While most of us have turned to virtual meetings to conduct business, graduate medical education entails much more. It includes educating and training the next generation of physicians to ensure they are read to provide safe, quality care. In the era of a pandemic, how does the University of Florida College of Medicine – Jacksonville and its training programs ensure residents and fellows are receiving the necessary skills and knowledge to be well-equipped, caring clinicians?

In March, the Accreditation Council for Graduate Medical Education began holding weekly meetings among designated institutional officials during which pandemic-related challenges and opportunities were discussed. Initial discussions focused on ensuring residents and fellows were safe and had access to adequate personal protective equipment to provide direct patient care. The ACGME allowed institutions to determine whether, and to what extent, their clinical learning environment was impacted by the novel coronavirus. Depending on the level of impact, institutions were guided on what accreditation expectations had to be met to remain in compliance with ACGME standards.

The stages of impact on GME include:

• Stage 1: Business as usual
• Stage 2: Increased clinical demands
• Stage 3: Pandemic emergency status

Additionally, the ACGME expected institutions to meet four requirements regardless of the “stage” the institution felt best described its situation. Those requirements are that:

• Residents and fellows have adequate resources and training to care for patients in the clinical setting.
• Residents and fellows are provided adequate supervision in the clinical care of patients.
• Rules for work hours are not violated, helping ensure patient safety and adequate rest for residents and fellows.
• Fellows can function in their core specialty if proper procedures are followed. Although no one would describe the clinical operations at UF Health Jacksonville as “business as usual,” we have remained in GME Stage 1.

RESIDENT AND FELLOW UPDATES

David Caro, M.D., director of the emergency medicine residency program and the disaster medical director for the campus, kept academic leaders, residents and fellows up to date on clinical operations on a regular basis through Zoom meetings. For incoming trainees, the Office of Educational Affairs sent a letter welcoming them and held two Zoom meetings to provide status updates and answer questions. These were designed to help ease the stress of coming to a new environment during a pandemic.

KEEPING TRAINING AT THE FOREFRONT

Zoom and other virtual platforms are great ways to conduct business and administrative meetings, but how do you best educate and train residents and fellows in our now-virtual world? Our GME program leaders have had to reinvent how they train. National academic and specialty-specific organizations, including the Association of American Medical Colleges and the ACGME, have provided resources for programs to use. Additionally, leadership has been resourceful in developing alternate ways to create an educational milieu in which residents and fellows can effectively learn.

Several of our programs shared innovative changes they have made in the past few months to address the challenge. The anesthesiology residency program ran two interactive sessions using the American Medical Association’s ethics podcast series. After introduction to the topic via Zoom, each participant took 30 minutes to listen to a podcast episode. The group then came back together via Zoom to have an interactive discussion on the topics that were presented.

Ayesha Mirza, M.D., and Kelly Komatz, M.D., from our pediatrics residency program, created a virtual elective in narrative medicine. The goals were to strengthen the residents’ skills in active listening, empathy building and creating meaning and purpose in one’s life. These are important skills for physicians to acquire to develop substantive doctor-patient relationships.

By using the Zoom platform, Caro said he was able to contact faculty members from other institutions to increase the emergency medicine residents’ exposure to invited professorships without incurring travel expenses.

In neurology, program director Scott Silliman, M.D., found that attendance has improved using Zoom. The locations of our downtown campus, the numerous satellite clinics and UF Health North make it difficult for faculty and residents to participate in live sessions due to the travel required. The virtual platform allows for greater participation in conferences. And by using the polling/voting function of Zoom, residents and fellows can more freely express their opinions.

PATIENT CARE

But what about actual care? Inpatient care is still happening. Patients in the outpatient setting still need to be evaluated, have questions answered and medications refilled. Bedside teaching is still occurring, although the number of learners at the bedside is reduced. To protect the health care workers and preserve PPE, not all learners go to the bedside with the attending physician, which had been the case in the past.

Faculty members, residents and fellows have had a crash course in telemedicine. Thankfully, our community health and family medicine colleagues were already using the technology, so the infrastructure was there to be utilized.

No one imagined we would go from 50 telehealth visits a day to 600 a day. Because of the urgent need for its use, the ACGME’s common program requirements regarding the usage of telehealth went into effect before July, the start of the new academic year. Utilization of telemedicine capabilities has allowed remote inpatient consultation and reduced potential exposure to the novel coronavirus. There has been a steep learning curve for faculty members and trainees, but residents are quite resilient and adaptable and have risen to the task. Faculty members are learning how to “supervise” a virtual visit and provide feedback to the trainees after these visits.

WELL-BEING

Amid all of these changes, we are monitoring our residents and fellows for stress and anxiety. The Center for Healthy Minds and Practice, or CHaMP, provides free virtual counseling services for trainees and has created resources for residents and others to address the stress and anxiety they may be feeling during this time of uncertainty.

In addition to our programs’ innovative and flexible ways of continuing resident and fellow education, the programs and chief residents have held Zoom happy hours and used other modalities to introduce new residents to colleagues in their respective programs.

GOODBYE AND HELLO

Lastly, celebrating our graduating residents and fellows and welcoming and orienting incoming trainees has changed considerably. Celebration of Resident and Fellow Education and Research Day was in early June. Using livestreaming technology, web-based presentations of research and scholarship, fun cutouts of graduates, leaders and Albert the Alligator, and a small in-person event, the UF College of Medicine – Jacksonville safely and successfully celebrated the numerous accomplishments of our graduates and wished them well in their next endeavors.

In late June, we welcomed new residents and fellows. The orientation was virtual, except for activities such as N95 mask fit testing, badge photos and a few other tasks that required a physical presence. The new academic year is here and we look forward to continued creativity among GME leaders to meet the challenges of training our future physicians in this new era.