Residency Training During a Pandemic

As we welcome and orient the third class of family medicine residents during the COVID-19 pandemic, it has become apparent that the pandemic will have lasting effects on family medicine education. The last 2½ years have been challenging for the medical profession. Our practices have changed dramatically and we are teaching medical students and residents who have had vastly different educational experiences than ever before. A recent systematic review documents changes in clinical experiences and interrupted educational experiences as very real outcomes of the pandemic.1 Surgical specialties, seeing decreased case numbers and periods of no elective surgeries, were especially affected.1 A survey by the Accreditation Council for Graduate Medical Education found that residency programs around the country were affected by reduced ability to conduct in-person didactic learning and limited availability of outpatient experiences for residents.2 As most medical educators can attest, a Zoom lecture is not as effective as one conducted in person. Many family medicine residents were pulled into extra clinical service to take care of the large numbers of people admitted with COVID. Extra inpatient time has negatively affected outpatient patient numbers in many settings.

My conversations with residents over the last 2½ years have illustrated some major changes in their learning. One resident disclosed that she was worried that she had not learned to take care of a wide variety of patients in the ICU. During her 4-week rotation, every single bed in the ICU was filled by a patient suffering from respiratory failure due to COVID. She did not see any people with diabetic ketoacidosis or sepsis, for example. A third-year resident came to talk to me about a young patient with an upper respiratory infection (normally a common presentation in primary care) and told me that it was the first person he had seen in the outpatient setting with respiratory symptoms. Our health system had spent the first 18 months of the pandemic separating anyone with respiratory symptoms from the general population of family medicine patients. Thus, this resident was seeing his first person with a cough 6 months prior to graduation. Many of our incoming first-year residents have had limited clinical experience as most medical schools pulled students from clinical rotations during the pandemic. Therefore, the students begin residency unable to work at a resident level, which disrupts patient care. Some fellowships were similarly affected. One former resident who did a sports medicine fellowship actually did a second year of fellowship (normally a 1-year experience) since there were no sports happening for months during the beginning of their fellowship.3

The relationships between faculty and residents has also been affected. Unless I see residents outside of a clinic or hospital setting, I don’t know what they look like without a mask on. Socializing has been discouraged due to infection risks. One colleague in obstetrics said she didn’t know the obstetrics residents as well as she usually did because instead of spending time with them at the nurses station, she spent any down time in her call room, desperate to take off her N-95 mask. It is hard to know whether this change in collegial relationship between residents and faculty will have any effect on educational outcomes or long-term career choices.

Three papers in this issue of Family Medicine explore the experiences of residents and faculty during the pandemic. The paper by Staloff et al4 describes interviews with four family medicine residents at programs across the country. The interviews document several interesting themes including the impact that the residents had on caring for patients with COVID both inpatient and outpatient, the variety of clinical care situations that they worked in (including telehealth, vaccine clinics, and community outreach activities), and also the profound effect that the pandemic had on them personally. Burnout and compassion fatigue were two factors that contributed to the toll COVID took on these residents lives. Parascondo and colleagues examined burnout among residents during the beginning of the pandemic using qualitative interviews of six family medicine residents.5 This study found that peer support and enhanced communication helped protect against burnout during the pandemic. Finally, Grace et al conducted a Council of Academic Family Medicine Educational Research Alliance (CERA) survey of program directors evaluating wellness curricula during the pandemic and found that program directors did not think there was a change in wellness curricula during the COVID pandemic.6

Ultimately, it will be years before we fully understand the impact that the COVID-19 pandemic has had on medical student and residency training. Meanwhile, it is important that all family medicine educators maintain vigilance in assessing residents’ well-being and ensuring their breadth and depth of training experiences.