key: cord-0927695-tx5osmw1
authors: Stark, Nicholas; Hayirli, Tuna; Bhanja, Aditi; Kerrissey, Michaela; Hardy, James; Peabody, Christopher R.
title: Unprecedented Training: Experience of Residents During the COVID-19 Pandemic
date: 2022-01-24
journal: Ann Emerg Med
DOI: 10.1016/j.annemergmed.2022.01.022
sha: b0d1308a41e0b7d324688eee8390f71c893ffc7e
doc_id: 927695
cord_uid: tx5osmw1

Introduction The COVID-19 pandemic significantly disrupted both the clinical training and personal lives of our next generation of Emergency Medicine leaders: resident physicians. The challenges and successes experienced by residents during the pandemic will likely shape the future of the field. Literature Review Over a year from the start of the pandemic, studies are exploring how COVID-19 affected trainees, particularly in four areas: clinical training, didactic education, board certification, and physical and psychological health. While posing significant challenges for residents, the pressures of the pandemic also spurred accelerated innovation in graduate medical education that will likely have positive impacts for future learners. Insight from the Field Our team explores how residents experienced the crisis through two critical components of well-being and career longevity: burnout and adaptation. While residents’ perceived burnout increased throughout the pandemic, many EM residents exhibited high levels of adaptation, which enabled them to continue honing their clinical skills and providing high quality care for patients. Looking Forward The COVID-19 pandemic forced the next generation of Emergency Medicine leaders to innovate, adapt, and act resourcefully. While they are certainly weary from the experience, residents demonstrated that the future leaders of the specialty – and the prospects of the field itself – are bright.

While we are beginning to understand the toll of the COVID-19 pandemic on healthcare workers, [1] [2] [3] [4] [5] less is known about the experience of our next generation of Emergency Medicine (EM) leadersresident physiciansduring this pivotal time. The COVID-19 pandemic significantly disrupted both the clinical training and the personal lives of resident physicians, pushing the bounds of their ability to adapt and spurring rapid innovation in medical education. The challenges and successes of residents during the pandemic may shape the future of Emergency Medicine and aid in encouraging adaptation and resilience for future leaders in the field. This article aims to further describe the COVID-19 pandemic's impact on EM resident physicians in two interrelated parts: first, by summarizing what is known to date through a broad literature review, and second, through an in-depth analysis of EM residents' experiences with burnout and adaptation at one residency program in the United States.

Over a year from the start of the pandemic, literature is increasingly exploring how COVID-19 affected trainees, particularly in four areas: clinical training, didactic education, board certification, and physical and psychological health ( Table 1) .

The COVID-19 pandemic profoundly affected residents' clinical training, though the gravity of these effects varied based on time and location. One major issue is related to many Emergency Departments (EDs) experiencing an overall decrease in patient volumes and variety of patient presentations throughout the pandemic. [6] [7] [8] [9] [10] In one study, the COVID-19 pandemic led to a decrease in the number of patients per hour (PPH) seen by residents (1.68 PPH at baseline to 1.33 PPH) during the first three months of the pandemic. 8 While there are no reported significant changes in severity of illness, lower patient volumes and decreased variety of patient presentations have subsequently reduced EM residents' case exposure in some instances. It is possible that decreases in case volumes and types may have several effects, such as delayed attainment of clinical competency as well as decreased clinical efficiency, although the existence or duration of these effects is currently unknown. [8] [9] [10] [11] A second key way in which COVID-19 affected clinical training is that efforts to protect residents from the virus resulted in fewer procedures and canceled clinical rotations. Early in the pandemic, while many institutions experienced critical personal protective equipment (PPE) shortages, resident participation and clinical exposure was limited to preserve PPE and decrease residents' risk of contracting the virus. 12, 13 For example, several training institutions adjusted their intubation teams to minimize viral exposure; this resulted in the most-experienced airway clinicianoften the attending physicianperforming intubations in place of trainees, limiting residents' clinical exposure to this critical procedure. 9, 14 Additionally, some off-service rotations were cancelled to augment ED staffing and/or further limit viral exposure and PPE use. [15] [16] [17] Considering these challenges, many training programs innovated outside of the clinical environment to augment clinical exposure to gap areas by using methods such as simulation, virtual reality, and mental imagery. [18] [19] [20] [21] One surgical program pursued a multi-modal hands-on strategy to prevent decay of procedural skills, which included a robust array of interventions such as at-home box trainers and virtual reality programs, homemade simulators, video games, and procedural videos. 21 Other programs added virtual rotations and created telehealth training to expand clinical scope and exposure. [22] [23] [24] Through such innovations, training programs added new value to their clinical education that may endure beyond the current pandemic.

Due to concerns about viral spread at in-person gatherings, the COVID-19 pandemic impacted resident didactic education, primarily via a transition from in-person to virtual didactics. Literature indicates that nearly every training program in the United States switched from inperson to virtual didactics at some point during the pandemic. [25] [26] [27] [28] [29] Virtual didactics take a variety of forms, including live sessions as well as recorded lectures designed for asynchronous viewing. Although transitioning to virtual sessions allowed for continuity of didactic education, virtual didactics may result in less overall engagement and also limit high-value in-person sessions such as simulation and procedure labs. [29] [30] [31] Despite these drawbacks, several studies uncovered positive impacts from the transition to virtual didactic education. Virtual education sessions allow for asynchronous learning via session recordings, which grants residents more control over their schedules and enables them to review sessions in the future. 27, 31 Additionally, virtual education eliminates geographic barriers, which expands opportunities for outside lecturersincluding nationally and globally-recognized expertsto join individual training programs for their didactic sessions. 26, 32 To help support engagement and interaction in the virtual format, training programs are employing a variety of strategies that boost interactive learning, such as small group breakout sessions and synchronous engagement tools like Slack, Poll Everywhere, and Kahoot. 32, 33 The changes to resident didactic education necessitated by the COVID-19 pandemic are also precipitating other innovations in education content and delivery. For example, while in-person simulation labs are typically central to resident didactic education, a variety of virtual options have surfaced, including tele-simulation delivered via online platforms that utilize standardized patients with faculty facilitators for simulations ranging from breaking bad news to leading resuscitations. 26 Many training programs are expanding their use of free open-access medical education (FOAM) resources for supplemental learning, utilizing a broader network to extend local resources. 33, 34 Ultimately, despite the challenges posed by the limitation of in-person didactic education, many programs created alternative education models that may remainat least in partafter the pandemic eases.

The ever-changing environment precipitated by the COVID-19 pandemic required dramatic adaptations in the board certification process. The American Board of Medical Specialties (ABMS), which houses certification boards such as the American Board of Emergency Medicine (ABEM), sought safe alternative methods to administer initial certification examinations for board eligible physicians. 35, 36 For many medical boards, including ABEM, this initially meant postponing the standard inperson board examinations, coupled with extending eligibility deadlines to accommodate the extraordinary circumstances caused by COVID-19. In many cases, this postponement was followed by flexible examination dates and pilot transitions to virtual oral board examinations. [36] [37] [38] [39] While most medical boards have yet to make definitive statements on future board examination formats, recent statements reaffirm commitments to maintaining high standards while also preserving the safety and well-being of candidates. [36] [37] [38] [39] [40] Physical & Psychological Effects Resident physicians, given their roles as both learners and clinicians, faced a unique combination of challenges posed by the COVID-19 pandemic. These challenges led to a range of physical and psychological effects that had far-reaching consequences on trainees.

Physically, many residents reported increased levels of exhaustion due to the rigors of residency coupled with long hours of wearing PPE. [41] [42] [43] Despite often desiring to self-isolate from partners and families to help reduce the risk of infectious spread after exposure to patients infected with COVID-19, many residents felt unable to do so in light of financial constraints or lack of accommodations. 42, 44 Residents also expressed concern for their physical health due to the risk of infection, especially in times of exponential infection spread and PPE shortages. 45 Psychologically, the COVID-19 pandemic led many resident physicians to experience increased levels of stress and depression. 46-51 A loss of control over many aspects of life and a decrease in coping mechanisms such as gym workouts and in-person gatherings made residents vulnerable to symptoms ranging from anxiety to exhaustion. This loss of control, coupled with minimal amounts of time available during residency training to reflect and decompress, led to increased anxiety for many trainees. [48] [49] [50] [51] [52] Many residents also experienced increased isolation: at work, due J o u r n a l P r e -p r o o f in large part to PPE limiting communication and the ability to connect with colleagues; at home, as a result of social distancing and shelter-in-place recommendations. 43 One study found that residents with regular exposure to COVID-positive patients experienced a higher prevalence of stress (29.4% vs 18.9%) than their peers who were not regularly exposed to patients with COVID-19 infection. 52 To support residents' physical and psychological well-being during the pandemic, institutions implemented a range of programs. Some of the most effective interventions included the construction of platforms to disseminate rapidly changing clinical information, improved access to psychological counseling services, increased mentorship opportunities, and augmented meal support. [53] [54] [55] [56] Many of these innovations may offer benefits beyond the pandemic and may further support trainees' physical and psychological health in the post-pandemic era.

Given the profound impact of the COVID-19 pandemic on everything from residents' education to their health, our team set out to further explore how residents have experienced the crisis through the lenses of burnout and adaptation. An investigation into these two critical components of well-being and career longevity sheds additional light on important factors shaping future healthcare leaders while they train during a chaotic and atypical time.

As part of a larger study on the effects of COVID-19 on teamwork in the ED, we studied two Emergency Departments affiliated with an academic medical center and EM residency program in California, USA, between June 2020 and January 2021. One training site is based at a large safety-net hospital and trauma center, while the other is located at a quaternary care center with a relatively smaller ED. Residents training at the EM residency program split their time between these two sites, and both hospitals experienced similar relative numbers of COVID patients during the study period.

We administered two waves of surveys to EM residents, as well as to others working in the Emergency Department. The surveys included validated questions to assess adaptation and burnout. Participants were recruited through a combination of email, flyers, and face-to-face communication. The total sample frame included 43 resident responses across two waves. We received 18 resident responses to the first survey (June-July 2020) for a response rate of 31.6%; 25 residents responded during second survey (Dec 2020-Jan 2021), yielding a 43.9% response rate. In addition to survey administration, our team also conducted interviews with 8 resident physicians from June to August 2020; interviewees were selected via convenience sampling and represented all training years. The 30 to 45-minute interviews were semi-structured and based on a guide which was developed through iterative discussions among the research team. The interviews were recorded on Zoom (Version 8) and subsequently transcribed verbatim. Prior to the administration of surveys and interviews, this study received IRB approval from the University of California, San Francisco and Harvard University.

Resident physicians reported low initial levels of burnout during the first survey period (June to July 2020), but these levels rose as the pandemic continued. During the initial wave of surveys, J o u r n a l P r e -p r o o f most residents reported that they felt "occasionally under stress, but not burned out" (Mean 2.22, St. Dev 0.43). However, when asked the same question during the second survey period six months later (December 2020 to January 2021), most residents felt that they were "definitely burning out and have one or more symptoms of burnout, such as physical or emotional exhaustion" (Mean 3.00, St. Dev 0.96) ( Table 2) . Interviews revealed that many resident physicians experienced an initial sense of purpose and missionbolstered by encouraging messages from friends, family, and broader societyand enjoyed more time to spend with individual patients due to reduced ED volumes, which gradually trended toward baseline as the pandemic wore on.

Our team also assessed perceived adaptation to the COVID-19 pandemic through a series of validated Likert-based survey questions (ranging from "strongly disagree" to "strongly agree") that included "we have invented new ways of providing care to adapt to this crisis," "the processes of caring for patients during this crisis have been improving every day," and "we regularly receive information that helps us track and improve care for COVID patients." Adaptation measures were relatively high among resident physicians, especially regarding innovation in healthcare delivery (Mean 4.22, St. Dev 0.54), which highlights the resilience and creativity that is central to Emergency Medicine ( Table 3 ). In addition to a sense of innovation, interviews revealed that residents also attributed other factors to their ability to adapt, such as self-driven learning and leadership on the parts of both co-residents and faculty. Common themes surrounding challenges to adaptation involved residents feeling overloaded with a constant influx of information, especially when rotating among several different clinical sites, as well as struggling with balancing their clinical training alongside risks to personal safety ( Table  4 ).

Our data reveals key insights about EM residents' levels of burnout and adaptation during the COVID-19 pandemic, which continue to change as the pandemic evolves. Worsening burnout among EM residents is of utmost concern, and based on interview themes, is likely due to a combination of factors ranging from societal influences to the prolonged duration of the pandemic. In addition, the stress caused by issues such as a lack of personal protective equipment (PPE), combined with social isolation and decreased access to typical coping mechanisms, likely affects the ability of residents to fully process their experiences in ways that help mitigate burnout.

Despite burnout challenges posed by the pandemic, many EM residents learned to adapt to their changing environment to continue honing their clinical skills and providing high quality care for patients. Adaptation, or the process of adjusting to different conditions, is a critical skill for resident physicians to learn and refine throughout training, and it is affected by factors ranging from cultural to psychological. 57, 58 High adaptation measures among EM residents highlights the resilience and determination of many residents to maximize their learning experiences despite challenging circumstances. For example, one junior resident highlighted that "for residents that rotate from site-to-site on a week-to-week basis, it was really hard to figure out, 'what am I supposed to be wearing at this hospital to stay safe?'". In response to this challenge of uncertainty and information overload, residents developed various workarounds; one noted a critical intervention was resident voice and leadership when their "chiefs worked so hard to streamline information", and another found empowerment when they "started listening to more EM:RAP" podcasts to stay up-to-date on the latest COVID-related information. Ultimately, maximizing the facilitatorsand minimizing the barriersto adaptation are especially important for EM resident physicians as they develop their clinical acumen and prepare to take on the healthcare challenges of tomorrow.

This study had several limitations. The study occurred at a single EM residency program in California, and as such, the generalizability of its results are limited. In addition, we obtained response rates of 31.6% (survey 1) and 43.9% (survey 2) and interviewed only eight resident physicians. Though the two-part survey component spanned multiple COVID-19 surges, the timing and intensity of the pandemic surges varies greatly across the U.S. and internationally, which may also limit generalizability. Future work is needed to further explore the long-term impacts of the COVID-19 pandemic on EM residents' burnout and adaptation.

EM resident physicians' training experience during the COVID-19 pandemic has been markedly different from prior years. By profoundly affecting their clinical training and personal lives, the pandemic posed challenges that pushed EM residents to their limits. The pressures of the pandemic also spurred accelerated innovation in graduate medical education that will likely have positive impacts for learners in the future. Further work to evaluate the longer-term impacts of the COVID-19 pandemic on resident physicians' education and well-being is crucial.

The COVID-19 pandemic forced the next generation of EM leaders to innovate, adapt, and act resourcefully. While they are certainly weary from the experience, EM residents also have the potential to emerge on the other side of this crisis with a transformed capacity for adaptation and resilience. Adjusting to constant change and thriving amid limited resources is the bedrock of Emergency Medicine. By embodying these principles during the most profound public health crisis of our time, EM resident physicians demonstrated that the future leaders of the specialtyand the prospects of the field itselfare bright. 

Balancing training and safety 'The PPE shortage was really rough in the beginning. There were times when R2's [second year residents] were not allowed in resuscitations, which was a huge change because our main job as R2's is resuscitation, but they wanted to be careful.'

Uncertainty 'Information was changing constantly, and it disrupted the confidence [I built] in how to care for patients.'

Information overload 'For residents that rotate from site-to-site on a week-to-week basis, it was really hard to figure out, "what am I supposed to be wearing at this hospital to stay safe?" Communication was a huge thing at that time, because everyone was getting 100 emails every two hours saying "this is the new thing, that is the new thing."'

Culture of resilience 'The ED is a place of incredible flexibility and resilience […and] those things allowed us to be successful…in the throes of everything.'

Resident voice and leadership 'Our chiefs worked so hard to streamline information for us.

[…] They definitely took on a huge burden by going to all these meetings, digesting, relaying to us., answering our questions. They were probably our biggest leaders during [COVID].'

Self-driven learning 'I started listening more to EM:RAP, this emergency medicine podcast. They did huge COVID related updates, like, "here's the latest updates; here's the randomized controlled trials."'

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