2):431-9. https://doi.org/10.1016/j.jsurg.2020.07.037

3. Daodu O, Panda N, Lopushinsky S, Varghese Jr TK, Brindle M. COVID-19 considerations and implications for surgical learners. Ann Surg 2020;272(1):e22-3. https://doi.org/10.1097/SLA.0000000000003927

4. ARECCI ethics screening tool. Edmonton: Alberta Innovates; n.d. Available: https://tinyurl.com/45ntsft3

5. Edigin E, Eseaton PO, Shaka H, Ojemolon PE, Asemota IR, Akuna E. Impact of COVID-19 pandemic on medical postgraduate training in the United States. Med Educ Online 2020;25(1):1774318. https://doi.org/10.1080/10872981.2020.1774318

6. Competence by design. Ottawa: Royal College of Physicians and Surgeons of Canada; 2021. Available: https://tinyurl.com/m5mawma9

7. Rakowsky S, Flashner BM, Doolin J, Reese Z, Shpilsky J, Yang S, Smith CC, et al. Five questions for residency leadership in the time of COVID-19: reflections of chief medical residents from an internal medicine program. Acad Med 2020;95(8):1152-4. https://doi.org/10.1097/ACM.0000000000003419

8. Wiener S. No classrooms, no clinics: medical education during a pandemic. Washington, DC: Association of American Medical Colleges; 2020. Available: https://tinyurl.com/d37bhj4n

 

Authors

Leanna S. McKenzie, MSc, MD, FRCPC, is the current deputy head of education at the Alberta Children’s Hospital, Department of Pediatrics, University of Calgary. She is a practising pediatric gastroenterologist with a master’s degree in medical education and has held many leadership positions throughout her career, including serving as program director and leading undergraduate medical school courses.

 

Amonpreet K. Sandhu, MSc, MD, FRCPC, is program director for the general pediatrics residency program, Department of Pediatrics, University of Calgary. She practises pediatric hospital medicine and she holds a master’s degree in medical education.

Author attestation: Both authors contributed to this research and preparation of the article. There are no declared conflicts of interest from the authors. There are no funding sources. Both authors have approved the final article.

 

Correspondence to:

Leanna.McKenzie@albertahealthservices.ca

 

This article has been peer reviewed.

 

 

 

 Top

 

 

CITATION: McKenzie LS, Sandhu AK. Postgraduate medical education during the COVID-19 pandemic: lessons learned and calls to action for medical education leaders Can J Physician Leadsh 2021;7(4):145-152 https//doi.org/10.37964/cr24740

Resident training experience during the pandemic: Most residents stated that the pandemic had slightly worsened their training experience (Figure 1), in alignment with other studies in the medical literature.2,5 Pediatric inpatient care saw a significant decrease in numbers of patients, which in turn has led to limited exposure to common problems, particularly respiratory ailments, which ironically decreased with the advent of COVID-19. Restrictions on entering the rooms of possibly infected patients led to further reduced clinical opportunities. Residents reported that communication issues were particularly strained at this time. Cessation of patient bedside rounds, challenging interactions with patients and families wearing personal protective equipment (PPE), and lack of ability to connect with colleagues and health care providers through nonverbal cues were all identified as barriers to inpatient work. However, despite these challenges, residents found that the low-volume/high-complexity patient profile allowed them to focus on learning complex medicine and teaching junior residents.

Outpatient experience has also been profoundly affected by the pandemic, as reflected in resident feedback (Figure 2), and this is supported by other studies examining residency experience during the pandemic.2,3,5 Specialty and subspecialty clinics were cancelled, and only the sickest or highest priority patients were seen. This led to a significant reduction in exposure to non-urgent but common pediatric problems, leaving deficits in resident training.

Impact of the pandemic on academic curriculum delivery: The effect of the pandemic on didactic learning, such as academic half-days and rounds, was one of the few areas that was not significantly negatively impacted, according to residents (Figure 3). Many enjoyed being able to attend academic half-days from home or watch it later if they were post-call. However, lack of team building and socialization amongst peers and less informal mentorship between residents and staff were frequently cited as negative impacts.

Impact of the pandemic on overall resident well-being: Not surprisingly, residents felt that overall, their well-being had suffered and was significantly worse because of the pandemic (Figure 4). The top pandemic-related factor cited as affecting mental health was social isolation, followed by lack of ability to participate in recreation and decision fatigue. Notably, fear of contracting COVID-19 was reported with less frequency, suggesting that social factors may weigh more heavily than medical factors. Most residents felt that friends and family were most helpful for emotional support during the pandemic, and many felt that peer support within the program was valuable. Top

However, PDs did note some unexpected “silver linings” in the altered clinical activity. As some staff mentioned, the direct observation of residents in virtual clinics has presented some excellent opportunities for feedback and coaching. Others feel that the pandemic is a once-in-a-lifetime opportunity to participate in an unprecedented public health event.

Impact of the pandemic on overall PD well-being: As educational leaders, PDs have shouldered a large load during the pandemic. Most felt that their personal overall well-being was slightly or significantly worsened during the pandemic (Figure 7). Reasons attributed to the decline in their overall well-being included staffing issues, physical and mental health concerns for both self and residents, decreased interaction with trainees, and decreased sense of community. The importance of clear and timely communication was cited as critical to establishing an overall feeling of stability during these difficult times.

Discussion

Resident training experience during the pandemic: Most residents stated that the pandemic had slightly worsened their training experience (Figure 1), in alignment with other studies in the medical literature.2,5 Pediatric inpatient care saw a significant decrease in numbers of patients, which in turn has led to limited exposure to common problems, particularly respiratory ailments, which ironically decreased with the advent of COVID-19. Restrictions on entering the rooms of possibly infected patients led to further reduced clinical opportunities. Residents reported that communication issues were particularly strained at this time. Cessation of patient bedside rounds, challenging interactions with patients and families wearing personal protective equipment (PPE), and lack of ability to connect with colleagues and health care providers through nonverbal cues were all identified as barriers to inpatient work. However, despite these challenges, residents found that the low-volume/high-complexity patient profile allowed them to focus on learning complex medicine and teaching junior residents.

Impact of the pandemic on overall PD well-being: As educational leaders, PDs have shouldered a large load during the pandemic. Most felt that their personal overall well-being was slightly or significantly worsened during the pandemic (Figure 7). Reasons attributed to the decline in their overall well-being included staffing issues, physical and mental health concerns for both self and residents, decreased interaction with trainees, and decreased sense of community. The importance of clear and timely communication was cited as critical to establishing an overall feeling of stability during these difficult times.