key: cord-0720904-66fi453d authors: Bansal, Nisha; Hall, Yoshio N.; Sambandam, Kamalanathan K.; Leonberg-Yoo, Amanda K. title: Lessons Learned: Nephrology Training Program Adaptation in the Time of COVID date: 2021-04-19 journal: Am J Kidney Dis DOI: 10.1053/j.ajkd.2021.03.012 sha: 03fb0fe13ce58b0f25cf41022d26ad70ac5d9476 doc_id: 720904 cord_uid: 66fi453d nan The COVID-19 (COrona VIrus Disease 2019) pandemic has prompted rapid changes to medical education. Across the U.S., graduate medical education programs have had to navigate abrupt declines in outpatient medical care, marked fluctuations in inpatient volume and acuity, and a rapid shift to online education. 1 Through our shared experiences across nephrology fellowship programs in three different U.S. regions, we identified three domains in which we faced the greatest challenges: changes in care delivery models, curricular adaptation, and fellow wellbeing. Here, we outline the specific challenges in these areas and highlight opportunities for innovation in nephrology fellowship training, stimulated by the COVID-19 disruption (Box 1). Telemedicine During the COVID-19 pandemic, outpatient nephrology practices rapidly pivoted to alternative care delivery models, with an emphasis on telemedicine. The Center for Medicare and Medicaid Services expanded telemedicine coverage on March 6, 2020 to include inpatient and outpatient consultation and in-center hemodialysis. 2 While isolated telemedicine programs existed pre-COVID for rural and transplant care, the rapid adoption of telemedicine left many nephrology training programs scrambling to simultaneously provide care and train fellows (and faculty) in the practice of remote medicine. 3, 4 The unexpected shift to telemedicine disrupted the traditional ambulatory teaching models which relied heavily on interaction with patients and preceptors in clinics and dialysis units. Moreover, trainees lost valuable training opportunities which require in-person contact (e.g., serial assessments of the maturing hemodialysis access, participation in home dialysis training and quality improvement initiatives), and interaction with nephrology's multi-disciplinary care teams of nurses, technicians, pharmacists, social workers, and dieticians. Finally, there were challenges in assessing fellow performance, since traditional J o u r n a l P r e -p r o o f models relied on direct observation and feedback from faculty as well as other members of the care team. 5 Despite these challenges, telemedicine enhanced several key elements of fellowship training in the understanding, coordination and delivery of nephrology care. It encouraged collaborative care by allowing multiple providers including home healthcare workers to join the visit. Telemedicine also facilitated outreach to rural constituents who may not have previously accessed nephrology care due to geographical barriers. Importantly, it also highlighted disparities in technology access, the home environment, family structures and other critical health determinants which often go unnoticed in a clinic visit. 6 Due to the disproportionate impact on acute and maintenance dialysis care, the COVID-19 pandemic exposed nephrology fellows to several novel learning opportunities. 7 For example, the critical importance of infection control in dialysis units was highlighted early in the pandemic, after the first reported death from COVID-19 in the U.S. occurred in a patient receiving in-center hemodialysis in Washington state. 8 Our fellows received early education in infection-control policies and witnessed their evolution, implementation, and shortfalls within and outside of the dialysis unit. Moreover, in areas that experienced critical shortages in intensive care, nephrology fellows often faced the need to ration renal replacement therapy. Some received training in acute peritoneal dialysis in order to manage the surge of patients with COVID-19 related acute kidney injury. Others witnessed and participated in developing multidisciplinary protocols for providing renal replacement therapy with infectious disease specialists, pharmacists, surgeons, intensivists, and bioethicists, among others. (Box 1). These unique training experiences arising in the context of the COVID-19 pandemic could substantially change nephrology training and practice (Box 1). The effective use of telemedicine in outpatient clinical settings and dialysis settings should now be part of the core education of fellows. Programs should develop new tools to assess fellow progression in this realm towards readiness for unsupervised practice. 9 Telemedicine training should also teach fellows to better identify, prioritize, and utilize resources to assist vulnerable patients with broad social needs, including those who lack access to technology, suffer from food insecurity, or face housing instability. In so doing, fellows may gain important insights into the social determinants of health that disproportionately sustain racial-ethnic and socioeconomic disparities in chronic kidney disease. 10 Finally, we hope these new multi-disciplinary experiences will lead to hybrid electives (e.g., pharmacology and nutrition), additional fellowships (e.g. nephrology-infectious disease, nephrology-critical care, nephrology-palliative care) and increased opportunities for cross-disciplinary scholarship. The COVID-19 pandemic disrupted traditional models of in-person instruction in nephrology and replaced them with virtual conferencing. With this shift from interactive, inperson sessions to on-line learning, we faced the common challenge of how best to promote and sustain learner engagement. We attempted to address this challenge by first optimizing technologic elements (e.g., bandwidth, cameras, microphones) and ensuring that participants were familiar with functions to facilitate interaction (e.g., polling, chat, breakout rooms, screen share, virtual whiteboard). We found that having a faculty facilitator for each session helped to support the presenter and to minimize the impact of technologic disruptions and other J o u r n a l P r e -p r o o f distractions. Furthermore, to reduce potential screen fatigue, we reduced the duration of each presentation and leveraged "pre-assignments" such as review of a key article, framework, quiz or "board-style" questions prior to conference. Needless to say, our programs worked hard to cultivate an expectation of participation and a safe space for questions and interaction. We also discovered several learning resources which functioned extraordinarily well in the virtual format. For example, fellows can now "meet" with a renal pathologist using a virtual platform to view biopsy slides in real-time. An alternative approach leverages several highquality online case files in renal pathology to provide tools for continued learning, either in a group setting or individually. There are a multitude of additional online resources (see Table S1 ) that can be integrated into a program's curriculum including nephrology blogs, online prerecorded lectures, question banks, and other novel learning tools. The COVID-19 pandemic should inspire nephrology programs to rethink traditional approaches to nephrology education and promote further curricular development (See Box 1). We hope to see programs evolve a more multi-dimensional approach to fellow didactic learning, instead of relying solely on self-directed reading and passive lectures. We suggest that the community leans into virtual conferencing as a tool that will facilitate cross-institutional exchanges of ideas and education through more guest lecturers. 11 Accompanying each of these innovations in curriculum development are research opportunities to study their effects. Although not unique to nephrology training programs, the COVID-19 pandemic highlighted threats to physician trainee wellbeing. A major challenge to our programs centered on the need for nephrology to contribute to COVID-related surge coverage in other areas of J o u r n a l P r e -p r o o f medicine while balancing the increased demands of our own inpatient consultative services. 12, 13 Trainees caring for patients with COVID-19 reported higher stress and increased burnout. 14 In order to mitigate workforce exposure and quarantine disruptions, our training programs shortened inpatient rotations. We also leveraged virtual technology to host regular meetings and Town Halls between leadership and trainees on all levels to foster community, both within nephrology and the broader institution. Moreover, added attention to fellow wellbeing served to stimulate initiatives to address determinants of burnout unrelated to the COVID pandemic. Several institutions enabled online access to wellness and mental health resources specific to healthcare workers. The most comprehensive program offered individual support, group sessions, and self-directed resources. The COVID-19 pandemic has forced a checkpoint for fellow wellbeing, and has provided opportunities to prioritize interventions to address burnout within our field. 15, 16 The pandemic has incentivized many programs to develop more tools to assess and monitor fellow wellness. These initiatives align with the ACGME requirements for the inclusion of wellbeing initiatives in the learning and workforce environment. 17 Data collection on the impact of these tools should be prioritized. The COVID-19 pandemic has undoubtedly disrupted traditional models for nephrology fellowship training. While the acute phase of the pandemic resulted in marked changes in care delivery, curriculum development, and fellow wellbeing, we should leverage this opportunity to re-evaluate and evolve nephrology training. We encourage additional collaboration among fellowship training programs nationwide to promote discussions around educational innovation. Can Covid Catalyze an Educational Transformation? Competency-Based Advancement in a Crisis Centers for Medicare & Medicaide Services, ed. Quality, Safety & Oversight Group -Emergency Preparedness2020 Protocol: Improving Access to Specialist Nephrology Care Among Rural/Remote Dwellers of Alberta: The Role of Electronic Consultation in Improving Care for Patients With Chronic Kidney Disease Telehealth model of care for routine follow up of renal transplant recipients in a tertiary centre: A case study How clinical supervisors develop trust in their trainees: a qualitative study Telehealth for Home Dialysis in COVID-19 and Beyond: A Perspective From the American Society of Nephrology COVID-19 Home Dialysis Subcommittee The COVID-19 pandemic: consequences for nephrology On the Frontline of the COVID-19 Outbreak: Keeping Patients on Long-Term Dialysis Safe Building Telemedicine Capacity for Trainees During the Novel Coronavirus Outbreak: a Case Study and Lessons Learned Patient Characteristics Associated With Telemedicine Access for Primary and Specialty Ambulatory Care During the COVID-19 Pandemic The Inevitable Reimagining of Medical Education Characteristics and Outcomes of 21 Critically Ill Patients With COVID-19 in Washington State Acute kidney injury in patients hospitalized with COVID-19 Exposure to COVID-19 patients increases physician trainee stress and burnout Burnout and Emotional Well-Being among Nephrology Fellows: A National Online Survey Addressing Physician Burnout: Nephrologists, How Safe Are We? Accreditation Council for Graduate Medical Education. The Program Directors' Guide to the Acknowledgements: We would like to acknowledge the commitment to patient care, education, and support for each other that has been exhibited by nephrology fellows across the country during this unprecedented time.Peer Review: Received July 31, 2020 in response to an invitation from the journal.