Eight hundred fifty. That’s the number of major procedures general surgery residents need to perform before graduating from residency.
As Covid-19 continues to spread across the United States, this requirement and those of other residencies become more difficult to achieve.
In mid-March, as the pandemic loomed in the U.S., the Accredited Council for Graduate Medical Education — the organization responsible for setting minimum case requirements for residencies — announced it would allow hospitals to redeploy residents to other specialties and suspend educational requirements for residency training programs.
As a yearlong patchwork pandemic becomes reality, with hot spots popping up across the country, more residents will leave the curricula of their chosen specialty education to become Covid-19 physicians. For residents in disciplines like general surgery, that could mean not meeting minimum case requirements. And that could mean not being able to competently perform some common procedures. In other words, inadequately trained doctors.
From March 2 to April 12, at the peak of the pandemic in New York state, 75% of residency programs in the New York metropolitan area deployed residents to Covid-19 units. Residents in specialties like dermatology, plastic surgery, and psychiatry were plucked from their curricula and placed in emergency departments and intensive care units to function as medical interns, stopping work in their specialties. For example, chief orthopedic surgery residents stopped operating, their educational lectures were cancelled, and they received pulmonary critical care training instead of orthopedic training.
Even residents who weren’t redeployed to other specialties, like my colleagues and I in radiology, saw dramatic shifts in their education. Imaging of the heart and chest is playing a bigger role in our education during the pandemic, for example, with a corresponding decrease in other types, like mammography, which is an essential component of residents’ training.
Many hospital departments have been operating on skeleton crews of a few residents assigned to hospital duties, such as covering urgent services and doing direct patient care, while “nonessential” residents have been quarantined at home, missing out on learning opportunities in the hospital.
For residents in areas that have (so far) been relatively spared by Covid-19, state lockdowns prevented many hospital departments from seeing patients. Some ENT surgery departments, for example, are resuming procedures this month. As a result, many residents are now struggling to demonstrate competence in some procedures they will likely have to perform after they graduate. Some general surgery residents lack the number of procedures needed to determine competence in some areas. Many of these procedures are the same ones with the lowest levels of reported operative confidence among chief residents, typically chosen as the program’s most talented trainees.
It is unlikely that specialties that are primarily outpatient, such as dermatology, will rebound to their pre-pandemic volume for some time. Once the scheduling of nonemergency procedures ramps back up, cases will need to be more widely spaced out in time to allow hospitals to perform new decontamination protocols. Social distancing guidelines may also limit the number of trainees permitted in operating or procedure rooms. For academic urban programs with a large number of residents, this means fewer cases per resident.
The response to this may be to cut training spots.
The Hospital for Special Surgery in Manhattan has already notified applicants to one of its fellowship training programs that it had to decrease the number of spots for the 2021-2022 application cycle. Residency spots could also be cut in certain regions, as they are funded by Medicare, which has the right to reduce the number of full-time residents at hospitals.
A recent analysis of rural hospitals spanning 40 states showed that almost 354 could close as a result of the lockdown, and with them their training opportunities for residents. The disruption a hospital closure has on resident education was evident when bankrupt Hanhnemann University Hospital in Philadelphia closed and its more than 550 residency spots were auctioned off to other hospital systems. Some of the residents went to smaller rural hospitals, which may now close, turning graduate medical education into a turbulent game of musical chairs that may worsen a parallel epidemic: the doctor shortage.
According to the Association of American Medical Colleges (AAMC), more than 3,000 medical school graduates did not match into residency positions this year. The increase in the number of medical school graduates has far outpaced the increase in residency training programs. The AAMC projects a shortage of as many as 43,000 doctors this year and 121,000 by 2030.
While the pandemic will most certainly worsen the doctor shortage, it may also prevent medical boards from testing doctors-in-training altogether.
As the pandemic forces standardized tests like the SAT to migrate to the web, board certification exams for residents are almost all still to be conducted in person. Many medical boards have had difficulty pivoting to online formats, delaying their exams until 2021. This could potentially put board eligibility for candidates in jeopardy and may unnecessarily prolong residency training for some new physicians.
As the pandemic continues to unfold, more residents will join the all-hands-on-deck response. The long-term effect of this on the training of young doctors — who will soon be out of residency and independently performing knee replacements on 65-year-old grandmothers or reading pediatric brain MRIs — is yet to be seen.
Corbin Pomeranz is a physician and chief radiology resident at Thomas Jefferson University Hospital in Philadelphia.
Thank you for reporting on this important topic. An important clarification is that the HSS change in Fellowship spots is just one, in Radiology (from 5 to 4), and that was a strategic decision unrelated to Covid-19.
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