Challenges of transitioning to residency during pandemic

Watch the AMA's daily COVID-19 update, with insights from AMA leaders and experts about the pandemic.

In today’s COVID-19 Update, a discussion with Kimberly Lomis, MD, vice president of undergraduate medical education innovations at the AMA, and Eric Holmboe, MD, chief research, milestone development, and evaluation officer at Accreditation Council for Graduate Medical Education (ACGME), about the challenges of transitioning to residency during the pandemic and resources that can help both medical students and residency programs. 

Learn more at the AMA COVID-19 resource center.

Speakers

• Kimberly Lomis, MD, vice president, undergraduate medical education innovations, AMA
• Eric Holmboe, MD, chief research, milestone development, and evaluation officer, Accreditation Council for Graduate Medical Education (ACGME)

Unger: Hello, this is the American Medical Association's COVID-19 Update. Today, we'll discuss the challenges of transitioning to residency during the pandemic and resources that can help. I'm joined today by Dr. Kimberly Lomis, AMA's vice president for undergraduate medical education innovations in Nashville and Dr. Eric Holmboe, chief research, milestone development, and evaluation officer at the Accreditation Council for Graduate Medical Education, or ACGME, in Chicago. I'm Todd Unger, AMA's chief experience officer in Chicago. Dr. Lomis, several years before the pandemic, the AMA started to focus on creating a better transition between medical school and residency. What prompted that need?

Dr. Lomis: Well, Todd, I think educators on both sides of the continuum, both medical schools and residency programs, have recognized that, over the years, students' roles have been curtailed a bit in terms of what they're able to do. And in many ways, they don't practice some of the common tasks that they're asked to be able to perform as interns as much as perhaps we historically did. In addition, we also are all aware that the competitive nature of the process of being selected for a residency program does impact students' performance and the way that they behave in these settings. And it really drives them to kind of conceal areas where they need to develop and grow as opposed to being able to openly show that, because they're incentivized to look good on paper for an application instead of being incentivized to really prepare. And so there's a need in a competency-based world to really create a developmental continuum that's much more seamless and it hasn't been seamless at all.

So in 2018, in our spring meeting of the American Medical Association's Accelerating Change in Medical Education Consortium, we talked about this problem and thought about what could we start to do to improve that. And one thing was to create more of a conversation at this window in time when students are graduating and getting ready to move into their next step.

Unger: Dr. Holmboe, from your perspective and from ACGME's perspective, did you see that same need? Or what spoke to you about that transition period in that window?

Dr. Holmboe: Yeah, I very much resonate with what Dr. Lomis has said. We were also very concerned about the transition. There's been a number of articles that have highlighted that as students enter their internship, they weren't fully prepared, particularly in key skills that were most important for that, especially discipline. There actually had been some pilots also using a tool that we have called Milestones, as part of the fourth year of medical school, to better prepare them for that transition and begin to think about the concept of a warm hand-off that we've also been interested in, actually for a number of years now.

Unger: Dr. Lomis had mentioned, early in her conversation, that things had kind of changed and you just mentioned this issue of kind of under preparedness for that transition in a residency. Can you speak in a little more detail about what caused it and what those particular issues might be?

Dr. Holmboe: Yeah, I'll just highlight a few things and turn it back over to Dr. Lomis. I think there are a couple of things. One is, as we well know, there tends to be a kind of overemphasis on things like medical knowledge and certain basic clinical skills. And it's not that knowledge isn't important, but we've increasingly learned that other skills such as communication, teamwork, professionalism, understanding how to work in systems, which by the way, AMA has been a real leader in, the kind of health system science, I do want to acknowledge that, weren't getting enough attention in medical school. And so when you look at some of the articles, it's these other skills that program directors were finding areas where people were struggling. And so thinking about that transition to make sure they have kind of a full complement, if you will, of abilities to start training is very important.

Dr. Lomis: Academic medical centers, like all medical centers, have been forced to really focus on efficiency because of funding and reimbursement issues. And in the short-term view, having a learner in the mix seems to slow things down. That is a very shortsighted view. And so what we see is, increasingly, students get marginalized as the student, and then suddenly people are surprised when they become residents that they aren't ready to do those tasks. And so we need to do a better job of reinserting them into meaningful roles on the teams, and many places do that as best they can. And then, making sure that they're appropriately supervised once that get into GME as well.

Unger: Well, I can't imagine that the pandemic made that situation better. Dr. Lomis, can you talk about how did the pandemic complicate that work that was already underway?

Dr. Lomis: Well, Todd, you and I have covered over the course of the year many educational disruptions related to COVID. And so I think it's important to recognize that not only was education disrupted for these students, but it happened in a very individualized way. Because of the differences in geographic reactions with the virus, in terms of the impact, some sites had clinical activity suspended for a very short period. Other sites had repeated disruption of clinical activities due to surges.

In addition, these changes were happening at a time in the students' training where they have more choice of what courses they're taking to prepare for their subsequent discipline in which they're matching. And so even if a given class is in the same institution and they're out for the same month, the way it impacted individual students is quite different. And so that's the particular challenge this year, is the variable nature of what was lost for each student. And it's really important to recognize that this is a loss in their experience. They're very capable, and we have full confidence that these students will go on to be fantastic interns. We just need to help them through this period and make sure that we're watching carefully as they adjust.

Unger: Dr. Holmboe, talk about the disruption and how you see the need to respond to that.

Dr. Holmboe: Yeah, just kind of building on what Kim talked about, in that the program directors themselves are preparing for the incoming class, knowing that they've had this highly variable experience for all the different reasons that Kim has laid out. From our standpoint, we've been involved in an effort to try to create a transition tool kit, and that was done collaboratively with the ECFMG, the AAMC and AACOM, and actually involve students. They were very helpful in creating that tool kit. It's mostly just a set of resources. And kind of building on something Kim said, some of the students said that their biggest concern was they didn't get certain experiences that were originally going to be electives, for which they will experience as interns and now will not come in having had that experience. And so their biggest concern is what is their schedule going to look like? Are they going to be put into a particular type of experience where they may not be fully prepared, that if it were scheduled late in the year would probably be better for them?

And so that's the other thing, kind of receiving end of this, that program directors are now struggling with. And we're seeing some innovative ways they're managing that such as having something called an OSCE during orientation week around clinical skills and procedures, kind of the can't miss type diagnoses, how to work with patients who are really ill, those sorts of things, making sure that they're fully prepared. I have no doubt, like Kim said, that this is an incredibly talented class. These students have been through a lot. They've demonstrated incredible resilience. They've often filled in in the front lines. They've done really honestly heroic type work, given their stage of training. And I think bringing that resilience and experience forward and then making sure we support them, understanding that they've had this variable experience, I think will be really important.

Unger: Dr. Lomis, the AMA has also been hard at work preparing some additional resources to complement the ones that Dr. Holmboe just mentioned. Can you talk about what those look like?

Dr. Lomis: Sure. Well, I think one important step is to acknowledge how hard it can be for interns to disclose areas of uncertainty. If we all think about it, no one would go to the first day of a new job and go to your boss and say, "Hey, now that you've hired me, by the way, you should know that I'm not feeling so confident about X, Y and Z." I mean, that's just not something that people feel very comfortable doing. And so part of our work has been to leverage the consortium's expertise in coaching and in the master depth of learner framework, as well as our competency-based expertise, and bring all that together to help learners and the GME programs think about how to make this a safe conversation. And so to compliment what Dr. Holmboe talked about, we have a really tangible tool that we're piloting with some of our Reimagining Residency initiatives.

As you know, the Reimagining Residency pilot has several projects that are focused on the transition. So we're collaborating with our colleagues in OB/GYN and emergency medicine who are working with us in that sphere, and having the GME programs invite their new residents to participate in this process in which they are walked through a survey to say, "What rotations did you miss? Why were you taking that? You wanted experience in the ICU, et cetera." And so, again, it's more about the experience as opposed to a judgment of the individual. And then walk them through, well given that, these changes, what you see as your strengths and areas that you need to work on, we'll help you develop an individualized learning plan around the transition. Not to try to fix it before the transition. There's just no time.

These students are moving to new cities and going through what kind of graduation celebration they may or may not get this year. And so it's really more about once you get there, how will you have this conversation? What resources will be there to help you? How do you make this a safe transition for yourself, for your patients? And so it's really a tangible method to carry out some of the ideas that are put forth in the tool kit that Dr. Holmboe mentioned.

Unger: Oh, I love the resources that you both outlined. And given kind of the situation that we've just moved through with the pandemic, it sounds right to say it kind of is what it is. And they could say for people to say, "This is the help that I need right now," and then provide them with those resources. So I appreciate all the work that both of you are doing. That's it for today's COVID-19 Update. We'll be back with another segment tomorrow. In the meantime, for resources on COVID-19, visit ama-assn.org/COVID-19. Thanks for joining us. Please take care.

Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.