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J Am Soc Nephrol. 2021 Mar 3; Online ahead of print.
Impact of the COVID-19 Pandemic on Nephrology Fellow Training and Well-Being in the United States: A National Survey
Kurtis A Pivert, Suzanne M Boyle, Susan M Halbach, Lili Chan, Hitesh H Shah, Joshua S Waitzman, Ali Mehdi, Sayna Norouzi, Stephen M Sozio
PMID: 33658283 DOI: 10.1681/ASN.2020111636
Impact of the COVID-19 Pandemic on Training, Morale and Well-Being Among the UK Renal Workforce
Hannah Beckwith, Ailish Nimmo, Manuela Savino, Haresh Selvaskandan, Matthew Graham-Brown, James Medcalf, Paul Cockwell
Open Access Published:March 15, 2021
DOI: https://doi.org/10.1016/j.ekir.2021.03.004
For clarity in this methods section, we will refer to the first study as “JASN” and the second study as “KIR”.
Introduction
In the blink of an eye the coronavirus infectious disease 2019 (COVID-19) pandemic changed the face of medical education. Physician trainees found themselves in a unique position during the early months of the COVID-19 pandemic. As many remained in front-line positions, they attempted to balance growing medical knowledge and development of clinical skills with navigating an uncertain and rapidly changing healthcare environment. Early in the pandemic, April 2020, a single-institution survey of medical and surgical residents demonstrated negative impacts were already apparent. Residents expressed concern about the loss of clinical/operative experiences, limited personal protective equipment (PPE), inability to find reliable childcare, and visa uncertainty. (Rana et al, Med Educ Online 2020)
Nephrology is not immune to these challenges. As with many other medical specialties, nephrology training programs implemented quick adaptations to meet pandemic-mediated safety measures. These included adoption or expansion of telehealth services, transition to virtual learning models, and changes to services and schedules. Two recent studies published in JASN and KI Reports describe the impacts of the COVID-19 pandemic on US nephrology fellows and the UK renal workforce, respectively. These survey results give us the first formal assessments of how new educational experiences and altered clinical practice models have affected nephrology workforces.
Since 2014, the American Society of Nephrology (ASN) has conducted an annual online survey of current nephrology fellows-in-training to obtain data on demographic and educational backgrounds, educational debt, career plans, job search experiences, and factors influencing job opportunities. As with so many things planned for 2020, the survey was cancelled. As the pandemic accelerated, it became apparent that there was a pressing need to determine how it was affecting nephrology fellows-in-training.
Methods
Design
JASN - ASN Data Subcommittee - en lieu of the annual survey, a research survey was developed to assess the effects of COVID-19 pandemic on US nephrology fellow education and well-being
JASN Survey (available from Aug 4 through Sep 14, 2020)
Included questions from annual survey (to facilitate longitudinal data collection)
Resident Well-Being Index (RWBI)
Complete Survey Instrument (available in Supplemental Data)
KIR - Research questionnaire was developed to characterize the impacts of the COVID-19 pandemic on the UK renal workforceIntervention
KIR Online Questionnaire (available from Jul 22 to Aug 28, 2020)
Questions for demographic information
Maslach Burnout Inventory (MBI)
Complete Survey Instrument (available in Supplementary Materials)
Study population (Survey frame)
JASN
Distributed via email and also advertised in a RFN post
Incentivized to complete (opportunity for 12 prizes, 2 complimentary registrations to ASN BRCU, 10 1- year ASN memberships). Similar incentive provided for annual ASN survey (e.g. RFN post).
Demographic characteristics of survey respondents, were compared with the most-recent data from the Accreditation Council for Graduate Medical Education (ACGME) for representativeness
KIR
Distributed via email, text message, and advertised on Twitter
No incentive offered to complete
Outcomes
Funding
JASN - Supported by NIH and ASN
KIR - UK Renal Association
Results
The ASN survey was distributed via email to 1,005 potential participants, and 425 completed responses were received (42.3% response rate). The demographic information for survey participants is listed (Table 1, Figure 1) and respondent demographics reflect those of the trainee population at large per available ACGME data. As such, the majority of responses were received from adult nephrology current fellows (n=230) and recent graduates (n=132).
Table 1 from K Pivert et al. JASN 2021. Demographic characteristics of survey respondents.
Figure 1 from K Pivert et al. JASN 2021. Respondent locations (circles) overlaid on a map showing cumulative patients with COVID-19 as of August 4, 2020.
Prior to the pandemic, many respondents had “never” or “rarely” used remote learning, and even fewer had experience with telehealth services. Rapid implementation of lockdowns and social distancing requirements made traditional in-person conferences (both large grand rounds as well as small-group learning) impractical. The majority of programs moved to completely online video-conferencing (Figure 2).
Figure 2 from K Pivert et al. JASN 2021. Changes to nephrology fellowship conferences.
Furthermore, COVID-19 surges, personal protective equipment (PPE) shortages, concerns about airborne transmission, etc. led many to adopt/expand telehealth services in both inpatient and outpatient consult settings keeping fellows engaged in patient care. Interestingly, this did not apply to the outpatient dialysis clinics, where it seems more than 50% of recent graduates were withdrawn from that setting (Figure 3). Of note, “telehealth” was not clearly defined in the survey.
Figure 3 from K Pivert et al. JASN 2021. Telehealth utilization stratified by patient care setting.
As the pandemic evolved, and with increasing vaccination rates among healthcare professionals, so has the educational setting. This is evident in the distinction between 54% of recent graduates being pulled from outpatient dialysis clinics compared to only 13% of current fellows. Similarly 44% of recent graduates completed all outpatient consults via telehealth versus only 15% of current fellows.
Figure 4 from K Pivert et al. JASN 2021. Management approaches used for inpatients who were COVID-19 positive.
Most fellows (64%) indicated that they did not provide in-person consultations for inpatients with COVID-19 (Figure 4). In those programs, the service was provided entirely via telehealth, by attending/faculty independently, or by an unspecified approach. Respondents seemed to agree that the preferred approach was a virtual evaluation in concert with the primary teams’ in-person assessment, unless a dialysis-access procedure was required. Digital tools were put into action beyond telehealth. For example, tablets were used for rounding, collaborative team meetings held via online conferencing platforms, and ICU live video feeds made available.
Figure 5 from K Pivert et al. JASN 2021. Effects of the COVID-19 pandemic on facets of trainees’ and graduates’ personal life.
Fellows did indicate negative impact to overall quality of life, with friend relationships and work-life balance suffering the most (Figure 6) Of the 412 who completed the RWBI, 15% (16% current fellows, 12% recent graduates) had a score above the distress threshold. There was a significantly increased risk for distress in respondents who perceived unmet educational goals (Table 2).
Figure 6 from K Pivert et al, JASN 2021. Effects of the COVID-19 pandemic on facets of trainees’ and graduates’ personal life.
Table 2 from K Pivert et al. JASN 2021. Association of perceptions of professional or personal factors with distress threshold score (RWBI score ≥5).
The UKRA survey was made available to 1224 members, and 195 responses were received (15% response rate). The majority were female (62%) which differs from that of the association at large (62% male). The demographic data of total respondents and those without burnout are listed (Table 3).
Table 3 from H Beckwith et al, KI Reports 2021 . Demographic characteristics of survey respondents.
Approximately 75% of respondents felt supported by their institution, but half of doctors and nurses experienced role reconfiguration (not clearly defined, decided at the local level) with negative repercussions. Those who were required to change their job role endorsed poorer work-life balance, increased fatigue, reduced supervision, and reduced sense of comradery. Trainees, specifically, also reported negative effects including reduced access to their specialty’s clinics/transplantation/procedures (75%), unplanned extension of training time (14%), and affected career planning (23%). Of the 195 responses, 155 had completed the MBI questions. Half of all MBI respondents (54%) had scores indicating burnout, and gender and ethnicity differences were apparent (Table 4). In the analysis of the free-text responses, four main themes were identified: emotional impact, perception of leadership, teamwork, and change to work/training patterns.
Table 4 from H Beckwith et al, KI Reports 2021. Multivariable logistic regression model examining factors associated with burnout.
Discussion
Overall, despite a myriad of changes, the majority of JASN study respondents (84%) felt their programs successfully sustained their nephrology education in preparing them for independent practice. Although one third of respondents reported the pandemic had negatively affected work-life balance and 42% reported overall quality of life was “worse” or “much worse”, only 15% met the occupationally-focused RWBI distress threshold.
Several strengths are apparent in the JASN (US Nephrology Fellows) study. First, there was a relatively robust response rate at 42% compared to other online physician surveys. For example, a similar survey of US gastroenterology fellows had just 177 respondents (Clarke et al, Dig Dis Sci 2020). For comparison, in the 2019-2020 academic year there were 594 first-year fellows in gastroenterology programs compared to 419 in nephrology. Second, the respondent demographics were nationally representative and comparable to demographics available from ACGME for US nephrology programs. Third, the timing of the survey was planned to provide some distance from the March/April 2020 hospitalization surge but to still be completed prior to the anticipated influenza season. Several limitations are also inherent to this survey-based study. Although respondent demographics were diverse, the study results may not reflect the views of those fellows who did not receive the invitation or chose not to participate. Additionally, since the timing of COVID-19 surge varied geographically across the US (Figure 7).
Figure 7 from L Leatherby, NY Times 2020. Geographical representation of daily new COVID-19 cases across the United States.
So the proximity timing of the survey to COVID-19 surges in the US may have still introduced recall bias. Which might explain some of the differences in responses between fellows-in training and recent graduates. Lastly, this study used a tool to assess fellows’ perception of their training, and thus cannot infer their actual readiness for independent practice. The KIR (UK Renal workforce) study also may have been limited by low response rate and thus potential selection bias. One strength of the study was apparent in analysis of the free text responses. By identifying key areas of concern, leadership strategically implement targeted, and ideally sustainable, solutions.
In a recent AJKD editorial, Bansal et al. similarly identified three primary challenges faced by nephrology fellowship programs - alternative care delivery models, curricular adaptation, and assessment of fellow well-being. Remarking that despite the disruption the pandemic has brought, we “should leverage this opportunity to re-evaluate and evolve nephrology training.” (Bansal et al, AJKD 2021).
Amidst the negative impacts and forced shifts, some positives come to light. The use of telemedicine likely enhanced fellows’ training in a way that would have otherwise not occurred. Telehealth can easily accommodate multidisciplinary visits and facilitate outreach to rural communities who may not previously have been able to access a nephrologist. The exclusive use of telehealth in some institutions highlighted disparities in technology access and other determinants of health. Beyond telemedicine, technology was used in curriculum adaptation. For example, increased utilization of video-conferencing has allowed fellows from one institution to participate in conferences at another across the country. Additionally, supply shortages created in the early throes of the pandemic required alternative approaches to care delivery e.g. expanded use of peritoneal dialysis in the ICU setting.
In addition to changes implemented at the individual fellowship program level, nephrology faculty and fellows in the US and around the world have increasing participation in collaborative virtual learning and social media endeavors. Interestingly, a pre-pandemic NephJC summary of Rope et al, JASN 2017 by Nathaniel Reisinger, MD described the emerging educational needs in nephrology. Rope’s study revealed that fellows were already turning toward web-based, open-access resources for their educational needs. It is no surprise then, that when a global pandemic disrupted traditional educational models, nephrology educators and nephrology fellows were able to adapt and persevere.
“In medical education’s darkest hour, social media answered the call. We went from an area where we lost our ability to do traditional teaching, and we engaged in post-publication peer review. In this great medical education crisis, FOAMed showed creativity, flexibility and ingenuity. The solutions borne of COVID-19 will outlast the pandemic and indelibly change medical education.” J Topf, Social Media During a Pandemic, 3/2021, Renal Physicians Association Virtual Meeting)