This summer, newly trained physicians completing residencies will be entering the medical profession workforce as attending physicians. These are the first group of physicians who did their residency training entirely during the COVID pandemic. Their education and view of medicine has been uniquely affected by their experiences. So, what can we expect from them?
Emergency medicine, internal medicine, pediatrics, and family medicine residencies are 3 years long. Other specialties are longer. U.S. hospitals were first affected by the COVID pandemic in March 2020. The physicians who started 3-year residencies in July 2020 have now completed residency and are either going out into practice or are continuing training in subspecialty fellowships. Residency is the most important experience that molds physicians and residency experience influences physicians’ practice for the rest of their lives. COVID has had an out-sized affect on these newly-trained physicians.
How did resident training change during COVID?
Almost overnight in the spring of 2020, education in the United States changed and residency education was no exception. What did these residents experience that previous generations of residents did not?
- Lost training time. In March 2020, outpatient clinics shut down, elective hospital admissions were canceled, and medicine, except for COVID, came to a standstill. Early on, there was a prevailing attitude from residency program leaders that as trainees, residents should not be required to care for patients with COVID infection. Across the country, residents were sent home. As a result, the effective duration of residency was shortened by weeks or months for many residents. Attending physicians had to prioritize caring for COVID patients rather than preparing lectures for residents and engaging in bedside teaching. For those residents who remained in the hospitals, procedural experiences were often limited. For example, in the months of the pandemic, I performed intubations and bronchoscopies on suspected COVID patients by myself, without residents or fellows in the room, in order to reduce the number of people exposed to aerosolized virus. Family medicine residents had virtually no sports medicine experiences in the first year of the pandemic since high school and college sports were cancelled.
- They didn’t attend national medical conferences. In 2020, national medical society annual meetings, such as the American College of Physicians, were canceled. In 2021 and 2022, attendance at medical conferences was down and many people attended virtually, rather than in person. This resulted in a loss of an important networking opportunity for residents during these years in addition to a loss of cutting edge knowledge about new developments in medicine.
- Remote learning. Prior to 2020, classroom space in most hospitals was premium real estate. Rooms had to be reserved for conferences and lectures months in advance and sometimes, there was simply no convenient place to hold these lectures. Furthermore, residents who either were off-duty due to working night shifts or were doing rotations off-site from the main hospital were unable to attend lectures. With the onset of COVID, lectures were all changed to remote learning by WebEx, Zoom, and Teams video conferencing. Although many educators lamented the loss of the in-person lecture, video conferencing allowed residents to attend more educational conferences than in the past, thus enriching their didactic training. Today, primary and secondary education has largely returned to in-person classroom instruction but residents still mostly attend lectures by video conferencing because it is more efficient. A few months ago, I gave a talk to our fellows – there were dozens of attendees on-line but I was the only person in the lecture hall.
- Telemedicine. When the pandemic hit and outpatient appointments were converted to telemedicine appointments, many older physicians had a difficult time adapting to new workflows, effective use of video, and the lack of physical exams. But for new residency graduates, telemedicine is normal medicine. Many of them performed telemedicine patient visits during residency before they performed in-office visits. These physicians are not only more comfortable using telemedicine but they will demand that Medicare and commercial health insurance companies continue to reimburse for it.
- A hostile segment of the population. Early in the pandemic, healthcare workers were revered heroes in the United States. But soon, anti-maskers, anti-vaxxers, and COVID-deniers became increasingly vocal skeptics of the medical community. Across the country, health department medical directors were threatened, public health officials were fired, and even Anthony Fauci was vilified. As a result, these newly trained physicians have felt hostility from a loud group of Americans and have developed a jaded view of public health.
- Compassion fatigue. The COVID pandemic desensitized many residents to grief. When patients are dying all around you, emotions become hardened. Early in the pandemic, it was the sheer numbers of the dead. Later in the pandemic, most of those hospitalized with COVID or dying of COVID were the unvaccinated and as a result, all too often, we ended up blaming the patients for their illness.
- More burnout. The pandemic stressed residents in training but also stressed the attending physicians who were their mentors. When the doctors that you are trying to emulate become cynical or want to leave the practice of medicine, the flames of burnout can spread to trainees. COVID brought out both the best and the worst in us. When it brought out the worst in an attending physician or a group of physicians, their trainees were impacted. This year’s group of residency graduates have experienced more burnout than previous groups – both personally and in their colleagues.
- An unbalanced clinical experience. I am a physician member of the AIDS generation. As a resident, I spent 2 months on the inpatient AIDS service. During my first year of pulmonary and critical care fellowship, I performed 350 bronchoscopies, more than half of which were performed to diagnose opportunistic pneumonia in patients with HIV infection. AIDS dominated my clinical experience. For this year’s group of graduating residents, it is COVID that has by necessity dominated many of their clinical experiences. This has made them very good at managing COVID infections but has often reduced the number of patients that they have seen with non-COVID medical conditions. Many have treated more patients with COVID than patients with heart failure. ICU rotations have been particularly unbalanced with disproportionately more COVID respiratory failure than other critical illnesses such as ketoacidosis and septic shock.
- Better attention to infection control. Before the pandemic, hospitals had to continually remind physicians to wash their hands after examining patients. Doctors frequently came to work despite having a cold or the flu. That all changed in the spring of 2020 when not wearing a mask or washing your hands could cost you your life. This year’s residency graduates are more attentive to nosocomial transmission of infections and this could make our hospitals and medical offices safer in the future.
What hospitals can do
In the United States, the majority of physicians are now employed by a hospital or health system. Newly trained physicians are even more likely to be hospital-employed. Our hospital leaders need to be aware that these new internists, pediatricians, ER physicians, and family practitioners are different than previous physicians – not better or worse, just different. In order to maximize the potential of these physicians, there are steps we can make today to ensure that they are happy, productive, and practice high-quality medicine.
- Optimize telemedicine capabilty. These doctors have learned to do telemedicine very effectively so give them the tools to do it. This means updating patient teleconferencing hardware, ensuring telemedicine seamlessly integrates into the electronic medical record, and the ensuring that the revenue cycle department is fully up to date on telemedicine billing. Dedicated telemedicine IT support is essential. Outpatient workflows and scheduling need to be re-engineered with telemedicine efficiency in mind.
- Enhance educational videoconferencing capability. Winding down the pandemic should not mean winding down videoconferencing. Teaching conferences, grand rounds, and departmental meetings should always have video options available.
- Promote career mentor relationships. Navigating the post-pandemic world could prove challenging for physicians who have only known the pandemic during their training. Ensure that every new physician has an assigned senior physician mentor from the first day of their employment. Over time, physicians usually identify their own career mentors but having an designated experienced physician who a young residency graduate can go to for career advice from day one is ideal.
- Smother the embers of smoldering burnout. Many of these newly trained physicians are already experiencing burnout and others are teetering of the edge of burnout. There are several practical measures that hospital leaders can take to fireproof their doctors against burnout. Making workplace wellness a priority is essential to bring out the best in the COVID generation of doctors.
- Step-up your CME program. By attending fewer (or no) national medical meetings during residency, newly trained physicians were dependent on their hospitals’ own attending physicians and on-line sources for their education. They often lacked exposure to opposing or innovative viewpoints on disease diagnosis and management. More than any other generation of physicians, they will benefit by continuing medical education in their first years in practice. Include CME expense allowances in their employment contracts to encourage them to attend regional and national meetings. At the risk of shameless self-promotion, consider a hospital subscription to the medical education webcast, OSU MedNet, that I moderated for 25 years.
- Keep momentum on infection control. This generation of physicians is more attuned to hand-washing and prevention of nosocomial infections than any other generation of physicians. It is much easier to maintain a culture of attention to infection control than to change a culture of inattention to infection control. Normalize healthcare workers staying home when they are sick and maintain adherence to hand-washing.
- Encourage proctoring. Because of an imbalance in clinical experiences during training and fewer opportunities to perform procedures during training, some recent residency graduates may not have adequate experience performing office procedures, performing hospital bedside procedures, and interpreting bedside tests. A proctoring program can ensure that they competent to perform these procedures. For example, a hospital could require a new internal medicine hospitalist to have 2 or 3 central venous catheter placements proctored before full central line privileges are granted. Or 2 or 3 IUD placements for a family medicine physician. Or 2 or 3 intubations for an emergency medicine physician.
- Re-kindle compassion. Compassion is not created by a CME lecture or by reading words in a book. Compassion is created when there is a culture of compassion among one’s peers. It is fostered by the example that is set by senior physicians and medical directors. That means being inspirational, showing empathy, and being considerate to not only patients but other healthcare workers.
The newly graduated residents represent the future of medicine. But they are different from previous generations of physicians with different strengths and weaknesses. It is up to us as medical leaders to ensure that they are able to grow to their full potential.
August 15, 2023