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.