This study documents some of the effects on fellows’ learning experiences and well-being due to changes in PEM fellowship training resulting from the COVID-19 pandemic. Decreases in patient volumes led to altered clinical experiences with both fellows and PDs expressing concern regarding sufficient training for competency upon graduation. The vast majority of didactics became virtual or a hybrid of virtual and in-person didactics and fellows had additional opportunities in COVID-19 research. Lastly, fellows and PDs had different levels of concern around well-being and safety.
As COVID-19 spread across the world, the medical education community pivoted to ensure the ongoing development of fellows while advocating for their physical and mental safety and adhering to government shelter-in-place orders. From masking to vaccine development and administration to changes to the everyday vernacular, the COVID-19 pandemic has led to multilayered changes to every facet of life. Much of the world instituted changes to business and education models that mimicked those that were enacted during the global public health threat of SARS in parts of Asia in 2003. Though short-lived, the abrupt changes to virtual education and closure of schools during that time formed a foundation for many of the actions of governing bodies in 2020.(19) In many respects, the pandemic was a shared experience and it is not surprising that PDs and fellows would have similar responses to survey questions. It is likely that some differences in PD and fellow responses are due to lack of institutional memory of trainees who may not be able to recognize changes in training.
One of the biggest challenges during the pandemic for any training program that relies on clinical experiences was the dramatic drop in patient volumes. Similar to our findings, Lo, et al found a dramatic decrease in the number of pediatric patients at their hospital in Taiwan, measured in patients seen per hour (PPH). Contrary to adults, the average PPH managed by residents in the pediatric ED decreased from 1.56 pre-pandemic to 0.51.(20) This was reported across disciplines.(2, 11, 21) While our PEM PDs and fellows feel that these changes in volume affected their clinical training and graduation readiness, they are not alone. Multiple surgical training programs reported trainees and educators having significant concerns about the acquisition of required hands-on skills given decreased volumes and canceled elective procedures.(12-14) In PEM, being a front-line provider necessitates fast-paced triaging patients, alleviating bottlenecks, ensuring safe disposition of patients, and adapting to an ever-changing environment is a learned skill. Reduced patient volumes will affect the acquisition of these skills.
Given the decrease in patient encounters during the early part of the pandemic, it is not surprising that PDs changed rotations and block schedules to maximize learning opportunities for fellows. In addition, with several areas of the country seeing pediatric patients relatively unaffected by the disease while illness across adult populations surged, several programs reported PEM fellows spending additional time in the adult ED and MICU. This could potentially have mitigated the decreased procedural opportunities that some fellows experienced. While ACGME core requirements for pediatric-trained PEM fellows do require at least 4 months of reciprocal time in an adult emergency setting, additional time spent on adult rotations is likely institution dependent. The effects of increased adult patient care with a reciprocal decrease in pediatric care are currently unknown, but likely to be small given the short duration of these changes for most programs.
Outside of the clinical arena, virtual learning became a mainstay during the COVID-19 pandemic, one of the silver linings noted by most respondents. The move to virtual conferences was not perceived as impacting fellows’ didactic education or the quality of conferences, and attendance to conferences reportedly improved. Many fellows or faculty may have been juggling additional non-academic responsibilities like overseeing education at home or caring for their children with the closure of schools and daycare facilities.(20, 22-24) Being able to attend conferences virtually likely allowed them to continue learning while still addressing important needs at home. Additionally, without the need to commute to the hospital for educational sessions, attendance may have increased with broader faculty participation leading to increased engagement and discussion, further augmenting fellow learning.
In an effort to support virtual learning, the national PEM-Program Directors’ Committee created a database for PEM fellowship programs to share information on their faculty and respective lecture topics. This provided a convenient means for programs to find and invite quality faculty lecturers who covered topics that may have been needed in a program’s education curriculum and increased the ease in accessing PEM lecturers and experts from across the nation. Videoconferencing is not new in medical education and shown to be effective internationally in post-graduate education.(25) Leveraging technology has allowed educational opportunities to expand and create new partnerships without imposing additional time, cost, or health risk related to travel.
Unsurprisingly, the biggest discrepancy between fellow and PD responses involved questions related to administrative functioning of the program or the hospital. While all PDs reported having adequate PPE available, close to 20% of fellow respondents reported they did not have or were not sure if their PPE was adequate. This may reflect the evolving definition of “adequate PPE'' during the pandemic.(26, 27) Early on, wearing an N95 mask for more than 1 patient was largely considered inadequate. However, as nationwide shortages of PPE became more apparent, many emergency departments reported “adequate PPE'' using 1 mask per day or week. In addition, fellows may have spent time in nontraditional rotations or roles (i.e. MICU) where PDs may not have true awareness of all available resources.
Similarly, we noted a discrepancy between PDs’ and fellows’ responses with regards to the fellows’ scholarly activities. PDs felt the pandemic negatively impacted fellows’ research productivity due to low patient volumes or because of hospital-imposed restrictions, however fewer fellows agreed to these statements. This is likely due to PDs having a better understanding of the ACGME scholarly requirements(28) and where a fellow should be in this endeavor based on their level of training.
And finally, there were differences between PDs’ and fellows’ responses to survey items related to the availability of mental health resources and additional support for healthcare providers’ mental health given the stressful nature of this global pandemic. Though 85% of PDs reported having additional services for fellows, 59% of fellows reported the same. PDs often have a detailed understanding of hospital and university level programs available to fellows involving counseling, academic, and social support after years of program administration. Fellows who are new or have not needed services in the past may not be as familiar. There was often a vast amount of information and frequent communication during the pandemic, and certain information may have been lost. Though the survey may also reflect regional differences between survey respondents, this finding could indicate a need for programs to consider how they can disseminate information around mental health services. Many of our fellow respondents were concerned about becoming infected or infecting their loved ones. While many fellows felt they had an opportunity to talk about their feelings, mental health services should have a broader reach in the future.
This study has several limitations. While the number of surveys distributed to PEM fellows and PDs is regulated and several attempts were made to collect responses from PDs and fellows, our response rate was less than ideal and does not represent all programs and trainees. Since this study was conducted about 1 year into the pandemic, these data represent effects that were notable to PDs and fellows over the earlier months of the pandemic. It is unclear if any of these findings were long-lasting or only took place over a short period of time. It is also unclear from these data what impacts any programmatic or didactic changes will have on fellow readiness for independent practice. The timing of the study did not allow for more objective measurements of the impacts on milestone acquisition, in-training scores, or board pass rates. Further studies may help clarify any effects, if any.