It was early April in New Orleans when the Tulane University Health Sciences Center reached its peak of COVID-19 patients. After treating their index case on March 9, hospital staff had quickly created COVID-only units to conserve personal protective equipment (PPE), but a month later, the entire hospital was essentially COVID-only.
To bolster the front lines, Jeffrey G. Wiese, MD, MACP, senior associate dean for graduate medical education, recruited residents from anesthesia, radiology, neurology, dermatology, and ophthalmology who had done their preliminary year with Tulane internal medicine. These volunteers began serving on the wards to support the medicine residents, allowing them to move up to the ICU, which had doubled in capacity. They also provided some intermittent rest time for the medicine residents, enabling sustainability of the effort. Psychiatry residents, unable to practice in their usual clinics, also moved to the ICU, serving as liaisons to patients' families to allow the ICU teams to focus on treatment.
The crisis did interfere with residents' didactics, but it also gave them an opportunity to prove themselves—one reminiscent of 2005, when Hurricane Katrina hit, said Dr. Wiese, who directed Tulane's internal medicine residency program for 20 years before stepping down in July 2019.
“I think about those residents that went through the Katrina years and just how much better of physicians in total they were at the time that they completed training,” he said. “I feel that that's going to be the same for the Tulane residents. I think the same will be said for all the residents nationally that have stepped up and shown that willingness to defer personal needs for the benefit of the patient . . . which, at its core, is the definition of professionalism.”
Dr. Wiese and clinician-educators across the country spoke about the various ways trainees have developed throughout the COVID-19 crisis, as well as how medical education has adapted to sudden changes necessitated by the pandemic.
Rethinking trainee competencies
Like everyone, residents and medical students have responded to the pandemic in various ways.
One survey asked 316 third- and fourth-year students, interns and residents in internal medicine and emergency medicine, and fellows in pulmonary and critical care at the University of Washington in Seattle to reflect on the unique ethical or practical challenges they'd experienced as a result of the pandemic. A sampling of the responses was published online in April by the New England Journal of Medicine.
Some worried about transmitting infection to others outside the hospital. Thanks to factors including shortages and rapidly changing recommendations regarding PPE, many felt vulnerable. As one internal medicine resident wrote, “It's a constant dialogue of ‘Am I safe? Is my patient safe? Is this care adequate? Am I doing all I can?’ All of this takes a serious toll on the psyche of trainees, and it's an impact that will likely be felt for a long time.”
Everyone in medical education, including faculty, is living in a world full of volatility, uncertainty, complexity, and ambiguity, said Mukta Panda, MD, MACP, professor of medicine and medical education at the University of Tennessee College of Medicine Chattanooga. Therefore, while the knowledge of students and trainees is still defined by competencies, educators must assess them on an individual basis, she said.
“Some of the learners have not been involved because of either lack of PPE or the place where they work, and some of the learners have been passed over into the front lines, so we are looking at learners with different stages,” said Dr. Panda. “It cannot be a one-size-fits-all.”
Educators can also think about competencies that might be newly or more intensely needed, she said. “We need to definitely give them the science. That is important to be a physician or to be a health care professional,” Dr. Panda said. “But we also need to give them skills,” from fundamentals like telemedicine to other new focuses like advocacy. (See sidebar for resources on teaching telemedicine and other skills.)
The most important competency right now, she said, is self-care and colleague care. “This pandemic situation that we are going through now has shown us very explicitly that being in this vocation has asked us to adapt, to improvise, and to overcome,” said Dr. Panda, who is also assistant dean for well-being and medical student education. “That becomes our resilience and allows us to recover, recharge, and rise above our challenges. This has to be incorporated right from the beginning.”
It's important to remember that not every resident has had the same level of exposure to coping skills, said Charlene M. Dewey, MD, MEd, MACP, professor of medicine and medical education and administration and chair of the faculty wellness committee at Vanderbilt University School of Medicine in Nashville. Although new physicians usually start to develop these skills during residency, it may take a while, she said.
“As an older physician, my first thing is, you rush to the problem. But there were some younger physicians that were fearful and thought, ‘I don't want to die,’ and they're going to run from that problem. So, is that bad? Is that wrong? Fear, as an emotion, is neither bad nor wrong,” Dr. Dewey said. “They're young, and they haven't had the time to fully develop their identity as a physician. It is up to us [faculty and older physicians] to help residents manage that fear and build resilience and shape identity.”
In the survey, some residents reported feeling excited or lucky to help, even though they were afraid. While faculty primarily cared for patients with COVID-19 at the University of California, San Francisco (UCSF), Parnassus campus, residents were involved in ICU care of patients with the novel coronavirus and were also allowed to admit overnight, said Bradley Monash, MD, associate chief of the division of hospital medicine and site director of the UCSF medicine residency.
“The residents really were an active voice and were requesting to be involved and did not want to be sidelined,” he said.
On this point, some students who responded to the survey said they felt underutilized due to being removed from their clinical rotations. With less opportunity for patient care during the pandemic and internship looming, it's “not an ideal time to be rusty,” said one concerned fourth-year student.
While working on an article about educational policies early on in the pandemic, Mel L. Anderson, MD, MACP, and coauthors reached out to medical schools. In a perspective published by the Journal of Hospital Medicine in April, they reported that students' face-to-face interactions with patients had temporarily been put on hold.
“That was not required by the [Association of American Medical Colleges], but they issued guidance saying they were supportive of schools making that decision,” said Dr. Anderson, who is the national program director for hospital medicine for the Veterans Health Administration.
In contrast, some schools in hard-hit areas, such as New York University, graduated some fourth-year medical students two months early to address potential workforce shortages. This is a practice common in some other countries, such as New Zealand, where final-year medical students work as “junior” interns, Dawn E. DeWitt, MD, MSc, MACP, wrote in a perspective advocating for the practice, which was published online in April by Annals of Internal Medicine.
“My reason for writing that was hearing how bereft our students were to be pulled out of clinical education. . . . Students were being sent home for safety when they should have been gearing up for residency, but they wanted to be doing something meaningful,” said Dr. DeWitt, who directs the inaugural fourth-year class of medical students at Elson S. Floyd College of Medicine at Washington State University in Spokane.
Much of the value of fourth year is in professional identity formation, and if medical schools have done due diligence assessing students, early graduation shouldn't pose a problem, said Benjamin Kinnear, MD, MEd, FACP, associate program director for the internal medicine-pediatrics residency and associate program director for the internal medicine residency's Medical Education Pathway at the University of Cincinnati in Ohio.
For the hospitalists who may find themselves working alongside these newly minted interns, he wrote a perspective on developing trust, which was published online in May by the Journal of Hospital Medicine.
He addressed the concept of “entrustment,” or how attendings balance supervision and autonomy for students and residents. This balance can be informed by assessment tools, he said. “The problem with that is . . . there's a lot of things beyond how well the resident or student is performing that affect how much we trust someone,” from the person's apparent confidence to their training background.
Hospitalist attendings should reflect on the variables that can affect their trust, he said. “We don't often think in our head, ‘This person is confident and I will therefore trust them more.’ It just kind of happens without us knowing,” Dr. Kinnear said, adding that especially during a pandemic, trust should be based on direct observation rather than more biased criteria.
The new didactics
As of June, many medical students had returned to the wards across the country. While safety was still a concern, Dr. Anderson said it was necessary for schools to re-engage their trainees.
“You can only do so much outside of direct patient contact. It's real patients that are the source of so much of our trainees' learning,” he said. “The task is, how do we do that in a way that maintains patient safety, maintains learner safety, and leverages the opportunities that are there [while] communicating transparently?”
As the crisis ramped up in New Orleans, Tulane established a comprehensive plan for residents, Dr. Wiese said. “It was very much like Katrina. Point No. 1 was assuring the base of Maslow's hierarchy of human needs: We weren't going to do furloughs, everybody was going to keep their job, all of the benefits were going to continue, etc.,” he said.
The plan also addressed the personal factors that could prevent someone who wanted to help from contributing, such as the need for child care. Because a large percentage of residents had kids in schools that were now closed, the university figured out how to give them supplemental pay for child care, Dr. Wiese said, adding that medical students also stepped up to care for kids of residents, faculty, and nurses.
When it came to didactics, the plan was to continue with video conferencing through the summer and likely into the fall before moving to in-person, physically distanced conferences of no more than 10 people. “Early on, we told the program directors, ‘Didactics have to continue; they're just going to have to continue in a different way,’” said Dr. Wiese. “For us, that meant Zoom. I think that's probably the case for all the programs nationally.” (See related story for tips on teaching through video.)
The residents likely missed some knowledge and skills they would have gained during usual in-person didactics, he said. “There was some recognition that during this time, we were going to learn different things. I don't have any qualms with that.”
But by putting aside their own personal needs in favor of patient care needs, the residents gained valuable skills in professionalism, Dr. Wiese said. “They were learning different attitudes. They were learning about themselves, discovering just what they were capable of doing,” he said. “I think all the credit really goes to the residents on this front. They stepped up like we knew they would. Months of deferring personal needs for the benefit of the patient had prepared them. They had been well trained.”
Even though Cincinnati wasn't hit nearly as hard as New Orleans, teaching at the bedside has changed dramatically, said Dr. Kinnear, a med-peds hospitalist at Cincinnati Children's Hospital Medical Center and University of Cincinnati Medical Center. Both hospitals typically had a patient-centered style of rounding where large teams of residents and students have a discussion with the patient in the room, during which the teaching often happens, he said.
Rounds changed during the pandemic “We've had to do more teaching outside of the room, more teaching away from the wards to try to limit exposure, so it's changed how education happens on the wards,” said Dr. Kinnear. As for educational conferences, “We obviously can't have 50 residents and students packed into a conference room, so everything has gone virtual,” he said.
Chief medical resident ACP Member Yevgeny Novikov, MD, built a distance-learning series of virtual modules that include both homegrown content and content curated from the Web, hosted on The Silver Fridge, the residency program's website.
Dr. Novikov, who is now a hospitalist at the University of Rochester in New York, started the website at the beginning of his third year of residency as a place for review articles, PowerPoint presentations, and other materials. “It was mostly just a reference site,” he said. “I think when COVID hit, that's when we started using it more as an educational site.”
It helped that over the prior two years, the residents had gotten used to the website, Dr. Novikov said. “I've noticed it takes about a generation of a residency to get a new idea started. So the first- and second-years were very involved in the education; the third-years, not so much,” he said.
At the beginning, the site mostly curated resources so that the residents could find vetted information that was worth their time, Dr. Novikov said. “And then, over the course of a few weeks, we formalized a curriculum” of four different components each week.
The residency program simply didn't have the time to create all original content for distance learning, said Dr. Kinnear. “You become a curator rather than a creator,” using extant resources—podcasts like the Curbsiders Internal Medicine Podcast and the Clinical Problem Solvers and videos like Louisville Lectures, he said.
For ACP Member Laura Bishop, MD, a med-peds hospitalist at the University of Louisville and executive director of Louisville Lectures, the pandemic has only sped up incorporation of recorded videos and online materials. “We're really growing a new breed of doctor that learns in a very different way than some of us did, in terms of actually going and sitting in lectures,” she said.
At her institution and others, the pandemic caused residency curriculums to suffer from not only the shift to virtual education but also the faculty's need to focus on COVID-19 preparations. “I've heard directly from residency program directors both locally and nationally that have been able to go to the Louisville Lectures recordings . . . to quickly fill the gaps in the didactic calendar and schedule,” said Dr. Bishop, who is also associate program director of the med-peds residency.
While the site's views typically decrease in the second half of the academic year, this year has been different, she said. “From January to June 1, we had double the YouTube views that we did in 2019. We're approaching half a million for this year so far,” said Dr. Bishop. “When I look at them, they're the lectures you would expect: lots of pulmonary and critical care, cardiac ICU, and then some of the Little Lectures that I did on COVID, and we had an infectious disease doctor give a grand rounds on COVID.”
Because clinical demands on medical educators are only growing and there is more and more to teach every year, the increased popularity of such resources is likely here to stay, she said. In addition, online materials allow learners to review topics they may have missed using information from anywhere in the world, and they can be updated as needed, said Dr. Bishop.
“My hope is that people who may have in the past thought that it was a flash in the pan or maybe it wasn't the way that they did medicine will hopefully see the benefit of it,” she said.
Ultimately, the proliferation of online resources over the past decade has helped prepare medical education for this sudden transition to virtual learning, said Dr. Kinnear. “I think a lot of programs are trying to take advantage of that,” he said. “It'll be interesting to see what happens when things go back to normal, if they do.”