In December 2019, when Chinese authorities alerted the World Health Organization of cases of pneumonia in Wuhan City, for which they were unable to identify a known cause, little did we know that this was just the tip of the iceberg that would leave us with (to quote a Lin-Manuel Miranda song title in “Hamilton”) a “world turned upside down.”
None of us signed up for this. There was a realistic fear of death to health care workers who were already taxed beyond what anyone could imagine. They may have questioned, “Will my patient die because of a bed or ventilator shortage?” “Will I bring this plague home to my family?” Furthermore, almost everything changed. Shopping, travel, dining, and family holidays had new definitions and restrictions, and social distancing required us to completely rethink how we provided medical education, something that up until now was always done on an in-person, hands-on basis. As a nephrology training program director for 20 years, nothing was more threatening to our fellowship's goals than COVID-19. We had to worry about our fellows’ physical safety and mental health, in addition to fulfilling our academic obligation to excellent training. We quickly became experts in video conferencing for lectures and conferences and “virtual” patient visits. In fact, we essentially became a virtual training program.
Not all of these mandatory changes were bad. In fact, I could argue that many were a silver lining to the COVID-19 cloud. Video conferencing made it easier to be present for curriculum activities, and thus both fellow and faculty “attendance” improved considerably. Being in front of our computer screens also allowed each of us to screen-share any information in real time. Additionally, these activities could be easily recorded. Still, we all missed human contact.
The above observations, however, are my perceptions and may not reflect those of our trainees. That is why “Nephrology Training in the Time of COVID-19. The 2021 ASN Nephrology Fellow Survey” is such an important document (1, 2). Although a number of topics were explored in the survey (Table 1), as a program director, I was most interested in fellows’ perception of how the pandemic affected their training. Additionally, I was very concerned about the mental health of the fellows who I believed were at risk of some form of posttraumatic stress disorder.
Main findings of the national nephrology fellow survey
From the standpoint of training, 83% of the respondents felt that their education was successfully maintained, and 87% felt they would be prepared for independent practice upon graduation. Only approximately 10% felt that their educational training was not sustained. These are encouraging data and speak to the resiliency and flexibility of faculty and fellows. From my personal experience, our fellows were extremely helpful in making this virtual transition. In fact, because of the ease of providing lectures and conferences over the internet, their suggestions led to an increase in our curriculum's teaching activities.
Fellow mental health was reported as a Resident Well-Being Index (RWBI), a measure of “burnout” and general mental quality of life. For this RWBI metric, we are presented data from 2020 and 2021, and the pandemic has clearly taken its toll. Over this single, 1-year period, fellows considered at a “distress level” went from 17.5% to 27.2% for women and from 12.6% to 17.7% for men. Whereas the long-term impact of this is not known, this may be the most important message from the survey and stresses the need for an open dialog between faculty and fellows that requires regular inquiry into fellows’ level of stress, anxiety, happiness, and sense of workload. This must remain a priority even after the pandemic and emphasizes the need for training institutions to have easily accessible and confidential free counseling.
Finally, I want to end this on a more optimistic note. Figure 12 of the survey (see Figure 1 below) demonstrates that since 2014, despite the doom and gloom of decreased nephrology fellowship match success and the less-than-optimal nephrology board pass rates over this time period, there was a persistent increase in the percent of fellows who would recommend nephrology to medical students and residents, from a low 70% to a high 80%.
Indeed, we did not ask for this, but we are doing better than I would have predicted. Still, we cannot let down our guard. But as it now appears in early 2022, there is light at the end of this dark pandemic tunnel, and it just may lead us to a better educational place.
American Society of Nephrology Alliance for Kidney Health. Nephrology training in the time of COVID-19. The 2021 ASN Nephrology Fellowship Survey. 2021. https://data.asn-online.org/reports/fs_21/
Pivert KA, et al. Impact of the COVID-19 pandemic on nephrology training and well-being in the United States: A national survey. J Am Soc Nephrol 2021; 32:1236–1248. doi: 10.1681/ASN.2020111636