In December 2019, an infectious respiratory illness of unknown causes was first identified in the city of Wuhan, in the Hubei province of China. The virus responsible for this syndrome was identified as a novel strain of coronavirus (SARS-CoV-2). It has subsequently undergone global spread, with the first case of the coronavirus disease (COVID-19) in the United States reported on January 20, 2020.1 As of April 30, 2020, there were over 3 million confirmed cases globally.2
Graduate medical education (GME) programs face numerous challenges posed by the spread of COVID-19, including short staffing due to resident illness and quarantine measures, heavy workloads from a high burden of disease in the population, and disruption of normal training activities and schedules. Training programs all over the world are currently experiencing this initial surge of COVID-19 infections, but it is possible that programs will need to plan for multiple waves of the disease.3
An institution's COVID-19 action plan should be developed by GME leaders in conjunction with clinical operations, employee health, and infection control leadership. Programs should develop strategies that balance resident and patient safety, clinical service, and education.
Resident and Patient Safety
During previous pandemics of viral illness, such as the global H1N1 influenza pandemic of 2009, physicians in training have reported high levels of exposure to circulating viruses, as well as low levels of adherence to work restrictions and personal protective equipment (PPE) recommendations.4 Appropriate PPE usage is as important for specialty training programs as it is for generalist services, as specialty programs care for patients on units throughout the hospital and draw from smaller pools of staff members. At all stages of pandemic preparedness, trainees should be given the opportunity to practice appropriate PPE techniques. For patient care requiring airborne precautions, trainees should be able to demonstrate the ability to appropriately use a powered air-purifying respirator and/or a N95 mask. Programs should be mindful that the model of N95 mask for which their residents are fit must match those available at each of their sites; fit testing is required for each model used. Consideration at some institutions has been given to excluding trainees from aerosolizing procedures on patients suspected of having COVID-19.5 Trainees often serve as leaders on cardiac arrest response teams. While the risk of COVID-19 transmission during cardiopulmonary resuscitation is not precisely known, the role of residents on cardiac response teams and any need for changes to standard “code blue” protocols should be discussed.6
Modification of normal program activities to comply with public health recommendations regarding social distancing must be considered.7 One of the most challenging elements of COVID-19 epidemiology is the high rate of presymptomatic transmission.8 There is a possibility that the virus could spread within a residency program before any residents even report symptoms. Adjustments should be made to decrease or eliminate close resident contact when possible.9 Programs have devised electronic means of performing patient handoffs, educational conferences, meetings, and social events.5,10,11 High-touch surfaces in shared workspaces (including keyboards, telephones, mobile workstations, door handles, and pagers) should be cleaned regularly using an agent approved for disinfection.12 When appropriate, conversations with patients can occur using communication equipment. Physical examinations by trainees can be grouped with attending physician assessments so that trainees do not have to enter patient rooms multiple times. This also has the benefit of decreasing the already limited amount of PPE used in caring for patients. Some surgical services have increased the use of dissolvable sutures so that fewer return visits for suture removal need to be performed.13
Institutional policies for returning to work after illness vary depending on available resources. Programs should be familiar with their institution's illness and COVID-19 testing policies. In general, residents with symptoms such as fever, cough, malaise, and myalgias should be excluded from work-related activities. Residents at risk of developing complications from COVID-19, such as those with immunosuppression or pregnancy, should be given an opportunity to confidentially contact program leadership with their concerns so that accommodations can be made to limit their exposure as much as possible. Finally, trainees during prior pandemics have reported high levels of stress and anxiety: programs should ensure mechanisms are in place for monitoring trainee emotional well-being.15
Resident physicians are a critical component of the health care workforce and can be an asset in caring for those infected with COVID-19. Challenges to maintaining required clinical services faced by training programs will vary by specialty and disease prevalence. The Accreditation Council for Graduate Medical Education has outlined 3 levels of disruption to training programs, ranging from “business as usual” to emergency status (Table).14 In areas with high COVID-19 prevalence, health systems have been strained to the breaking point. Training programs in hospital systems overwhelmed by COVID-19 cases may find that they must shift their residents to help meet increased patient care demands. Training programs must partner early with clinical operations leaders in their health care system to develop a plan for what increased staffing requirements will be needed, as well as what can reasonably be provided by trainees. In a pandemic emergency, trainees will likely be asked to shift to higher acuity settings, such as intensive care units or hospital wards. In some cases, trainees may be asked to provide care in areas in which they have not traditionally been assigned.5 Institutional GME leadership should identify potential roles suitable for different groups of trainees before emergency status is reached. Programs should ensure that adequate supervision of trainees is provided, especially for those assigned to units with which they are less familiar.
Clinical services also become disrupted in areas of lower COVID-19 prevalence due to the canceling of elective procedures and limiting of travel outside the home. Educating trainees in the use of telehealth equipment, procedures, and etiquette is vital to ensure patients are still able to receive care.13 Due to the likelihood of trainees becoming ill during the pandemic, thought should be given to expanding backup coverage of critical service lines.9,10 With the closure of schools and day care facilities, alternative sources of childcare should be identified.
The challenges to trainee education from the COVID-19 pandemic vary by specialty. Many programs have reported success in providing didactics over videoconferencing software, even for interactive sessions such as morning report.11,16–18 In addition to maintaining education as a priority, continuing educational conferences helps maintain a feeling of normalcy, which programs have reported residents desire.10 The COVID-19 pandemic itself has served as an educational opportunity for residents to learn about epidemiology, population health, systems-based care, and advocacy.11
Some programs will experience an impact on their trainees' ability to participate in enough cases or clinical activities to advance their training. This has been noted as a concern in surgical specialties, radiology, and radiation oncology.16–19 Possible methods proposed for providing exposure to a larger number of cases include the use of simulation centers, faculty-led review of surgical videos, and online discussion of board examination questions and topics.17 The cost of online and teleconferencing resources and simulation center time must be considered. Institutional subscriptions to these services should be leveraged when possible. Blinded historical radiology studies can be considered for evaluating reading aptitude.16 Time away from clinical duties due to canceled elective cases can be spent on scholarly activity.19 Ultimately, program leadership will need to closely monitor resident exposure to critical procedures in order to ensure they have the experience necessary to progress.
Finally, providing trainees with clear, consistent messaging is both challenging and important. Programs should consider developing a standardized format and frequency of updates to prevent confusion from information overload.10,20 The pandemic also threatens the sense of community within programs. Programs should consider using virtual hangouts, social media, and check-ins with mentors to maintain this sense of community during the pandemic. The trajectory of the pandemic is uncertain; therefore, programs should have protocols for onboarding and graduating trainees if in-person orientations and graduations are not possible.
The world currently faces perhaps the greatest acute public health crisis since the 1918 influenza pandemic. It is not known how long the challenges imposed by the COVID-19 pandemic will persist. However, GME programs will likely need to be prepared for future waves of infection. Each institution's response must be tailored to its unique circumstance and constantly adjusted as the situation develops. Now is the time to refine strategies that balance safety, clinical service, and education in order to weather the storm.