Residency Training in the COVID-19 Pandemic: Adaptation, Exhaustion, Opportunity

By Ecler Jaqua

As the COVID-19 pandemic advanced, many rapid changes had to be made in medical education. Residency programs had to be adaptive and creative to deal with the ever-changing CDC landscape protocols to educate residents in a restrictive in-person environment.

In a matter of days, our family medicine residency clinic had to change all the in-person visits to telehealth. Video visits were something that was being tested and executed in the faculty clinic, but nothing similar was done on the residency side. At first, it was very challenging to our residents, but especially to our patients who had no idea how to use the app for the video visits. Many appointments had to be changed to telephone visits instead due to technical issues and poor literacy. However, as time went by, most of the residents, faculty and some patients started to get more familiar with the current system. Telehealth is here to stay, and I don’t think it will ever leave us. On the positive side, telehealth has now opened up opportunities for patients who previously were unable to attend their doctor’s visit.

Unfortunately, the pandemic just not affected the way we take care of patients but also negatively affected the training of residents. It led to many modifications for safety reasons within the clinics and hospitals that resulted in decreased volume of procedures, simulation laboratories, face-to-face teaching, hands-on training, and skill-based teaching activities. Elective rotations had to be canceled, reducing interpersonal connections in favor of social distancing and home isolation. The residents’ clinical skills competence in doing a physical exam weakened as they no longer have access to patients under supervision. The conventional bedside teaching where residents and faculty can ask patient questions in real-time and have essential discussions as a team had to be discontinued. Numerous residents were unable to attend conferences, complete research projects, or participate in extra-curricular activities that could help them get a competitive fellowship or their dream job.

Several residency programs at my institution had to restructure their residency training and redeploy many residents to services in need. Due to these rapid changes, the hospital shifts were at times very exhausting for the residents – not only because of the long hours and multiple days working in a row but also the constant fear of spreading the virus to a loved one. On top of all these changes having to wear personal protective equipment (PPE) all the time can be very uncomfortable. Residents many times felt a mix of anxiety, fear, emotional and physical exhaustion during these extraordinary times.

The weekly didactic teaching sessions, a crucial component of residency training, changed radically with the pandemic. All the in-person lectures moved online through platforms such as Zoom. The advantage of having the didactic session online was the ability to have everyone attend from any location and being able to invite speakers from different institutions. Virtual rounding was also implemented in countless residency programs to keep the whole medical team safe. The virtual rounds involve a pre-round done by the residents and medical students, and the attending physician would join remotely to discuss the cases with the whole team. During this time, it is an excellent opportunity for the attending physician to teach, showing research papers and PowerPoint slides about the cases that are being presented. As soon as the virtual round is ended, the attending physician would see the patients by him- or herself and resume the virtual round in the afternoon to discuss their physical exam findings and any other pertinent information from the patients or medical staff. Although there is no replacement for the face-to-face bedside teaching and observation of the resident or medical student performing the physical exam, this model is efficient, delivers substantial educational value, maximizes patient care time, and provides a safe environment to both trainees and patients.

Residency programs across the nation adopted video interviews for virtual residency recruitment. One of the advantages of virtual recruitment is the amount of money and time saved during the interview season. Not having these expenses can be a relief to the medical students and the residency program, especially as the financial crisis precipitated by the pandemic led to budget cuts for recruitment in many programs. Virtual recruitment also allows the residency program to interview more applicants as more interviewers may be available. The downside of virtual recruitment is the limited opportunities to socialize with current residents and faculty. It may also cause video fatigue if an applicant doesn’t take a break or stays uninterrupted for more than two hours in an interview.

Although these are challenging times, we were able to reconsider our current resident education and welcome ground-breaking methods while providing a high quality of care. Even though the pandemic affected residency education, several research studies show that the level of knowledge and clinical practices with virtual learning was acceptable. I believe we gained an understanding of how to integrate technology with the current teaching modality without compromising patient care. We also learned how to improve health care systems and redesign curriculums to ensure appropriate training.  

In the near future, as the pandemic subsides, we will see a hybrid of these models. Learning telehealth skills along with classroom and bedside teaching, the flexibility to have lectures in person and virtual so that everyone can attend, and virtual interviews with an option for an in-person interview and visit the residency program site. These adaptations are still a work in progress, but I am hopeful that all the changes and discoveries we had this past year will positively impact medical education.

Ecler Jaqua, MD, DipABLM, DipABOM, FAAFP is a geriatrician and assistant professor of family medicine at Loma Linda University Health. She is the California Academy of Family Physicians Riverside-San Bernardino Chapter president-elect.

I Have Hope – Reflections on Medical Education from the First Wave of the Pandemic

By Suzanne Minor, MD, FAAP

Every month I receive the evaluation comments written by fourth year students about their rotations, sites, and preceptors.  I read through these looking for possible concerns around faculty development and resident development especially with regards to teaching our students.  I want to make sure that if there are any trends, I am on top of them; if there any opportunities, I can quickly work to support faculty as needed.  

This past Fall, I read our first evaluations since our students started back after the pandemic.  I did not know what to expect.  Actually, I expected negative comments to jump out at me.  In the months since our faculty had last worked with students, the coronavirus pandemic had ravaged  South Florida.  Our affiliate hospitals were overwhelmed with COVID-19 admissions and our already busy faculty had born the burden of caring for sick patients with limited PPE. They had to attend to patient families through virtual means, and do so while working long hours. They often had to isolate from loved ones to protect them from possible illness.  And there was not reprieve in site.  One of our affiliates had asked community physicians to do hospital shifts to spell over-worked hospitalists.  I didn’t know what students would experience as they returned to the clinical setting. 

As I read, I noticed I had been holding my breath and my shoulders were tight with tension. But I didn’t need to be worried, after all.  I felt my throat catch and a surge of sad happiness, probably a release of pent up emotions related to this crazy pandemic.  The comments by students were amazingly positive.  Over and over students spoke about the excellent, high-quality teaching provided.  Students on hybrid rotations commented about the incredible learning experiences they received through virtual rounding and cases plus in-person scrubbing for surgeries. Particular patient care experiences were sometimes cited.  I know those hybrid rotations were crafted quickly and with great effort in order to provide optimal learning experiences despite the pandemic.  Some faculty took more students than usual yet still provided outstanding teaching and supervision.  They were taking on added duties even in this situation and I imagined that they would probably write quite a few letters of recommendation in the coming months, adding further to their time demands. 

There are just a few comments about faculty performance being negatively impacted by COVID-19.  Still, those comments are rare.  Our dean of clinical education took great care in working with sites to ensure that students would not work with patients suspected of having or diagnosed with COVID-19 and to ensure the safety of patients, students, staff, and faculty.  The COVID-19 admissions slowly declined; students are only able to be in the clinical setting because the numbers were coming down. Yet, in spite of this pandemic, our faculty is giving their all to students and patients.  Not only are faculty teaching during a pandemic, they are teaching well even in this different environment, providing meaningful experiences to learners while also accounting for safety. 

As I continue to review the report, I am aware of the halo/horn effect and wonder if students were so grateful to be back in the clinical setting that they are providing more positive comments about faculty that they might have  had there not been a pandemic-mandated pause in their clinical training.  I also wonder if faculty were just so grateful to have students back that they were nostalgically reminded of the joys and wonders of teaching and passing on our wisdom and passion for patient care to those coming after us – those who will probably be our doctors one day.  Whatever the reason, joyous teaching interactions leapt from the report with jubilant aplomb. 

The end of the report contains students comment about the teaching they received from residents.  The comments about resident teaching were just as positive and strong.  I admit that I shed a few tears when I read comments about our former graduates who are now residents in multiple clinical programs and sites teaching our students in such a challenging situation.

These comments weren’t just positive.  They detailed specific high-quality teaching moments.  I’m so grateful to bear witness to the interpersonal connections at play with each other: patients, students, staff, residents, faculty.  

These observations carried through to the personal statements of our fourth-year students applying to residency.  So many students were inspired by the physicians that cared for them or their loved ones in their formative years.  We are all interconnected.  It may sound very “airy fairy” or New Age, but I notice this connection again and again: physicians inspiring patients to become physicians-in-training, physicians and residents teaching students who will one day become physician educators themselves, patients receiving care but actually who are educators.  We are all connected and in this report I see this so clearly.

I’ve been thinking a lot lately about the interconnectivity of each person within society and on this planet.  It is so clear to me during this pandemic that we as a people are only as strong as the weakest link.  If just a few people are not wearing masks or are gathering together, the novel coronavirus will continue to spread.  But if we follow basic guidelines, we are strong together and our unity-in-action speaks to our interconnectedness.

Medical education and patient care are intricately woven together like a tapestry with every thread contributing its own texture and color to the pattern and strength to the structure. I am so honored and grateful to witness and be a part of the beauty on the report before me, because I know that the words written are just a glimpse of the overall experience students had at their sites with their preceptors, residents, and patients. 

Suzanne Minor, MD, FAAP, is the Assistant Dean for Faculty Development and an Associate Professor at the Florida International University Herbert Wertheim College of Medicine She is a member of the Editorial Board of Reflective MedEd. Follow her on Twitter @minor_se