From 5 Questions to 5 Reflections: A Residency Leadership “Sign-Out” During COVID-19—Part 1

Editor’s note: This is the first of a two-part blog post. Read the second part of this blog post, with the final 2 reflectionshere.

As a chief resident and program director in our internal medicine residency program, we set out at the end of academic year 2019–2020 to prepare the annual sign-out for the incoming chief medical residents and launch a new academic year. This exercise is typically straightforward, a practice refined over years of repetition. However, this academic year had been defined by the sentinel crisis of the entire medical enterprise: the COVID-19 pandemic. In this two-part blog post, we reflect on the 5 questions we posed for residency leadership in a recent Academic Medicine article and provide 5 reflections for moving forward.

1. In a crisis, begin with first principles: What are our program’s core values, and how do we maintain them?

This question has stood the test of the pandemic; it was the first one we posed and the one we referred back to most commonly. In reflecting on this question, we realized the answer was established long before COVID-19 emerged. It existed in our core values and how we ran our program each day. During the height of the pandemic, when the daily tasks designed to uphold our core values were becoming increasingly impossible to continue, we referred back to this question when answering the logistical questions that followed: How should we restructure residency education? How will we support the residents if they get exposed? Is this PPE distribution policy fair? How will we protect the most vulnerable? By revisiting our core values, we found an anchor with which to steady ourselves as we addressed these difficult questions.

2. A crisis can be an opportunity for innovation.

Due to the hard work of many members of our team, the restrictions imposed by the pandemic resulted in positive innovations in medical education and community building. Using virtual platforms for teaching and meetings has become a part of usual operations. Creating a well-produced video is easier than we thought and can generate conversation and optimize participation. Virtual platforms have also made it easier for those of us with care-giving responsibilities to maintain engagement in critical program meetings while structuring our work-days to meet the many new demands brought on by the pandemic. Many of these innovations will hopefully be here to stay and will be integrated into the relational, in-person, synchronous components of our work.

The COVID-19 pandemic has also heightened public awareness of an older and ever present pandemic: racism. Our residents have experienced the devastating inequities their patients face based on racial and socioeconomic status alone. Now, more than ever, they are compelled to embody the role of the physician advocate, as they see the urgency of supporting their patients beyond the confines of traditional medical care. To respond to and support our residents as they navigate this important role, we increased education around topics related to social justice, provided guided forums to discuss avenues for advocacy, and created a social justice pathway to help those with a focused interest grow in this role. We expect to continue and strengthen training in this vital area in the future.

3. A crisis can also validate what must stay the same.

Although virtual asynchronous learning and gathering has brought about exciting innovation as mentioned above, we have learned that virtual platforms can fall short. At their core, the acts of teaching and communing are relational, and teaching and providing patient care in a virtual setting can reinforce a sense of loneliness and isolation that conferences and precepting rooms naturally avoided.

Health care providers’ encounters in the hospital are unique and deeply personal, especially during the pandemic, and set us apart from our family and friends. The communal experience of residency training provided a venue for connectedness, both between the educator and learners and among learners. However, as a resident recently told me, in the era of ongoing group restrictions and universal masking, “I still can’t even tell you what most of the interns look like.” These relationships have been hard to replicate with our current technology.

By: Shana Rakowsky, MD, and Kelly L. Graham, MD, MPH

S. Rakowsky is a former chief medical resident and current gastroenterology fellow, Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts.

K. L. Graham is director, Ambulatory Residency Training, and director, Primary Care Track, Beth Israel Deaconess Medical Center, Boston, Massachusetts.

Further Reading

Rakowsky S, Flashner BM, Doolin J, et al. Five questions for residency leadership in the time of COVID-19: Reflections of chief medical residents from an internal medicine program. Acad Med. 2020;95:1152–1154.