The SARS-CoV-2, or COVID-19, pandemic has made an immense impact on virtually every facet of our lives, with tens of millions of lives lost and countless more affected globally.¹ Specifically, the health-care and education sectors have gone through unprecedented perturbations, the long-term effects of which remain unclear. Graduate medical training lies at the intersection between these two arenas, and the pandemic has already had an enormous impact on ophthalmology training at virtually every level. As we are based in New York City, we saw firsthand that training programs here were hit particularly hard during the domestic COVID-19 surge in March 2020. Many needed to abruptly pivot to online learning, severely limit or close ambulatory clinics and shut down surgical suites for elective cases well ahead of colleagues in other geographic areas. Beyond these upheavals, ophthalmology residents were deployed to take part in the direct care of patients with COVID-19, alongside trainees from virtually every medical specialty.

Here’s a look at how residency programs sought to meet these challenges.

DIDACTICS EVOLVE

When the virtual became essential

While online learning platforms have broadly permeated the educational landscape, graduate medical education in ophthalmology has traditionally relied heavily on live lecture formats. Residency programs of course needed to change this immediately once social distancing policies were enacted. Typical educational activities such as didactic lectures, seminars, journal clubs and grand-rounds lectures were moved to virtual platforms such as Microsoft Teams.

While initially fraught with technical challenges and difficulties, this transition has enabled many positive changes to training programs. Online formats have facilitated collaboration and enhanced didactics via lecture sharing across programs.² Improved attendance from geographically isolated faculty and trainees who need not commute to centralized lecture facilities has proven to be of enormous benefit, leading to more robust discussions and improved communications within the department.

The change to virtual activities is not without its drawbacks, however. To keep participants engaged, lecturers need to expend extra effort to make their talks interactive, make use of graphics and videos and incorporate time for breaks to maintain attention.³ Furthermore, the loss of human interaction that takes place when participants are together is a somewhat intangible but extremely significant loss. This valuable time for casual conversation with colleagues is difficult to recreate in a virtual format. Physical separation can translate to less participation in lectures and difficulty for presenters to gauge audience reactions and engagement.

Medical societies and industry step up

With numerous online resources available from the AAO, such as the Ophthalmic News and Education (ONE) Network, many educators began incorporating multimedia content more formally into their curriculum. At Montefiore-Einstein, Eyelecture.com was developed within the Institution. This ophthalmic learning portal and lecture management system instantly gained traction and has fostered significant interest in a multi-institutional collaborative effort. Subspecialty societies have extensive surgical training modules and videos available that, in conjunction with industry-sponsored content, can provide observational resources to teach the fundamentals of ophthalmic surgery.

The transition to virtual conferences has furthermore improved access to high level content for many residents who previously may not have been able to attend in person, albeit at the cost of major networking opportunities. It is likely that many societies will evolve conferences into some form of a hybrid model given the enormous benefits that have been realized in some respects.

In conjunction with increased virtual platforms for learning, a commensurate shift to virtual platforms for assessments has also occurred. Residents will take the 2021 Ophthalmic Knowledge Assessment Program online, and the American Board of Ophthalmology oral examination moved to a virtual format.⁴

CONSIDERATIONS IN CLINICAL TRAINING

When surgeries stopped

Along with new restrictions in education, ambulatory surgeries came to an abrupt halt early in the pandemic. In a worldwide survey of ophthalmology educators in April 2020, the majority of respondents reported residents and fellows had either completely suspended surgical training or were only performing emergency surgeries.⁵ Although the initial timing of the spring surge affected surgical exposure for residents graduating in 2020, many of these trainees already had 8-9 months of experience as primary surgeons. Residents graduating from training programs that allow high volumes of primary surgery (hundreds of cataract surgery cases, for example) were far less impacted than those graduating from programs that offer closer to the ACGME-recommended minimum of 86 primary cases.

Thankfully, many residents went on to a 1-to-2-year subspecialty fellowship starting in July 2020, which allows the potential for additional supervised experience. However, those residents who joined practices directly from residency have likely been operating far more independently despite the truncation in training. At Montefiore, we were fortunate to have had relatively high surgical volumes, and all five of our graduates began fellowships in the summer.

Delays in transitioning more junior residents to the operating room will also have a long-term impact, particularly as we head into the second wave of the pandemic with the potential for additional scaling back and shutdowns. Furthermore, at many programs, strabismus surgical experience occurs during the PGY-3 year during a pediatrics elective. Some of these residents may have spent an entire rotation with little to no strabismus surgical experiences.⁶

The simulated surgery option

As residents had fewer surgical cases, the approach to teaching surgery has shifted. As with didactics, an even greater emphasis on electronic platforms has emerged, including surgical videos, teaching conferences and virtual simulators such as the Eyesi Surgical (Haag Streit). Free online videos such as those available at Orbis International’s Cybersight cover surgeries across ophthalmologic subspecialties and often enable an enhanced viewing experience with the use of stereo glasses.⁷

Simulators were available prior to the pandemic but are now receiving an even greater focus in resident education. These tools enable surgical practice to be targeted to each resident’s level of training. Additionally, educators can observe residents in a controlled setting to ensure trainees exceed all competency standards before graduation. The Association of University Professors of Ophthalmology, along with industry partners and professional societies, are in the process of further developing courses to build formal simulation curricula within residency training programs. These programs can have an enormous impact on resident training and competency. For example, a recent analysis of virtual reality surgical simulation has demonstrated reductions of up to 38% in actual complications for novice surgeons.⁸

Residents have additional opportunities for individualized learning, such as reviewing cataract surgery videos one-on-one with surgical mentors. At Montefiore and other programs, state-of-the-art wet labs are available as sites to enhance resident surgical training. Despite the inconveniences of these sessions being held during off hours and in smaller groups, residents tell us they find many of the simulation and guided practice sessions to be the most engaging and highest yield of their curriculum.

New gauges necessary

The expected decrease in total surgical numbers for the classes of 2020 and 2021 also led to a more qualitative approach to determining graduation requirements. This emphasis on quality rather than quantity of resident surgical experiences may have a long-lasting positive impact, and, with carefully vetted metrics, may prove to be a more robust system to optimize resident evaluations and ultimately patient safety.

MORE COVID FALLOUT

Teleophthalmology comes to residency training

As all practicing ophthalmologists have experienced, the COVID-19 pandemic introduced a number of changes to in-person patient care, including further innovations in teleophthalmology to limit patient exposure. While these visits were not a traditional component of residency education prior to the pandemic, many see this as an unavoidable facet of the ophthalmologist’s future practice.^2,9,10

The pandemic was the first time a number of residents experienced teleophthalmology, and, in our experience, responses have been mixed. Many felt limited by the care they could provide over the phone, seeing the virtual visit as little more than a bridge to an eventually necessary in-person visit. In oculoplastics, however, televisits were often adequate for visualization of external lesions and for initiation of treatment plans, even if subsequent in-person procedures would be necessary.

Televisits may additionally allow for a more personalized and efficient interaction with patients for routine tasks such as clarifying drop regiments, reviewing imaging studies utilizing screen-sharing and even obtaining a basic external examination for emergency consultation and after-hours care. As these hybrid care models continue to gain acceptance, it is very likely that residents will be formally trained on how to incorporate advanced communications to patient care.

Deployed to the front lines

With training programs largely shut down in spring 2020, many ophthalmology residents were deployed to internal medicine and emergency department services to assist in the direct care of patients with COVID-19.2 Early in the pandemic, much less was known about transmission risks, so many frontline residents worked without adequate access to personal protective equipment and some were infected with the COVID-19 virus. In one study of resident physicians, the three specialties that emerged as high risk for infection were emergency medicine, anesthesiology and ophthalmology.¹¹ Ophthalmology may be a higher risk specialty due to the close proximity to patients required for clinical exams and extensive contact with ocular secretions.¹² Fortunately, in this study few residents were hospitalized, and no resident deaths were reported.¹¹

The emotional and physical stress of these deployments cannot be understated. Many residents were enormously fearful of bringing the virus home, often completely isolating themselves from loved ones for extended periods of time. Personal narratives from residents on the front lines in New York City demonstrate their intense feelings of meaning and gratitude but also of pain, loss and exhaustion while performing this work.¹³ Residents who were not deployed reported feelings of guilt and shame about their modified schedules that enabled sleep recovery and time for self-care during this period of great stress for their colleagues.¹⁴

Beyond worries for their mental and physical health, many residents are concerned about their education and future employment opportunities. The mandated reduction in social interactions has introduced a challenge for co-residents, faculty and program directors to check in with one another at a time when many residents have been feeling increasingly isolated and overwhelmed. This has emphasized the need for enhanced wellness activities, which has been difficult with restrictions in place.

Some programs have enacted socially distanced gatherings or internet-based activities. At Montefiore, the residents are a close-knit group, and with a reduction in daily interactions, it has been important to deliberately protect time for them to spend together. Residents enjoyed several outdoor gatherings while the weather was warm, including a walking tour of the Bronx, a Pilates class in the park, a trip to the New York Botanical Gardens and several picnics. The residents have also been able to uphold some valued traditions, such as an annual winter holiday gift exchange — modified with precautions, of course.

Although wellness has gained focus over the past several years in the educational sphere, this is a particularly important time to consider trainees’ mental health and emotional wellbeing. For example, recognizing that PGY-2 residents are unable to attend their highly anticipated global health trip, “wellness days” were implemented, where residents are periodically relieved of all clinical responsibilities. The needs of individual residents will differ, but program directors should feel comfortable speaking to residents directly and soliciting their feedback about what resources they feel they need. All residents should have access to and be directed towards general mental health resources that they may engage with voluntarily and confidentially. As an example, at Montefiore a Caregiver Support Center and Network was developed, and is providing real-time counseling, food and desperately needed respite to any provider or worker who is in need. Open lines of communication, transparency and constant check-ins are critical and have helped many of our trainees through the most difficult portions of their deployments.

THE FUTURE REMAINS BRIGHT

The COVID-19 pandemic has introduced unprecedented challenges while simultaneously fostering monumental change in every facet of resident education. While we mourn the losses that many have endured, the future for the current trainees that have helped mount our nation’s frontline response remains bright. Their resilience, strength, compassion and bravery as they participated in our nation’s pandemic response will forever distinguish them. The lessons learned from the challenges residents have faced will help us evolve as educators for generations. OM

REFERENCES

1. WHO Coronavirus Disease (COVID-19) Dashboard: United States of America. World Health Organization. https://covid19.who.int/ . Updated December 30, 2020. Accessed 30 December 2020.
2. Chen RWS, Abazari A, Dhar S, et al. Living with COVID-19: A Perspective from New York Area Ophthalmology Residency Program Directors at the Epicenter of the Pandemic. Ophthalmology. 2020;127:e47-e48.
3. J R. Twelve tips for COVID-19 friendly learning design in medical education. MedEdPublish. 2020;9:1-16.
4. COVID-19 Information Center. American Board of Ophthalmology. https://abop.org/covid19 . Accessed December 30, 2020.
5. Chatziralli I, Ventura CV, Touhami S, et al. Transforming ophthalmic education into virtual learning during COVID-19 pandemic: a global perspective. Eye (London, England). 2020:1-8.
6. Wagner RS. Strabismus Surgical Training During the COVID-19 Pandemic. Journal of pediatric ophthalmology and strabismus. 2020;57(4):211-212.
7. Cybersight. Free online courses in ophthalmology. https://cybersight.org/online-learning/ . Accessed Jan. 1 2021.
8. Ferris JD, Donachie PH, Johnston RL, Barnes B, Olaitan M, Sparrow JM. Royal College of Ophthalmologists' National Ophthalmology Database study of cataract surgery: report 6. The impact of EyeSi virtual reality training on complications rates of cataract surgery performed by first and second year trainees. The British journal of ophthalmology. 2020;104:324-329.
9. Bakshi SK, Ho AC, Chodosh J, Fung AT, Chan RVP, Ting DSW. Training in the year of the eye: the impact of the COVID-19 pandemic on ophthalmic education. The British journal of ophthalmology. 2020;104:1181-1183.
10. Ferrara M, Romano V, Steel DH, et al. Reshaping ophthalmology training after COVID-19 pandemic. Eye (London, England). 2020;34:2089-2097.
11. Breazzano MP, Shen J, Abdelhakim AH, et al. New York City COVID-19 resident physician exposure during exponential phase of pandemic. The Journal of clinical investigation. 2020;130:4726-4733.
12. Romano MR, Montericcio A, Montalbano C, et al. Facing COVID-19 in Ophthalmology Department. Current eye research. 2020;45(6):653-658.
13. Rosenberg JB, Nair A, Jin S, et al. Editorial: Perspectives from the front lines of COVID-19: New York City ophthalmology resident narratives. Current opinion in ophthalmology. 2020;31(5):386-388.
14. Ramirez DA, Dawoud SA. Resident Perspectives on COVID-19: Three Takeaways. American journal of ophthalmology. 2020;220:A2-a4.

About the authors

Jenna Tauber, MD, is a PGY-2 ophthalmology resident at Montefiore Medical Center/Albert Einstein College of Medicine, in the Bronx, N.Y. She completed her internship in Internal Medicine at the same institution. E-mail her at: jtauber@montefiore.org.

Anurag Shrivastava, MD, is an associate professor of ophthalmology and serves as the assistant dean for Montefiore Medical Center, Albert Einstein College of Medicine. He has served as program director and is actively involved in the GME response to the COVID-19 pandemic at the Montefiore Health System in the Bronx, N.Y. E-mail him at ashrivas@montefiore.org.