The COVID-19 Pandemic and Graduate Medical Education Silver Linings

Introduction

The COVID-19 pandemic devastated communities across the globe, leaving socioeconomic and health disparities in its wake. The pre-vaccine era was defined by hardships. Despite this, we continued to care for the ill, advocate for the vulnerable, and promote science, all while demonstrating remarkable creativity.

Recognition is important, not just for morale but also for defining and building a shared vision of our post-pandemic identity. The silver linings of this challenging era offer insight into what might be an optimal future. This article highlights the positive changes within graduate medical education (GME) inspired by COVID-19 perturbations.

The pandemic stimulated GME to innovate at an unprecedented speed and scale. For example, GME adapted to the growing knowledge about the virus and therapeutic modalities, the fluctuating availability of supplies, as well as the evolving guidelines regarding physical distancing and accommodating high-risk groups. Further, GME programs nationwide adjusted their educational modalities, recruitment platforms, and clinical care structures.

Effect on Medical Education

The COVID-19 pandemic profoundly impacted medical education, especially GME. In response, the Accreditation Council for Graduate Medical Education (ACGME) swiftly cancelled all accreditation site visits, accreditation meetings, and Clinical Learning Environment Review (CLER) visits. The Council also named certain key “inviolate” requirements they expected all programs to uphold:

1. Adequate resources and training
2. Adequate supervision
3. No change in work hour requirements, and
4. Fellows functioning in their core specialty for up to 20% of their annual education time.¹

While the clinical mission of programs nationwide braced for the worst, the educational mission persisted. Overnight, non-clinical teaching became virtual. All educational sessions converted to virtual platforms. The constructivist learning theory emphasized the experience of the learner and led us to engage learners in real time through the computer screen. We became creative with screen sharing, using whiteboards, polling, annotation, breakout rooms, non-verbal feedback, and chat functions. Perhaps, most useful was the ability to record teaching sessions.

Nationally, the increased use of social media for educational purposes, with the increased use of twitter threads and tweetorials, was another significant innovation. The expansion of the #MedTwitter community innovated medical education. Podcasts were effective, on-demand learning tools; they also promoted cross-institution collaborations and dissemination of education globally.

Virtual platforms solved geographic dilemmas both within and between institutions. By necessity, educators discovered the ease at employing virtual platforms, and this will likely promote continued inter-institutional invitations to teach.

Effects on GME Recruitment

By ACGME mandate, the 2020-21 residency and fellowship recruitment seasons were the first ever to be completely virtual to curtail COV ID-19’s spread.^2,3 However, the 2021 National Resident Matching Program (NRMP) results suggest some secondary positive effects. On average, pandemic-era applicants added more programs to their rank lists such that 2020 saw the largest single-year jump in this statistic.⁴ NRMP data showed programs expanded their lists thereby causing average ranks per available position to rise from 12.95 in the three years prior up to 15.35 in the 2021 online cycle.⁴ In other words, everyone broadened their searches. This was likely due to lowering the financial barriers that accompanied the ACGME mandate. Virtual interviews benefited cost-constrained applicants and possibly promoted greater equity in application patterns along socioeconomic gradients.

Obviating the travel requirement for interviews also supported the psychosocial well-being of applicants and reduced the opportunity costs of interviews. Since travel was unnecessary, applicants could be more present in their family, educational, and work lives.

Programs toiled to optimize the outcomes of the ACGME mandate. Many institutions offered video interview coaching and/or provided staged interview areas. To attract prospective applicants, programs developed creative programs, such as “virtual away rotations” that allowed learners to virtually participate in rounds and social events. Many programs revised their websites and social media to include more details, photos, and video testimonials of current residents and faculty. These updates allowed applicants to glean details about programs’ core values from afar.

We are optimistic many of these changes will be incorporated for mitigating inequities in GME recruitment going forward and promote a diverse and equitable workforce.

Effect on Clinical Experiences

Clinical experiences were also significantly affected. The healthcare system was charged with workflow redesign and contingency planning. Within this chaos, GME programs needed to safeguard the physical and mental health of trainees while upholding the pillars of patient care and clinical teaching.

Early in the pandemic, medical students were often abruptly pulled from clinical rotations, while resident rotations were adjusted to meet the evolving clinical needs. Other clinical concerns included national shortages of personal protective equipment (PPE) and, from a teaching standpoint, the potential lack of diversity in case load as hospital beds filled up with patients with COVID-19.⁵

In the hospital setting, physical distancing guidelines led to innovative bedside rounding: tele-rounding. At some institutions, this took the form of virtual rounding via tablets or other electronic devices. Virtual platforms also facilitated interdisciplinary rounds, easily convening doctors, pharmacists, social workers, and case managers simultaneously. Compared to bulky computer stations, tablets could be more readily visible to all team members and thus potentially enhance teaching about radiographic or EKG findings.

In addition to tele-rounding, there was an urgent need for telehealth competency. This was driven both to limit the infectivity of COVID-19 and to conserve PPE. In the inpatient setting, many consultants provided recommendations via synchronous and asynchronous modalities. As data is being collected to determine its impact, the electronic consultations in many cases improved workflow for inpatient teams. Ambulatory telemedicine provided vulnerable patient populations continued access to care. Ambulatory electronic consults rose steadily during the pandemic and will likely persist. Trainees of the pandemic era will be adept at telemedicine from the start of their careers.

Conclusion

The COVID-19 pandemic profoundly impacted our approach to recruitment, clinical care, and education in GME. While the COVID-19 era can be characterized negatively, we would be remiss to ignore the innovations and accomplishments outlined here. Many will likely persist. Virtual recruitment allowed residency programs to review and interview a more diverse applicant pool that helped level the playing field among all applicants. Additionally, the clinical and educational innovations during the COVID-19 pandemic improved patient care and training our learners. While we would not have chosen this crisis, it was not wasted. Medical educators innovated and raised the bar on maintaining educational excellence, and we are better educators for it.