The Impact of COVID-19 on Nephrology Fellows—A Perspective From the 2020-2021 AJKD Editorial Intern Class

Beyond its devastating toll, the ongoing pandemic of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has forced people to change many of the most basic aspects of their work and home life. While many of these changes have been difficult and inconvenient, others have proven to actually be beneficial. In this editorial, we, the 2020-2021 AJKD editorial interns, discuss some of our experiences during the last year, including our training as nephrology fellows, patient care and family experiences, career decisions, and how we worked through these challenges and sometimes saw rewards.

Krishna Agarwal, MD (Beth Israel Deaconess Medical Center): Forging Team Approaches

Overwhelming hospitals and emergency rooms, coronavirus disease 2019 (COVID-19) brought logistical challenges to the forefront of care for nephrologists and their patients receiving kidney replacement therapy (KRT). While the outside world was using social distancing for protection, inside the hospital my nephrology colleagues and I were in near-constant proximity to COVID-19. States were able to procure ventilators from federal stockpiles, make temporary hospitals, and reuse personal protective equipment, but we saw dialysis resources stretched beyond expectation. Patients with severe COVID-19 flooded our intensive care units (ICUs) and the need for KRT expanded at a frightening pace. At the same time, patients receiving maintenance dialysis were risking their lives 3 times per week by leaving their homes to obtain dialysis, and many developed COVID-19. The rapid escalation in COVID-19 cases required us to quickly adjust nephrology care to a resource-limited setting—which, in the world’s richest nation, was hard to imagine.

As nephrologists, we often are asked to initiate dialysis earlier than we might otherwise choose to do so by ICU physicians, despite lack of agreement on clinical indication. During the pandemic, however, we all relearned to reduce futility and maximize utility. For example, ICU teams were now requesting KRT only for absolute indications and were reassessing patients receiving continuous KRT more frequently to determine dialysis requirements. We stopped initiating or continuing KRT in situations where there was uncertain clinical need in order to ensure those patients who required KRT could be quickly and adequately treated.

Similarly, the pandemic reinforced the importance of strong communication between clinicians and the interdependence of clinical teams for delivery of complex care. To limit use of personal protective equipment, we and other subspecialty medicine teams became dependent on the primary medical team’s daily patient assessment. While less than ideal, this dependence forced me and other physicians on subspecialty teams to communicate closely with the primary team and with each other. The crisis may have forged more shared decision-making across teams for complex patient care, which hopefully will continue beyond the pandemic.

Arun Rajasekaran, MD (University of Alabama at Birmingham): Travel

My stress of fellowship was compounded by social distancing norms and travel constraints. Being an international medical graduate on a J1 visa, I vividly remember the anxiety I faced when traveling back from India to the United States during the second week of March 2020. My plane landed a day prior to the US borders being temporarily closed owing to the pandemic. In January of 2021, I traveled back to India to visit my family and distinctly remember the intense planning required and multiple obstacles. First, I needed to ensure I received both COVID-19 vaccine doses to protect myself and my family. In addition, international flights flying from the United States to India were limited and expensive. Moreover, visas were difficult to obtain. Most US embassies in India were shut down at this time, but luckily I was able to secure an approved visa in an expedited manner. I was fortunate, but many other nephrology fellows, particularly those on visas, were unable to travel and be with family, which likely widened feelings of isolation and frustration.

Because the pandemic imposed restrictions on multiple aspects of life, I feel that I am better able to empathize and understand the multiple and daily challenges my patients face. During the height of the pandemic, many patients missed multiple dialysis sessions owing to lack of transportation. Vaccination for COVID-19 has mitigated the social isolation for most of us, while patients with kidney failure being treated with dialysis or kidney transplantation remain at heightened risk for COVID-19 regardless of vaccination status. Because of the pandemic, I try to talk more with my patients, not only about their health concerns but also about their personal lives, and I try to encourage them to stay motivated to protect their health during the pandemic. I remind them that we are all in this pandemic together—because we are.

Debbie Chen, MD (University of California, San Francisco): Telehealth and Delivery of Care

Since March of 2020, the number of telehealth visits in our nephrology clinics has increased substantially. For many patients in my continuity clinic, telehealth has been the silver lining of a rough year. They appreciate the opportunity to eschew traffic and parking and instead be seen in the comfort of their own homes. While the idea of telehealth initially seemed impersonal to me, I have come to realize that seeing patients in their home environment is in many ways more personal and enlightening than traditional clinic visits. Family members coming in and out of the screen shed light on patients’ support systems, home decorations may reflect their personalities or hobbies, and stationary bikes in the background have been conversation starters about their lifestyle.

Telehealth, however, has not benefited every patient. At the start of the pandemic, clinic visits at our safety-net county hospital were rapidly converted to a virtual format. For many patients who did not have access to video technology, this meant telephone visits. While I was able to more easily reach patients who would have otherwise been unable to physically come to clinic, I felt that I could provide only limited assessments through the phone. Since a phone interpreter was required for many visits, even more seemed to be lost in translation. It was clear that telehealth was not a silver lining for all. As vaccination prevalence increases in our communities, telehealth may become less necessary, but its use will likely evolve with the pandemic. It is clear that telehealth is here to stay, and future nephrology fellows will also experience its benefits as well as limitations.

Racquel Holmes, MD (Duke University): Job Hunting During a Pandemic

The search for a postfellowship career requires fellows to choose between private practice, academia, or industry and then select a geographic location to work, and these decisions are never easy, regardless of a pandemic. I and the other graduating nephrology fellows of 2020 and 2021 faced substantial obstacles to making major career decisions in the setting of limited travel, scarce job postings, and social isolation. Major decisions on career opportunities and relocation were often based on telephone or videoconference conversations. Hospital tours and dinners with potential colleagues were traded for internet research and video calls with strangers.

Normally, relocation requires the input of family members, but during the pandemic I had to gather and weigh information on my own. Travel routines with hotel stays were halted, so I was forced to visit potential areas for relocation without my family to determine if they were suitable living situations. Determining the pros and cons of an area from the windows of your vehicle is much different than exploring an environment on foot, and I was not allowed to step inside potential places of future employment owing to visitor restrictions. My experiences mirrored those of most other nephrology fellows, and some fared worse. The financial uncertainty introduced by the pandemic meant many academic institutions and private practice groups were not actively recruiting or had vastly different timeframes for updating applicants on potential positions. Limited options for employment opportunities were the norm for most fellows who finished training in the summer of 2020.

I think one of the more important messages of this recent nephrology interview cycle is the need to maximize the utilization of available resources. For example, during these challenging times the job hunt requires a clear picture of the desired postfellowship career. Fellows should know exactly how they want to spend their time and where they want to live. Owing to lack of face-to-face interactions, fellows should draft a list of questions that can efficiently obtain the information needed to discern if a job is the right fit. Throughout our training, we’ve been told to “go with your gut” when ranking training programs, but during a pandemic I relied on objective data. Although I missed out on face-to-face interviews, informal conversations, and dinners with potential colleagues, I expanded my self-awareness and gained clarity of what I really want for my future career and self.

Closing Statement

The challenges of a pandemic have forced us, as graduating nephrology fellows, to reevaluate how we treat patients, communicate as a clinical team, navigate logistical challenges for maintaining contact with our family and friends, and search for postfellowship employment. We now know that we can navigate the most difficult clinical situations and continue to provide excellent care for our patients. We also can move our careers forward during the most demanding period of our lives despite social distancing and isolation. Our success has been dependent on the incredible support from our families and colleagues. We would also like to thank the editors and staff of AJKD for their support, education, and mentorship during the past year in which we served as AJKD editorial interns. It has been an incredible learning experience, one that amazingly the AJKD team was able to keep going despite the pandemic.