Training Programs Adapt During COVID-19

Be flexible.
Be creative.
Be persistent.

In 2020, these characteristics became the essential elements in pediatric training programs — not just for residents and fellows, but also for program directors and coordinators.

Drs. Mary Smyth, Stacey Chittle Shubeck, Ashima Goyal, Kerry Mychaliska, and Meg SambergSome training programs shortened or canceled rotations because of COVID-19. Parents and other caregivers postponed clinic appointments for healthy children. Often, the number of physicians who could have contact with a child was limited, so trainees were not allowed into hospital and examining rooms with patients. And some residents missed weeks of training because they were sick themselves or were caring for ill family members.

Program directors were challenged to find ways to maintain high standards for quality education and training amid these disruptions — without putting careers on hold or children’s health at risk.

Dr. Nicole Shilkofski“Like everyone else, we had to move our educational conferences and morning reports to a virtual platform,” says Nicole Shilkofski, MD, MEd, Associate Professor of Pediatrics, Vice Chair of Education, and Residency Program Director in the Department of Pediatrics at Johns Hopkins University School of Medicine. “But the biggest impact has been clinically.”

Dr. Stacey Chittle ShubeckStacey Chittle Shubeck, MD, Director, Internal Medicine/Pediatrics Residency Program and Section Head of Ambulatory Pediatrics at Beaumont Children’s Hospital in Royal Oak, MI, agrees.

“Visits to our clinic plummeted,” she says. “We switched to telemedicine early on, but still had far fewer visits than normal. Our ACGME [Accreditation Council for Graduate Medical Education] clinic number requirements are going to be a challenge this year for sure.”

Juggling residents’ schedules was another huge challenge, says Dr. Chittle Shubeck.

“At the height of the pandemic, all available residents were pulled off pediatric rotations and internal medicine electives to work the [adult] inpatient floors,” she says. “When COVID slowed down, I was then left to figure out how to adjust future schedules to ensure my fourth-year residents could graduate and to make up for the rotations that all the other residents had missed.”

During interviews about COVID-19 and other topics, residents told the ABP they had fewer opportunities than their predecessors to see patients. While the impact is greatest on first-year residents and medical students, even some third-year trainees had been excluded from going into rooms with attending physicians during rounds.

However, most residents also gained experience and training in telemedicine, building skills that are likely to be useful when they are practicing.

“They have to learn to use their powers of observation since they can’t lay hands on a child,” Dr. Shilkofski says. “We’re lucky in pediatrics because often powers of observation are enough to determine whether a patient is sick or not. You can look at a rash [via video], for example. But there’s no substitute for listening to a patient with a stethoscope. It’s hard to assure yourself that you’re evaluating a patient adequately.”

Trainees who were interviewed said that, despite the pandemic, they had been exposed to a variety of patient and care experiences and felt well prepared for fellowships or general practice. They also acknowledged there may be gaps in their training and noted it will be important to understand what the gaps are and find ways to fill them.

Dr. Suzanne WoodsACGME, the organization that accredits programs and sets the requirements for training, worked with individual institutions that needed flexibility in the core program requirements, explains Suzanne Woods, MD, ABP Executive Vice President for Credentialing and Initial Certification.

The ABP allowed a reduction in the number of continuity clinics that a graduating resident was required to complete before qualifying to take the General Pediatrics Initial Certifying Exam. In addition, the ABP extended flexibility around the “Absences from Training” policy and worked with programs on behalf of individual trainees.

“The ABP understands the challenges that training programs are experiencing, and we wanted to offer program directors and trainees flexibility and support during the time of the pandemic,” says Dr. Woods. “Still, it is critical to ensure that trainees receive a quality education and training experience. The care they provide to children and youth depends on that.”

Most medical specialty and subspecialty training programs require trainees to spend a fixed amount of time on required rotations. Dr. Woods says, however, that the challenges and opportunities presented by the pandemic may persuade more programs to more fully embrace competency-based medical education (CBME), where the amount of time spent on a rotation could vary, depending on how long it takes the trainee to become competent.

Dr. David TurnerDavid Turner, MD, ABP Vice President for Competency-Based Medical Education, says the pandemic has put CBME in the spotlight and helped the pediatric community think more creatively about what is possible for the education and assessment of residents and fellows.

“Because of the pandemic, many trainees had limited educational opportunities in some areas,” Dr. Turner says. “These limitations led to challenges for programs directors in assessing the competence of their trainees in these areas and in making decisions regarding progression to the next level of training.”

Rather than focusing exclusively on time spent in a given experience, CBME provides a different approach, he says. A CBME framework, including milestones and entrustable professional activities (EPAs), allows program directors to address training disruptions caused by the pandemic by assessing what a trainee knows and where weaknesses exist, irrespective of time spent on a specific rotation. CBME also can be used to facilitate development of individualized learning plans and curricula to fill educational gaps.

Photo: Drs. Mary Smyth, Stacey Chittle Shubeck, Ashima Goyal, Kerry Mychaliska, and Meg Samberg