Impact of the COVID-19 Pandemic on Physical Medicine and Rehabilitation Residency in the Epicenter of the Outbreak

Introduction

The COVID-19 pandemic has impacted all aspects of healthcare delivery, including resident education. Emotional, physical, and cognitive stressors have compromised the U.S. Healthcare paradigm, particularly in New York State, where our system is based. As of April 30^th, 2020, New York State reported 294,715 cases comprising 30 % of total U.S. cases.¹ This short commentary describes the impact of COVID-19 on the Physical Medicine and Rehabilitation (PM&R) residency programs at Burke Rehabilitation Hospital (BRH) in White Plains, Westchester, New York and Montefiore Medical Center (MMC) in the Bronx, New York. This pandemic has provided a unique opportunity for residents to foster teamwork, enhance domains of the Accreditation Council for Graduate Medical Education (ACGME) core competencies, practice conflict resolution, and acquire leadership skills.

New York State’s index case was confirmed March 01, 2020², followed by three confirmed cases at Montefiore Health System (MHS) by March 10^th, 2020. When the novel coronavirus (SARS CoV-2) pandemic seemed imminent, Graduate Medical Education (GME) leadership at MMC and BRH anticipated differing needs for the two programs. There was early recognition that these needs would be staged and depend upon the level of response required. New York State ultimately proved to be the American epicenter of the COVID-19 pandemic with more than 2,000 patients hospitalized in MHS alone by April 14, 2020.

Strategic Planning and Actions of BRH and MMC PM&R Programs

The separate PM&R training programs of BRH and MMC have inpatient and outpatient services dispersed throughout the Bronx, Westchester, and the Lower Hudson Valley of New York. The system’s ability to pool resources and redirect care was critical in the response, with additional guidance provided by the Association of Academic Physiatrists (AAP) Program Directors group and ACGME.³ Planning and execution of the response became centralized, and relegated to the Designated Institutional Officials (DIOs), Graduate Medical Education (GME) leadership, and Chief Medical Officers (CMOs) of the separate institutions.

Table 1 serves as a timeline and summarizes the description of different phases of the COVID-19 response for both clinical operation and changes to the Burke and MMC residency programs. Declaration of ACGME stage 3 emergency status reduced the regulatory burden of the sponsoring institutions and provided flexibility to meet the surge of COVID-19 patients. As per ACGME, work hour restrictions remained in place to ensure effective care delivery.⁴

Table 1.

Phases of Graduate Medical Education response to COVID-19 pandemic

Lessons learned

Communication

Daily communication was essential to coordinate the pandemic response across MHS for both residency programs. Examples included daily hospital-wide medical updates over conference call by BRH CMO and MHS’ (President and CEO of MHS, Philip Ozuah, MD) daily system-wide sessions. Teleconferencing provided a virtual platform for clinical staff to discuss the pandemic and implement local/national recommendations. Weekly virtual resident meetings at BRH were provided in a forum with the Program Directors (PDs) and DIO. Concerns raised during these meetings were shared with administration. For example, residents were the first to suggest the use of plexiglass shielding in code situations, later implemented.

Use and knowledge of personal protective equipment (PPE)

At Burke, virtual PPE education was provided by the CMO and infection preventionist. As an example of PPE use at MMC, floors established Green (no PPE beyond face masks), Yellow (COVID-19 contaminated zone requiring gloves/gowns/face masks), and Red zones (COVID-19 high risk areas with potential/known secretion aerosolization requiring full PPE including face shields, N-95 masks, gloves, gowns).

Ethical Lessons

Ethical scenarios were discussed in conjunction with the Montefiore Einstein Center for Bioethics (MECB), available for both BRH and MMC residents. This relationship was particularly important for end-of-life discussions. MMC residents were often faced with resource allocation issues, as up to 1/3 cases admitted during peak to medical-surgical units were admitted for palliative care (poor prognosis and ICU/ventilator/ECMO limitations). Scripts/scenarios formulated by MECB assisted clinicians in discussions regarding clinical condition and code status.

Well Being

Inevitable isolation from family and friends incurred a significant psychologic effect on both resident populations. BRH Neuropsychologists and the MMC Department of psychiatry provided free/confidential counselling for residents. The PD at BRH wrote a weekly newsletter (“Burke is Buoyant”), providing self-care resources, and disseminated hospital-wide. The President of MHS provided daily inspirational videos to celebrate the contributions of MMC employees and patients. At BRH, a resident COVID-19 illness-related policy to accommodate CDC guidelines, as well as a modified vacation policy to support residents/fellows’ well-being due to missed vacations/leave was developed. BRH provided pay to residents for all days missed during the pandemic, or the ability to roll-over vacation days, as allowed by ACGME. MMC’s PM&R residency program adopted similar policies.

Didactics/Education

Face-to-face lecture-based didactics for resident education was necessarily changed, and both programs utilized a video-conferencing platform to continue educational content and to hold residency town-hall meetings. These educational sessions provided a sense of structure for residents.

Milestone/ Resident Evaluation

The Clinical Competency Committees (CCC) at MMC and BRH will chart milestones with due leniency allowed by ACGME regarding case and procedure volumes, mostly from direct faculty feedback.⁵ All available metrics will be used to substantiate competence. A significant component of the program evaluation this year will be in assessing the program’s performance during the COVID-19 crisis with a focus on virtual format didactics, communication, and the ability to maintain resident wellness.

Conclusions

PM&R trainees at both programs, in very different environments, showed tremendous adaptability during the COVID-19 pandemic. Important actions taken during this crisis include clear ongoing communication, staying up-to-date with guidelines and regulations, ensuring institutional compliance under rapidly changing guidelines, and implementing changes to both resident education and clinical rotations. Residents embraced the need for patient care and demonstrated growth in multiple domains (interpersonal communication skills, professionalism, flexibility, team building, leadership), but most importantly human compassion.