The Immediate Impact of the Coronavirus Pandemic and Resulting Adaptations in Physical Medicine and Rehabilitation Medical Education and Practice

Abstract

Since January 2020, the coronavirus disease 2019 (COVID-19) has swept across the United States affecting all facets of the population. As of the end of May 2020, there have been over 100 000 deaths in the United States attributed to the infection.1 COVID-19 has put an unprecedented strain on the U.S. healthcare system. In Physical Medicine and Rehabilitation (PM&R), the scope of challenges varies greatly depending on location, practice setting, and subspecialty.2 In some states where the outbreak was especially severe, such as New York, many physiatrists found themselves working on the front line.3 For doctors with outpatient practices, telemedicine visits became the new normal.4 This pandemic not only shifted the medical practice of PM&R but also had a great impact on medical education.5 Fellows and residents faced alterations in their schedules and routines as many were redeployed to other services to work with COVID-19 positive patients in the emergency department, intensive care unit, or other medical unit.3 In an effort to not slow education, didactics and other learning opportunities moved to the virtual realm.3 PM&R societies and subspecialty organizations hosted daily didactics for interested learners and webinars on navigating care during COVID-19. Medical students also felt the impact of the global crisis as in-person classes were moved online, clinical rotations were canceled, and board exams were postponed.6, 7 Changes in work environment and policy standard as a result of COVID-19 posed great challenges for the entire field of physiatry. At every level, these challenges gave way to opportunity for innovation using available technologies. To understand the immediate impact of the COVID-19 pandemic on PM&R medical education and practice, and gain insights into how technology was leveraged for health care and education, the experiences and insights from persons within, or committed to, PM&R were pooled. This information was utilized to create an anonymous survey that was distributed online to the PM&R community. We also share portions of the personal accounts used to inform the surveys as they offer unique perspectives on the impact of COVID-19 on PM&R. This study was classified as exempt by the institutional review board at the University of Texas Health Science Center at San Antonio. In an attempt to capture the mood and environment of the time, and inform the survey, the investigators compiled experiences and feelings of COVID-19's effects on the landscape of the field of physiatry from persons committed to the field: a medical student, an intern, a resident, a residency program director, and a department chair. Using these compiled experiences and opinions, the survey was designed with the goal of determining the adoption of the use of virtual patient care and education modalities in PM&R during the COVID-19 pandemic. The survey was designed to provide a series of questions customized to the responder's level of education (medical student, intern, resident/fellow, or attending physician). Once each responder selected their level of education, they received a tailored set of questions to gauge their challenges and experiences with education and patient care. Regardless of survey track, the electronic survey consisted of a series of approximately 15 questions. Responders to the survey answered multiple choice, short answer, and Likert scale questions. The survey is available online here: https://bit.ly/2TBBqrT. Participants from the field of PM&R and medical students interested in the field were invited to participate in the anonymous electronic survey that was distributed online via Google Forms, through social media platforms, and via email by way of program coordinators and program directors at the 93 Accreditation Council for Graduate Medical Education (ACGME) accredited PM&R residency programs in the United States. No identifying information was collected, and all responses were kept anonymous. The survey's online dissemination and anonymity prevented the ability to calculate a response rate. Responses were collected from 21 April 2020 to 30 April 2020. Responders were medical students and interns committed to PM&R, PM&R residents, PM&R fellows, and attending physiatrists. Descriptive statistics were evaluated for each level of education separately to summarize the descriptions of single variables for each group (ie, percentage responses). Chi-square and Kruskal-Wallis H tests were performed on the Likert scale data by converting each answer (strongly disagree-strongly agree) to an ordinal value (1-5). Our analysis focused on each individual level of education independently and did not look at the differences between these groups. All statistical analysis was conducted using SPSS Statistics (SPSS for Mac OSX, Version 26.0.0.0, IBM Corp., Armonk, NY). The survey was completed by 501 people including 178 (35.5%) attending physicians, 183 (36.5%) residents and fellows, 29 (5.8%) interns, and 111 (22.2%) medical students. One resident began but did not complete the survey. Thirty-nine states were represented, as well as the District of Columbia and Puerto Rico. The states most represented were Texas (20.1%), New York (10.9%), Pennsylvania (9.9%), Illinois (6.4%), and Ohio (6.2%). Responses from other states represented <5% of the sample each. Demographics of those responding to the survey are reported in Table 1. Of the 178 attending physicians responding to the survey, 84.3% spent a majority of their time in patient care prior to the viral outbreak. This decreased to 60% following the outbreak. Physicians spending most of their time doing administrative work increased from 10.7% to 26.3% after the outbreak. Prior to the outbreak, physicians responding to the survey were evenly distributed across inpatient and outpatient work settings. After the outbreak, a majority of physicians reported telehealth as being their main workplace. Many others responded that they were now working in a completely inpatient setting with 7.3% of responders noting a redeployment to inpatient medicine teams (Table 1). A small minority of physiatrists reported using telehealth for patient care before the pandemic. This number increased to over 86% after the viral outbreak (Table 2). Following the start of the pandemic, the majority of attending physicians responded agree or strongly agree to the question, “I feel comfortable with telehealth.” A summary of attending physician opinions on telehealth can be seen in Figure 1. At the time that the survey was collected, most physicians reported that they felt that telehealth visits were inappropriate for an initial patient encounter. However, 82.5% of the same sample felt that the service was sufficient for follow-up visits (Figure 1). Almost all physicians responding to the survey also felt that telehealth is going to play a larger role in patient care after the COVID-19 pandemic (Figure 1). The number of physicians utilizing telehealth after the viral outbreak increased in all practice settings, with the largest increase being an 84.5% increase in physicians practicing in a mixed inpatient/outpatient setting. The changes in telehealth use from before to during the pandemic can be visualized in Figure 2. Physicians who were practicing in mixed outpatient or completely outpatient settings were significantly more comfortable with telehealth use than those who worked mostly or completely in inpatient rehabilitation (χ2(4) = 19.180, P = .001). Practice setting prior to the viral outbreak had no impact on views of the future of telehealth within the field (χ2(4) = 5.127, P = .275). These results can be seen in Figure 3. Before COVID-19, PM&R trainees, as would be expected, worked in a variety of settings, evenly distributed through inpatient and outpatient services. Following the outbreak, most residents shifted to inpatient rehabilitation services with 13.5% of residents being redeployed to non-PM&R services (Table 1). Only 20.3% of residents reported attending virtual lectures prior to the virus. This number grew to more than four times the amount after the COVID-19 pandemic (Table 2). Half of trainees responding to the survey reported that their institution collaborated with other institutions for virtual didactics. A total of 78.6% of residents reported having either attended didactics from other institutions or hosted by a national organization during the pandemic. Of the residents surveyed, 76.4% enjoyed virtual didactics and the majority of residents felt that they were as effective as in-person didactics; 52.2% felt that this new platform was the future of resident education. Residents who attended virtual didactics provided by other residencies or national organizations were more likely to report that they enjoyed virtual didactics in general (χ2(4) = 9.881, P = .020), thought they were as effective as in-person didactics (χ2(4) = 11.509, P = .021), and preferred them to in-person didactics (χ2(4) = 10.477, P = .033). Residents' opinions of virtual education can be viewed in Figure 1. Before COVID-19, interns worked in a variety of settings across inpatient and outpatient medicine, with 65.6% working in the inpatient setting. After the outbreak, 98.7% found themselves working on inpatient medicine team, or in the emergency department (Table 1). Approximately one third of interns surveyed had their United States Medical Licensing Examination (USMLE) Step 3 or Comprehensive Osteopathic Medical Licensing Examination (COMLEX) Level 3 exam canceled because of the outbreak. Virtual didactics were available to less than a quarter of interns that responded to the survey prior to COVID-19 and almost universally to all of them after the pandemic (Table 2). Interns' opinions of virtual education can be viewed in Figure 1. Of medical students who responded to the survey, 87.5% had scheduling of their USMLE Step 1 or COMLEX Level 1 affected and 55% had scheduling of their USMLE Step 2 or COMLEX Level 2 affected. In addition, 94% of students that responded to the survey had scheduling of fourth year elective rotations affected and 60.4% of fourth-year medical students who responded to the survey had their graduation date affected. Virtual lectures were more common at all times among medical students who responded to the survey with 51.8% of first- and second-year medical students reporting having attended online lectures prior to the outbreak and 100% of students reported attending lectures online after the pandemic. A majority (62.9%) of students felt that online learning makes them more productive and 62.5% of students will seek out further virtual learning opportunities after the pandemic. Additional students' opinions on virtual education can be seen in Figure 1. PM&R has felt the impact of the global crisis, and day-to-day activities of both patient care and education have been greatly affected, as demonstrated by our survey results of attending physicians, trainees, and students in the field of PM&R. Many physicians saw a shift in their work environment and residents had to adjust to new services and modes of education. The severity of the pandemic led to some physiatrists and residents in epicenters to work on the frontlines. Practice settings may continue to be affected for some time as COVID-19 patients survive the acute illness and transition into a post-acute phase of rehabilitation. In order to capture the environment at the time that this survey was completed, we have chosen to include extended portions, both in table and narrative form, of the personal perspectives obtained when formulating the survey (see the Limitations section and Table 3). Difficulty maintaining resident education for ACGME and for board exam preparation Physicians quickly made the adaptation to using telehealth as the viral outbreak evolved with the percentage of physiatrists using telehealth increasing from 14.6% to 86.5% of physicians. The use of telehealth was seen to ubiquitously increase across all practice settings, regardless of the percentage of time spent in the outpatient setting. Although many physicians did not think that the service was amenable to initial patient visits, they did believe that telehealth had value for patient follow-up. Most physiatrists responding to the survey felt that telemedicine will be utilized to a greater extent as the medical community moves forward from the threat of COVID-19. This sentiment was not affected by the work setting of the responder of the survey, further indicating that the use of this platform may continue by all members of the field. Physicians who practiced more in the outpatient setting prior to COVID-19 felt more comfortable with the use of telehealth than those who spent a majority of their time in the inpatient setting. Despite this, all attending physicians showed a rapid adaptation of telehealth. This finding mirrors some findings of a recent survey study focused on one outpatient sports medicine department that found that most patients found value in their telehealth visits, nearly all of the physicians in the study rated their experience with telehealth positively and all of the physicians in the study planned on using telehealth if reimbursement for the service continued.8 This use of telehealth has rapidly expanded because of a waiver from the Center for Medicare and Medicaid Services (CMS), and organizations like the American Medical Association (AMA) plan on fighting to maintain these new policies post pandemic.9, 10 There are barriers to the use of telehealth including difficulty in communicating with patients with sensory disability, the inability to perform a majority of the physical exam, and technological faults.8 The use of telehealth within physiatry will most certainly be an area for deeper evaluation and reflection. Not only were clinical patterns changed by COVID-19, but so was education. Medical education of trainees and medical students could not continue in the same way given the new safety considerations brought on by COVID-19. Still, educational opportunities had to continue in order to prepare residents for board exams and maintain national accreditation standards (ACGME) as much as possible.11 Many residents had virtual lecture and education experiences in medical school; however, this was not the norm in residency with only 19.9% of residents reporting virtual didactics pre-COVID-19. With over 90% of residents reporting attending virtual didactics after the viral outbreak, it is clear that this was an adjustment made by residency programs to continue providing the training their residents required. Residents that attended virtual didactics from other residency programs and national institutions had a significantly more positive outlook on virtual didactics, with 60.9% who attended collaborative didactics finding virtual didactics to be as effective as in-person didactics, compared to 38.4% of the cohort who did not attend collaborative virtual didactics sharing this sentiment. Similarly, 81.2% of the residents who attended collaborative didactics found virtual didactics to be enjoyable compared to only 59.0% of those that did not attend collaborative didactics. This model of communal and virtual education affords the ability to consistently provide high quality lectures from leaders in the field to all trainees and could aid in standardizing didactic education across programs. There are clear limitations to the virtual education model as many didactic sessions have a hands-on focus such as ultrasound skills and injection technique, which can be lost by using a virtual platform. Despite limitations, virtual education has the potential to enhance traditional medical education following the resolution of the pandemic. Postponement and cancellation of examinations and elective rotations will have ramifications on the 2021 residency match cycle and beyond and may affect interns as they transition into their first year of PM&R training. Almost a third of current interns had their board exams rescheduled and may be forced to take exams during their PM&R residency. Preparing for their final USMLE or COMLEX exam as they start their physiatry residency may have an impact on their transition to the field. Additionally, the medical school class of 2021 faces new challenges during the residency application cycle as the AAMC along with other national organizations have advised against away rotations and have recommended that all residency interviews be held virtually.12 These changes and challenges may have lasting impacts on the incoming PM&R residents for the upcoming residency application cycles. Although this study focused on the technological impact of the COVID-19 pandemic, the burden the crisis imposed was widespread and variable. Future areas of study should focus on the economic impact on the field of physiatry, and operational changes of the virtual that were forced to take to the of care Our study has limitations, including the results of this survey. of the of the survey being online, it is not to calculate a response rate. Although the survey was with all residency program directors and program coordinators in the to the anonymity of the survey we could not which institutions responded to or the Although a response could not be it has been found that for a survey with no response is approximately by on a virtual platform there may be responders with a to the use of virtual To the findings of the survey, we and share from the personal accounts and opinions that were used to create the survey. We felt these not to the and of the environment the field of physiatry at the time the survey was Medical students and because of changes to of medical education. of board exam with from and among those who spent After of their and themselves for the residency application medical students are with the the of elective rotations and In to of match and fourth-year students had to the of the of year during a pandemic. and those on the front Although the crisis and provided challenges to some found opportunities for and innovation to their medical and also their The and future for medical students can be found in Table 3. training during COVID-19 pandemic completely Medical examinations were canceled, along with didactics, and hands-on and virtual education became the new had to quickly the effects of this crisis, including the of their medical education in the an during COVID-19 was unique and provided a of and However, there was the opportunity for residency programs and trainees to and resident medical education an during COVID-19 pandemic was on many These challenges interns to and than they would have and a and for their practice of on and future for interns can be found in Table 3. COVID-19 in 2020 was most in the U.S. medical were not of the threat that COVID-19 would of the and effects of COVID-19, PM&R residents began the and potential on their experience as was spent the number of and learning more the disease from Although some PM&R residents, including many in New York would participate in acute medical care of persons with COVID-19 to high disease burden on their the majority of the shifted their focus to inpatient rehabilitation and clinical as by our survey were by virtual at the level of national societies and The use of clinical is of to One model that was by some PM&R the use of teams to inpatient resident The was inpatient burden residents from residents were available to provide care if some were This also and in a unique way and program as residents work more to one and on and future for residents can be found in Table 3. PM&R residency programs didactic resident and more in order to training of their residents to all COVID-19 has and to strain these in a of new and One of the most this is is through There is no but it is that PM&R residency education during the time of COVID-19 is For many programs in New York have been with residents redeployed to general medicine or intensive care These residents are working and are and from working on these services. not have time, are they to study PM&R or attend PM&R didactics. many programs in other states the are not emergency but are limitations in education to social The PM&R community has and programs are sharing online and virtual education with one is to during this time in residents or PM&R is made of many however, most trainees did not PM&R they would with daily and The of such could certainly to or many residents, their or are affected by COVID-19. can a resident be to for one of their is in the other residents to in this Regardless of resident physical can take over time and the most of a residency program is providing a of community and In the all residents are and all should be with and feel this of the new of PM&R education in the time of COVID-19 will The and future for program directors can be found in Table 3. Many at the level during COVID-19 have been required. have many patient and In PM&R, we have an that the physical medicine and rehabilitation. Although some in the inpatient rehabilitation setting may have seen to their daily the role of the outpatient PM&R physician and elective were canceled and there is now more of As we from experiences the COVID-19 pandemic, we have to in the way we care. this changes in how a patient is being For an attending physician may be the only one a patient or may have to all visits via patient care and education will there to be and with and and a is in this There be that of and will be high in this and health services should be and trainees may have personal for with may also be given of and being a department should create a to create a new as we continue in this pandemic. The and future for the can be found in Table 3. The COVID-19 pandemic has every of the medical in the United States. The field of PM&R has had to quickly to the rapidly burden of the global Although these changes have many patient care and education, they have also provided the opportunity for adaptation and by to virtual modalities for patient care and education. The survey provided that PM&R physicians made the transition to telemedicine to provide care to Responders to the survey also the of residency programs and national organizations across the to provide lectures through virtual to maintaining educational The pandemic provided that PM&R to traditional routines in medical education and to new to enhance educational and patient As the field moves forward and the pandemic the will continue to the of patients and education of We use of these new virtual to enhance patient care and education.

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