Many hospitalists remember what their work was like during the COVID-19 pandemic, especially during its initial days and before a COVID-19 vaccine was available.
Work habits and patient volumes weren’t the only things that changed. Clinical training for medical students and residents also saw major changes. Some of those changes were scrapped post-pandemic, while others continue to be a part of today’s clinical training and influence how training may take place during future pandemics.
Dr. Rawal
“It had a pretty drastic impact, more than we had anticipated,” said Rachna Rawal, MD, assistant professor with the Feinberg School of Medicine at Northwestern University in Chicago, who was working at the University of Pittsburgh Medical Center (UPMC) during the pandemic’s earlier years. “That was partially because no one knew how it would impact training, and everyone wanted to protect the trainees.”
Hospitals tried different plans to keep trainees safe from infection while also trying to expose them to as much hands-on training as possible. At UPMC, Dr. Rawal said trainees were mostly shielded from COVID-19 patients to protect them from the infection, or they would see COVID-19 patients only in a smaller group.
That had some unintended effects, however.
“It made rounding more disjointed and impacted the team dynamic. That said, there was more focus on bread-and-butter medicine for them,” she said.
Dr. Kuchera
Because of smaller bedside rounds, constant masking, and infection-control precautions, it was harder to communicate effectively with patients and with each other, which ultimately negatively affected team camaraderie, said Timothy Kuchera, MD, clinical assistant professor of medicine and associate program director for internal medicine residency education at Thomas Jefferson University (TJU) in Philadelphia.
“Schedules changed rapidly, institutional restrictions affected travel and daily life, and many of the end-of-year milestones that are usually a source of joy and closure, such as graduation and related celebrations, were significantly altered or lost. Those changes were emotionally hard for residents, and they shaped how trainees experienced that phase of training,” Dr. Kuchera said.
At that time, Dr. Kuchera was initially a chief medical resident and eventually transitioned into hospital medicine as an attending within the Jefferson system.
Dr. Vick
On the administrative side, the back-up call “jeopardy” system at the University of Kentucky became complex because of the long quarantine periods for residents with COVID-19 infections, said Sarah E. Vick, MD, FACP, SFHM, associate professor and associate program director of the internal medicine residency program at the University of Kentucky in Lexington.
Leadership there discussed safe patient care and called in replacements when staffing fell below those minimum standards. Ultimately, they had to increase the number of people on backup coverage, Dr. Vick said.
Dr. del Pino Jones
At the University of Colorado School of Medicine in Aurora, clinical rotations were paused or reduced to conserve personal protective equipment and reduce virus spread. Although students were temporarily removed from direct patient-care experiences, residents and fellows remained at the bedside. Students and trainees participated in virtual patient care, including telehealth and virtual rounding. “They were instrumental in supporting our communities in other ways, including developing and providing educational materials, volunteering, and soliciting protective equipment donations,” said Amira del Pino-Jones, MD, associate dean for health opportunities and professional engagement, and associate professor in the division of hospital medicine at the University of Colorado in Aurora, Colo.
Of course, virtual training also became a mainstay during the pandemic.
Dr. Theodorou
For instance, “in-person didactics such as morning report transitioned to Zoom, which allowed for sustained resident attendance but reduced the in-person camaraderie that conference typically fosters,” said Maria Theodorou, MD, FACP, FHM, associate program director for the internal medicine residency program, and assistant professor in the division of hospital medicine at Feinberg School of Medicine at Northwestern University in Chicago.
Ultimately, that led to a higher rate of burnout and an increased need for accessible mental health resources. On the plus side, leaders were able to integrate telemedicine, which had not previously been used, into training experiences for the ambulatory rotation.
Lessons Learned
With the COVID-19 pandemic years behind them, many hospitalists are now considering how the events of the pandemic may impact future pandemics. Here are some of the lessons these clinicians learned and are adding to their training toolkits.
Switching to virtual platforms more easily.
Although virtual learning has its downsides, it could be needed in certain situations, Dr. Kuchera said. “During the initial pandemic response, that transition was rocky but ultimately succeeded. Now we have a much stronger foundation for virtual learning, including broader institutional resources across the university enterprise. We have built in flexibility so that if another pandemic scenario arises, we can transition more seamlessly,” he said. He added that a hybrid model that combines in-person and virtual sessions can make remote participation in medical education easier to follow.
Maintaining virtual possibilities for activities like career planning and resident counseling.
Dr. Zavodnick
While Jillian Zavodnick, MD, associate professor of medicine, medicine clerkship director, and associate program director for internal medicine at Thomas Jefferson University, loves in-person advising meetings, she said it’s obvious that virtual meetings allow students to schedule with much less disruption to their rotations.
Finding a better balance of hands-off and hands-on learning.
Dr. Rawal’s institution was cautious about limiting residents’ exposure to COVID-19 during the pandemic, but she said that came with some learning drawbacks. If another pandemic occurs, she believes that hospital leaders wouldn’t be opposed to a more hands-on approach while maintaining caution about spreading any infection. “Also, maybe we wouldn’t exclude the younger trainees as much. Hopefully, there’s a safer way we can make things happen,” she said.
Being ready to pivot to a different way of training and provide more protection.
Dr. del Pino-Jones said her hospital now essentially has a “playbook” on how to make remote learning as educational and interactive as possible. Educators who taught during the pandemic and who are still there have adapted their curricula so they can be provided both in person and virtually. Her hospital system also uses protective equipment responsibly to help build up the supplies that may be needed for continued patient care and education during pandemics.
Keeping resident wellness in the forefront.
Future pandemics will require hospitals to maintain workplace flexibility while also prioritizing the wellness, education, and clinical experience of resident physicians, Dr. Kuchera said. “Residents are in a unique position as both learners and essential contributors to patient care, and preparedness planning should be mindful of both realities,” he said. Once restrictions were lifted during the COVID-19 pandemic, the University of Kentucky prioritized opportunities for residents to spend time together both inside and outside the hospital to foster connection—another important component of resident wellness, Dr. Vick said.
Looking at scheduling differently.
To shrink the size of medical teams during the pandemic, Dr. Zavodnick said her hospital began to introduce a night experience for sub-interns. The motivation was to have fewer people assigned to any given team; it’s an experience that continues now in a modified form. Dr. Theodorou’s hospital had the same results by testing different rotation lengths. “We learned that shorter rotation lengths did not have an adverse impact on learning or patient care, as we had previously feared they might,” she said.
Encouraging trainees to stay home when they’re sick.
“Prior to COVID-19, it was very common and almost a point of pride for many to come to work sick and push through illness,” Dr. Zavodnick said. “During the early days of COVID-19, there had to be an intentional culture shift framed not as self-care but as patient care—you can’t come to work if you’re sick because you might infect others and your co-residents, and who will be there to care for patients?” She’s seen a shift in more willingness to call out of work sick, to the point that the residency program has needed to change the way it provides illness coverage. She perceives this as a positive change, both for now and in the future.
Preparing to rely more on electronic records versus face-to-face interaction with other care team members.
“A senior nurse who has known me since I was a trainee noted that she no longer recognizes many of the residents. She feels it’s because they are on the units less frequently and rely more heavily on electronic systems,” Dr. Kuchera said. This is a change that happened during the pandemic that remains and will continue, but it’s a more challenging phenomenon—not necessarily a positive one, he said.
Maintaining clinical variety.
“When pandemics concentrate disease into specific areas, such as COVID-19 and respiratory illness, we monitor clinical volumes and adjust assignments to maintain variety,” Dr. Vick said. “I would anticipate the same response if something like this occurred again.
Moving clinical rotations more frequently.
“In recognition of the risk of burnout during stressful times, resident rotations were changed from the traditional four weeks to a shorter two-week block, a change that continues,” Dr. Zavodnick said.
Involving family as much as possible.
One major downside Dr. Vick observed during the COVID-19 pandemic was the lack of family input due to efforts to limit infection exposure. Not having family members at the bedside also affected residents’ learning and interactions. This type of family interaction is something that she hopes can be incorporated more if other similar situations occur in the future.
Applying lessons learned from the pandemic to other scenarios.
There are often crossover lessons. In addition to pandemic planning, Dr. Theodorou said residency leaders participate in hospital-wide planning and tabletop exercises for mass casualty events or surge planning for excessive patient volumes.
Changes That Won’t Stick Around
Just like there were pandemic-era changes that will likely remain in place for the future, such as virtual learning when appropriate, there were some initiatives that are better left behind. These include:
- The use of Zoom for highly interactive sessions. That’s because engagement was lower and educational outcomes suffered, Dr. Vick said. “Additionally, facilitators found it challenging to engage both in-person and online participants equally.” Dr. Zavodnick paints a vivid picture of online training at that time. “Students were crouched in stairwells and noisy cafeterias trying to squint at a slide on a phone screen, probably retaining nothing from the lecture,” she said. In fact, everyone interviewed by The Hospitalist for this article said that virtual platforms have their place in education, but they would be used less by their institution if or when another pandemic occurs.
- Sticking to only virtual conferences. In-person conference attendance has helped to restore social connection, Dr. Vick said.
- Continuing mid-month ICU team switches. This was no longer needed as COVID-19 census volumes decreased, Dr. Vick said.
- Teaching telemedicine as a part of the curriculum, but only because of the lack of sustained insurance funding for telehealth services, Dr. Theodorou said.
Incorporating Resident Feedback
As hospitalist education leaders plan future training, they consider student and resident feedback. The pros and cons of virtual training are something that comes up often.
“While some students were happy with virtual learning and had improved attendance and increased flexibility in schedules, many missed interacting with their classmates and experienced fatigue from video conferencing and online learning,” Dr. del Pino-Jones said.
At the University of Kentucky, the hospital prioritized cohorting COVID-19 patients to specific units to try to limit exposure and the spread of COVID-19. This meant that one resident ICU team cared almost exclusively for COVID-19 patients, and it limited their contact with other etiologies of critical illnesses.
“Based on feedback, we implemented mid-month team switches to ensure residents had adequate exposure to a variety of conditions and not only acute respiratory distress syndrome,” Dr. Vick said.
Still, residents said that they enjoyed feeling a shared sense of caring for patients in need, especially before the COVID-19 vaccine was available.
Although Dr. Kuchera occasionally heard expressions of frustration over the risk involved with treating COVID-19, he more frequently felt and heard a sense of resilience and bravery. “Many trainees rose to the occasion, supported their colleagues, and displayed extraordinary dedication to patient care and to one another,” he said.
Dr. Rawal observed many residents having a hard time discerning which information to trust, as they would hear about different COVID-19 protocols from peers at other institutions. This led to confusion and unpredictability.
At the same time, she saw residents become more comfortable with sicker patients who were part of the mainstay of care at that time. “Now I think people feel calmer, as if that’s something they can handle. It raised people’s confidence,” she said.
Some Final Lessons
Although in-person connections can be a challenge during a pandemic, Dr. Kuchera hopes they will be something that can be done more often if another pandemic scenario arises.
“The overarching lesson the pandemic reinforced for me is the irreplaceable value of in-person, face-to-face interaction in medicine. In internal medicine, especially, much of our work is not procedural. It’s about being at the bedside, reading subtle cues, and building trust through direct conversation,” he said. Although clinicians can use technology and virtual tools when needed, they don’t fully replace the nuance and shared understanding that comes from physical presence, he said.
Despite the many challenges hospitalists faced as clinicians and educators during the COVID-19 pandemic, they adapted and forged ahead, bringing with them lessons learned and best practices to help them better weather whatever comes next.
“The COVID-19 pandemic was challenging as a hospitalist and educator. It taught us the importance of rapid adaptation and flexibility in the face of limited precedents. It also emphasized the importance of family at bedside to enhance our understanding of that patient and improve the care we provide,” Dr. Vick said.
Vanessa Caceres is a medical writer in Bradenton, Fla.