Supporting family medicine residents during a pandemic
Our experience at the Mount Sinai Academic Family Health Team
The COVID-19 pandemic has required extensive education, flexibility, and adaptation in order to keep our patients, staff, and learners safe, while ensuring that we continue to provide the excellent resident education and care that our patients count on. Here, we highlight the strategies we undertook at our academic family health team to maintain high quality patient care and resident training.
1. Supporting Wellness
Early on, wellness was prioritized by incorporating two chief residents, one from each training cohort, on our COVID Leadership Committee to promote resident empowerment. This committee met three times a week to discuss COVID’s impact on clinic operations. Residents and faculty had an open line of communication to provide the resident perspective on virtual clinics, safe clinic operations, and social distancing measures.
Leadership was responsive to changes, which allowed residents to feel that their voices were heard. We moved our portfolio reflection sessions to a virtual platform where residents could reflect on difficult experiences clinically and personally1. The Resident Social and Wellness Committees found innovative ways for our team to interact, through virtual games nights with food deliveries reimbursed by the family health team. Two of our residents developed a COVID Infographic for Residents with tips for thriving during a pandemic2. Furthermore, our COVID Leadership Committee began distributing a weekly email entitled “Wellness Wednesdays”, highlighting strategies for wellness, exciting events, and uplifting videos. Lastly, our Mount Sinai Hospital Department of Family Medicine Faculty Newsletter prioritized wellness and resilience as one of its central themes to further promote everyone’s wellbeing, such as through sharing wellness resources and opportunities to join a virtual physician choir.
2. Championing Safety
While we are not quite at a “new normal”, we made significant changes to champion safety for our team. From the start, we identified the educational needs of our team with respect to personal protective equipment training. In partnership with the hospital, we provided N95 fit testing and “Donning & Doffing” education and practice sessions for staff and learners. We understood that the key to managing anxiety regarding personal safety and personal protective equipment supply was by having open communication. Weekly Q&A sessions gave people the opportunity to express concerns and ask questions. We frequently reviewed the most up-to-date and relevant research and guidelines available. This ensured that we were following best practice guidelines and were able to provide explanations and rationale for the recommendations regarding types of masks and eye protection, which was successful in allaying fears.
In order to decrease both the volumes of patients as well as the number of staff and residents coming into our unit, while maintaining continuity of care for our patients, we made many modifications to our usual operations, including through the rapid shift to virtual care. Our weekly Grand Rounds and all of our team meetings also transitioned to a virtual format, which has interestingly resulted in better attendance. We have also hosted our social events such as graduation and holiday parties through a video conference platform that has allowed the opportunity to connect more informally to maintain the collegial relationships that we are so intensely missing during these challenging times. These adaptations have been instated to facilitate physical distancing while maintaining personal connections.
3. Providing Opportunities for Resident Leadership and Education
When the first wave began in early 2020, it was clear that we needed “all hands-on deck” to prevent a worsening situation. Our residents stepped up in no small measure to lead the response. When Mount Sinai Hospital proposed its own COVID Assessment Centre, they were instrumental in its creation, planning, and staffing. Many of our graduates continue to staff the COVID Assessment Centre to this day. Given that they were there from the very beginning, our residents were able to provide effective feedback that substantially improved the Assessment Centre’s efficiency and flow. Two of our residents were further featured in the Mount Sinai Hospital newsletter for their leadership role in this regard3.
Moreover, the COVID Assessment Centre provided an opportunity for our residents to practice strong health advocacy for our patients and community. Rather than simply swabbing patients and sending them home, they took the time to enquire about social concerns and ability to safely self-isolate. One of our residents created a one-pager on social and financial resources with the help of our social workers for distribution to patients. These included resources for mental health, homelessness, food and income security, and domestic violence.
4. Pivoting Educational Opportunities
Our academic family health team quickly pivoted all but essential in-person care to virtual visits, allowing residents to maintain their family medicine clinical experiences. Along the way, we adjusted the proportion of face-to-face and virtual care visits, but overall, family medicine clinical time has remained stable. The larger educational issue arose when ambulatory rotations were cancelled in the early days of the pandemic. Over a period of approximately four months, residents had both core ambulatory rotations and electives cancelled, leaving significant educational gaps. These were addressed in two major ways: (i) creation of virtual learning opportunities, and (ii) moving residents into clinical areas of increased need as a result of the pandemic. The central Department of Family and Community Medicine at the University of Toronto quickly compiled a list of online resources to address some of the identified gaps and this list was distributed widely to learners4. Several off-service teachers offered online seminars to try to address some of the learning objectives of the missing rotations. While access to ambulatory care rotations disappeared overnight, the need for physicians in other hospital areas ballooned quickly. In addition to their work in the COVID Assessment Centre, family medicine residents volunteered to work extra shifts in the emergency room to assist with increasing volumes, as well as to spend additional weeks on the internal medicine service to help manage increasing inpatient numbers.
Moreover, one new elective opportunity was borne from the pandemic. Women’s College Hospital Department of Family Medicine created a virtual COVID@Home program and our residents were invited to participate5. This allowed them the opportunity to learn about the medical and psychosocial implications of COVID. Our family health team has since instituted a similar program that allows residents to proactively assess, triage and create treatment plans for patients diagnosed and quarantined at home with COVID. In addition, we developed an informal plan to identify, phone, and check-in on the most vulnerable patients on our patient rosters whenever there was downtime between patients.
To continue providing education to our residents in this new virtual space, a number of novel initiatives were necessary. Firstly, for clinical teaching, we created a virtual supervision schedule, and triaged and rescheduled our patient appointments. We assessed, managed and reviewed most of our patients by phone and at the end of each clinic day, reviewed as a group over Zoom. This allowed us to continue with daily teaching sessions uninterrupted. We also strengthened our existing networks to support each other via instant message at point of care, and throughout the clinical shift. Furthermore, we were able to quickly pivot our weekly academic half-day sessions to Zoom, which still allowed for both didactic and interactive teaching. Any sessions cancelled were filled with peer-to-peer teaching through the use of modules from The Foundation for Medical Practice Education (FMPE) Practice Based Small Group (PBSG) Learning Program, which has been favourably received by the residents. Throughout the entire process, feedback from our residents was elicited, and adjustments were made frequently, to maximize the perceived value of these virtual learning opportunities.
The pandemic has abolished all of our existing notions of what can be achieved and has inspired us to explore new opportunities and strategies in delivering quality resident education and patient care. As we all adapt to our new normal, we hope that this reflection on our experiences can help other family medicine teams adapt and innovate during this exceptional time.
All authors are affiliated with the Ray D. Wolfe Department of Family Medicine, Mount Sinai Hospital and the Department of Family and Community Medicine, University of Toronto.
Dr. Elliot Lass is a Care of the Elderly Resident at the University of Toronto. Dr. Lass completed his family medicine residency in the Integrated 3 Year Program based at Mount Sinai Hospital where he also obtained a master’s with his residency from the University of Toronto.
Dr. Erin Bearss is a family physician who practices comprehensive family medicine and emergency medicine at the Mount Sinai Academic Family Health Team. Dr. Bearss is an Assistant Professor in the Department of Family and Community Medicine at the University of Toronto and the Associate Chief of Academic and Special Programs for Family Medicine at Mount Sinai Hospital.
Dr. Noam Berlin is a Palliative Care Resident at the University of Toronto. Dr. Berlin completed his family medicine residency based at Mount Sinai Hospital from the University of Toronto.
Dr. Bernard Ho is an Emergency Medicine Resident at the University of British Columbia. Dr. Ho completed his family medicine residency based at Mount Sinai Hospital from the University of Toronto.
Dr. Natalie Morson is a family physician who practices comprehensive family medicine and maternity care at the Mount Sinai Academic Family Health Team. Dr. Morson is a Lecturer in the Department of Family and Community Medicine at the University of Toronto and the Family Medicine Site Residency Program Director at Mount Sinai Hospital.
References
1. Schenker C. Reflection on Professional Identity: A Novel Way to Support Resident Wellness. Canadian Conference of Medical Education Virtual 2020 Conference. Submission ID 51198.
2. Nasirzadeh Y., Singhal N., Bhatia M., Peng J., and Multani J. COVID-19 Resources for Residents. 2020. [cited 2020 Dec 8]. Available from: https://my.visme.co/projects/pvg3d4we-covid-19-wellness-infographic?fbclid=IwAR3Ga69fmxyjyjA2OPTqVW5957QIrw4x_WueKb2lCF9vRDj0d7pHpd537L4
3. From Family Medicine Residents to COVID-19 Responders. Sinai Health News and Media. 2020 May 27 [cited 2020 Dec 4]. Available from: https://www.sinaihealth.ca/news/from-family-medicine-residents-to-covid-19-responders/
4. COVID-19 Updates and Resources for Faculty, Staff and Residents. The Department of Family and Community Medicine at the University of Toronto. 2020 [cited 2020 Dec 8]. Available from: https://dfcm.utoronto.ca/covid-19-updates-and-resources-faculty-staff-and-residents
5. COVID-19 Clinical Assessment Tip Sheet [Internet]. COVIDCare@Home. Women’s College Hospital; 2020 [cited 2020 Dec 4]. Available from: https://covidcareathome.ca/files/CaH_Clinical_Tool_v3_2.pdf
