The COVID-19 pandemic has created unprecedented stress for global health care systems. In the spring of 2020, southeast Michigan became an epicenter of the pandemic, necessitating an accelerated expansion of our institution’s intensive care unit capacity to accommodate the rapid increase in the number of COVID-19 patients. 1 This expansion required extensive health care restructuring to provide the workforce needed for these critical care units. As part of these efforts, our Department of Surgery dramatically and quickly restructured clinical operations to accommodate the surge of acute patient needs during the COVID-19 pandemic, while considering resource scarcity. It was recognized that most Department of Surgery trainees have several months of exposure to critical care and intensive care unit experience in one or more of the following environments: surgery intensive care unit, trauma burn intensive care unit, Veterans Affairs intensive care unit, and cardiovascular intensive care unit. Given this critical care experience, Department of Surgery trainees were identified as essential members of this workforce. Therefore, the reduction and compacting of normal clinical services quickly correlated with trainee redeployment into COVID-19 critical care units and required many surgical trainees to abandon traditional curricula and the operating room.
The enormous stress and psychological impact associated with caring for medically complex COVID-19 patients have already been described. 2,3 Before COVID-19, burnout and depression were already significant concerns among physicians and trainees. 4,5 Given the association of burnout with increased medical error, these ramifications may affect the quality of patient care. 5,6 Therefore, in times of crisis such as this, it is imperative that we take care of each other and ourselves to take care of our patients.
In line with findings from Bui et al suggesting that wellness champions have positive effects on well-being, the Department of Surgery at the University of Michigan responded during the COVID-19 pandemic with the development of a Trainee Wellness and Advocacy Committee. 4 This team of faculty and trainees was formed to monitor wellness, promote team building and self-care initiatives, offer support, and mitigate the effects of trainee redeployment on well-being. In these efforts, this leader group and our department tried to follow the principles of the fundamental state of leadership laid out by Robert Quinn: to be results centered, internally directed, other focused, and externally open. 7 Importantly, Sharp and Burkart have previously described the importance of leadership, among other things, on physician burnout. 8
This article describes the practices employed by the Department of Surgery at our institution that may also be adopted elsewhere. We describe our perspective regarding practices surrounding redeployment, provider safety, and wellness. While these solutions were formed by a surgical department, they may be easily applied across medical settings, and many will continue to be relevant even beyond the COVID-19 pandemic (see Table 1 for the main elements of our strategy). Additionally, although some of these efforts are specific to the COVID-19 context, these wellness efforts could be beneficial to trainee wellness exclusive of COVID-19. Notably, our department was in the midst of expanding wellness programs pre–COVID-19, and we strongly believe that these efforts and our culture supported our collective response during this crisis.
Faculty and Trainee Redeployment
Redeployment required several important considerations, and while many of these have overlapping elements, each warrants individual attention.
Reframing the team mindset
As our general surgery program director eloquently said:
In the days and weeks to come, remember that this is not a medicine problem or a surgery problem. This is not a house officer problem or a faculty problem. This is a human problem. 9
All surgical trainees and faculty were physicians first and were not defined solely by their subspecialty. In these stressful moments, it was crucial to highlight this team mindset and recognize our role as critical care providers in our larger medical community. Our Department of Surgery houses the sections of general surgery, plastic surgery, oral and maxillofacial surgery, vascular surgery, and thoracic surgery. All trainees, faculty, and advanced practice providers were reallocated based on experience, independent of specialty. Additionally, the department redeployed surgical trainees alongside surgical faculty, taking into consideration each trainee’s skill sets and any high-risk status for exposure to COVID-19 (this self-designation, shared confidentially, is discussed later in the article). We honored voluntary redeployment whenever possible.
Culture of grace and forgiveness
The stresses of this pandemic are unfamiliar and uncomfortable to many providers, and so some tension was expected. Therefore, our department advanced a culture of grace and forgiveness. This mindset was promoted by our department’s chair, reiterated by all levels of leadership, and embraced by all. Practically, providers were encouraged to trust that colleagues have the best of intentions and to be empathetic.
Multidisciplinary wellness committee
The Trainee Wellness and Advocacy Committee was formed with a diverse group of individuals from a variety of specialties and levels of experience. The inclusive nature of the group was intentional. Trainees of all subspecialties were purposefully included to return some amount of control to the house officer community. Diverse representation allowed for the implementation of creative and effective strategies surrounding the complex issues related to COVID-19. 10
Decisions surrounding redeployment were especially difficult due to competing personal, professional, and educational priorities. While our trainee scheduling is typically run by the trainees, COVID-19 restructuring decisions were centralized to faculty. This approach avoided any guilt senior house officers might have experienced if they had had to assign co-trainees to potentially risky situations and also reduced confusion and potential miscommunication.
Communication was transparent, consistent, and centralized. Clear communication by leadership drives positive change and, anecdotally, was responsible for quelling several anxieties in our department. 11 The department chair provided daily electronic COVID-19 updates, and communication around redeployment was centralized to 3 faculty leaders. In addition, virtual platforms were used weekly for informational town halls. These town halls incorporated insight from institutional experts on specific concerns. For example, our trainees expressed concern about disease transmission; therefore, we invited an infectious disease faculty member to address these questions. Finally, our department disseminated COVID-19–related resources via a centralized electronic folder.
Interdepartmental and program coordination
COVID-19 restructuring required effective cross-specialty communication. Our institution’s Graduate Medical Education Office assisted in facilitating these discussions and was helpful in making the COVID-19 hospital redeployment response even less specialty-centric over time. In line with our “we are physicians first” mentality, multidisciplinary strategizing among departments with the help of the Graduate Medical Education Office resulted in the identification of the unique skill sets available in each trainee provider population and allowed for appropriate redeployment by aligning these skills with patient need.
Our COVID-19 restructuring was phased, based upon immediate and potential patient needs. For example, in our Department of Surgery, we created phased responses proactively. We also compacted our normal clinical services into essential services due to resource scarcity during the surge and the needs of COVID-19 critical care during peak capacity. During each of these phases, house officers and attending surgeons were redeployed based upon their skill sets and in accordance with patient needs, institutional directives, and educational missions. Early planning allowed our group to respond dynamically.
Scheduling flexibility and redundancy
Two principles were critical to ensuring a sustainable model of redeployment: flexibility and redundancy. Therefore, we developed a model that minimized personnel in the hospital. Several services across various subspecialties were consolidated, and only emergency surgeries were performed, in accordance with state government mandates. 12 As house officers transitioned primarily to a critical care setting, teams of 2 (a senior trainee and a junior trainee) were assigned 12-hour shifts for 6 to 7 days followed by 6 to 7 days of recovery. After recovery, the team returned to the hospital for another week of service. If a trainee became ill, there were reserve providers available. Our institution also ceased all external moonlighting to maintain a healthy workforce and create flexibility.
Adherence to training regulations
Despite the practical issues surrounding restructuring, it was important that redeployment practices adhere to the training regulations of the Accreditation Council for Graduate Medical Education (ACGME). The ACGME provided guidance for institutions that entered a stage 3 pandemic emergency status. 13 These regulations necessitated adequate resources and training, adequate supervision, adherence to duty hours requirements, and allowance for fellows to function in their core specialty. 13 Of note, the American Board of Surgery made several hardship modifications to training requirements in light of the pandemic. 14 Moving forward, programs should be aware of any hardship modifications provided by relevant accrediting bodies as a result of COVID-19.
Designation of a trainee ombudsperson
Concerns around restructuring were expected. Two practical dilemmas were how to elicit honest, confidential feedback from trainees and how to address these concerns in a timely manner. For these reasons, we designated a well-respected nonclinician leader in our community, outside of the surgical hierarchy, as our departmental trainee ombudsperson. This person was a member of our Trainee Wellness and Advocacy Committee. A primary role of the ombudsperson was to advocate for house officers and provide a voice to trainee concerns in a confidential manner. This role can clearly be helpful beyond the COVID-19 pandemic.
Physical health considerations for high-risk individuals
COVID-19 care has inherent risk. According to the Centers for Disease Control and Prevention (CDC), people have varying risk of developing severe illness if they contract COVID-19. The CDC classified high-risk individuals as those who are aged 65 years or older, have comorbid conditions (e.g., chronic lung disease, moderate or severe asthma, serious heart conditions, obesity, diabetes, chronic kidney disease with need for dialysis, liver disease), or are immunocompromised. 15 Similar concerns exist for those who are pregnant, breastfeeding, or have high-risk family members at home. Due to this differential risk, our department allowed for trainees to self-classify as high risk without requiring any additional explanation. While this information was critical to ensuring appropriate protections for house officers, it was clearly sensitive. Therefore, trainee high-risk statuses were managed confidentially in our Department of Surgery by a single individual, the trainee ombudsperson. The trainee ombudsperson also had input regarding scheduling to ensure that high-risk trainees were not placed into frontline care. The ombudsperson also assisted with identifying other clinical opportunities for high-risk trainees, including but not limited to calling patient families, writing clinical notes, and participating in telemedicine initiatives.
Our department used the same care deimplementing changes in a systematic way that we had used to implement the restructuring efforts. We avoided aggressive deimplementation that did not incorporate the principles discussed above to limit the ramifications that these stressful situations have on well-being.
Significant media coverage and fear have surrounded the exposure of health care workers to COVID-19 and the risk of death for health care providers. 16 These fears are compounded by concerns associated with the availability of appropriate personal protective equipment (PPE). 17,18 Provider safety was one of the highest priorities during redeployment, and our department’s safety-specific initiatives are discussed here.
Trainee safety advocate
As part of the work of the Trainee Wellness and Advocacy Committee, a resident was selected as the trainee safety advocate. This advocate acted as the liaison between the surgery department, leadership responsible for institutional policies surrounding PPE, the wellness committee, and trainees. Centralizing communication to this individual standardized the information that was shared with the community as policies were updated.
Personal protective equipment
In accordance with ACGME guidelines, it is the responsibility of the institution and department to ensure that trainees have access to appropriate PPE. 13 Institutions have come up with a number of novel methods and policies to ensure appropriate use, availability, and conservation of PPE. 17,18 The trainee safety advocate assisted with gathering and disseminating updated information surrounding use and reuse, sterilization, and proper disposal of PPE.
At the request of members of our community, we provided information on how to optimize safety at home. This information was provided in easy-to-read pamphlets or infographics on daily life, including advice on grocery shopping and reducing the possibility of COVID-19 contamination of the home.
Alternative housing options
There was understandable fear surrounding the risk of transmitting COVID-19 to family members, compounded if loved ones were classified as high risk. 19,20 Alternative housing options were considered. Potential options included but were not limited to hotels, dormitories, and rental properties. Some reasons for use of temporary housing included respite, location for safe decontamination, and self-isolation due to COVID-19 exposure or high-risk individuals at home.
At the University of Michigan, the Department of Surgery instituted several initiatives to promote wellness. Since wellness is multidimensional, promoting physician wellness required a multidimensional approach. 21 An important step was the creation of the wellness committee, discussed above, with a diverse group of faculty and trainees. 8 Having dedicated wellness champions alone has been previously shown to have a positive impact on burnout. 4 A nonexhaustive list of other important initiatives is provided below. Programs can perform a needs assessment to develop an institution- or department-specific approach. 8
Promoting psychological safety through inclusive leadership and minimizing power differences can encourage trainees to report concerns. 22 Consequently, our leadership created multiple avenues for trainees to raise concerns and also normalized discussions surrounding individual and collective stresses. Recognizing that one size does not fit all, we also launched the following initiatives to elicit feedback and identify trainee concerns.
As stated above, the ombudsperson functioned as an advocate for trainees and navigated concerns confidentially.
Weekly anonymous survey.
Each week, anonymous feedback was elicited via an electronic survey. This feedback went directly to the wellness committee for rapid response.
Intentional peer support and accountability.
For each surgical class of trainees, 2 faculty advocates participated in weekly meetings via a virtual platform with the class (in accordance with social distancing guidelines). These virtual weekly engagements were unstructured and included a variety of themes (e.g., hangout, happy hour, game night). These faculty–trainee pairings were also specialty-specific. These events allowed trainees and attendings to bidirectionally express emotions, fears, and stresses in a relaxed social setting.
Trainee Wellness and Advocacy Committee membership.
The Trainee Wellness and Advocacy Committee was intentionally set up with a wide membership representation from all specialties and various levels of experience. Therefore, each committee member served as another point of contact who could field concerns from trainees.
Mental health resources
Significant provider stress has been reported during the COVID-19 pandemic. 2,3,23 Providing easily accessible information to mental health resources for providers during this time was critical. 23 Our department first surveyed the institution and community for local resources. Others have detailed the many available electronic services. 24 Additional resources that were considered included but were not limited to psychiatry and psychology care, meditation guides, and gratitude practices. 23–25 Our department also used stress management coaches. To widely disseminate this information, leadership added these resources to weekly communications or to an accessible electronic drive. The trainee ombudsperson also had adequate knowledge of these resources.
Even in a pandemic, residents and fellows are still trainees. Therefore, our programs strived to continue their educational mission of training physicians. While our educational work was limited to some extent during this time, we used virtual technologies when possible for didactic and interactive educational activities. At our institution, many sections developed multi-institutional didactic programs and asked alumni to lead and attend didactic sessions. Some programs also opened up monthly events, such as journal clubs, to alumni; these events have improved the depth of educational experience and provided social engagement with former trainees. Maintaining this form of continued education helped reduce the educational gap created by limited traditional learning opportunities.
Fostering community through appreciation
As part of a professional community, we were accountable for each other’s wellness. Therefore, actions that solidified this sense of community were celebrated (e.g., thank you cards from children of community members, gift lunches or gift baskets for staff and trainees). Additionally, in response to the social distancing regulations instituted in the spring of 2020, prioritizing virtual engagement helped to maintain and solidify this community. Frequent reminders that leadership and faculty deeply care for the well-being of trainees had powerful positive effects on morale in our department. We strongly encouraged genuine expressions of appreciation and compassion as another way to promote well-being.
Attentiveness to childcare
As a result of COVID-19, many childcare programs temporarily closed, creating several stressors for adequate childcare coverage for health care workers. At our institution, medical students and other members of the health care community volunteered to provide childcare for those working on the frontlines. We encouraged our staff to explore nontraditional options for childcare in the uncertain times resulting from the pandemic. Childcare needs were carefully considered during redeployment.
Use of social media
Social media offered the potential for our institution and department to encourage positive morale and highlight important work and achievements. It allowed health care workers to connect with and receive support from the local community. These efforts were carried out in collaboration with institutional communication specialists to ensure that all uses adhered to institutional policies.
The COVID-19 pandemic has had significant ramifications. Determining how to redeploy trainees during these unprecedented and challenging times required several important considerations to promote well-being. Our department took many steps to champion trainee wellness (see Table 1) and adhered to several principles (see Figure 1). Importantly, these initiatives are indiscriminate of specialty and should continue to have value outside of the COVID-19 context. Anecdotally, several faculty and trainees in our community expressed gratitude for the efforts described in this article and requested that we maintain these efforts after the COVID-19 pandemic; therefore, we are continuing many of them. We encourage all institutions to be proactive in developing similar creative policies that promote trainee well-being during the pandemic and beyond.
The authors are fortunate to have a plethora of human resources at their institution that made the significant efforts described in this article possible. The authors want to thank institutional leadership and staff for their important work. They also want to acknowledge departmental and program director leadership of general, vascular, thoracic, oral and maxillofacial, and plastic surgery who provided steadfast support. Finally, the authors want to acknowledge the wonderful leadership of the 2020 general, vascular, thoracic, oral and maxillofacial, and plastic surgery chief residents.
1. Johns Hopkins Coronavirus Resource Center. https://coronavirus.jhu.edu
. Accessed April 18, 2020.
2. Lai J, Ma S, Wang Y, et al. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw Open. 2020;3:e203976.
3. Neto MLR, Almeida HG, Esmeraldo JD, et al. When health professionals look death in the eye: The mental health of professionals who deal daily with the 2019 coronavirus outbreak. Psychiatry Res. 2020;288:112972.
4. Bui AH, Ripp JA, Oh KY, et al. The impact of program-driven wellness initiatives on burnout and depression among surgical trainees. Am J Surg. 2020;219:316–321.
5. Rothenberger DA. Physician burnout and well-being: A systematic review and framework for action. Dis Colon Rectum. 2017;60:567–576.
6. Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010;251:995–1000.
7. Quinn RE. Moments of greatness: Entering the fundamental state of leadership. Harv Bus Rev. 2005;83:74–83.
8. Sharp M, Burkart KM. Trainee wellness: Why it matters, and how to promote it. Ann Am Thorac Soc. 2017;14:505–512.
9. Gauger PG. Professor of Surgery and Program Director for Surgery, University of Michigan. Personal communication to Department of Surgery house officers, March 29, 2020.
10. Page SE. The Diversity Bonus: How Great Teams Pay Off in the Knowledge Economy. 2017.Princeton, NJ: Princeton University Press;
11. Kueny A, Shever LL, Lehan Mackin M, Titler MG. Facilitating the implementation of evidence-based practice through contextual support and nursing leadership. J Healthc Leadersh. 2015;7:29–39.
12. Office of the Governor, State of Michigan. Executive Order No. 2020-17. Temporary Restrictions on Nonessential Medical and Dental Procedures. https://www.michigan.gov/whitmer/0,9309,7-387-90499_90705-522451--,00.html
. Accessed April 18, 2020.
13. Accreditation Council for Graduate Medical Education. Stage 3: Pandemic emergency status guidance. https://acgme.org/COVID-19/Three-Stages-of-GME-During-the-COVID-19-Pandemic/Stage-3-Pandemic-Emergency-Status-Guidance
. Accessed April 19, 2020.
14. American Board of Surgery. Modifications to training requirements. https://www.absurgery.org/default.jsp?news_covid19_trainingreq
. Accessed April 19, 2020.
15. Centers for Disease Control and Prevention. People who are at higher risk for severe illness. https//www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-at-higher-risk.html
. Accessed April 18, 2020.
16. In memoriam: Healthcare workers who have died of COVID-19. Medscape. https://www.medscape.com/viewarticle/927976
. Accessed April 19, 2020.
17. Cook TM. Personal protective equipment during the coronavirus disease (COVID) 2019 pandemic—A narrative review. Anaesthesia. 2020;75:920–927.
18. Rowan NJ, Laffey JG. Challenges and solutions for addressing critical shortage of supply chain for personal and protective equipment (PPE) arising from coronavirus disease (COVID19) pandemic—Case study from the Republic of Ireland. Sci Total Environ. 2020;725:138532.
19. Centers for Disease Control and Prevention. Clinical questions about COVID-19: Questions and answers. https://www.cdc.gov/coronavirus/2019-ncov/hcp/faq.html
. Accessed April 20, 2020.
20. Adams JG, Walls RM. Supporting the health care workforce during the COVID-19 global epidemic. JAMA. 2020;323:1439–1440.
21. Kuhn CM, Flanagan EM. Self-care as a professional imperative: Physician burnout, depression, and suicide. Can J Anaesth. 2017;64:158–168.
22. Appelbaum NP, Dow A, Mazmanian PE, Jundt DK, Appelbaum EN. The effects of power, leadership and psychological safety on resident event reporting. Med Educ. 2016;50:343–350.
23. Kang L, Ma S, Chen M, et al. Impact on mental health and perceptions of psychological care among medical and nursing staff in Wuhan during the 2019 novel coronavirus disease outbreak: A cross-sectional study. Brain Behav Immun. 2020;87:11–17.
24. Pospos S, Young IT, Downs N, et al. Web-based tools and mobile applications to mitigate burnout, depression, and suicidality among healthcare students and professionals: A systematic review. Acad Psychiatry. 2018;42:109–120.
25. Yale Center for Emotional Intelligence. Gratitude practice explained. http://ei.yale.edu/what-is-gratitude
. [No longer available.] Published 2015. Accessed April 19, 2020.