• 1.

    Hilberg R, et al. Medical education during the COVID-19 pandemic: Learning from a distance. Adv Chronic Kidney Dis 2020; in press. doi: https://doi.org/10.1053/j.ackd.2020.05.017

    • Search Google Scholar
    • Export Citation
  • 2.

    Jhaveri KD, et al. ‘WhatsApp®’ening in nephrology training. Clin Kidney J 2019; 13:813. doi: 10.1093/ckj/sfz045

  • 3.

    Hirsch JS, et al. Acute kidney injury in patients hospitalized with COVID-19. Kidney Int 2020; 98:209218. doi: 10.1016/j.kint.2020.05.006

  • 4.

    Parikh R, et al. The war we call COVID-19: A letter from the front in New York. Am J Kidney Dis 2020; 76:A13A14. doi: 10.1053/j.ajkd.2020.05.007

COVID-19 Reshapes Residency Education, Exposure to Nephrology

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The COVID-19 pandemic has upended all areas of society, including medical residency education. Residency programs were forced to change almost overnight this spring, presenting new challenges as teaching went online and some aspects, like electives and clinics, were halted at many institutions. But there were bright spots and technology advances that residency programs may continue to embrace long after the pandemic.

While challenging, moving residency conferences to platforms like Zoom allowed for more participation and flexibility. “Zoom is very convenient; you can log in from anywhere,” said Sylvia Wu, MD, a third-year internal medicine resident at Donald and Barbara Zucker School of Medicine at Hofstra/Northwell in New York, who is applying for a nephrology fellowship. “During one of our morning conferences, our chairman invited colleagues from different institutes, which was a valuable experience.”

Trainees can catch up on online conferences if they missed them, can rewatch them, and can look for education outside their program or institution. Plus, residents on maternity and paternity leave can choose to watch at their convenience, even though it’s not required, said Samira Farouk, MD, FASN, assistant professor of medicine and medical education at Mount Sinai in New York.

“In the past, we didn’t really have mechanisms to record lectures,” Farouk said. “It’s really allowed us to capture a lot of our teaching materials.” Farouk co-wrote a paper on medical education during the pandemic for Advances in Chronic Kidney Disease (1).

While residents on nephrology elective at Mount Sinai are welcome to attend divisional and fellowship conferences as well, now anyone interested can watch online. “Even if folks are not officially with us, the links are always available, so you don’t have to be on a nephrology elective,” Farouk said. “If you’re a second-year internal medicine resident, you got the email, you thought the topic was interesting, you can always log in to view that recording later. I think this has really opened up the venues for learning.”

In fact, at Farouk’s hospital, they created an all-virtual nephrology residency elective that can be implemented if COVID-19 cases spike and the hospital is forced to shut down programs again. They may also use the online version if too many residents seek a nephrology elective, especially as the hospital follows physical distancing guidelines, and they cannot accommodate everyone in person.

In the virtual program, an attending would serve as virtual elective leader. The residents would do virtual rounds each morning and be assigned real patients. Nephrology faculty worked with electronic medical records (EMR) staff so they will be able to create a separate EMR list for those patients for virtual service. “We would really have a robust curriculum over the two- or three-week elective students may join us for,” Farouk said.

While some nephrology programs had already embraced the use of social media and online gaming to enhance education, that may also increase in residency education. In 2018, the Northwell nephrology fellowship program created a group chat via the WhatsApp platform. It included the program’s eight fellows and seven selected faculty members. At least one multiple-choice question was provided each week.

“To our surprise, there was more discussion in that group than lectures we were giving live,” said Kenar Jhaveri, MD, FASN, professor of medicine and associate chief in the Division of Kidney Diseases and Hypertension at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, who has a special interest in innovative nephrology education. “It actually became more lively during COVID because that was one of the only sources the fellows had for learning,” he said. “Faculty were excited and were posting COVID-related questions with references and explanations. So, we keep doing more of such tools as adjunct while we continue the didactic and live lectures when possible. We feel these parallel learning methods might be adjuncts, but then they might become primary during times like COVID.”

While Northwell’s WhatsApp chat is for fellows, residency programs could develop similar channels. Jhaveri studied Northwell’s use of WhatsApp for teaching and reported on it in Clinical Kidney Journal in February 2020 (2).

Another program that has been widely adopted during the pandemic has been telehealth. While not new, telehealth has provided a safe way for physicians to continue to take care of patients. At the height of the pandemic, most internal medicine residents were treating COVID-19 patients. But as the cases decrease in some states, residents are going back to their previous responsibilities.

This opens the opportunity for more residents to get involved in telehealth visits, said Matthew Sparks, MD, FASN, assistant professor of medicine, director of medical student research, and associate program director of nephrology fellowship at Duke University. Sparks didn’t use telehealth before the pandemic. Suddenly, he was seeing 80% of his patients via telehealth phone calls.

Margaret DeOliveira, MD, a fourth-year internal medicine/pediatrics resident at Duke who is applying for a nephrology fellowship, said it was interesting to see just how quickly telehealth became the prominent way to interact with many patients.

DeOliveira believes telehealth is here to stay, which means it should be taught to residents. “While there is a learning curve, I think it does open up interesting possibilities for how telehealth can be more fully integrated into residency education programs in the future and how all levels of training will be fully integrated into this new system,” she said.

Wu agreed: “We hadn’t been exposed to telemedicine prior to the pandemic, but we got fully immersed in it very quickly,” she said. “I think it’s good to learn telemedicine during residency. That’s a career path that you can think about—doing remote visits.”

One of the challenges of telehealth that needs to be worked out, Sparks said, is how to precept a televisit with residents and fellows. “Do we come on the phone on a three-way call? At what point do you do that? Do you call the patient later and verify?”

Adoption of telehealth could potentially improve a patient’s experience. “There are some patients who have transportation issues,” Jhaveri said. “Let’s just visit their homes through a televisit and only bring them in once a year for a physical exam. Why have them come to every doctor’s visit and put them at risk for falls and infections?”

Jhaveri said he’s excited about using telehealth with dialysis patients, which could enhance physician work-life balance—and attract more residents to the field. Instead of nephrologists rounding to dialysis centers about four times a month per patient, they can, for example, in some stable patients, do three visits via telehealth and see the patient once a month in person. This was allowed and covered by payers during the pandemic and should be made permanent, he said.

Facing the challenges

Of course there have been challenges during the pandemic, and residents’ lack of exposure to nephrology has weighed on faculties’ minds. “Even before COVID, there were challenges with residency education and recruitment in nephrology,” Jhaveri said. Much of that exposure was through a nephrology rotation, but those are electives at most programs.

“During COVID, unfortunately, all electives were canceled for residents, so whatever exposure they could have had to nephrology was also taken away,” he said. “And that was the biggest challenge that we faced because we had no residents doing any electives in nephrology, both inpatient and outpatient. None of these residents had time to do any electives because they were so busy taking care of COVID patients.”

It is possible that residents connected with nephrologists more in the emergency department and ICU, as consults increased. Jhaveri said nephrology consults increased at their health system by 39% at the peak of COVID. He’s heard similar numbers from other institutions. “We saw the residents noticing a lot of us—not just at this hospital but at other hospitals—doctors on the frontlines fighting COVID because 37% of hospitalized COVID patients had acute kidney injury,” he said (3).

As nephrology didactic sessions started back up this summer, Farouk’s first one was about the impact of COVID-19 on the kidneys. All three classes of residents were invited to attend via Zoom, and more than 50 showed up, interested to hear a nephrologist’s firsthand perspective on the virus.

“I think that was also another way to show them an important side of our field, and moving forward, for medical students and residents thinking about subspecialty choices, I think the impact of the pandemic and how it was approached by each specialty is going to have an important role in how they choose a specialty,” Farouk said.

But with the intense pace of care, there wasn’t much time for personal interaction in the emergency department and ICU. In fact, that loss of face-to-face communication has been a detriment during the pandemic.

“Having less personal contact with people has been hard. … I think that’s where we are realizing that education is not just knowledge—it’s getting to know people, it’s social, it’s connections, it’s mentorship,” Sparks said. “I think that it’s important for us to realize that we have to change how we interact with trainees so that we can still provide all those intangible things that make a fellowship program and a residency program amazing and contribute to the career development of the trainee.”

Jhaveri said it’s too early to know how the COVID-related changes might affect nephrology recruitment. “This just happened in February, March, and April of 2020 for the northeastern US. We will only know when we see the fellowship applications,” he said. “If we see an increase in applications in nephrology, then maybe seeing nephrologists be heroes in the frontlines of the COVID war worked (4).

References

  • 1.

    Hilberg R, et al. Medical education during the COVID-19 pandemic: Learning from a distance. Adv Chronic Kidney Dis 2020; in press. doi: https://doi.org/10.1053/j.ackd.2020.05.017

    • Search Google Scholar
    • Export Citation
  • 2.

    Jhaveri KD, et al. ‘WhatsApp®’ening in nephrology training. Clin Kidney J 2019; 13:813. doi: 10.1093/ckj/sfz045

  • 3.

    Hirsch JS, et al. Acute kidney injury in patients hospitalized with COVID-19. Kidney Int 2020; 98:209218. doi: 10.1016/j.kint.2020.05.006

  • 4.

    Parikh R, et al. The war we call COVID-19: A letter from the front in New York. Am J Kidney Dis 2020; 76:A13A14. doi: 10.1053/j.ajkd.2020.05.007

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