A Holistic Approach to Pathology Education During the Coronavirus Disease 2019 (COVID-19) Pandemic

To the Editor.—We read with great interest the article by Mukhopadhyay et al¹  that comprehensively outlined available technologies to promote remote learning in a time of social distancing measures. Indeed, these technologies were rapidly deployed in our department. However, we quickly realized the need to address key technology barriers as well as communication and wellness-related issues before this “new norm” of pathology education could be widely adopted.

The University of Toronto (U of T) Anatomical Pathology (AP) residency program, one of the largest of its kind in Canada, is a 5-year training program. Training occurs at multiple sites including 4 academic hospitals, a children's hospital, affiliated community hospitals, and the provincial forensic pathology service.

Provincially mandated social distancing restrictions were instituted in March 2020 in response to the coronavirus disease 2019 (COVID-19) pandemic. However, differing Infection Prevention and Control (IPAC) measures amongst the multiple training sites resulted in confusion and mixed messages for our residents. In addition, a decline in surgical procedures led to a decrease in surgical pathology cases.

Stress and anxiety related to the unknown only worsened as our residents were temporarily redeployed to non-AP services to meet the clinical demand of COVID-19 infections. During the months of April and May 2020, as COVID-19 test volumes rapidly increased, 17 residents at 2 training sites were scheduled for in-person shifts to fill an expanded medical microbiology service rotation. Selection was initially site-dependent, which then evolved into a partially voluntary basis, made in collaboration with the Post-Graduate Medical Education Office (PGME), AP Residency Program Committee, and the AP resident body. Anatomical Pathology residents performed tasks such as triaging (where applicable) and accessioning microbiology specimens as well as releasing/reporting test results. Several measures were taken to minimize the impacts of redeployment on resident education and wellness. Most residents were redeployed for only a few shifts to perform tasks that posed little health risks. The residents were exempted from pathology work during the days they were scheduled for microbiology shifts and were entitled to lieu days for overnight and weekend shifts. The redeployed residents were encouraged to use provided alternative education resources for self-study. New evaluation assessment forms were used for these rotations, based on new U of T PGME guidelines.

An anonymous survey of our residents' learning experience during the early phase of COVID-19 was conducted from May 13 to 19, 2020. At the time of the survey, AP residents (redeployed and non-redeployed) had had 1.5 months of lockdown measures, reduced pathology workloads, and self-study (using traditional textbook and available alternative learning resources at the time). Of the 30 current AP residents, 20 (67%) responded. Unsurprisingly, 15 residents (75%) rated the educational yield (defined as perceived learning opportunities from gross rounds, individual or consensus case review and sign-outs, and tumor boards) of rotations during the COVID-19 pandemic as less or significantly less than prepandemic rotations. Most trainees readily identified the need for virtual learning resources. Work modifications such as changing rotations to busier services and sharing cases amongst residents also improved the learning experience. Almost all residents felt that maintaining some form of sign-out was needed for optimum learning, and 13 of 20 residents (65%) reported having modified sign-outs using telephone/email briefing and/or online or conference room meetings. In general, learning using online meeting platforms was well received. While adequate internet connectivity and hardware were important, staff familiarity with these technologies was crucial for effective learning. Two-thirds (13 of 20) of residents were satisfied with workplace safety precautions such as physical distancing and mandatory masking. Flexible work arrangements to address safety concerns were also favored by many residents. Residents commented on their low morale and high stress during this challenging time, along with the importance of social activities for psychological support.

One of our first educational initiatives was to increase the virtual learning resources available to our residents. Residents were encouraged to review external online learning collections, including those from the College of American Pathologists and United States and Canadian Academy of Pathology, as well as online learning modules created by our staff and residents. Digital slide learning was facilitated by using the U of T Digital Library of Medicine (http://dlm.lmp.utoronto.ca; accessed March 29, 2021), a curated library of digital pathology slides. Lectures and unknown slide rounds were delivered virtually with online meeting platforms such as Zoom (Zoom Video Communications, Inc, San Jose, California) and MS Teams (Microsoft Corporation, Redmond, Washington). We started citywide weekly “Virtual Gross Round” and “Virtual Autopsy Round” webcasts to address the dearth of in-person rounds. We also successfully delivered a completely online resident in-house exam. Quercus (Instructure Inc, Salt Lake City, Utah), a feature-rich and robust learning management system, was used to organize these educational initiatives.

In our initial efforts at online teaching, we faced many issues related to participation. Resident representatives noted that these were due to technical reasons such as lack of appropriate hardware, spotty connectivity, and the inconsistent use of different devices ranging from smartphones to desktop computers. Moreover, in-person teaching with glass slides became challenging as sign-outs using multiheaded microscopes were discontinued across most training sites. In addition, whole-slide image scanning was not readily available at each site. In response to these challenges, we provided a “Technology Care Package” to each resident, consisting of (1) a 1080p webcam with microphone, (2) headphones, and (3) a USB plug-and-play microscope camera. This package was tested for installation and transferability across all training sites. With the technology barrier lowered, our residents could more easily participate in “face-to-face” online meetings, lectures, and sign-outs.

While virtual learning is at least as effective as in-person learning for knowledge acquisition, studies have shown that skill and attitude are still best acquired through in-person teaching.^2,3  Therefore, our program strived to maintain in-person teaching while still respecting individual teaching site's IPAC measures. This included the installation of Plexiglas on multiheaded microscopes, the uniform masking by staff and residents during in-person teaching, the use of conference rooms with projection of glass slides for teaching, phone or online conferencing for case briefings with residents, and grossing specimens from COVID-negative patients.

Open communication was essential to ensure rapid responses to residents' concerns, especially given the dispersed nature of our teaching sites. This was achieved through weekly virtual town hall meetings with all residents and residency program committee members. The program director initiated regular communication with other AP residency programs across Canada. There was also a constant flow of information between the program and both the PGME office and the Royal College of Physicians and Surgeons of Canada to ensure up-to-date and consistent practices and messaging.

Wellness has been identified as an important issue during the COVID-19 pandemic. A recent review on the psychological impacts of COVID-19 on health care workers found that depression, anxiety, and other psychological distresses affect a quarter to a third of health care workers.⁴  Our program widely promoted and supported formal and informal wellness initiatives, including online wellness resources, a virtual trivia night, distribution of jackets with the U of T AP logo to all trainees, physically distanced outdoor and virtual parties for incoming and graduating residents, and a wellness photo social media competition. We also held a physically distanced outdoor picnic and yoga class in lieu of our annual wellness day between the first and second waves of the pandemic. Staff at each teaching site were asked to accommodate work arrangements such as flexible work hours and self-directed learning from home to address concerns regarding safety and childcare.

As the COVID-19 pandemic persists, we continue to be mindful of the ongoing stressors negatively affecting our residents' training. Digital tools and online education resources are steps in the right direction but we must also promote open communication and program-sanctioned wellness initiatives. We are optimistic that residents will be well prepared and able to adapt to any transformative change that may be imposed by this pandemic moving forward.