Internal medicine residency has always been challenging, but the COVID-19 pandemic posed new problems for learning and well-being.
“The impact that the pandemic had on trainees in the U.S. was huge in so many ways,” said Frédérique St-Pierre, MD, FACP, a third-year hematology/oncology fellow at Northwestern University in Chicago and Past Chair of ACP's Council of Resident/Fellow Members (CRFM).
To analyze those effects, the CRFM developed a survey asking 25 questions about the impact of the pandemic on trainee clinical education and well-being. ACP distributed the survey to 23,289 internal medicine residents and subspecialty fellows, 1,128 who completed surveys and 269 who partially completed surveys.
Most respondents reported a disruption in their clinical schedule (76%) and a decrease in both didactic conferences (71%) and protected time for education (56%), according to the results, which have not yet been published. About 81% reported an increase in burnout, and 41% reported a decrease in direct supervision. Still, 78% of respondents said they felt well prepared for clinical practice after graduation.
ACP Internist spoke with Dr. St-Pierre about the survey results and their implications.
Q: Why did you do this survey?
A: In early 2020, I was on the CRFM, and one of the biggest things that we were trying to work on was how to mitigate the effects of the pandemic on the trainees and how to improve their experience, which was obviously a huge challenge. The Council is comprised of a diverse group of about 15 residents and fellows in internal medicine or a subspecialty, and we all train in different parts of the country. We all have conversations with our colleagues from medical school or with our other colleagues from residency, and it became very apparent very quickly that our lives were being deeply affected by the pandemic, as everyone's lives were … and we decided that we needed to gather more information about the problem before we could find ways to address it.
Q: What were your biggest takeaways from the results?
A: The biggest takeaways are the extent of burnout and mental issues that arose from this. We know that mental health issues during COVID were a huge thing for everyone, but an 80% perceived increase in the level of burnout in a population of people that is already extremely prone to burnout is really concerning. There are studies that show that at baseline, even prior to the pandemic, the level of burnout among trainees is close to 60% … and what our study found was that there was an 80% increase in that level, and about 40% of trainees actually described this as a significant increase in their level of burnout. That means that only 20% of trainees had an experience that allowed them to not feel burnt out, which is unacceptable.
The impact on the educational curriculum was [also] very important. We found that more than 60% of trainees felt that there was a decreased amount of teaching time on rounds, 70% found that they had decreased didactic experiences, and overall, there was greater than 50% who had decreased protected time for education. On top of this, there was also an almost 40% perceived decrease in the level of direct supervision. In the early weeks of the pandemic, of course, everyone was all hands on deck, and that's fully understandable. But as the months went on, and even up to a year in some cases, our survey demonstrated that these changes persisted for a really long time.
Q: What are the implications of these educational changes and increased burnout?
A: When we enter training, we have this book knowledge from medical school, but we need to turn it into practical knowledge, so our No. 1 goal is to develop the knowledge and the skills that we need to become excellent, independently practicing physicians. This is something that we've all been working for years on, maybe some of us even our entire lives. … So the impact that a decrease in the educational experience has on mental health is huge, and I think that the level of burnout that we saw was directly correlated with the decreased amount of educational experiences. Not only are we asked to change our schedules, increase our work hours, and come to help as much as we can—we're also seeing that the things that we need out of our training are being put at risk.
There didn't seem to be a big change in the perceived preparedness to independent practice, which is great. I think what that shows is that trainees are resilient, and they found ways to get what they needed out of the experiences that they were given. But certainly, I think that … we had to find other ways and take our own personal time to complement the decreased protected time for education.
Q: What about the pandemic experience helped trainees prepare for independent practice?
A: I think any experience taking care of patients is valuable. Working in the COVID units is an important learning experience, working in the ICUs is an incredibly important learning experience. That being said, there are so many other important skills to learn and so much important knowledge to gain that just can't be gained through those specific rotations or experiences. And [residents] probably had decreased elective time, so they had less time to figure out if they want to do general medicine or if they want to subspecialize. This is where it's really important to preserve a diverse curriculum for our residents.
Q: How do you think the early pandemic experience will affect trainees as they become early career physicians?
A: I do think that in ways that we can't really measure, it probably did significantly impact what trainees decided to do later. Trainees had a lot more ICU experience, and I know pulmonary/critical care is an incredibly popular and competitive specialty, but perhaps because of the additional exposure in that specialty, more people felt like they wanted to go towards that specialty. We actually did ask in our survey if trainees thought that there was a difference in their career choices based on their experiences, and there were several trainees that responded that they thought that it would make them more likely to go towards pulmonary/critical care. … In the grand scheme of things, I'm certain that the residents and the fellows who are graduating found ways to get what they needed to be excellent physicians, and I don't see a drop-off there. I think the training was still good, and I think that people still feel prepared for independent practice. But we may have robbed some trainees of experiences that could have changed their career choices, and I think that's really unfortunate.
Q: What can individual trainees do to mitigate any negative impacts on their education and well-being?
A: Trainees are a very vulnerable population because we enter training in a program, and from that point on, if we want to practice independently, we have to finish this program. It's not easy to switch programs at all; it's actually very hard to do that. If you decide that you've had enough, you can't really quit because then you're not done with your training, and the options from there are very limited. It's extremely difficult to cut back on hours, because partly, that's just not really part of the culture in training. Asking to cut back on hours can be viewed as a very negative thing.
We say a lot, within the CRFM and at ACP, that you can't yoga your way out of burnout. You can do everything that you can to maintain a healthy lifestyle, to exercise, to see friends. But when you have a very challenging experience already, and then a situation comes in where you're having to work more hours on top of the already very busy work schedule, you're having to miss out on diverse experiences that you were looking forward to in exchange for experiences that maybe you don't feel that you need as much training on. You just don't have a lot of options for recourse. You can do all the right things, but on an individual level, what you can do is very limited.
Q: What are some potential solutions that residency programs could apply in the future?
A: I think we need to turn to quality improvement (QI). On a more local level, there's a lot of QI initiatives that we can develop for improvement of education. In situations where it may be unsafe to have large gatherings, we do have the virtual options now that everyone is very familiar with. But virtual options are a lot of times less engaging and possibly not as good of a learning experience as having a small group around a table talking about a case and asking questions and discussing. So what are some creative initiatives that we could come up with to improve the virtual learning and make it more engaging?
There would [also] be a lot of opportunity for QI at the system level, which I think is potentially the most important in the sense that it dictates the entire culture of training. We need to consider the vulnerable position that trainees are in, and this needs to be at the forefront of all of the decisions that are made when it comes to coming up with emergency plans for natural disasters, pandemics, other global emergencies, other local emergencies. It's OK to have all hands on deck for a few weeks, but there needs to be a very specific plan to, first of all, keep everyone safe, have adequate [personal protective equipment] and whatnot, which was a huge issue at the beginning of the pandemic, but also to make sure that we can bounce back quickly so that the educational experience of trainees is not affected and, importantly, to make sure that we're not using trainees as a backup option and switching up their schedules, switching up their rotations, taking away some of the diversity in their training, and taking away the protected time for their education, to have people that can work longer hours and fulfill some of the lack in personnel. That's just not what training is for.
Dr. St-Pierre acknowledges the coauthors of the study manuscript: Romela Petrosyan, MD, FACP; Arjun Gupta, MD, ACP Resident/Fellow Member; Stephen Hughes, MD, ACP Member; John Trickett, MD, ACP Resident/Fellow Member; Susan Read, PhD; Vanessa Van Doren, MD, ACP Resident/Fellow Member; Andrew Zeveney; and Christiana Shoushtari, MD, ACP Member. She also acknowledges the contributions of Jacob Quinton, MD, MPH, FACP, Past Chair of the ACP Council of Resident/Fellow Members.