Article In Brief
Residency program directors across eight academic medical centers discuss the plans they have put in place—and the changes they anticipate having to make—in response to the COVID-19 epidemic.
Day by day, neurology residency programs from New York to Seattle are ramping up their response to the COVID-19 outbreak in an unprecedented effort to protect residents and patients alike.
From limiting the number of individuals who can enter patients' rooms during rounds to requiring one-third or more of residents to stay home at any one time, hospitals are leveraging cell phones, laptops, and online communications software in ways unimaginable just a month ago.
“As the situation evolves and changes, the key is flexibility,” said Arielle M. Kurzweil, MD, associate professor of neurology and residency program director at NYU Langone Health. “Changes are being made fluidly, on a daily basis.”
In interviews with Neurology Today, residency directors at eight university health systems emphasized that whatever steps they were taking at the moment were likely to change in the coming days and weeks.
As of Wednesday, March 25, medical students scheduled to begin clinical internships had been assigned to remote learning rather than showing up at the hospitals associated with the University of California, San Francisco. Clinically experienced students on subinternships, however, were still providing care on clinical rotations. “But by the time your article goes to print, that policy may have further changed,” said John Engstrom, MD, FAAN, the neurology residency director.
“Health care providers are now being asked to use the same N95 or surgical mask for an entire shift, keeping it in a paper bag for reuse,” said Dr. Engstrom, who holds the Betty Anker Fife Distinguished Chair in Neurology. “My current understanding is that we are actually implementing that policy today.”
The particulars of how residency programs are responding vary, with some hospitals permitting up to three physicians at a time inside a patient's room during rounds, and others allowing only one or two.
Some programs are making up for the loss of patient contact with the innovative use of audio-video links, permitting residents to see and hear what is happening during an exam without being physically present.
Other programs are depending on more traditional post-exam briefings in the hallways outside of patients' rooms. As of this writing, some have almost entirely converted outpatient services to a telemedicine model, while others continue to permit some in-person appointments.
Yet consistent among all eight programs contacted by Neurology Today is a complex mood of anxiety and determination, eagerness to serve during a historic national challenge combined with fear of what will come.
Technology to the Rescue
Beginning the week of March 16, two of the adult teaching hospitals associated with Harvard University, Massachusetts General and Brigham and Women's, rolled out a “virtual rounds” protocol for neurology as a pilot for other services.
“The team that takes care of a neurology patient is generally a large group, with an attending physician, multiple residents, nurse practitioners, and of course registered nurses,” said Michael P. Bowley, MD, associate director of the two hospitals' combined neurology residency program.
“We realized that the need for social distancing in the age of COVID-19 wouldn't allow for such a large group working shoulder to shoulder. We have also begun to experience labor losses with some of our residents needing to self-quarantine because of possible exposures to the coronavirus. The question was how to ensure our residents could still participate in patient care in this new environment.”
Dr. Bowley worked with Lee Schwamm, MD, professor of neurology and vice president for virtual care at Partners Health Care, to harness the potential of Microsoft Teams, which is part of the Office 360 platform.
“It was already available on all of the hospitals' workstations and computers, and on all of our cell phones,” Dr. Bowley said. “It's a virtual workspace, a common space for people to connect using the audio, visual, and screen sharing.”
During patient visits, the attending wheels in a work station with an integrated camera that can be turned to face the patient and senior resident, as he or she talks with and examines the patient, so that other residents and staff can view the interaction whether from their home, in the hallway, or in a call room.
“I shared a level of skepticism about how well this would be adapted by trainees, faculty, and staff with different levels of technological skills,” Dr. Bowley said. “Surprisingly it has been easily adapted at all levels. It worked almost seamlessly from the first day.”
On the morning of that first day, a senior resident who had been on overnight duty had to present eight admissions from a call room.
“We thought, oh boy, this is going to be tough,” Dr. Bowley recalled. “But it still worked.”
One clinical pearl gleaned from the first two weeks of the digital rounds model is that everyone participating must wear headsets to avoid feedback and the need to shout.
“Sound has been the greatest challenge,” Dr. Bowley said. “Without headsets, you get feedback if two people with microphones are in close proximity. We recommend that everyone brings in a headset and a charger.”
A Lower-Tech Response
While technology is being used across the nation for didactics and telemedicine, residency program director at hospitals in Baltimore, Denver, and Seattle expressed caution about the notion of digital rounding.
“We can't really do that for inpatients,” said Patricia Oakes, MD, assistant professor of neurology and residency program director for the University of Washington School of Medicine in Seattle. “We are doing our didactics and conferences by Zoom. And we offer telephone visits to outpatients. But it's a little hard for me to imagine our inpatients having only video contact with the neurology team. For neurology, an exam is important.”
Just outside of Denver, the residency program director at the University of Colorado Anschutz Medical Campus said his hospital is simply not equipped to broadcast rounds outside of patients' rooms.
“Observing rounds by video is a really neat concept, but we just don't have the ability to do that right now,” said Douglas Ney, MD, associate professor of neurology and neurosurgery. In the meanwhile, he said, “We're allowing one attending and one resident responsible for the patient's care to go in at any one time. We're shifting all learning and didactics to online platforms. We're doing lectures via Zoom, and we've pared down who actually needs to be in the hospital at any given time.”
In Baltimore, Carolyn A. Cronin, MD, PhD, associate professor of neurology and director of the neurology residency program at the University of Maryland School of Medicine, said that having much of her hospital's administrative support staff at home has left faculty floundering at times with technical gadgetry.
“It's hard when so many people are logging in remotely, especially without our administrative support to get everything set up,” Dr. Cronin said. “I did a webcast for our residents and it frankly took some troubleshooting.”
She emphasized, however, that didactic lessons offered on AAN's NeuroLearn page, and the videos offered on its NeuroByte page, have been helpful for remote learning. An AAN listserv for neurology program directors has also been helpful for her. “A bunch of people have been sharing resources together,” Dr. Cronin said. “That's been great.”
Virtual Mentoring Pods
Although the technology is in place to do virtual rounding for the neurology service at UVA Health in Charlottesville, VA, for now they haven't felt the need, said Nicole Chiota-McCollum, MD, MEd, assistant professor of neurology and director of the residency program.
“We are certainly not in the precarious situation that California and New York are in,” she said. “At this point we haven't had any patients on the neurology service who are under suspicion for having COVID-19. But we have already implemented the first phase of our plan to preserve our workforce and the safety of our patients, and if we need to implement a second phase to stay one step ahead of things, we will.”
“If a year ago someone had a fever and infection, the chief resident would pitch hit for the time. Now, because we need a surge capacity and need to mobilize multiple people, we developed a jeopardy system. For every day and a two-week block, we made a rank list of who can be called on to fill in. If one resident is in jeopardy and can't come to work, we have someone else who can.”
—DR. KRISTEN MCCARTNEY
For now, no more than three physicians, whether residents or attending, can be in a patient's room at any time, Dr. Chiota-McCollum said. “The biggest change for her neurology residents is that two-thirds of them must now work from home at any given time.
“That will give us a deep bench to pull from in case people become exposed or symptomatic or otherwise need to be quarantined, said Dr. Chiota-McCollum.
To keep their spirits up, residents continue to meet with their mentoring pod, but now do so virtually.
“The pods usually include a first-year, second-year, third- and fourth-year residents with a faculty advisor,” Dr. Chiota-McCollum said. “They become a little family within our program. Typically the pods meet for social outings and near-peer mentoring. We have now moved them to meet virtually. Two pods met last night via Zoom. Hopefully it will prevent isolation. We are cognizant of the risks of social distancing to our teams' emotional health. Hopefully telementoring will prevent the sense of isolation.”
Scrubs and Jeopardy
Ralph F. Józefowicz, MD, FAAN, professor of neurology at the University of Rochester School of Medicine and Dentistry and director of its neurology residency program, was prepared for social distancing and self-quarantines. But when his senior resident came to him with the suggestion that they be allowed to wear scrubs, he had to think twice.
“It was a big change for me,” Dr. Józefowicz said. “I like to maintain a professional demeanor for my residents. But right now, with the risk of infection, they felt it would be safer for them to wear scrubs. So I acquiesced, but I'm hoping things return to normal as soon as possible.”
Kristen McCartney, MD, the PGY4 chief neurology resident, said the decision wasn't easy for residents either. “The dress code has always been a tenet of our program, and all of us respect that,” she said. “Honestly, we could all do with a little normalcy right now. But in the interest of patient and resident safety right now, wearing scrubs is the safest thing we can do.”
The switch to wearing scrubs was, of course, just one small part of the residents' COVID-19 response. Key to their plan was an evolution of their usual approach to covering for a sick resident.
“If a year ago someone had a fever and respiratory infection, the chief resident would pitch hit for the time,” Dr. McCartney said. “Now, because we need a surge capacity and need to mobilize multiple people, we developed a jeopardy system. For every day and a two-week block, we made a rank list of who can be called on to fill in. If one resident is in jeopardy and can't come to work, we have someone else who can.”
Just the knowledge that plans have been put in place to deal with the looming crisis has been a comfort to her fellow residents, Dr. McCartney said.
“We're allowing one attending and one resident responsible for the patient's care to go in at any one time. We're shifting all learning and didactics to online platforms. We're doing lectures via Zoom, and we've pared down who actually needs to be in the hospital at any given time.”
—DR. DOUGLAS NEY
“Leadership in the hospital and within our department has done a really good job of keeping everyone informed and up to date,” she said. “I've seen a lot of amazing resilience and compassion from all my colleagues.”
Dr. Józefowicz said he has been “extremely proud” of his residents so far. “Within 24 hours of our first COVID patients arriving in our hospital, they had a plan in place,” he said. “There's anxiety obviously, but my residents are an absolutely extraordinary bunch.”
Strict Limits in Clinic Rounds
It should be no surprise that neurology residency programs in New York City, with by far the highest number of COVID-19 cases in the United States, have put in place the strictest measures so far to protect staff and patients alike.
“We've limited rounds to only one person going into a patient's room,” said Dr. Kurzweil of NYU-Langone when reached on March 23. “Our outpatient rotations have been put on hold for now. All of our continuity clinics where residents see their own patients have been changed to televisits. And we've gone to a skeleton schedule for inpatient care to minimize the number of residents who need to be in the hospital at any given time.”
In normal times, about 20 residents are in-house at any one time, she said. “We've tried to halve that. The other residents are basically at home, helping on COVID-19 hotlines, seeing patents through televisits, and just being ready to be deployed to wherever they're needed as the situation unfolds.”
Even as the number of neurology inpatients has dwindled—in part to protect them from the risk of exposure, and in part to keep beds free for COVID-19 patients—emotions among residents are running high, Dr. Kurzweil said.
“Things are tense right now,” she said. “Cases are growing by the day. We have a lot of patients who are intubated and a lot of doctors who are getting sick. But I was on call this past weekend with the residents and was so impressed and struck by their keep-calm-and-carry-on attitude. Certainly there is anxiety and fear, but everyone also feels fortunate to be part of history and help on the front lines of this crisis. It's really been inspiring and impressive to watch.”
Her one suggestion for hospital neurologists across the country with residents and staff has nothing to do with schedules, policies, or technologies.
“Food is love,” Dr. Kurzweil said. “We can't give real hugs, so we've been trying to shower our residents with as much food as we possibly can. We have faculty and leadership dropping off cookies and individually wrapped items. We are still holding resident forums once a week to get together virtually with no agenda, to just talk about emotions and what is needed logistically. That's been hugely helpful. But everyone appreciates food.”