The COVID-19 Pandemic and Pediatric Graduate Medical Education

Abstract

The coronavirus disease 2019 (COVID-19) pandemic has changed the landscape of pediatric graduate medical education. We anticipate that pediatric residents and fellows will acquire new skills to carry with them as practicing pediatricians of the future. Here, we present the collective observations of a resident, fellow, and hospitalist, with the intention of highlighting the challenges and opportunities in trainee education during this unusual and unpredictable time.A central tenet in medical education is that spending time at the bedside is best: examine your patients and then examine them again. As Osler observed, “Medicine is learned by the bedside and not in the classroom,”1 and “We miss more by not seeing than we do by not knowing.”2 In a time when the Centers for Disease Control and Prevention is releasing guidelines to conserve personal protective equipment3 and the public is being asked to distance themselves both socially and physically, thoughtful decisions are being made as to who should examine the patient and how often. In this environment, direct patient interaction is limited, and this central tenet of medical education must be reexamined.Although encounters with inpatients are modified, live outpatient encounters conducted by trainees are near nonexistent. Although some trainees are participating in virtual visits, this opportunity is not yet available to all trainees, and many of the continuity relationships cultivated through well-child checks and routine examinations are on hold. With that, the opportunities to counsel on preventive health, manage chronic disease, and become familiar with less acute yet crucial physical examination findings are lost.Social and physical distancing guidelines have interfered with the interactions of trainees with the larger interdisciplinary team. Impromptu visits to review imaging with radiologists or slides with pathologists are canceled, and recommendations by consulting teams are now transmitted by phone. Nutritionists and social workers no longer come by to share their impressions. Many trainee-led research and quality improvement projects have been put on pause. The once bustling community of academia that had enlivened medical trainees’ days and nights is now eerily absent from the hospital, leaving in its place a unique sense of self-isolation.In the current climate, traditional teaching at the bedside on rounds is on hold in the name of efficiency and social responsibility. Noon case conferences are canceled amid the hospital’s efforts to reduce group interaction and infectious spread. Virtual noon case conferences have been piloted but require lecturers and learners to familiarize themselves with teleconference platforms. Although trainees have expressed appreciation for the creative and innovative approaches being developed by educators, it is hard to ignore that question of whether trainee education is worth pursuing amid a pandemic.Trainee rotation schedules and clinical experiences have been significantly altered during the pandemic as a result of canceled clinic visits, decreased inpatient volume, postponed elective procedures, and dramatic changes to staffing protocols that limit the number of trainees in the hospital. Trainees, therefore, may no longer meet their traditional graduation requirements. Although the American Board of Pediatrics and Accreditation Council for Graduate Medical Education have announced flexibility in meeting these requirements,4,5 trainees and program directors still wonder if trainees have acquired the competencies expected of program graduates before moving on to their respective fellowships or attending positions.There is no doubt that those residents and fellows who are training during the COVID-19 pandemic will come away from the experience changed by it. Given the cancelation of traditional educational opportunities, trainees on the “front lines” may feel that emphasis is now tilted toward “service” on the service-learning spectrum.6 We are optimistic, however, that trainees will emerge from this global pandemic as uniquely skilled doctors, able to call on the approaches to clinical decision-making, patient communication, health system navigation, and self-directed learning acquired during this difficult time.In the face of a pandemic and the necessary staffing changes, trainees will need to consider when to escalate care, when their examination is and is not sufficient to determine the next steps in a patient’s care, and when the use of personal protective equipment is more important than its conservation. Trainees will need to maximize every moment spent in patient rooms to limit unnecessary exposure, learning to perfect an efficient, tailored physical examination. As trainees become more comfortable with committing to independent assessments, they may be entrusted with increasing patient care and pushed more frequently to their zone of proximal development.7Those training during the COVID-19 outbreak will adapt to become more effective communicators within the constraints of social distancing. On inpatient rotations, they will be challenged to paint the medical and psychosocial picture for providers who cannot enter the room. They will learn to make patients and their families feel heard, even when live encounters are replaced by virtual visits: when a sympathetic look through a screen is the closest they can get to holding a patient’s hand. Trainees will listen to their patient’s worries about the evolving pandemic and reassure them, when able, while also recognizing that there are limitations to the reassurance they can provide in a world of unknowns. As telehealth technology becomes increasingly available, trainees will also become adept at conducting virtual outpatient visits, learning to foster relationships from afar.In addition to learning how an individual patient fits into the larger health care system, trainees now must also learn how to triage effectively during a global pandemic. Is the safer recommendation for a patient with cystic fibrosis and worsening cough to come in or is it to stay home and avoid a busy emergency department? What are the benefits to care provided virtually and what are the limitations? What is the value of a well-child check? Is that value changed in the current climate? Given the limited resources during the COVID-19 outbreak, trainees will learn creative problem-solving skills and gain a practical understanding of the relationships of value, cost, and quality to medical care.Today’s trainees will need to educate themselves about COVID-19 (the epidemiology, clinical manifestations, and management) but also ensure that their general training continues to be well rounded. We predict that trainees will identify gaps in their knowledge and fill these gaps with self-directed learning. In the hospital, they will seek out one-on-one and small-group teaching along with just-in-time online and virtual resources. At home, they will learn alternative ways to supplement their missed clinical experiences. The COVID-19 pandemic will further motivate program leaders to partner with trainees to customize their learning, and we anticipate that this increased attention to individualized learning will continue after the pandemic.We believe, in the years to come, we will look back at this experience and celebrate how this crisis helped to shape some of the most clinically savvy, knowledgeable, and resourceful physicians yet.We are proud to count ourselves among the trainees and educators whose experience will be shaped by the COVID-19 pandemic and feel privileged to work beside all of the clinicians and scientists who will help return the world to wellness.

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