It could be argued that hospital medicine in the United States was made vital by a major infectious disease epidemic – the HIV/AIDS crisis – said Emily Gottenborg, MD, a hospitalist and program director of hospitalist training at the University of Colorado at Denver, Aurora. Certainly, it was born out of the need for change, for physicians who could coordinate complex patient care plans and serve as the “quarterbacks” of the hospital. “As a result, we have always been very nimble and ready to embrace change,” said Dr. Gottenborg.
That hospitalist-honed agility and penchant for innovation has proven to be invaluable during the current COVID-19 pandemic as hospital medicine–focused residency programs have been forced to pivot quickly and modify their agendas. From managing the pandemic’s impact on residents’ day-to-day experiences, to carefully balancing educational needs and goals, program leaders have worked tirelessly to ensure that residents continue to receive excellent training.
The overarching theme across U.S.-based residency programs is that the educational changes and challenges during the COVID-19 pandemic have often been one and the same.
Service versus education
At the beginning of the pandemic, trainees at the University of Pittsburgh Medical Center were limited in seeing COVID patients in order to curb exposure. But now that COVID appears to be the new normal, “I think the question becomes: ‘How do we incorporate our trainees to take care of COVID patients since it seems it will be staying around for a while?’ ” said Rachna Rawal, MD, a hospitalist and clinical assistant professor of medicine at UPMC.
This dilemma highlights the conflict between service and education. Residents have been motivated and eager to help, which has been beneficial whenever there is a surge. “At the same time, you want to preserve their education, and it’s a very difficult balance at times,” said Dr. Rawal. It’s also challenging to figure out the safest way for residents to see patients, as well as how to include medical students, since interns and residents serve as important educational resources for them.
Keeping trainees involved with daily virtual conferences rather than in-person interactions raises the question of whether or not the engagement is equivalent. “It’s harder to keep them accountable when they’re not in person, but it’s also not worth the risk given the COVID numbers at times,” Dr. Rawal said. The goal has become to make sure residents stay safe while still feeling that they are getting a good education.
A balancing act
“I think early on, there was a lot of pride in what we were doing, that we were on the front line managing this thing that was emerging,” said Daniel Ricotta, MD, a hospitalist and associate program director of the internal medicine residency at Beth Israel Deaconess Medical Center and assistant professor of medicine at Harvard Medical School, both in Boston. “And now I think people are starting to feel a little bit weary.”
It has been demanding trying to manage ongoing educational needs through this time. “At the end of the day, residents are still trainees and have to be trained and educated. They’re not just worker bees taking care of patients,” Dr. Ricotta said. Residents need a well-rounded clinical experience – “they can’t just take care of COVID patients and then be able to graduate as general internists,” he said – but that becomes onerous when the hospital is full of patients with COVID.
Along with balancing residents’ clinical immersion, Dr. Ricotta said there has been the challenge of doing “the content-based teaching from didactics that occur in the context of clinical work, but are somewhat separated when you need to limit the number of people in the rooms and try to keep as many people at home as possible when they’re not taking care of patients in order to limit their level of risk.” Adjusting and readjusting both of these aspects has had a major impact on residents’ day-to-day education.
“A big part of residency is community,” noted Dr. Ricotta, but the sense of community has been disrupted because some of the bonding experiences residents used to do outside the hospital to build that community have necessarily gone by the wayside. This particularly affects interns from around the country who are meeting each other for the first time. “We actually had a normal intern orientation this year, but last year, when everything was virtual, we were trying to find ways to bridge relationships in a way that was safe and socially distanced,” he said.
UC Denver is unique in that they have a 3-year program specifically for hospital medicine residents, said Dr. Gottenborg. Right away, “our residents rose to the challenge and wanted to be part of the workforce that helps care for this critical population of [COVID] patients.” The residents were able to run the ICUs and take care of COVID patients, but in exchange, they had to give up some of their elective rotation time.
One aspect of the UC Denver hospital medicine residency program is participation in projects that focus on how to improve the health care system. Over the past year, the residents worked on one project in particular that focused on restructuring the guidelines for consulting physical therapists. Since many patients end up needing a physical therapist for a variety of reasons, a full hospital puts increased strain on their workload, making their time more precious.
“[The project] forced us to think about the right criteria to consult them,” explained Dr. Gottenborg. “We cut down essentially all the inappropriate consults to PT, opening their time. That project was driven by how the residents were experiencing the pandemic in the hospital.”
Learning to adapt
“The training environment during this pandemic has been tumultuous for both our residents and medical students,” said Alan M. Hall, MD, associate professor of internal medicine and pediatrics and assistant dean of curriculum integration at the University of Kentucky, Lexington. Along with treating patients with COVID-19, he said trainees have also had to cope with anxiety about getting the virus themselves or inadvertently bringing it home to their families.
Like most medical schools, University of Kentucky students were shifted away from clinical rotations and into alternative and online education for a time. When they returned to in-person education, the students were initially restricted from seeing patients with confirmed or suspected COVID-19 in order to reduce their personal risk and to conserve personal protective equipment.
This especially impacted certain rotations, such as pediatrics. Because respiratory symptoms are common in this population, students were greatly limited in the number of new patients they could see. Now they are given the option to see patients with COVID-19 if they want to.
“Our residents have had to adapt to seemingly endless changes during this pandemic,” Dr. Hall said. For example, at the beginning of the surge, the internal medicine residents trained for a completely new clinical model, though this ultimately never needed to be implemented. Then they had to adjust to extremely high census numbers that continue to have an effect on almost all of their rotations.
Conversely, the pediatrics residents saw far fewer inpatients last winter than they typically would. This made it more difficult for them to feel comfortable when census numbers increased with common diagnoses like bronchiolitis. “However, those respiratory viruses that were hibernating last winter caused an unusual and challenging summer surge,” Dr. Hall said.
The biggest challenge though “is knowing that there is not a perfect solution for this global pandemic’s effect on medical education,” said Dr. Hall. “We can’t possibly perfectly balance the safety of our learners and their families with the dangers of COVID-19.”
As a residency program leader, Dr. Ricotta said there are conversations about multiple topics, including maintaining a safe learning environment; providing important aspects of residency training; whether to go back to full in-person teaching, keep doing virtual teaching, or implement a hybrid model; and how to help residents understand the balance between their personal and professional lives, especially in terms of safety.
“They have to their lives outside of the hospital, but we also are trying to instill ... what their responsibility is to society, to their patients, and to each other,” said Dr. Ricotta.
A more recent discussion has been about how to manage the COVID vaccine boosters. “We can’t have everyone getting vaccines at the same time because they might have symptoms afterward, and then be out sick – you’re missing half your workforce,” Dr. Ricotta said. But staggering residents’ booster shots created yet another dilemma around deciding who received the booster sooner rather than later.
The biggest consideration for Dr. Gottenborg’s leadership team was deciding whether to use their residents to help with the COVID surges or keep them in a traditional residency experience. While the residents wanted to be part of the pandemic response, there were many factors to consider. Ultimately, they came up with a balance between the amount of time residents should spend taking care of COVID patients while also assuring that they leave the program with all the skills and experiences they need.
Though Dr. Hall works more closely with medical students than residents, he sees the challenges and effects as being similar. Creating harmony between a safe learning environment and students’ educational goals has been the topic of endless discussions. This includes decisions as to whether or not students should be involved in person in certain activities such as large classroom didactics, written exams, seeing patients in clinical settings, and small group discussions.