Abstract
Background
The COVID-19 pandemic has impacted the residency experience for physicians across all specialties. There have been studies examining resident perspectives on changes in curriculum and clinical experiences due to the pandemic; however, little research has been conducted on how residents in different specialties interpreted their educational experience and rates of burnout during the pandemic.
Methods
We extended surveys to 281 residents across 15 separate residency programs between November 17, 2020, and December 20, 2020. The questions pertained to burnout and the effects of the pandemic on their careers. Differences between general and specialty medicine resident responses were analyzed using descriptive statistics and the Mann-Whitney U test.
Results
The final analysis included 105 responses (40% response rate). We received 62 surveys (59%) from general medicine residents and 43 surveys (41%) from specialty medicine residents, with a higher response rate from junior level trainees in both groups. We found no significant differences between general and specialty residents on the level of burnout, impact on clinical experience, or future career due to COVID-19, though there was a significant difference between resident groups on the perceived impact of COVID-19 on learning.
Conclusion
Specialty medicine residents reported a negative perception of the pandemic’s impact on their learning during residency suggesting a greater impact on training than was perceived by the general medicine residents. Residents from general and specialty medicine programs reported similar levels of burnout and similar perceptions of the pandemic’s impact on their clinical experience and future career prospects. Understanding the impacts of the COVID-19 pandemic on resident education and well-being should serve graduate medical education administrators well and prepare them for future interruptions in the traditional learning process.
Keywords: COVID-19, pandemics, professional burnout, psychological well-being, wellness, well-being, graduate medical education, internship and residency, surveys and questionnaires
Introduction
The COVID-19 global pandemic has had a substantial effect on graduate medical education (GME) across all specialties. At the time of this writing, there have been more than 7 million deaths worldwide due to COVID-19.1 The role of residents during the pandemic differed widely across hospital systems, ranging from reductions in clinical duties to decrease viral spread, increased medical responsibilities secondary to hospitals functioning over capacity, to complete care management in COVID-19-specific intensive care units.2 An increase in average working hours or repeat deployment to COVID-19 wards had a significant negative impact on resident morale,3 and the limitations to obtaining adequate personal protective equipment (PPE) for residents with direct COVID-19-patient exposure have previously been associated with increased overall anxiety.4 A number of studies comparing resident burnout during the pandemic versus before the pandemic demonstrated increased overall rates of burnout.5,6 This is in comparison to recent retrospective survey-based reports that did not support a significant difference in residency burnout pre- and post-pandemic during the initial 6 months of global spread,7 illustrating the need for further study of resident burnout during global pandemics.
The differential impact of pandemic-driven changes in GME on general medicine versus specialty care residency programs has not been thoroughly studied. In one study examining the difference in impact of pandemic-driven changes on GME, senior residents believed the COVID-19 pandemic was more disruptive to their residency compared to junior residents,4 with greater fears of potential career impacts. There is a need to quantify the disruption, identify the impact on current burnout rates, and identify opportunities for intervention by GME administrators to mitigate the adverse effects of potential deficiencies in experience.
To identify resident burnout and the impacts of COVID-19 on GME, in addition to the need for additional resident support, we surveyed residents within the HCA Healthcare system, a for-profit health care system that operates 186 hospitals across the United States and the United Kingdom. Our primary objective was to compare the effects of the COVID-19 pandemic on education, burnout, and help-seeking behavior between general and specialty medicine residents.
Methods
In our analysis, we used one question from the Mini-Z burnout inventory and 3 COVID-19-related questions based on the questions developed by Rana and colleagues.4 The Mini-Z burnout inventory has been validated in many previous studies,8,9 and the use of a single item from Mini-Z (“Own definition of burnout”) has also been shown to adequately capture burnout.10,11 The survey developed by Rana and colleagues was not validated, as it was developed during the COVID-19 pandemic, and no other comparable instruments existed at the time.4
The survey was issued to 281 residents across 15 HCA Healthcare residency programs with a survey response window of November 17, 2020, to December 20, 2020. We received 115 responses (40% response rate). The respondent characteristics are summarized in Table 1. Due to the ordinal nature of the data, a Mann-Whitney U test was used to compare residents from programs designated as specialty medicine to residents in programs designated as general medicine. Three COVID-19-related questions and a single question about burnout from the Mini-Z burnout inventory were analyzed. When interpreting the mean and median for self-reported burnout, participants were given a scale of 1 to 5; higher numbers equated to a stronger feeling of burnout. When interpreting the responses to the 3 COVID-19-related questions, lower numbers equated to more negative feelings, while higher numbers equated to more positive feelings. This study received an Institutional Review Board exemption.
Table 1.
Demographic Information for Participating General Medicine and Specialty Medicine Residents
| General medicine (n = 62) | Specialty medicine (n = 43) | |
|---|---|---|
| n (%) | n (%) | |
| Age | ||
| 18–24 | 2 (3) | 0 (0) |
| 25–34 | 48 (78) | 35 (82) |
| 35–44 | 12 (19) | 7 (16) |
| 45–54 | 0 (0) | 1 (2) |
| Gender | ||
| Female | 27 (44) | 24 (56) |
| Male | 35 (56) | 19 (44) |
| PGY level | ||
| PGY 1 | 25 (40) | 12 (28) |
| PGY 2 | 17 (27) | 13 (30) |
| PGY 3 | 18 (29) | 7 (16) |
| PGY 4 | 1 (2) | 9 (21) |
| PGY 5 | 1 (2) | 2 (5) |
Abbreviation: PGY = physician graduate year
Results
After excluding surveys with incomplete information (n = 10), 105 responses were included in the final analysis. Among the 105 respondents, 62 were from general medicine programs (family medicine or internal medicine) and 43 were from specialty medicine programs (neurology, psychiatry, transitional year, or general surgery). The 2 groups had similar age distribution (Table 1). There was a slightly higher percentage of females in the specialty medicine group and a slightly higher proportion of males in the general medicine group. There was a higher proportion of physician graduate year 1 respondents in the general medicine group than in the specialty medicine group (Table 1).
We found no significant difference between general and specialty medicine residents in their level of burnout or their perspective on the impact of the COVID-19 pandemic on their future careers (Table 2). There was a statistically significant difference between general medicine and specialty medicine in the perceived impact of the COVID-19 pandemic on learning (U = 1631.5, P = .04) and a non-statistically significant difference in the impact on clinical experience (U = 1591, P = .08). The effect sizes of these differences can be classified as medium/small (Table 2).
Table 2.
Comparison of General Medicine Versus Specialty Medicine Residents Survey Responses Regarding COVID-19 Effects on Resident Education
| General medicine (n = 62) | Specialty medicine (n = 43) | Mann-Whitney U test results | |||||
|---|---|---|---|---|---|---|---|
| Mean ± SD | Median (IQR) | Mean ± SD | Median (IQR) | U | P | Effect size (r) | |
| Burnout | 2.31 ± 0.84 | 2 (1) | 2.49 ± 0.93 | 2 (1) | 1222 | .439 | −.076 |
| COVID-19 impact on learning | 3.06 ± 1.10 | 3 (2) | 2.60 ± 0.95 | 3 (1) | 1631.5 | .042 | .198 |
| COVID-19 impact on clinical experience | 3.43 ± 1.17 | 3 (1) | 2.98 ± 0.86 | 3 (2) | 1591 | .080 | .172 |
| COVID-19 impact on future career | 4.14 ± 1.25 | 4 (2) | 3.93 ± 1.05 | 4 (1) | 1447.5 | .435 | .076 |
Abbreviation: SD = standard deviation; IQR = interquartile range
Discussion
In this study comparing general and specialty medicine residents, we found that overall burnout levels associated with the COVID-19 pandemic, as well as concerns for its impact on clinical experiences and future careers, did not differ between groups. We did find that residents from specialty medicine programs reported a significantly more negative impact of the pandemic on their learning compared to their general medicine resident colleagues.
The significant difference between resident groups related to perceived learning and clinical experiences during training was likely multifactorial. It can be postulated that the cessation or drastic reduction in elective and outpatient procedures impacted these responses. General surgery, neurology, and psychiatry are fields in which procedures and outpatient clinical experiences are essential to the progression to independent practice; transitional year residents are often planning to pursue specialties requiring these procedural experiences as well. This finding is supported by previously published data from post-graduate anesthesia residents, a subspecialty that was not included in our dataset, in which decreased caseload, altered rotations, and changes in supervision had a negative impact on perceived skill development.7 On the other hand, hospital-based internal medicine and family medicine continued unabated or were more easily adapted to a telehealth-based practice. As residents were reassigned to bolster the care of COVID-19 patients, it can also be postulated that general medicine residents interpreted the pulmonary and critical care skills they acquired as beneficial to their future careers; this is a sentiment that may not have been shared by specialty medicine residents. The majority of survey respondents were junior residents, and it is during these beginning years that the foundations of procedural skills are learned. This dearth of skill training may also have contributed to the perception of a more substantial impact of the pandemic amongst specialty medicine residents.
We found that burnout levels between general and specialty medicine residents did not differ significantly, which may be an indication of a discrepancy between resident burnout rates and resident educational experiences or workload between specialties. It may also be that the COVID-19 pandemic did not directly affect rates of resident burnout, as is illustrated by a recent report of survey responses from post-graduate residents at a single institution in the Chicago area before and during the pandemic.12
To understand the implications of our findings, it is important to keep in mind several limitations. This survey was originally part of a quality improvement project aimed at a longitudinal understanding of resident wellness and was based on a convenience sample. The 3 questions about the COVID-19 pandemic came from a previously used, but not validated, survey, thus the responses to these questions must be interpreted with caution. It is also possible that the residents who responded to the survey differed in their views of the impact of the pandemic on their training from the residents who did not respond to the survey. Additionally, our survey response rate limits the generalizability of our findings. Though many transitional year residents pursue procedure-heavy specialties, including ophthalmology, dermatology, anesthesiology, or interventional radiology, the experiences of transitional year residents can vary drastically depending on the program and the resident’s future goals. These transition year-related differences may have skewed our data as well.
It would be beneficial to administer a follow-up survey to the resident respondents once they become senior-level residents to assess their perceptions of the degree to which their learning was impacted during the COVID-19 pandemic, in a retrospective fashion. This would allow us to reassess residents’ perceptions of the pandemic’s impact on their careers during the time of job application. Furthermore, interval follow-up with this cohort may demonstrate our current findings as a new baseline reference of resident burnout rates and perception of GME as we continue to progress from the COVID-19 pandemic.
Conclusion
Overall, our review supports the hypothesis that specialty medicine residents experienced a stronger negative impact on their overall learning and residency experience than general medicine residents due to the COVID-19 pandemic. This specialty-specific difference provides valuable feedback on resident perceptions of their own educational experience to GME administrators. It also highlights the necessity of assessment during interruptions to traditional learning processes, such as the COVID-19 pandemic, in order to provide appropriate resources and guidance to the residents.
Acknowledgment
We would like to thank the HCA Healthcare residents who participated in this survey.
Funding Statement
This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare-affiliated entity.
Footnotes
Conflicts of Interest: The authors declare no conflicts of interest.
Drs Backen and Quan are employees of Swedish Medical Center, a hospital affiliated with the journal’s publisher.
Drs Dziadkowiec and Guldner and Mr Durbin are employees of HCA Healthcare Graduate Medical Education, an organization affiliated with the journal’s publisher.
This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare-affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.
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