Nephrology Fellow Mental Health and Well-Being during the COVID-19 Pandemic

While the coronavirus infectious disease 2019 (COVID-19) pandemic has significantly affected all health care workers, graduate medical education (GME) trainees have been especially impacted. The personal and professional obstacles faced during GME training are unique compared to those that attending physicians face, as trainees are concerned not only about protecting their patients and loved ones, but they also have additional stressors related to attaining the skills necessary for independent practice, advancing their research, ensuring education goals are attained, securing a job, and passing their board certification exam, among others. A recent national survey assessing the impact of the pandemic on cardiovascular fellows found that 69% of respondents were concerned about fulfilling their training requirements (1). While a recent study done in the UK showed high burnout rates among nephrology trainees during the pandemic (2), little is known about how the various stressors related to training during the pandemic have specifically burdened North American nephrology fellows, a group that already suffers from significant burnout (3). Two recent initiatives spearheaded by the American Society of Nephrology (ASN) sought to answer some of the questions surrounding the mental health, professional development, and overall well-being of nephrology fellows.

One of these initiatives took place on January 13, 2021, when ASN hosted a 90-minute, virtual COVID-19 roundtable unlike any it had held previously. This roundtable was unique in that it was created for and led by fellows in adult nephrology. The panelists and audience members consisted entirely of nephrology fellows from the United States and Canada. Two guest faculty members from New York, Dr. Daniel Cukor and Dr. Jia Ng, experts in the fields of GME behavioral health and COVID-19 response, respectively, also helped facilitate the roundtable. The forum was organized to discuss the COVID-19 pandemic from fellows’ perspectives in an environment conducive to facilitating constructive dialogue. Difficult topics were discussed, personal testimonies were shared, and institutional policies compared.

The second initiative was a survey sent out in August 2020 to 1005 current and recently graduated adult and pediatric nephrology fellows from the United States, which received 425 responses (42% response rate) (Figure 1). Themes of the survey focused on the effect of the COVID-19 pandemic on trainees’ experiences and well-being. Pivert et al. (4) reported on the results of this survey in JASN.

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The COVID-19 pandemic and US nephrology fellow training and well-being

Citation: Kidney News 13, 4

Reference: Pivert et al. (4).

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In the first segment of the roundtable, titled “The COVID-19 Experience,” the mental health of trainees was highlighted. The initial discussion focused on emotions felt early in the pandemic, of which fear was ubiquitous, especially in the hotspots. Several themes emerged, such as fear of getting infected, fear of infecting a loved one, and the fear of not being able to get back into the country as an international medical graduate. The personal stories shared were heart-wrenching. Another common theme was sadness. Having to see patients sick and dying with COVID-19 day in and day out was a lot to bear. However, having to do this while also witnessing rampant anti-Asian sentiment, racial injustice against Black individuals, and communities of color disproportionately burdened by the pandemic weighed heavily on many of the trainees.

Feelings of loneliness were also quite common, with some fellows preferring to be at the hospital, just so they did not have to deal with the isolation that came with being at home. Importantly, the majority of fellows stated that their programs provided resources and outreach to improve fellow well-being. Despite these good intentions from the fellowship programs, some of the negative downstream effects of these emotions were captured in fellow responses on the survey (4), with 42% of respondents indicating that the pandemic had a negative effect on their overall quality of life (QOL) and 33% stating it negatively affected their work-life balance (Figure 1). Additionally, residents who completed the survey filled out a tool called the Resident Well-Being Index (RWBI), which is meant to correlate with QOL, fatigue, meaning in work, and burnout, among other things, with a score of 5 or greater (on a 0−7 scale) consistent with distress (5). Surprisingly, only 15% of respondents actually met this distress threshold, a much lower number than expected, demonstrating the resilience of fellows during the crisis (Figure 1). The authors theorize that this unexpected finding could have been related to the sense of unity and purpose that nephrology fellows felt being on the front lines. However, another possibility may be related to some themes that came up during the second half of the roundtable discussion.

During the final 45 minutes of the roundtable, titled “The Division Experience,” the focus shifted from trainee mental health to how individual institutions managed fellow safety and education. It became clear after hearing multiple testimonies that many institutions diminished or eliminated the need for fellows to perform daily physical exams on patients with COVID-19, in an effort to both limit spread and protect trainees. This was consistent with the survey results (4), which showed that 64% of fellows did not have any in-person consults on inpatients with COVID-19 (Figure 1). Of the fellows who did perform consults on these patients, 27% reported managing them via telehealth, 29% by in-person visits by faculty without fellows, with another 9% taking a different approach. The fellows at the roundtable made it clear that they strongly appreciated the efforts taken by their programs to protect them. Additionally, one of the most difficult aspects of the pandemic—the lack of resources in hotspots like New York—turned out to be an invaluable learning experience for many trainees. With limited resources to perform kidney replacement therapy (KRT) given the large number of patients who required it, nephrology divisions had to become creative. This included atypical uses of modalities such as emergent peritoneal dialysis and sharing continuous KRT (CKRT) machines. Even dialysate supplies ran short, requiring the repurposing of peritoneal dialysate to be used during CKRT.

And what about learning outside of the hospital? While most fellows had scarcely, if ever, used remote learning prior to the pandemic, 76% of survey respondents said that at the onset of the pandemic, all conferences shifted to online only. With these massive changes in nephrology education, it would not have been surprising if trainees felt negatively impacted. However, the majority of survey respondents indicated that despite all of these changes, they did not feel that their professional development was affected significantly. In fact, >80% of fellows and graduates felt their training programs had successfully maintained their education throughout the pandemic, with only 24% of respondents expressing concerns about sufficient case variety and clinical experiences. Nearly 90% of respondents felt prepared for unsupervised practice (Figure 1). These findings were noticeably more favorable than what was seen among UK nephrology trainees, in which >75% of respondents noted they had reduced access to specialty clinics, transplantation, and procedures (2).

Now more than 1 year since the beginning of the COVID-19 pandemic and with the emergency-use authorization of three COVID-19 vaccines creating a metaphorical light at the end of the tunnel, it is easier to look at some of the positive aspects these ASN initiatives revealed. Nephrology fellows, despite dealing with significant stressors during the COVID-19 pandemic, have largely remained optimistic. They have taken a terrible situation and somehow managed to find a silver lining. Nephrology fellowship programs in general showed they cared about the well-being of their trainees, and this was clearly appreciated given the survey responses and roundtable testimonials. However, we must remember that trainees are a heterogeneous group, and although the majority of fellows may have weathered the pandemic better than expected, we cannot ignore the individuals who are not all right, many of whom may be suffering in silence. Furthermore, although the survey had a 42% response rate, that means we still do not have any idea of the feelings of more than half of the fellows in the country. Nephrology fellowship programs need to continue to provide mental health resources and outreach to their trainees. Moreover, we as fellows need to continue to have the difficult conversations surrounding our own struggles and well-being. By normalizing this type of discourse now, we can ensure that openness, honesty, and discussing shared experiences are the legacy that we leave to the next generation of trainees, long after the end of the pandemic.