How Coronavirus Has Impacted the Training of Medical Residents

Just as the novel coronavirus pandemic has had a profound impact on almost every other aspect of life, it has also had a keen effect on otolaryngology resident training. While some otolaryngology residents have been reassigned to work in intensive care units or emergency departments to handle surging COVID-19 cases, others have experienced diminished opportunities to train in non-emergent otolaryngology areas due to halted elective surgeries and office visits from mid-March through May 2020.

But otolaryngology programs around the country were able to shift from didactic, in-person lectures to robust online sessions and focused hands-on surgical training in the areas that were available—generally head and neck cancer cases—to continue their residency training during the pandemic. The changes, experts say, offer valuable insights into the future of otolaryngology graduate education.

In lectures, we’ve really tried to focus on residents reviewing cases, with a review of surgical decision-making. While it isn’t an exact replacement for being in the OR, it is crucial to their development as surgeons. —Alexander Hillel, MD, Johns Hopkins Medicine

“I’ve never encountered any challenge to the system and to healthcare anywhere near as severe as what COVID-19 has done to us,” said Michael Ruckenstein, MD, professor, vice chairman, and residency program director of otorhinolaryngology–head and neck surgery at the Hospital of the University of Pennsylvania in Philadelphia. “We are all naïve in having to deal with this. The fact that residents experienced this event is an incredible education in and of itself. It’s very significant for the future because it’s likely that something like this will happen again during their careers. They’re part of the front line for intervention for COVID-19. They won’t get an exam on it, and I hope they never have to encounter it again, but if they do, they’ll have a real jump-start compared to what we had.”

Working and learning through the pandemic also brought a sense of unity, even while practicing the social distancing necessary to slow COVID-19’s spread. “There’s a recognition that we’re all in this together: as a world, a country, a state, the city of Baltimore, and the hospital we’re in,” said Alexander Hillel, MD, the residency program director and an associate professor in the department of otolaryngology–head and neck surgery at Johns Hopkins Medicine in Baltimore.

Training Challenges

In March, as the country began to shut down, residents’ schedules were affected based on where in the country they were located. “Some areas of the country were significantly more affected than others,” said Stacey Tutt Gray, MD, the vice chair of education, residency program director, and associate professor in the department of otolaryngology–head and neck surgery at Harvard Medical School, and the Sinus Center director at Massachusetts Eye and Ear in Boston. Across the country, many otolaryngology residents were reassigned to non-otolaryngology specialties, including ICU and medicine wards, to take care of patients with COVID-19. Elsewhere, she explained, “as the majority of elective otolaryngology care was put on hold, many programs changed the way rotations were structured. Residents continued to be involved with emergency otolaryngology cases and head and neck cancer care, but involvement in non-urgent otolaryngology cases and clinic was limited,” she said. “Due to concerns about higher-risk procedures that generated aerosols, most programs focused on ways to limit trainee exposure to COVID-19.”

As of June, “We’re now in the start of the recovery phase and focusing on ways to make up for lost time,” said Dr. Gray. “In terms of resident educational experience, it isn’t one size fits all. Depending on what rotations were missed, making up surgical and clinic time will be different. We’ll figure out how to regain that experience depending on where they were in their training.

“During this pause, most of the residents have been involved in a variety of activities, including completing research projects, writing opinion pieces, and catching up on studying,” she notes. “This has been a time to really focus on independent learning, and I think they’ve all taken advantage of the opportunity.”

At Hopkins, fewer elective surgeries has meant more time for otolaryngology residents to spend on didactics every day, with all of the faculty engaging in lectures daily, said Dr. Hillel. “In lectures, we’ve really tried to focus on residents reviewing cases, with a review of surgical decision-making. While it isn’t an exact replacement for being in the OR, it is crucial to their development as surgeons. We tried to encourage faculty to focus on surgical decision-making and developing the residents’ thought process,” he said. As elective surgeries return based on the Maryland governor’s guidelines, residents are assigned to cases on a weekly basis.

Graduate medical education is moving more toward competency-based training, rather than doing “20 specific procedures,” Dr. Gray said. “The key is individualizing the recovery plan for each resident and, as faculty, being able to gauge competency and comfort in those clinical areas.”

A potential positive that can come out of this is that it has expediated our learning curve on how we effectively educate residents, particularly in the virtual realm. —Brett Comer, MD, University of Kentucky

Competency Concerns?

The good news is that residency experts say no, they don’t believe residents will be at a disadvantage because of the pandemic’s effect on their training.

“As far as competency is concerned, every program is responsible for assessing the graduating residents’ ability to practice independently at the conclusion of training,” said Dr. Gray. “This is even more important this year. Many residents will be entering fellowship at the conclusion of training. Fellowship directors will need to be sensitive to the fact that the incoming fellows might have less experience than what’s typical. It will be important to support new fellows this summer to make sure they’re confident and appropriately supervised.”

Those chief residents who are starting an independent comprehensive otolaryngology practice this July should also be provided with support and mentorship, she added. “The other members of the group should make themselves available for questions and concerns as new physicians ease into their practices.”

Others agree, saying their chief residents were already well trained before the pandemic hit.

“We feel that most of our residents have received excellent surgical training through PGY4 [post-graduate year 4], such that they use the chief resident year to hone their skills and get additional training in any areas where they feel they need extra work,” said Niels Kokot, MD, associate professor of clinical otolaryngology–head and neck surgery and the residency program director at the Keck School of Medicine at the University of Southern California in Los Angeles.

“As such, all our graduating chief residents had met their surgical case minimums necessary to graduate prior to COVID shutdowns and are deemed competent to go into independent practice,” he said. “Our PGY4 residents have also met many of their case log minimums and have been operating daily since the end of March. I feel they should be able to complete their competencies as we slowly ramp up elective surgeries over the next couple of months. Beyond next year’s class of chief residents, it’s difficult to predict how COVID-19 will affect resident training,” he said.

And, despite missing out on a few months of otolaryngology graduate education, the lessons that have been learned will serve doctors well. “Keep in mind that we’re training physicians who will go out into a world where COVID-19 will continue to exist,” said Shannon Kraft, MD, associate professor and residency program director in the department of otolaryngology–head and neck surgery at The University of Kansas Health System in Kansas City, Kan.

Shifting Education Online

As residents sheltered at home, education quickly went virtual.

“We’ve had to rethink medical education that’s been traditionally based on didactics and in-person teaching,” said Sonya Malekzadeh, MD, academic vice chair, residency program director, and professor of otolaryngology at Georgetown University Medical Center in Washington, D.C. “The curriculum that was previously delivered in a very organized fashion is no longer possible. Now, we’re learning to incorporate virtual learning and digital telehealth into the resident experience.”

In March, three major otolaryngology consortia for residency training began. The Collaborative Multi-Institutional Otolaryngology Residency Education Program, called the West Coast Consortium or CMIOREP, launched first at the University of Southern California. Next came the Consortium Of Resident Otolaryngologic kNowledge Attainment (CORONA) Initiative in Otolaryngology, known as the East Coast Consortium, started by the University of Kentucky, and then the Great Lakes Otolaryngology Consortium for Resident Education (GLOC) began at Case Western Reserve University in Cleveland. In these consortia, otolaryngology faculty from more than 50 American institutions have presented 30 to 45-minute lectures with 15-minute interactive discussions, Q&As, and/or oral board-type case presentations. Education is available at different times of day, every day, for residents around the world to log in and learn from. While some lectures ended in April and others continued through June, all are still available to view online.

“While this has been an incredibly stressful time, and it has impacted the nation and the community deeply, it has also forced us to rethink how we educate our students,” said Dr. Kraft. “It revived that conversation about getting away from PowerPoint and traditional one-sided lectures. It forced us to get out of our comfort zone and realize we can do more, do better, and meet people where they’re at. It’s been a great opportunity, and I hope we carry that with us as we develop additional educational opportunities for residents.”

While this has been an incredibly stressful time, and it has impacted the nation and the community deeply, it has also forced us to rethink how we educate our students. —Shannon Kraft, MD

The consortia ramped up within days. “A potential positive that can come out of this is that it has expediated our learning curve on how we effectively educate residents, particularly in the virtual realm,” said Brett Comer, MD, residency program director and an associate professor in the department of otolaryngology–head and neck surgery at the University of Kentucky, and cofounder of the East Coast Consortium. “The consortia have had tens of thousands of hits on their recorded videos,” he said.

Sheltering in place and moving to virtual learning also have the potential to take a toll on the mental health and well-being of residents. “Isolation is really felt by our residents,” Dr. Hillel said. “To counteract it, they’ve made a strong effort to stay in touch and regularly get together virtually.”

The pandemic’s impact on well-being cannot be overstated, added Dr. Malekzadeh. Many residents are struggling with the very real issues of having insufficient PPE, dealing with inadequate leave policies, being unprepared for deployment or reassignment, having unfulfilled requirements for training or graduation, handling housing and transportation concerns, suffering from financial distress, and/or struggling with social isolation, she said. “Department and institutional support, as well as readily available resources, are critical during this time.”

Ultimately, what’s been learned through all this has value for the future of medicine in a world where crises will occur. “It’s been a very important educational experience,” said Dr. Ruckenstein. “It’s one that I wouldn’t like to replicate, but it was really important, with residents gaining much more significant experience compared to the month or two of surgical exposure that they lost.”

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Cheryl Alkon is a freelance medical writer based in Massachusetts.