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| COMMENTARY |
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| Ahead of print publication |
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The predicament of the medical postgraduate residents during the COVID-19 pandemic
Alka Subramanyam, Hrishikesh Bipin Nachane
Department of Psychiatry, TNMC and BYL Nair Ch. Hospital, Mumbai, Maharashtra, India
| Date of Submission | 08-Aug-2020 |
| Date of Decision | 03-Oct-2020 |
| Date of Acceptance | 27-Dec-2020 |
| Date of Web Publication | 15-Apr-2021 |
Correspondence Address:
Hrishikesh Bipin Nachane,
Department of Psychiatry, TNMC and BYL Nair Ch. Hospital, Mumbai - 400 008, Maharashtra
India
 Source of Support: None, Conflict of Interest: None DOI: 10.4103/aip.aip_85_20
The advent of the COVID-19 pandemic saw the deputation of postgraduate residents all over the country to round the clock COVID duties. Residents from various departments came together to face the pandemic as a team. This impacted their daily routines, studies, and exams. It carried with itself uncertainties in both their professional and personal lives. Nonetheless, all residents rose to the challenge at hand. This commentary discusses their predicament during the COVID-19 pandemic and highlights suggestions for some of the problems they faced.
Keywords: COVID-19, pandemic, postgraduate, residents
How to cite this URL:
Subramanyam A, Nachane HB. The predicament of the medical postgraduate residents during the COVID-19 pandemic. Ann Indian Psychiatry [Epub ahead of print] [cited 2023 Mar 30]. Available from: https://www.anip.co.in/preprintarticle.asp?id=313754 |
| Introduction | |  |
From February 2020, India saw a sharp rise in novel COVID-19 cases.[1] This put immense pressure on the health infrastructure of the country. Whereas smaller states such as Goa were able to control the number of rising cases, bigger states such as Maharashtra, Rajasthan, and Tamil Nadu found themselves at the brink of explosion. Various state governments and municipal corporations stepped up and started fortifying their hospitals with necessary ammunition such as ventilators, isolation facilities, and personal protective equipment (PPE). The bulk of the medical force in most government setups is formed by its postgraduate (PG) residents. This article highlights the changes the PG students endured in the face of the pandemic and the unprecedented role they assumed.
| Changes in A Postgraduate Resident's Life | | |
As the COVID-19 cases started surging in India, the nation went into a total lockdown.[1] This presented with several challenges to the resident doctors. A few who were home were stranded and unable to return to work. There was an amount of uncertainty regarding getting basic amenities such as food. Many shops were closed. Travel had become difficult within cities and so daily commute for many was a hassle. Several residents faced a dilemma in the wake of COVID exposure, whether they should return home at all and risk exposing their family members or not. Their workplace also had to undergo dramatic changes. Several departments across the world had to change their functioning. Nonessential procedures were reduced in numbers. Many wards were converted to COVID wards, thereby limiting the number of admissions. This meant lesser clinical interaction which would impediment their learning. Few teaching hospitals were completely converted to dedicated COVID hospitals, which led to the closure of their wards and outpatient departments. Thus, resident doctors of those departments had to do COVID duties exclusively which will definitely impact their skill learning. Turner et al. have described a fallacy of a service-education balance that has to be maintained, given the increasing administrative demands, duty hour limitations, and service demands.[2] In times of crisis such as this, education indeed takes a backseat as services become a priority. Literature exists on changes in education and the need for their continuation in earlier pandemics.[3] It is imperative that this COVID pandemic also does not hamper PG learning.
| Medical Pedagogy | | |
A global crisis such as this will invariably have a deep impact on PG medical education. Classroom teachings and in-person demonstrations stopped everywhere. Even before the pandemic, medical pedagogy was seeing a transition from conventional classroom teachings to technology-based novel concepts such as flipped lectures and simulation-based learning.[4] Several faculty shifted to the online classroom forum and using applications such as Zoom, conducted online classes for several subjects and colleges. Departments from other countries too have resorted to online continuing medical educations for imparting knowledge.[5],[6] Several residents have stated that this also serves as means of peer support and solidarity at a time of isolation and segregation.[6] Sahi et al. have highlighted several methods of propelling medical pedagogy during pandemic times, based on previous successes.[3] Importance of videoconferencing and telemedicine has especially been highlighted. This will also serve as a great opportunity to sensitize trainees to telemedicine. Research from the west has reported 60% of the US medical schools have included telemedicine in their curriculum.[7] However, such practices are lacking in India. The pandemic has compelled us to experiment with and understand the importance of telemedicine and teleconsultation. The Medical Council of India (MCI) has also come out with guidelines for telemedicine, eventually realizing its potential.[8] Hopefully, these practices will continue postpandemic as well. While e-learning appears lucrative, we are still far away from implementing such modalities in routine practice and teaching.[9] It requires extensive planning, trained workforce, and finances to be considered a viable method. Educators will need to be trained efficiently to adopt strategies to maximize the educational potential of e-learning.[10]
Moreover, applicability of such forums for PG medical pedagogy is limited. First, it is difficult to develop skills through online classes. Several PG courses require exhaustive training including skill-based hands-on training, for example, cardiothoracic surgery. Surgical techniques are not simply learned over a Zoom call. Using simulations for the acquisition of surgical skill has been suggested as an alternative.[11] However, such provisions are not available in all Indian hospitals and procuring them, especially in the face of a pandemic is going to be increasingly difficult. Moreover, majority of the resident force is working in COVID duty round the clock, leaving little time for education. Having various duty rosters make it difficult for all residents of a particular branch or year to assemble at one given point. There is no doubt that each and every medical postgraduate across the globe has stepped up to the challenge and is doing his/her duty diligently. However, is it right to take them away from their area of specialization and to compromise their skills is the question we all must ask ourselves. Experts have argued that refraining from posting residents in a pandemic also has its downside. Considering that today's students will be tomorrow's doctors, it is arguably counterproductive to artificially shield them from the realities of medicine in crisis times. Very few doctors, whatever be their specialization, can boast of serving the society at a time of pandemic. Working in such crisis may add on to their expertise, no matter the specialty. Researchers have given importance to self-study during this period. When the pressure of meeting deadlines for presentations, presenting routine rounds or studying up for cases is lifted, internal motivation to study assumes a greater importance. Well-motivated students have found time to work on unfinished projects, attend various webinars to keep up with their clinical studies. Many are taking up newer research projects with respect to the new COVID illness.
| Exams | | |
Several residents are currently in their final year of residency and are expected to appear for their exams. The MCI has directed them to continue working in their respective universities to add to the anti-COVID workforce. PG final exam is a big deal and requires exhaustive preparations, as it is the culmination of 3 years of knowledge, hard work, and skill development. Several institutes give a month or two to the residents to prepare for their final exams. However, this maybe a treat they may have to forgo in the present scenario. There are several institutes that have conducted theory and have withheld practical exams. As majority teaching hospitals are catering to COVID patients, they have reduced their intake of patients with other disorders. Thus, procuring cases for practical exams is going to be an uphill task. Adding fuel to the fire is the fact that several institutes have declared their exam dates for super-specialization entrances. Having certain exams on time and some being delayed has definitely added to the PG students' anxiety levels. This makes it imperative to relieve the residents of their duties and conduct the exams in an orderly fashion. Some have navigated a solution. Institutes have had external examiners attend the exams through internet calls and assess the candidates. This strategy was used during the 2003 SARS outbreak in China.[12] This seems like a viable solution given the state of things. A recent article by Kishor et al.[13] has highlighted various possible solutions for conducting examinations without compromising safety. Online theory exams, scanning, and uploading of answer scripts, simulated patients, objective structured clinical examination (OSCE), and tele-OSCE are a few of their suggestions. Experts have questioned the caliber of residents that would be produced at this juncture. Having people focus on subjects other than their own, with less than appropriate evaluation methods or no evaluation in some cases (there are petitions to promote residents without conducting exams) seems to have provoked a discussion on the quality of residents who will graduate and become consultants in the future. A possible solution is to consider these 6 months separately and extend the term, so quality of training is not compromised.
| Handling postgraduate's Health | | |
It is important to take care of the resident students' physical and mental health during the COVID-19 pandemic. Resident doctors face burnout even in normal working hours. Thus, the COVID pandemic is going to take a larger toll on the resident doctors' health. They are expected to work in COVID wards where they risk their own exposure to COVID. Several resident doctors across the country have been infected by the virus. They not only have defeated the virus but also rejoined the service to help others. Ensuring their safety by giving them adequate PPE and strict imposing of quarantine after duty is essential. However, several institutes have failed to live up to this mark. Universities across the country opted different strategies and duty rosters, despite the University Grants Commission coming out with their own recommendations. Quarantine period is lacking or inadequate which has led to them being reinfected and also gives rise to the so-called “super spreaders.” Some institutes are making the resident doctors do non-COVID work during their quarantine period, thereby defeating its purpose. Making sure they get a nutritious diet is equally important. A great initiative taken by Tata in this respect is the provision of packed lunches and dinners to residents on duty in the city of Mumbai. Several donors have also donated refreshments in several institutes such as fluids, dry fruits, and the like to ensure the residents have a good diet. Few residents report anxiety of joining duty, exhaustion post–PPE, and stress in face of the uncertainties they face. It has been suggested to include disaster medicine in medical curriculum.[14] This will help in preparedness and allay anxiety among residents. Our institute took an active initiative and reached out to all residents on duties and those who turned positive to check on their mental health. Several institutes have in house counseling services, helplines for residents so as to take care of their mental health. One can look into opportunities the pandemic has provided – to strive for better team work, look after one another, and to acquire skills and strengths which they previously lacked.
| Conclusions | | |
The PG trainees have been the heart of the pandemic and their contribution as corona warriors cannot be undermined in any way. It is an important task to balance on one hand the requirement of the current role – from a perspective of safety, nutrition, quarantine, and viral exposure and maintaining an environment and opportunity conducive to training and skill development on the other. While training through digital platforms and new technology is important, it is equally important to start non-COVID work and regain hands-on training so that the quality of doctors emerging from this does not suffer. The warriors may add to their armament and not strip themselves of their basic gear that they enrolled for. It is important that universities in India and across the globe recognize this and take active steps in this regard.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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| 2. | Turner TL, Fielder E, Ward MA. Balancing service and education in residency training: A logical fallacy. JAMA Pediatr 2016;170:101-2. |
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