Article Text

Single-centre study surveying neurology trainees’ and faculty’s perceptions of the impact of the COVID-19 pandemic on residents’ medical education
  1. Hisham Alhajala1,
  2. Ahmad Riad Ramadan1,
  3. Aarushi Suneja2,
  4. Lonni Schultz1 and
  5. Iram F Zaman1
  1. 1Neurology, Henry Ford Health System, Detroit, Michigan, USA
  2. 2Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
  1. Correspondence to Dr Hisham Alhajala; halhaja1{at}hfhs.org

Abstract

Objective To assess perceptions of our neurology residents and faculty regarding training experience and medical education during the early COVID-19 pandemic.

Methods We distributed two online, voluntary and anonymous surveys to trainees and teaching faculty of our Neurology Department at Henry Ford Hospital. Surveys inquired about trainees’ stress, well-being, clinical experience and satisfaction with medical education and available support resources during the first wave of the COVID-19 pandemic in Michigan (mid-March to June 2020).

Results A total of 17/31 trainees and 25/42 faculty responded to the surveys. Eight (47%) trainees reported high stress levels. Nine (57%) were redeployed to cover COVID-19 units. Compared with non-redeployed trainees, redeployed residents reported augmented medical knowledge (89% vs 38%, p=0.05). There was no difference in the two groups regarding overall satisfaction with residency experience, stress levels and didactics attendance. Twenty-one (84%) faculty felt that the redeployment interfered with trainees education but was appropriate, while 10 (59%) trainees described a positive experience overall. Both trainees and faculty believed the pandemic positively impacted trainees’ experience by increasing maturity level, teamwork, empathy, and medical knowledge, while both agreed that increased stress and anxiety levels were negative outcomes of the pandemic. Twelve (70%) trainees and 13 (52%) faculty were interested in pursuing more virtual didactics in the future.

Conclusion Our findings provide an objective assessment of residents' experience during the COVID-19 pandemic and can guide teaching programmes in their medical education response in the face of future global crises.

  • COVID-19

Data availability statement

All data relevant to the study are included in the article or uploaded as online supplemental information. The survey participants were deidentified. The surveys results are included in the article.

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Introduction

The COVID-19 pandemic has changed healthcare systems across the USA and the world. In addition to the increased need for material and human resources, the pandemic presented practical and logistical challenges that disrupted medical education and training.1 2 These challenges mandated a quick and effective response to transform traditional educational methods while introducing novel methods for teaching and learning.3 The state of Michigan, and particularly the Detroit metropolitan area, rose as one of the ‘hot spots’ in the country with a steep surge in the number of cases beginning in early March 2020. Henry Ford Health System (HFHS) adopted a quick plan in response to the severity of the situation and the increased number of patients afflicted with COVID-19. Across all departments, this response included modifications to residency and fellowship programme routine workflow and didactics in order to comply with social distancing measures and limit the exposure of trainees to confirmed or suspected cases. Previously, we described the organised response of our HFHS Department of Neurology response to the pandemic which included putting a moratorium on all ‘non-essential’ rotations, redeploying residents to provide care for patients in overwhelmed COVID-19 units, implementing teleneurology outpatient visits, and shifting to online learning modules and lectures.4 In this study, we conducted two anonymous surveys: one distributed to our neurology trainees (residents and fellows) and one given to our neurology faculty, to assess and compare their perceptions of trainees’ medical education, clinical experience and well-being during the pandemic. To our knowledge, this is the first study to objectively report both neurology trainee and teaching faculty perspectives on the challenges faced in education and work conditions during the early COVID-19 response.

Methods

We conducted two anonymous, voluntary and confidential online surveys using SurveyMonkey from 1 June 2020 to 1 July 2020, intended to inquire about the period stretching from mid-March 2020 to June 2020, which corresponds to the first wave of the pandemic in Michigan. The trainees and faculty survey forms and the consent for participation can be found in online supplemental tables 1 and 2, respectively. One survey was sent to neurology residents and fellows of all postgraduate year (PGY) levels. Another survey was sent to all teaching faculty within the Department of Neurology at HFHS. The study protocol was reviewed and approved by the Institutional Review Board of HFHS. Our goal was to assess the trainees’ perception of their well-being, stress level and the effects of changes brought to their education on clinical and didactics grounds during the pandemic. We queried the faculty with similar questions to survey their opinions on trainees’ well-being and the quality of the medical education they received during COVID-19. We also compared level of stress, lecture attendance, and overall satisfaction with the experiences in redeployed vs non-redeployed residents. Participants were electronically consented to take part in the study prior to answering the questions.

Supplemental material

Supplemental material

Surveys

Trainee survey

In order to protect respondent anonymity, the only demographic question that was asked to trainees was their level of training. The answers to each question were pooled in order to prevent tracing back answers to the individual respondent. The survey was made of 33 questions, spanning 5 categories: demographics (PGY level), wellness, experience with redeployment to COVID-19 units, medical/didactics education and perceived performance. Query formats were a combination of single-answer multiple choice questions (MCQs), multiple-answer MCQs and open-ended questions.

Faculty survey

This survey was made of 22 questions, the format of which was a combination of single-answer MCQs (satisfaction level, yes/no), multiple-answer MCQs and open-ended questions. The categories of questions were faculty demographics (number of years in practice, subspecialties, types of interaction with trainees such as inpatient, outpatient, research, didactics and mentoring), perception of trainees’ well-being and satisfaction with trainees’ education. Similar to the trainee survey, responses were pooled for each question, limiting the cross-referencing with demographic answers. Questions for both surveys are included in Exhibit X.

Statistical analysis

Statistics describing survey responses included sample sizes, percentages and the corresponding 95% CIs. Fisher’s exact tests were done for comparisons of redeployed and non-deployed residents experiences. The impact of the pandemic on medical training from trainees and faculty responses were compared using Fisher’s exact tests.

Results

Demographics

In March 2020 to July 2020, the HFHS Neurology Department had 31 trainees (24 residents, and 7 fellows across 3 subspecialties) and 42 teaching faculty. A total of 17/31 (54.8%) of Neurology Department trainees completed the survey. Trainee surveys were sent to all postgraduate year (PGY) residents and fellows (table 1). Survey participation was rather evenly distributed across PGY levels. A total of 25/42 (60%) supervising neurology faculty completed the faculty survey. Faculty respondents spanned all neurological subspecialties available at HFHS. Of the participating faculty, all but one worked full time. Regarding faculty practice experience, four (16%) of the faculty had 1–3 years of practice, nine (36%) had 4–10 years, nine (36%) had 11–20 years and three (12%) had more than 20 years of experience. All but 1 faculty member routinely interacted with trainees, with 20 (80%) interacting through didactics, 17 (68%) through mentorship, 17 (68%) in the outpatient setting, 14 (56%) in the inpatient setting and 13 (52%) through research (table 1).

Table 1

Characteristics of surveyed trainees and faculty

Trainee survey

The personal stress level during the COVID-19 outbreak was high for 8 (47%) of the residents, moderate for 8 (47%), and low for 1 (6%); whereas family stress level was extremely high for 4 (24%), high for 8 (47%), and moderate for 5 (29%) of the trainees. All residents were aware of how to access emotional support resources, with 14 (82%) of them being at least satisfied with the resources made available to them. None of the residents reported violating their clinical work hours. Three residents were confirmed or suspected to have contracted COVID-19. Of these residents, two were satisfied with the amount of time-off they received and one had a neutral response (table 2 and online supplemental table 3).

Supplemental material

Table 2

Trainees survey results. (complete responses to all questions can be found in the online supplemental table 3)

Regarding work allocation, nine (53%) of the residents were redeployed to a COVID-19 unit and all of them were satisfied/very satisfied with the supervision on COVID-19 units, the personal protective equipment (PPE) provided, the overall effort to decrease exposure, and the nursing staff support. All found their time on COVID-19 units at least moderately fulfilling.

When asked if they agreed that the amount of work was overwhelming during the pandemic, two (12%) residents agreed with the statement, seven (41%) were neutral, five (29%) disagreed and three (18%) strongly disagreed. All but one resident were at least satisfied with their overall performance during the COVID-19 outbreak. While 10 (59%) residents responded that their overall experience was positive during the outbreak, 4 (24%) had a neutral experience and 3 (18%) had a negative experience.

When asked about the positive ways that the pandemic had contributed to their training experience, 11 (65%) answered solidarity/teamwork, 11 (65%) indicated expanded medical knowledge/skills, 9 (53%) indicated increased maturity and 9 (53%) answered enhanced empathy. When asked about the negative impact the pandemic had on their experience, 14 (82%) responded increased stress, 8 (47%) fear/anxiety and 5 (29%) reduced productivity (table 2 and online supplemental table 3).

Responses of redeployed versus non-redeployed trainees

Residents who were redeployed to COVID-19 units and those who were not were compared for their responses to their personal stress level, family stress level, lecture attendance, overall satisfaction with the experience, and ways the COVID-19 outbreak affected their experiences. Residents who were redeployed reported a positive effect on expanded medical knowledge/skills relative to non-redeployed residents (89% vs 38%, p=0.05). Although not statistically significant, redeployed residents were also less likely to report decreased self-confidence as a negative impact of the pandemic compared with non-redeployed residents (0% vs 38%, p=0.082). There was no significant difference in the two groups regarding overall satisfaction with residency experience, personal or family stress levels, and ability to attend didactics (table 3).

Table 3

Comparing redeployed and non-redeployed trainees’ responses

Faculty survey

During the COVID-19 outbreak, 22 (88%) surveyed faculty members had significant interactions with residents, with 10 (40%) interacting through didactics, 8 (32%) through mentorship, 14 (56%) in the outpatient setting, 13 (52%) in the inpatient setting and 12 (48%) through research (table 4).

Table 4

Faculty survey results

While nine (36%) faculty members witnessed emotional distress in residents, two of them were directly approached by trainees for emotional support (table 4). Regarding medical education, 13 (52%) of the faculty were satisfied/very satisfied with the didactics given to trainees during the COVID-19 outbreak, 9 (36%) were neutral, and 3 (12%) were dissatisfied/very dissatisfied. When asked their opinion about the impact that the pandemic had on residents’ education, 9 responses (36%) were positive, 8 (32%) were neutral, and 8 (32%) were negative. When asked about whether redeployment had interfered significantly with resident education, 4 (16%) of the faculty answered not at all, 11 (44%) said a little, 7 (28%) said moderately and 3 (12%) said a lot. When asked about the positive ways the pandemic had contributed to residents’ experiences, 21 (84%) of the faculty said solidarity/teamwork, 19 (76%) enhanced empathy, 16 (64%) increased maturity and 12 (48%) expanded medical knowledge/skills (table 5). When asked about the negative ways the pandemic had contributed to residents’ experiences, 18 (72%) responded increased stress, 18 (72%) fear/anxiety and 11 (44%) feeling overwhelmed. Responses for these and other questions can be found in tables 4 and 5.

Table 5

Comparing residents and faculty’s responses

Trainee and faculty responses

Both residents and faculty were asked about the positive and negative ways the pandemic contributed to the residents’ experience. For the positive ways, residents had higher rates for expanded medical knowledge/skills (65% vs 48%) and greater clinical competence (41% vs 32%), while faculty responded with higher rates for solidarity teamwork (84% vs 65%), increased maturity level (64% vs 53%), heightened assertiveness (32% vs 12%) and enhanced empathy (76% vs 53%). However, none of these differences were statistically significant between the two groups. For the negative ways, residents responded with higher rates for increased stress (82% vs 72%) and decreased self-confidence (18% vs 8%), while faculty had higher rates for fear/anxiety (72% vs 47%), feeling overwhelmed (44% vs 24%), and decreased sleep (16% vs 0%). Again, none of these differences reached statistical significance (table 5).

Discussion

To adapt to the rapidly changing landscape brought by the early COVID-19 pandemic, health systems had to reorganise their operations at all levels, such as clinical care in outpatient and inpatient settings, visitation limitations, screening of patients, visitors and employees, procurement and rationing of PPE, and deferment and cancellation of elective procedures and surgeries. Teaching programmes all over the country were also impacted and had to undergo temporary restructuring to limit potential exposure of trainees to a virus of which little was known and to funnel manpower to those areas of hospitals in dire need of medical personnel.5 We have previously described our experience and challenges as a Neurology Department at the beginning of the pandemic.4 In this study, we surveyed our own neurology trainees and teaching faculty using two anonymous and voluntary web-based questionnaires to assess their viewpoints on the impacts the pandemic had on our trainees’ well-being, performance, education and clinical experience. To our knowledge, this is the first study to analyse and compare perceptions through surveying both neurology faculty and trainees at a teaching institution serving an area hit hard by the early COVID-19 pandemic.

In 2020, during the first wave of the pandemic, the Neurology Department at HFHS was composed of 42 teaching faculty, 24 adult neurology residents with 6 residents in each PGY level and 7 fellows. Most of our inpatient services, with the exception of the neurointensive care unit, were converted to isolation units to accommodate a rising number of patients with COVID-19 while hospitalisations for neurological diagnoses experienced a sharp decline, as reported by ourselves and others.4 5 Eighteen of the 24 neurology residents and 3 of the 7 fellows were redeployed to cover COVID-19 services. The residency programme director and chief residents together determined which residents were to be redeployed based on the residents’ rotation schedules. Priority was to redeploy second- and third-year neurology residents who were on elective rotations, keeping in mind programme and graduation requirements. General and specialty neurology clinics were closed for in-person encounters and converted to telehealth visits. All educational activities migrated to virtual platforms in observance of the strict social distancing policies enforced by the hospital’s administration.

The majority of trainees reported high personal and family stress levels, whether redeployed to COVID-19 units or not. The stress was mainly imputed to fears of exposing family members but also concerns with training being disrupted and graduation being delayed should the redeployment last longer than a couple of months. Importantly, the majority of residents thought that their training experience during the pandemic was a fulfilling one (59%) and, surprisingly, although not statistically significant, more redeployed trainees reported a positive experience than those who were not redeployed (67% vs 50%). This observation likely stems from the fact that a larger number of them felt that their medical knowledge and skill set were significantly expanded as a result of caring for patients with COVID-19 and a sense of making a significant contribution in the treatment and improvement of these patients. Despite the uncertainty and increased stress levels, both trainees and faculty took ownership of education and wellness by sharing ideas on how to creatively respond to the current crisis. This included knowledge sharing, launching research projects, and conducting daily virtual meetings with department leadership for updates and available resources that helped foster transparency and address resident concerns. The department put an emphasis on mental health and wellness in particular, with a variety of resources made available. Faculty also prioritised resident safety by incorporating innovative ways to reduce trainee exposure. For example COVID-19 patients in COVID-19 units were virtually pre-rounded, and faculty went in alone to examine the patients to reduce potential trainee viral exposure. Similarly, on consultation services, the majority of the team remained outside of the room while only faculty examined the patients.

Faculty’s outlook on the impact of the pandemic on residents’ medical education was, however, more divided. While the trainees’ perception was a predominantly positive one, our surveys indicate that faculty were evenly divided between positive, neutral, and negative impressions. Approximately 40% of surveyed faculty thought that the pandemic had at least moderately interfered with resident education, although none of them believed that the redeployment had been inappropriate. The concern by many faculty who thought that the impact had been a negative one is in line with the reduced exposure of trainees to neurodiagnostic rotations such as electromyography, electroencephalography and transcranial doppler ultrasound, as nearly all non-urgent outpatient procedures were halted for several months. Finally, migration to virtual learning was positively received, as 70% of trainees and 52% of faculty who answered the surveys were interested in pursuing more virtual avenues for didactics in the future. This may potentially become important as virtual online platforms have experienced a sharp increase in utilisation during the pandemic and can now provide trainees on off-site rotations the ability to attend lectures remotely, even as normalcy returns.

The impact of the COVID-19 pandemic on postgraduate medical education has been published in several papers,6 7 a few of which have used surveys. For instance, surveys of surgical residents reported reduction in clinical exposure with the cancellation of elective surgeries and limited operative time.8–10 Similar to our findings, one study found that residents reported higher levels of stress that were attributed to uncertainty, decrease in clinical exposure, and concern for visa situations.11 Our study was innovative in that it was designed to take into consideration both trainee and teaching faculty viewpoints on various aspects of postgraduate neurological medical education during the pandemic, while comparing survey answers from redeployed and non-redeployed trainees.

Despite these strengths, our study bears a few limitations. First, our findings are limited by the average participation rates among trainees (53%) and faculty (60%). That being said, the large size of the Neurology Department at HFHS, one of the largest medical groups in the country, yielded a satisfactory sample size, which allowed us to make valuable observations. Second, the single-centre experience limits generalisability of the findings to other teaching institutions, and more information could have been gathered from surveying other neurological teaching programmes in the area. While this is certainly a limitation, we believe that our experience can be representative of similarly diverse urban academic centres which, like Detroit, were significantly impacted by high infectivity and mortality rates during the early days of the pandemic. Third, some survey questions could have been asked differently so that more direct comparisons could have been made between trainee and faculty responses. Lastly, inclusion of a prepandemic comparator for faculty/resident perspectives of residency training may have yielded valuable information and could have augmented some of our observations. To that effect, a postpandemic follow-up study may be extremely informative to gauge the significance of the impact the pandemic has had on medical education.

Our study uniquely surveyed neurology faculty and trainees and their perceptions of residents’ well-being and the quality of medical education received during the first wave of the COVID-19 pandemic in the US amidst redeployment and virtual learning initiatives. While the pandemic is still raging around the world and many institutions have adapted to this new and unprecedented reality, our findings can guide teaching programmes tailor their own responses in times of future pandemics and crises.

Data availability statement

All data relevant to the study are included in the article or uploaded as online supplemental information. The survey participants were deidentified. The surveys results are included in the article.

Ethics statements

Patient consent for publication

Ethics approval

This study involves human participants and was approved by This study was approved by the Henry Ford Health System IRB reference number/ ID: 13902.Approval date May 2020 to May 2021.The first question of each survey asked participants whether they agree to participate in the online surveys. We only included answers from participant who answered with yes.

References

Supplementary materials

Footnotes

  • Twitter @Alhajalihisham, @RiadRmdn

  • Contributors HA and ARR equally contributed to writing the manuscript. IFZ, ARR and AS designed and conducted the surveys. HA, ARR and LS performed the statistical analysis and interpretation of results. All authors discussed the results.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; internally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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