Nephrology Fellowship Education: Moving Apart to Come Together during COVID-19

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SARS-CoV-2 infection, the causative agent of coronavirus disease 2019 (COVID-19), was declared a pandemic on March 11, 2020, with more than 1.4 million people afflicted by April 8, 2020, and more than 80,000 deaths (1). Physical distancing is the cornerstone of slowing disease transmission to mitigate an overwhelming demand for healthcare resources that exceeds capacity. This strategy was used as early as the fifth century BC (2), more recently during the 1918 influenza pandemic, and during the 2009 severe acute respiratory syndrome (SARS) and 2012 Middle East Respiratory Syndrome epidemics. Early physical distancing has in part been credited for the success Taiwan and Hong Kong have experienced in controlling SARS-CoV-2 transmission (3). Official recommendations for physical distancing in the United States began in March 2020.

Physical distancing, however, is the antithesis of medical education. Bedside teaching through rounding—originally championed by Sir William Osler at the Johns Hopkins Hospital—has been a cornerstone of medical education for more than 130 years. Those bedside interactions have grown over the years to include educational venues ranging in size from small group didactics to auditorium presentations. Preparations for and actual care of patients with COVID-19 have, literally overnight, required a transformation in how medical education is delivered to trainees. This certainly presents novel opportunities along with considerable concerns for the adequacy of ongoing instruction. Moreover, for specialties such as nephrology, which already face recruitment and training challenges, the loss of personal, small-group engagement may be yet another impediment to growing the specialty. The need to balance education with safety requires attention to workplace policies, formal didactics, and trainees’ wellness.

Workplace policies

Effective teaching requires receptive and engaged learners. Fellowship curricula can continue during a pandemic, but the workplace must first be structured to permit a learning environment. The safety of patients and providers is paramount, and well-delineated, informed clinical practice paradigms must be operational. Given the uncertainty and constant flux of information associated with COVID-19, keeping abreast with current government, professional society, and local recommendations is a requirement for all training programs. Major resources for monitoring the pandemic and informing best practice include the Centers for Disease Control (https://www.cdc.gov/coronavirus/2019-ncov/index.html), the World Health Organization (https://www.who.int/emergencies/diseases/novel-coronavirus-2019), and the Johns Hopkins Coronavirus Resource Center (https://coronavirus.jhu.edu/). State and local health departments are of critical importance to local practice. Dialysis and transplant populations may be especially vulnerable during this period, and guidance is available from the American Society of Nephrology (https://www.asn-online.org/ntds/) and the American Society of Transplantation (https://www.myast.org/covid-19-information). NephJC (http://www.nephjc.com/covid19) has emerged as a focused, high-yield resource for nephrologists.

In addition, institutional dissemination of information should be structured to avoid overwhelming staff, trainees, and faculty. Information overload may cause significant stress and information fatigue syndrome (4). Summarized digests of information distributed several times a week or once a day are manageable. We have maintained a continuously updated, highly curated repository of information specific to operations, clinical care, and trainee education in a division-wide OneNote (Microsoft Corporation, Redmond, WA) notebook accessible by phone and desktop app. A weekly division-wide interactive videoconference (IVC) town hall meeting that includes all faculty, trainees, and staff allows for social connection, updates to major initiatives, and an opportunity for questions.

With respect to inpatient workflow, given that most nephrology programs operate multiple simultaneous consultation teams, consider assigning COVID-19–positive patients and persons under investigation for COVID-19 to a single team to minimize exposure to providers. To conserve personal protective equipment (PPE), these patients are usually evaluated at the bedside only by the attending nephrologist. Billing requirements have evolved quickly during this crisis, and it is now often possible for the provider to communicate with a patient through IVC without entering a protected zone.

Although the threat of infection should not prevent appropriate medical care, there are times when the trainee and attending nephrologist can deliver effective nephrology care without always having to be at the bedside. This was likely not envisioned by Osler, and it is imperative that clinicians and educators do not succumb to this slippery slope. Technology can be leveraged to this end. Innovative approaches, such as the use of a head-mounted phone under PPE or camera-enabled workstations on wheels, can allow multiple team members to engage in bedside clinical care through IVC while only one provider is at the bedside. Care providers such as pharmacists and case managers, for example, could even join rounds from an off-site location to maximize physical distancing in the hospital.

Backup protocols for fellows, training program directors unable to work

It is critical to have defined protocols for backup clinical coverage should a fellow be unable to work. Moreover, all training programs should identify faculty and staff responsible for assuming control of the operations and accreditation of the fellowship if the program director and/or coordinator should be incapacitated. This backup plan should include ensuring that these individuals have the necessary credentials for accessing key electronic systems, both nationally and locally.

Whereas the pandemic has appropriately focused considerable effort on inpatient operations, maintaining continuity of outpatient care is critical. The nationwide rollout of telemedicine by IVC has rapidly expanded. The Accreditation Council for Graduate Medical Education, having originally planned for a July 1, 2020, beginning, issued emergency authorization on March 18, 2020, allowing trainees to participate in telemedicine visits where “the supervising physician and/or patient is not physically present with the resident and the supervising physician is concurrently monitoring the patient care through appropriate telecommunication technology.”

Multiple IVC solutions allow for the attending nephrologist to monitor the entire patient care encounter or to join at the conclusion of the visit. The attending can discuss the plan of care with the trainee by telephone or IVC after pausing the patient’s audio and video connection. If rooms and camera interfaces compliant with the Health Insurance Portability and Accountability Act (HIPAA) are available, the trainee and attending can maximize physical distancing by remaining in separate locations. Rescheduling patients can be cumbersome initially, and we have used the following strategies to aid triage:
 

  1. In-person: acute medical needs requiring physical examination and/or visit are paired with an intervention (e.g., injection of erythropoiesis-stimulating agent); the necessity of the evaluation needs to outweigh the risk of acquiring infection.
  2. Telemedicine: medical needs requiring evaluation without physical examination.
  3. Reschedule: safe to wait at least 2 to 3 months, thereby facilitating rollout of telemedicine to patients with greater need.
     

Given the unique precepting and educational needs inherent to the outpatient clinical training of fellows, it remains to be determined how telemedicine will be best used in the long run. Unquestionably, this is a practice environment in which fellows must now be fluent at the conclusion of their training, and our response to this pandemic will likely uncover novel applications for the technology.

Fellowship didactics

Acutely, structured education may be deferred while response plans are implemented. In its place, trainees receive firsthand experience in public health epidemiology, medical triage, crisis response, resource conservation, and rapid operationalization of translational medicine. The extent to which a program is affected by COVID-19–infected patients will dictate the timeline for returning to a more typical curriculum. Ultimately, however, the formal educational mission must continue as soon as possible, and trainee engagement needs to be sustained. Moving didactics to an IVC has helped mitigate this issue.

Interactive video conferencing has been used for some time as an adjunct in medical education and in nephrology specifically (5, 6). Programs such as the Glomerular Disease Study and Trial Consortium (GlomCon) (https://glomcon.org) have succeeded at delivering educational content to participants around the world in real time. In that scenario, the achievement lies in delivering interactive content on a topic for which no in-person contact is expected. The current challenge is to engage participants locally who would otherwise expect the social interaction inherent in a group activity. When an IVC ends, participants instantly separate without opportunity for informal discussion, personal connection, or reinforcement of delivered content. Table 1 describes some advantages and disadvantages of IVC-based education. IVC is not limited to prepared didactics, and it can be used for “chalk talks” through on-screen annotation, kidney biopsy review, and real-time education in urine microscopy. Our program facilitated the transition to IVC through the initial use of lighter topics that required participation, such as NephMadness (https://ajkdblog.org/category/nephmadness/) and board review. The following guidelines can help ensure a productive IVC with maximal impact:
 

  1. Use the same link for standing conferences and distribute to participants’ calendars.
  2. Disseminate conference links to internal medicine residents and other interested divisions and departments.
  3. Invite hospital programs that have fewer resources to maintain both clinical and educational activities during a crisis response.
  4. If internet bandwidth permits, ask participants to enable their video links, thereby making interactions as in-person and focused as possible.
  5. Mute microphones of nonspeaking participants during formal presentations.
  6. Encourage audience participation through polls and individual participant-directed questioning; open-ended questions to the entire group do not work well.
  7. Follow up a presentation with an email summary of learning points or questions to stimulate further learning.
  8. Verbally present all content for the benefit of participants connected by audio only.
  9. Shorten sessions to maximize attention and to allow for technical constraints on time.
  10. Notify participants if the presentation is being recorded, because the material may be available for later review. Unquestionably, if protected health information is to be discussed, the IVC software must be HIPAA compliant, and software security settings should be reviewed to prevent third-party hacking (“Zoombombing”).
     
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Trainee wellness

The psychologic effects of physical distancing and quarantine have been well documented. Healthcare workers subject to quarantine are known to experience exhaustion, detachment, and depression (710). Low mood and irritability are the most prevalent symptoms (11), and trainee burnout rates could rise during this period.

We have attempted to strengthen resiliency and minimize the risk of burnout by acknowledging the resolve, sacrifice, and contributions of our fellows during the pandemic. The institutional response is a shared mission, with both faculty and trainees jointly contributing wherever service has been needed. Informal weekly IVC check-ins and “happy hours” help maintain program cohesion. Social networks, even when remote, have been demonstrated to alleviate not just immediate anxiety but also long-term distress (12, 13). During infectious disease outbreaks, organizational support has been shown to protect the mental health of healthcare staff (14).

The Graduate Medical Education Committee at the Johns Hopkins University has provided extensive wellness resources, extending from free mindfulness apps to mental health counseling. Housing assistance has been made available for providers unable to live at home because of quarantine restrictions or family members at high risk for complications from COVID-19 infection. Advance planning, crowdsourcing, and good resource stewardship have fortunately afforded trainees the necessary PPE to enable an appropriately safe work environment.

Safety helps create an environment conducive to learning. Unfortunately, physically safe learning and work environments have not been possible for all training programs during the COVID-19 pandemic. In those situations, IVC could allow programs currently less challenged by an influx of COVID-19 patients to share educational content with trainees at more heavily constrained institutions.

The crisis of COVID-19 has undoubtedly brought major challenges to clinical care and education in fellowship training. Technology can be leveraged to support trainee education during periods of physical distancing, heavy clinical workload, and heightened stress. Although the concept of bedside teaching espoused by Osler has been restructured during COVID-19, we now have an opportunity to engage new participants and other programs in a way not previously emphasized. The eventual benefit to nephrology education rests in once again physically connecting to our patients and colleagues while maintaining a newfound inclusivity. By moving apart, we may ultimately come closer together.

June 2020 (Vol. 12, Number 6)

References

1. WHO director-general’s opening remarks at the media briefing on COVID-19. 11 March 2020. https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020.

2. A brief history of quarantine. https://vtuhr.org/articles/10.21061/vtuhr.v2i0.16/.

3. What we can learn from Singapore, Taiwan and Hong Kong about handling coronavirus. https://time.com/5802293/coronavirus-covid19-singapore-hong-kong-taiwan/.

5. Bertsch TF, et al. Effectiveness of lectures attended via interactive video conferencing versus in-person in preparing third-year internal medicine clerkship students for clinical practice examinations (CPX). Teach Learn Med 2007; 19:4–8.

6. Colbert GB, et al. The social media revolution in nephrology education. Kidney Int Rep 2018; 3:519–529.

7. Liu X, et al. Depression after exposure to stressful events: Lessons learned from the severe acute respiratory syndrome epidemic. Compr Psychiatry 2012; 53:15–23.

8. Wu P, et al. The psychological impact of the SARS epidemic on hospital employees in China: Exposure, risk perception, and altruistic acceptance of risk. Can J Psychiatry 2009; 54:302–311.

9. Bai Y, et al. Survey of stress reactions among health care workers involved with the SARS outbreak. Psychiatr Serv 2004; 55:1055–1057.

10. Brooks SK, et al. The psychological impact of quarantine and how to reduce it: Rapid review of the evidence. Lancet 2020; 395:912–920.

11. Lee S, et al. The experience of SARS-related stigma at Amoy Gardens. Soc Sci Med 2005; 61:2038–2046.

12. Manuell M, Cukor J. Mother nature versus human nature: Public compliance with evacuation and quarantine. Disasters 2011; 35:417–442.

13. Rubin GJ, et al. Psychological and behavioural reactions to the bombings in London on 7 July 2005: Cross sectional survey of a representative sample of Londoners. BMJ 2005; 331:606–611.

14. Brooks S, et al. A systematic, thematic review of social and occupational factors associated with psychological outcomes in healthcare employees during an infectious disease outbreak. J Occup Environ Med 2018; 60:248–257.