Abstract
Background
In December 2019, a novel coronavirus (COVID‐19) caused widespread clinical disease, triggering limited in‐person gatherings and social‐distancing guidelines to minimize transmission. These regulations led most emergency medicine (EM) residency training programs to rapidly transition to virtual didactics. We sought to evaluate EM resident perceptions of the effects of COVID‐19 on their didactic and clinical education.
Methods
We performed a cross‐sectional survey study at seven EM residency programs using a mixed‐methods approach designed to understand resident perceptions regarding the impact of COVID‐19 on their educational experience. Quantitative data were presented as percentages with comparison of subgroups, while open‐ended responses were analyzed using qualitative methodology.
Results
We achieved a 59% response rate (187/313). The majority of respondents (119/182, 65.4%) reported that the COVID‐19 pandemic had a negative impact on their residency education with junior residents disproportionately affected. A total of 81 of 182 (44.5%) participants reported that one or more of their clinical rotations were partially or completely canceled due to the pandemic. Additionally, we identified four themes and 34 subthemes highlighting the contextual effects of the pandemic, which were then divided into positive and negative influences on the residency experience. The four themes include systems experience, clinical experience, didactic experience, and wellness.
Conclusion
Our study examined the impact of COVID‐19 on residents’ educational experiences. We found overall mixed responses with a slightly negative impact on residency education, wellness, and clinical rotations, while satisfaction with EM as a career choice was increased. Factors influencing this included systems, clinical, and didactic experiences as well as overall wellness.
INTRODUCTION
In December 2019, the novel respiratory virus SARS‐CoV‐2 began rapidly spreading with over 20.4 million cases globally and over 5.1 million cases in the United States by August 13, 2020. 1 , 2 , 3 The 2019 coronavirus disease (COVID‐19) created a public health emergency, triggering social‐distancing guidelines to minimize transmission. 3 , 4 , 5 , 6 These regulations led most emergency medicine (EM) residency training programs to rapidly transition to virtual didactics in an effort to continue to meet the requirements set forth by the Accreditation Council for Graduate Medical Education (ACGME) for the provision of 5 hours of educational conference weekly. 7 , 8 , 9 , 10 Additionally, clinical experiences and curricula were modified in many locations as emergency department (ED) volumes changed and the scope of patient pathology narrowed, necessitating redeployment of residents off of some rotations. We sought to evaluate EM resident perceptions of the effects of COVID‐19 on their education.
METHODS
Study Design
We implemented a cross‐sectional survey study using a mixed‐methods approach designed to assess resident perceptions regarding the impact of COVID‐19 on their educational experience. The survey utilized a 7‐point Likert scale along with open‐ended questions informed by a literature search. After developing the survey tool in Research Electronic Data Capture (REDCap) software and refining the questions among the investigators, it was piloted in a representative population of four residents across all postgraduate year (PGY) levels including those from various geographical locations and from both 3‐year and 4‐year EM residency programs with subsequent minor changes made for survey clarity. Residents in the pilot group were excluded from the study. The study was deemed exempt by the institutional review board at the University of Utah.
Study Setting and Population
The study subjects were current EM residents training at seven residency programs across the United States intentionally selected to represent geographic diversity, program length diversity, and variable prevalence of COVID‐19 infections. We obtained the rates of confirmed cases of COVID‐19 per capita in the county housing each institution on June 14, 2020. 11 All EM residents from PGY‐1 to ‐4 were eligible for inclusion other than those in the pilot group and one study author. EM residents in combined programs (e.g., EM combined with internal medicine, family medicine, and pediatrics) were excluded to limit confounding from differences in curricula. We excluded verbatim duplicate sets of data with consideration for technologic error and double submission of the survey.
Study Protocol
The tool was administered through an electronic mail link to the REDCap survey in May through June 2020. Each participant received three total weekly e‐mail reminders to complete the survey. Residents were reminded about the survey during conference each week. After receiving consent information in an attachment to each weekly e‐mail, subjects provided informed consent as the first question of the survey; data were excluded if this question was skipped.
Data Analysis
Quantitative data were analyzed using Microsoft Excel for Mac (Version 15.27) and were presented as percentages. We then used Vassarstats.net to perform a chi‐square test to evaluate for any differences between groups, with p < 0.05 considered statistically significant.
Qualitative data were explored using an inductive approach associated with the framework method of analysis. 12 Coding and framework development was performed by three authors (ES, DE, TF). Two coders, formally trained and with practical experience in qualitative analysis (ES, DE) provided methodologic instruction for the third coder (TF). Reflexivity was employed by acknowledging and incorporating the contextual factors of the researchers in the analysis. All three coders were practicing emergency physicians during the COVID‐19 pandemic and served in resident supervisory roles in the residency programs of study at the time of data collection. Responses were reviewed and coded collaboratively by all three coding investigators until preliminary conceptual categories emerged. This framework was then applied to additional responses and iteratively refined until a final framework was established. Thematic saturation was reached, but did not influence the endpoint of data collection given the concomitant quantitative aspect of the study. Subsequently, one investigator (TF) charted the data in the framework. All three coding investigators and then interpreted the results in their entirety and established the final language for themes. Any disagreements were resolved by discussion until a consensus was reached.
RESULTS
We achieved a 59% response rate with 187 of 313 invited participants completing the survey (Table 1). Two respondents were excluded after declining or deferring consent. Two pairs of duplicate responses were identified, and one of each was excluded. Another participant was excluded after specifying participation in a combined program. A total of 182 individual responses were included in the final data analysis.
Table 1.
Participant Demographics
Site 1 | Site 2 | Site 3 | Site 4 | Site 5 | Site 6 | Site 7 | Total | |
---|---|---|---|---|---|---|---|---|
Included respondents | 14 | 24 | 44 | 26 | 33 | 22 | 19 | 182 |
Potential respondents | 48 | 58 | 60 | 35 | 41 | 46 | 25 | 313 |
Response rate | 29% | 41% | 73% | 74% | 80% | 48% | 76% | 58% |
PGY‐1 | 4 (29%) | 10 (42%) | 12 (27%) | 9 (35%) | 10 (30%) | 8 (36%) | 7 (37%) | 60 (33%) |
PGY‐2 | 3 (21%) | 5 (21%) | 11 (25%) | 10 (38%) | 8 (24%) | 7 (32%) | 7 (37%) | 51 (28%) |
PGY‐3 | 1 (7%) | 7 (29%) | 12 (27%) | 7 (27%) | 10 (30%) | 7 (32%) | 5 (26%) | 49 (27%) |
PGY‐4 | 6 (43%) | 2 (8%) | 9 (20%) | ‐ | 5 (15%) | — | — | 22 (12%) |
Program length (years) | 4 | 4 | 4 | 3 | 4 | 3 | 3 | — |
County COVID‐19 incidence (cases/100,000 population)* | 1,690 | 2,401 | 1,642 | 1,642 | 255 | 205 | 616 | — |
Location of program | New York County, NY | Suffolk County, MA | Cook County, IL | Cook County, IL | Fresno County, CA | Duval County, FL | Salt Lake County, UT | — |
As of June 14, 2020.
The majority of respondents (119/182, 65.4%) reported that the COVID‐19 pandemic had a negative effect on their residency education (Figure 1) with a significant difference in the effect between PGY levels with more junior residents reporting at least a slightly negative effect than those in more senior classes (p = 0.03; Table 2).
Figure 1.
Effect of the COVID‐19 pandemic on overall residency education, overall wellness, clinical rotation schedule, and satisfaction with EM as a career choice
Table 2.
Subgroup Analysis
PGY‐1 | PGY‐2 | PGY‐3 | PGY‐4 | 3‐Year Program |
4‐Year Program |
Low COVID‐19 Incidence |
High COVID‐19 Incidence |
|
---|---|---|---|---|---|---|---|---|
Negative effect on overall residency education |
47/60 (78.3%) |
32/51 (62.7%) |
30/49 (61.2%) |
10/22 (45.5%) |
45/67 (67.2%) | 74/115 (64.3%) | 46/74 (62.2%) | 73/108 (67.6%) |
p = 0.03 | p = 0.70 | p = 0.45 | ||||||
Negative effect on organized residency didactics | 27/60 (45.0%) | 22/51 (43.1%) | 19/49 (38.8%) | 5/22 (22.7%) | 37/67 (55.2%) | 36/115 (31.3%) | 32/74 (43.2%) | 41/108 (38.0%) |
p = 0.06 | p < 0.01 | p = 0.48 | ||||||
Negative effect on clinical rotation schedule | 37/60 (61.7%) | 26/51 (51.0%) | 22/49 (44.9%) | 8/22 (36.4%) | 35/67 (52.2%) | 58/115 (50.4%) | 38/74 (51.4%) | 55/108 (50.9%) |
p = 0.15 | p = 0.81 | p > 0.99 | ||||||
Negative effect on overall wellness | 41/60 (68.3%) | 33/51 (64.7%) | 35/49 (71.4%) | 15/22 (68.2%) | 48/67 (71.6%) | 76/115 (66.1%) | 47/74 (63.5%) | 77/108 (71.3%) |
p = 0.91 | p = 0.44 | p = 0.26 | ||||||
Positive effect on satisfaction with career in EM | 30/60 (50.0%) | 23/51 (45.1%) | 24/49 (40.0%) | 12/22 (54.5%) | 26/67 (38.8%) | 63/115 (54.8%) | 29/74 (39.2%) | 60/108 (55.6%) |
p = 0.90 | p = 0.04 | p = 0.03 | ||||||
Negative effect on ED clinical shift experience | 43/60 (71.7%) | 33/51 (64.7%) | 22/49 (44.9%) | 11/22 (50.0%) | 40/67 (59.7%) | 69/115 (60.0%) | 47/74 (63.5%) | 62/108 (57.4%) |
p = 0.02 | p > 0.99 | p = 0.41 |
Just under half of participants 81 of 182 (44.5%) reported one or more of their clinical rotations was partially or completely canceled due to the pandemic (Figure 2). The most commonly canceled rotations included ultrasound (n = 24), electives (n = 18), anesthesia (n = 16), and pediatric specialties (n = 10).
Figure 2.
Clinical rotations canceled due to COVID‐19 pandemic
The overall perceived effect on residents’ organized didactic experience was neutral with 73 of 182 (40%) reporting a negative effect, 64 of 182 (35%) reporting a positive effect, and 45 of 182 (25%) reporting no effect. There was a significant difference by program length with 37 of 67 (55.2%) respondents in 3‐year programs reporting at least a slightly negative impact compared to 36 of 115 (31.3%) in 4‐year programs (p < 0.01).
Junior residents reported a disproportionately negative effect on their clinical experience in the ED with 43/60 (71.7%) PGY‐1, 33/51 (64.7%) PGY‐2, 22/49 (44.9%) PGY‐3, and 11/22 (50.0%) PGY‐4 residents reporting at least a slightly negative impact (p = 0.02).
A total of 124 of 182 (68.1%) participants reported an overall negative effect on wellness. In addition, 89 of 183 (48.9%) participating residents declared that the pandemic had a positive effect on their level of satisfaction with EM as a career choice. There was a significant difference in reported effect on career satisfaction between programs in an area with a high incidence of COVID‐19 (≥1,000 cases/100,000 people) and those in areas of low incidence (<1,000 cases/100,000) with 60 of 108 (55.6%) of those in high‐incidence areas and 29 of 74 (39.2%) in low‐incidence areas reporting at least a slightly positive effect on career satisfaction (p = 0.03). There was also a difference based on program length with 63 of 115 (54.8%) of respondents from 4‐year programs and 26 of 67 (38.8%) from 3‐year programs reporting at least a slightly positive effect (p = 0.04) on career satisfaction.
Qualitative Results
We identified four themes and 34 subthemes, which were then divided into positive and negative effects of the COVID‐19 pandemic on the residency experience (Table 3).
Table 3.
Themes and Subthemes
Themes | Positive Subthemes | Negative Subthemes |
---|---|---|
Systems experience | Operational knowledge gained from participating in a disaster response | Frustration with frequently changing protocols |
Increased innovation | Changes to schedules or rotation cancelation | |
Positive view of EM as a specialty | Disruption in clinical workflow | |
More efficient hospital workflow and improved interdepartmental relationships | ||
Clinical experience | Increased knowledge and experience in the management respiratory pathology |
Frustration with protocolized restrictions on which patients providers could treat |
Increased comfort with the implementation of infection control measures |
Limited experiences for junior residents |
|
Increase in time available on shift |
Decreased patient volumes |
|
Increased exposure to procedures and critical care for senior residents |
Decreased clinical variety |
|
Decreased clinical acuity | ||
Decreased on‐shift teaching opportunities | ||
Concern for the impact of anchoring bias | ||
Didactic experience | Experience with independent learning |
Less engagement with virtual didactics |
Increased convenience or flexibility with virtual didactics |
Negative effect of virtual didactics on interpersonal interactions with colleagues |
|
Inclusion of outside speakers with virtual didactics |
Inability to travel to national conferences |
|
Decreased education in core content due to increased focus on the management of COVID‐19 | ||
Decrease in simulation | ||
Wellness |
Increased time for residents to do things they enjoy |
Negative impact on mental health |
Career affirmation |
Frustration and discomfort related to personal protective equipment |
|
Increased camaraderie and resilience |
Concern for physical safety of self and close contacts |
|
Negative impact on social interactions | ||
Anxiety regarding future career implications |
Theme 1: Systems Experience
The first theme was systems experience. Many participants that felt they benefited from the operational knowledge gained from participating in a disaster response:
It has taught me a lot more about healthcare systems and public health.
Improved understanding of department flow, management of a pandemic situation.
In addition, residents had positive perceptions of increased innovation both in the patient care environment and in their education:
It is so excellent that we have found out how much of our job and education can be effectively performed remotely.
I also got to try out telemedicine which was an interesting educational experience.
More innovation/collaboration/problem solving around a very serious problem.
Participants felt that the pandemic generated a positive view of EM as a specialty:
I think other services have more respect for our specialty overall than before, which has improved the work environment.
For once, EM feels as though it is getting the recognition it deserves.
Finally, some respondents saw the benefits of a more efficient hospital workflow and improved interdepartmental relationships:
As volumes have decreased and there is less boarding I actually feel like an emergency medicine physician as a senior resident. Instead of spending the majority of my shift taking care of sign out patients I can focus on taking care of new patients and actually "moving the room."
Improved organization and interdepartmental coordination.
There were also negative effects on residents’ systems experience. The first subtheme demonstrates frustration with frequently changing protocols:
I am losing touch with our normal airway algorithms. Too often there is an institution/nurse/day of the week specific criteria for using nonrebreather, bipap and nebulizers.
Had to spend more time learning rapidly changing protocols and algorithms rather than clinical medicine.
Next, many residents felt the negative impact of changes to schedules or rotation cancelation, including reassignment of their clinical roles:
Being pulled from high‐acuity shifts at a program with graduated responsibility has made me feel like a second rate resident who isn't prepared to fill the role of [a third‐year resident].
Senior residents in my program were relegated to seeing only COVID patients, not staffing junior residents' patients, and just churning through. This was to meet the needs of the department, but I do feel that education especially of the junior residents, and my own in terms of managing a room, was slightly hampered.
Some residents felt that there was disruption in clinical workflow:
Takes more time to gather information about patients and provide family updates because multiple phone calls to family have to be made rather than the family member being at the bedside.
Delays in imaging and drawing labs for some [patients under investigation for COVID‐19] that interrupts normal work flow.
Theme 2: Clinical Experience
The second theme was clinical experience, with many comments reflecting the perceived effect of decreased patient volumes and variety along with changes in patient acuity.
Many participants felt that their education was furthered by increased knowledge and experience in the management of respiratory pathology:
More comfort with [the] chain of escalation of respiratory support, particularly prior to intubation.
I think It forced me to manage vents more frequently, more closely, and with more nuance than I had before.
They also commented on increased comfort with the implementation of infection control measures including personal protective equipment (PPE):
Learned a lot more about infection control and prevention.
Enhanced knowledge/preparedness with the use of regular and enhanced PPE.
Many residents felt that, with lower clinical volumes, there was an increase in time available on shift:
During the height of the pandemic with lower volumes I had significantly more time to read the medical records of patients and interview them for longer. I felt that I had significantly improved rapport with patients and consequently nurses because we worked more as a team.
I can spend more time learning about my patients and reading about my patients and pathologies on shift. I have more time to discuss cases with attendings and fellow residents.
There was also increased exposure to procedures and critical care for senior residents:
As a senior resident, it has led to many more intubations and procedures than before and I do feel like it has had a filter effect where we are seeing a lot of critically ill patients in the ED later than we would initially.
Increase in critical care as a senior in the ED since this shifted from juniors to seniors for intubation, etc.
However, some expressed frustration with protocolized restrictions on which patients providers could treat:
We're not allowed to do some procedures vital for our training at this time, e.g., chest tubes while on the trauma service, some intubations in the ED.
Attempts to protect [residents’] health by decreasing access to procedures and higher risk cases has led to less opportunities to fine tune procedural skills.
Multiple participants lamented limited experiences for junior residents:
Procedures taken from junior residents set a bad precedent. For months seniors and attendings have had first pass at intubations and any procedures with covid positive patients. While juniors will get their numbers eventually you will have seniors next year who still need procedures which throws off the work flow.
No intubations for juniors and limited participation in possible COVID case resuscitations has vastly cut down our critical care experience these past few months.
In addition, many residents highlighted the negative effects of decreased patient volumes:
[Decreased] volumes in the department, and therefore decreased exposures to pathology and decreased experience/practice/learning overall.
Certain off‐service rotations had minimal or no census, and I think the off‐service learning was severely compromised.
Another common theme was frustration with decreased clinical variety:
Decreased volumes of 'bread and butter' EM cases. Large volume of sick patients with singular pathology.
2–3 months (potentially longer) of residency disproportionately devoted to management of one specific disease entity, with a decrease in volumes of all other ED [presentations].
Some participants felt that they saw decreased clinical acuity as well:
Lower acuity outside the critically ill covid patient.
My MICU rotation was absolutely abysmal … absence of many sick or complex patients.
In addition, staffing changes led to decreased on‐shift teaching opportunities for many residents:
I have supervised junior residents less due to staffing changes, which is a separate skill than just doing things myself.
I felt less on shift teaching occurred due to lack of senior residents available to provide that on‐shift teaching.
Finally, some residents expressed concern over the impact of anchoring bias related to the pandemic:
… has curtailed some of our standards of practice, which can lead to missed/delayed diagnoses. We must remember that there is more than just COVID on the differential and many other life‐threatening diseases.
Every patient was a covid patient and we were anchoring on that a lot.
Theme 3: Didactic Experience
The third theme was the effect on residents’ didactic experience. Many respondents had positive perceptions of their experience with independent learning:
It has showed me my self study flaws that need improvement.
It's made me dig into journals much more and take a more active self learning role again.
Some residents commented on increased convenience or flexibility with virtual didactics:
I like Zoom conference because of the flexibility it gives us.
Online lectures are easier to [attend] after long shifts or before going to shift.
Others enjoyed the opportunity for inclusion of outside speakers with virtual didactics:
The ease of having presenters [from] outside institutions present has greatly increased the conference experience.
Some participants experienced less engagement with virtual didactics:
The virtual conference is hard for me to stay engaged with. I am an adult learner through and through, and to be subjected to hours of video lecture is hard.
I feel less engaged during virtual didactics and more inclined to log in to "check a box" rather than participate in learning.
In addition, others felt that there was a negative effect of virtual didactics on interpersonal interactions with colleagues:
Virtual education takes away the group setting of learning which at times helps me with having content stick, especially since I can ask my peers different questions.
I think the limiting of actual interactions between attendings/lecturers and ourselves has a negative impact.
Some residents regretted the inability to travel to national conferences during the pandemic:
The biggest effect is that COVID has limited travel to conferences, which leads to those experiences, exchange of knowledge and networking not happening.
A commonly mentioned negative aspect of the pandemic was decreased education in core content due to increased focus on the management of COVID‐19:
I feel like so much of both our clinical and conference time has become purely dedicated to COVID that I have stopped learning nearly enough about the other 99.9% of things I need to know to be a competent emergency physician.
I know a lot about COVID and not much about anything else.
Many residents felt that a decrease in simulation negatively impacted their education:
Having less SIM has been a real disadvantage.
There have been no simulation sessions in almost four months.
Theme 4: Wellness
The final theme was the impact on resident wellness. Many residents reported increased time to do things they enjoy:
More time for wellness and extracurricular opportunities given canceled rotation.
More time at home with family, less time commuting,
In addition, there were multiple comments reflecting feeling of career affirmation during the pandemic:
Reinforcing career decision, fun to learn with the whole specialty together.
I feel privileged [to] be on the front lines and serve my community during these trying times.
Participants had a positive experience with increased camaraderie and resilience among providers:
Highlights how adept our faculty/program/staff are at responding to challenges, how much we care about each other.
I've found residents and staff looking out for and appreciating each other more.
Some residents felt that there was a negative impact on mental health:
It has taken a large mental, emotional toll on residents.
Increased anxiety for myself, almost all my patients, coworkers and family members.
In addition, many voiced frustration and discomfort related to PPE:
The mask can be itchy, uncomfortable, smelly, makes it harder to breathe, decreases how often we can eat or drink, and creates a barrier between making personal connections with patients. No patient has seen us smile in months!
PPE is stressful, donning and doffing takes time and reduces agility during shift.
Others expressed concern for physical safety of self and close contacts:
The main challenge at work has always been patient care. Now having to also think of how to keep ourselves safe is difficult.
New things to have to think about—do I have the right PPE? will I have time to get into the right PPE before my critically ill patient arrives? Where are the safe spaces to eat or drink? What happens if I get sick and have to have a bunch of shifts covered?
Participants felt there was a negative impact on social interactions:
My wellness is affected less so by residency related things and more by COVID‐related restrictions that prevent socializing.
Less relationships with fellow residents and attendings, which is a core part of our residency.
In addition, many reported anxiety regarding future career implications:
In addition to losing core knowledge and 8 weeks of rotations, I will also lose the time in the future I will have had to explore my academic interests.
Uncertainty now in looking for employment and how the hospital business has to deal with cost.
DISCUSSION
To the best of our knowledge, this represents the first multicenter study of EM resident perceptions regarding the COVID‐19 pandemic on residency education. Overall, our study revealed mixed positive and negative findings. While most residents felt that the pandemic had negative effects on their education overall, there were some positive themes that emerged.
Systems Experience
The ACGME has identified six core competencies, of which all training programs are responsible for assessing resident progress. 8 One of these competencies, systems‐based practice (SBP), is defined as “an awareness of and responsiveness to the larger context and system of health care, including the social determinants of health, as well as the ability to call effectively on other resources to provide optimal health care.” This has been cited as one of the most difficult competencies to address and assess. 13 Although our study did not directly address the assessment of SBP, we identified that the pandemic may have increased resident awareness of the system’s effects on patient care.
Additionally, the effect of ED overcrowding has been previously described as contributing both negatively and positively to resident education. 14 Shayne et al. 14 discuss that ED crowding can lead to an increase in opportunities for learning and involvement but can also limit the “provision of clinical care at acceptable clinical standards.” Overall health care volumes decreased substantially during the early days of the pandemic in the United States. 15 , 16 Our qualitative data highlights the positive impacts of decreased ED patient boarding on hospital workflow, provider efficiency, and interdepartmental relationships.
However, many participants expressed frustration with frequently changing protocols. While these were necessary to provide clinicians with updated practice standards in the setting of a dynamic situation, resident responses were consistent with past literature reporting the negative impact of conflicting or inconvenient guidelines. 17 Some of these policy changes also led to a perceived negative effect on clinical workflow. Specific examples noted by participants included delays in laboratory tests, imaging, or disposition to definitive care along with changes in visitor policies.
Our study also suggests a negative impact from schedule changes and canceled rotations. Approximately half of the residents reported a loss of at least one clinical rotation, most commonly ultrasound, anesthesia, or an elective. Rescheduling will present a significant challenge for programs based on the total number of rotations that need to be provided and the limited length of time current residents have remaining in training.
Clinical Experience
Decreases in hospital volumes had a mixed effect on the resident clinical experience. Residents noted an increase in time available on shift, allowing additional opportunities to review patient histories, develop interprofessional relationships, pursue “just‐in‐time” on shift learning, and engage in discussions with attendings and peers. These are important aspects of clinical education recommended by the Council of Emergency Medicine Residency Directors that may be challenging in the setting of a busy ED. 18 , 19 However, participants frequently lamented a loss of experience caused by decreased patient volumes and patient variety. Many patients with urgent and, tragically, even emergent complaints elected to stay at home and not seek emergency care during the pandemic. 20 , 21 Hence, the typical interleaving of patient presentations across a wide spectrum of pathologies and acuities fundamental to the experiential learning of residents was reduced.
Our data also reflect the inevitable downside of the COVID‐19 pandemic for junior residents, with more PGY‐1 and PGY‐2 residents reporting a negative effect on their ED shift experience compared to senior learners. Within the EDs of many academic medical centers, including those of this study’s authors, attendings and senior residents were often the first assigned to care for patients under investigation for COVID‐19, particularly during the early days of the pandemic, to protect the junior residents from unknown harm and to improve outcomes for these physiologically challenging patients when intubation was necessary. 22 Although well intentioned and likely necessary, an unfortunate side effect was the loss of patient volume, diversity, acuity, and procedural experience for junior residents. However, this did lead to increased exposure to procedures and critical care for senior residents.
Didactic Experience
The overall perceived effect on residents’ organized didactic experience was neutral. However, more residents in 3‐year programs expressed negative experiences when compared with those in 4‐year programs. One proposed explanation for this difference is learner concern over the time required to cover all of the traditional curricular material before the completion of training, with multiple residents reporting that there was significant emphasis on COVID‐19 content during didactics, limiting exposure to other topics. While this was critical for the understanding of a novel disease process, as both residents and faculty learned about pathophysiology and treatment options together, this shift may have contributed to some of the concerns of residents in shorter training programs. In addition, while there was no significant difference between areas with high and low incidences of COVID‐19, we can assume that there may be some overlap given most of the included 3‐year programs were in areas with low incidence.
The qualitative analysis provided insight on many positive themes identified with regard to didactics. Residents enjoyed the increased flexibility associated with virtual conferences and the avoidance of the associated commute. Some residents commented on the increased likelihood of attending didactics in the context of shifts that normally would have prevented or decreased their attendance. Residents enjoyed the expanded network of speakers available for didactics. The virtual platform allowed programs to invite speakers from other locations without the need for transportation and accommodations. Programs that were previously limited by funding limitations may have been able to gain access to outside faculty or join didactics of other programs. 23 A study of orthopedic residents also demonstrated a positive perception of virtual learning during the COVID‐19 pandemic and the desire to continue supplementing educational activities with this format in the future. 24 The transition to virtual didactics may have a lasting impact as some projections indicate that in‐person gatherings may be limited until 2022. 25
There were multiple comments on the positive aspects of the incorporation of self‐directed learning. Participants specifically commented on the identification of gaps in their knowledge and the fear of a lack of competence in the future due to abridged didactic content, which may have motivated learners to independently review core topics. We suspect that many programs shifted to more a traditional lecture‐based style with the transition to a virtual platform, and residents reported decreased engagement with digital sessions. This may have further contributed to self‐directed learning. The incorporation of multiple methodologies in the usual conference setting is helpful to the varied learning styles noted among trainees and may encourage the use of innovation in the virtual space for content delivery. 26 , 27
The lack of in‐person conferences has been challenging for some residents. Conference provides an opportunity for residents to connect with each other and engage in community building. While some have had increased ability to attend virtually with the removal of other constraints, there is a benefit of socialization and collaboration with onsite didactics. The use of simulation was severely limited in the early stages of the pandemic with some institutions ultimately having some modified reopening. Simulation provides opportunities for multiple components of learning related to procedural skills, communication, interprofessional education, patient safety, and medical knowledge. 28 , 29
Wellness
The primary positive effect of the pandemic on individual resident wellness was an increase in time available to engage in extracurricular activities due to a decreased need to commute to weekly didactics. This seemingly small protection of time was noted, especially among those residents juggling the need to spend time with their families while fulfilling the obligations of residency training. This may represent an area of potential improvement in future resident wellness initiatives, although the advantages must be weighed against the benefits of conference as a social environment where residents can both connect with their colleagues and remain engaged and invested in learning through traditional teaching.
Studies have demonstrated an increased level of stress and anxiety in EM providers during the acceleration phase of the pandemic, noting increases in stress both at work and home as well as increased emotional exhaustion and burnout. 30 In our study, residents noted significant frustration with the inability to socialize along with a sense of increased stress, both from the fear of potential virus exposure for themselves and others and from the additional logistics and discomfort of PPE at work. In addition, residents expressed anxiety regarding the future, lamenting the loss of clinical experiences from canceled rotations or elective opportunities that could help them identify a career niche, along with possible limitations in job opportunities due to the financial impacts on the job market. These findings align with those from a study of surgical residents which demonstrated significant concern for virus transmission to others and the potential impacts of decreased operative exposure. 31
Overall, our study suggested that there was a trend toward greater satisfaction with EM as a career choice in residents, especially in those participating in 4‐year programs and those residents training in areas of high COVID‐19 incidence. As previously noted, there may be some overlap between these groups, but many residents commented on an increased sense of pride in their specialty during the pandemic. Additionally, participants appreciated an increase in camaraderie among staff and the resilience shown by their coworkers during the pandemic, which may have impacted their career satisfaction.
LIMITATIONS
This study was conducted shortly after the first peak of COVID‐19 cases in the United States. Accordingly, these data represent effects that were notable to residents in the short term. It is unclear from these data to what degree perceived negative educational impacts will be addressed by programs and over what time interval this will occur. The timing of this study also did not allow for more objective measurements of impacts on resident education and performance, such as changes in milestone or other competency rating trends, in‐training examination scores, or board examination pass rates. Future studies of longer‐term impacts on resident education could include objective measures such as these.
Additionally, while this was conducted at seven institutions with intentional variation in program length, location, and COVID‐19 prevalence, this may not reflect all residency program experiences. While the incidence of COVID‐19 was included for the county housing each investigated program, we did not assess objective data regarding the effects of the pandemic on each included hospital (patient volumes, rates of COVID‐19 patient admissions, etc.) to examine the impact of these differences. Finally, while the survey response rate was considered acceptable, it is possible that selection bias may have been present, with those who perceived a greater impact being more likely to complete the survey.
CONCLUSIONS
Our study examined the impact of COVID‐19 on residents’ perceived experiences. We found overall mixed responses with a perceived slightly negative impact on residency education, wellness, and clinical rotations, while satisfaction with emergency medicine as a career choice was increased. Factors influencing this included both positive and negative effects on systems experiences, clinical experiences, didactic experiences, and overall wellness. Program leaders will need to develop and continually refine strategies to mitigate any long‐term negative impact to ensure that residents achieve the necessary competencies of emergency physicians. Future research should assess changes in perceptions over time and longer‐term implications for learning and wellness as a result of COVID‐19.
CONFLICT OF INTEREST
The authors have no relevant financial information or potential conflicts to disclose.
ACKNOWLEDGMENT
The authors thank Dr. Troy Madsen at the University of Utah for his statistical expertise and Margaret Carlson for her assistance with research coordination.
Ford TR, Fix ML, Shappell E, et al. Beyond the emergency department: Effects of COVID-19 on emergency medicine resident education. AEM Education and Training. 2021;5:1–12. 10.1002/aet2.10568
Supervising Editor: Anne Messman.
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