Impact of early waves of the COVID-19 pandemic on family medicine residency training: Analysis of survey data

Abstract

Objective To identify how graduating and incoming family medicine residents (FMR) experienced changes to their education during the early waves of the COVID-19 pandemic.

Design The Family Medicine Longitudinal Survey was modified with questions related to the impact of COVID-19 on FMR and their training. Short-answer responses underwent thematic analysis. Responses to Likert scale and multiple-choice questions were reported as summary statistics.

Setting Department of Family and Community Medicine at the University of Toronto in Ontario.

Participants Graduating FMR in spring 2020 and incoming FMR in fall 2020.

Main outcome measures Residents’ perceptions of the impact of COVID-19 on clinical skills acquisition and preparedness for practice.

Results Surveys response rates were 124 of 167 (74%) and 142 of 162 (88%) for graduating and incoming residents, respectively. Important themes for both cohorts included reduced access to clinical environments, reduced patient volumes, and lack of exposure to procedural skills. While the graduating cohort indicated they felt confident to begin practising family medicine, they described being impacted by the loss of a tailored learning environment, including canceled or altered electives. In contrast, incoming residents reported the loss of core skills, such as physical examination competency, as well as the loss of face-to-face communication, rapport, and relationship-building opportunities. However, both cohorts endorsed gaining new skills during the pandemic, including conducting telemedicine appointments, pandemic planning, and interfacing with public health.

Conclusion Based on these results, residency programs can specifically tailor solutions and modifications to address common themes across cohorts to facilitate optimal learning environments in pandemic times.

The COVID-19 pandemic has posed severe disruption to medical education globally. In particular, physical distancing measures1 substantially challenged clinical training for both undergraduate and postgraduate trainees in Canada.

On March 11, 2020, the World Health Organization declared a global pandemic.2 In mid-March of 2020, all Canadian preclerkship and clerkship undergraduate medical students were removed from clinical duties.3 Medical schools quickly pivoted to deliver online curricula via virtual platforms and pre-recorded lectures.3-5 At the University of Toronto in Ontario, clerkship students were not reintegrated into the clinical environment until July 2020.

There has been discussion in the literature about the impact COVID-19 has had on medical education training. To date, publications discussing the effect on undergraduate training have largely been commentaries and opinion pieces.3-5,6 However, few empirical studies have examined these impacts, especially in Canada. One US study that surveyed 104 preclerkship students revealed that they believed remote learning had negatively affected the quality of their instruction and their ability to participate.7 A UK survey of 440 final-year medical students across 32 schools revealed that 77% had had their electives canceled and that disruptions to regular curricular activities and assessments had substantially impacted students’ preparedness to enter their first year of training.8

Likewise, the impact of COVID-19 on residency training programs has been well-described in opinion pieces and editorials. Educators have commented that postgraduate trainees experienced reduced outpatient volumes, limited opportunities to perform procedures, reduced diversity in disease pathology, and fewer networking opportunities.9 Authors describe that residents have been impacted by the transition from in-person to telemedicine visits,4,10 as well as by the delay of licensing examinations.11

While several studies have empirically examined the impact of the pandemic on specialty training programs such as urology12-14 and radiology,15,16 few have focused on family medicine training. However, an American study by Hogan and Holmboe in 2022 found that family medicine residents (FMR) were among the most substantially impacted by the pandemic.17 The effects of the pandemic on FMR included decreased clinical activity, an impaired sense of safety, increased stress at work, and increased administrative responsibilities.18-21

To date, there is still little empirical evidence examining the impact of COVID-19 on family medicine trainees in Canada. An article by Chawla et al in 2020 reported that 70% of FMR at Western University in London, Ont, believed their training had been substantially affected by the pandemic.22 More recently, a qualitative study among 25 FMR in Vancouver, BC, revealed that challenges associated with the pandemic included loss of hands-on experience with clinical skills, as well as disruptions to self-care and personal life.23 Our paper represents data from the largest family medicine training program in Canada highlighting the impact of the COVID-19 pandemic on FMR clinical skills and training, as self-reported by graduating and incoming FMR.

METHODSStudy information

An existing national survey instrument, the Family Medicine Longitudinal Survey (FMLS), was modified with questions related to the impact of COVID-19 on FMR and their training. The FMLS was designed by the College of Family Physicians of Canada to evaluate various aspects of the Triple C Competency-based Curriculum in family medicine training programs across Canada.24 It has been used in several evaluative studies and shows adequate validity evidence for evaluation purposes.25,26 Of note, the FMLS includes a modifiable component in which each individual training program can ask specific questions relevant to their context. Questions related to COVID-19 are found in Appendices A and B, available from CFPlus.*

Survey items included a 5-point Likert scale indicating agreement with statements, as well as open-ended short-answer questions. The survey was distributed via e-mail to 167 FMR graduating in spring 2020 and 162 residents incoming in fall 2020, all of whom were students at the University of Toronto in Ontario.

Ethics approval was obtained from the University of Toronto Research Ethics Board.

Analyses

Likert-scale responses are reported as summary statistics. We compared responses to the question “I am confident to begin the practice of comprehensive family medicine in any community in Canada” between the graduating cohort of 2020 and the pooled data of previous cohorts of graduates (from 2017 to 2019). Analysis was completed using an independent samples t test with the α value set at .05.

Short-answer responses to the question “Please specify what clinical skills acquisition you feel has been negatively affected by the COVID-19 pandemic” underwent thematic analysis. Responses were categorized into themes and subthemes inductively at the semantic level.27 One author (L.D.) conducted the initial coding, which was then reviewed by 2 other authors (M.F., K.K.). Based on feedback the coding scheme was adjusted and finalized. Below we report on the most common themes and subthemes and provide illustrative quotes from the open-ended data.

RESULTS

Surveys response rates were 124 of 167 (74%) and 142 of 162 (88%) for graduating and incoming residents, respectively. A summary of common themes is reported in Box 1.

Box 1. Themes and subthemes among graduating and incoming FMR cohorts’ responses to FMLS question: Please specify what clinical skills acquisition you feel has been negatively affected by the COVID-19 pandemic.

Both cohorts

Graduating FMR

Incoming FMR

Loss of exposure to core skills

Loss of exposure to physical examination skills

Loss of face-to-face communication and rapport

Reduced opportunity for relationship building

FMLS—Family Medicine Longitudinal Survey, FMR—family medicine resident.

Main themes among graduating and incoming FMR

Reduced access to clinical environments. This was the most commonly reported theme. It was commented on 81 times among graduating residents and 104 times among the incoming cohort. Specifically, residents mentioned that their clinical experience was limited due to canceled clinic visits, transition to virtual care, reduction of in-person visits, and overall reduced patient volumes.

Reduced patient volumes. This subcategory was commonly reported on by both cohorts. One graduating respondent expressed the impact of reduced patient volumes on the diversity of patient presentations:

Luckily, most of my core clinic-based blocks were completed prior to the pandemic ... however, volumes have been limited, and I think this has negatively affected the variety of learning experiences in FM [family medicine] blocks.

Lack of exposure to procedural skills. Examples of procedures frequently mentioned included intrauterine device insertions, endometrial biopsies, skin biopsies and excisions, Papanicolaou tests, joint injections, intubations, and abscess drainages.

Graduating FMR

A total of 122 individuals in the 2020 cohort and 313 in the cohorts from 2017 to 2019 responded to the question “I am confident to begin the practice of comprehensive family medicine in any community in Canada.” Overall, the 2020 graduating cohort generally felt confident with readiness to practise family medicine, with most (68%) either agreeing or strongly agreeing with the statement. This was slightly lower compared with the 2017 to 2019 cohorts, of whom more than 74% expressed agreement with the statement—a statistically significant difference (t=2.2, P<.03). However, an estimate of the effect size using Hedges g showed that this difference was small (g=0.23), indicating it likely has minimal educational significance.28 Very few individuals in each cohort expressed strong disagreement (n=1 and n=2, respectively). Moreover, when asked to respond yes or no to the statement “My training prepared me to adapt to providing care during the COVID-19 pandemic,” 94% of graduating FMR responded yes.

Despite indicating they felt confident and prepared, graduating residents described being tremendously impacted by the COVID-19 pandemic with respect to the loss of a tailored learning environment. The most common subtheme was canceled or altered electives. One respondent shared,

I had initially planned to do a global health elective working in addictions medicine and working with innercity and marginalized populations. Unfortunately, that had been canceled, which would have been a major part of my learning with working in this area.

Another FMR graduate reported,

I had elective blocks during block 11 and 13 that I had planned to use to improve my learning in areas [in which] I felt I was deficient (example: endocrinology and [rheumatology]) but these were canceled because of the transition to virtual care.

Incoming FMR

In contrast, numerous incoming residents commented on the loss of exposure to core skills and physical examination skills, the latter specifically including musculoskeletal and gynecologic examinations. One resident remarked, “My obstetrics/[gynecology] rotation in medical school was canceled—I [had] never done a pelvic exam until a few days ago in residency.” Still, when asked “Has the COVID pandemic impacted your readiness to start residency training?” about one-third of residents (33%) reported “not at all,” and when asked “How prepared do you feel to start residency training?”, very few reported they were “not at all” prepared (6%). Larger proportions reported positive feelings of readiness (50%) and preparedness (75%).

Losses of face-to-face communication, rapport, and relationship-building opportunities—with both patients and colleagues alike—were frequently reported among incoming residents. Regarding patient connections, one respondent expressed, “I also just think it is harder to [meet] people and form the valuable FM [family medicine] relationships with [COVID-19].” Another incoming resident shared, “I think past generations of residents learned a lot by osmosis from being around colleagues in clinic—[they] always had someone to answer questions, but our cohort is not benefiting from that.”

New skill acquisition

Despite some losses in learning and experience, the COVID-19 pandemic allowed both graduating and incoming residents to gain new skills. When asked “Are there any skills you feel you have acquired as a result of your clinical experiences during the COVID-19 pandemic?” both cohorts endorsed gaining skills pertaining to the conduct of virtual care (111 graduating FMR; 132 incoming FMR), followed by pandemic planning (33 graduating FMR; 31 incoming FMR), and interfacing with public health (34 graduating FMR; 27 incoming FMR) (Figure 1).

Figure 1.Figure 1.Figure 1.

Graduating (n=124) and incoming (n=142) FMR responses to the FMLS question: Are there any skills you feel you have acquired as a result of your clinical experiences during the COVID-19 pandemic? Select all that apply.

DISCUSSION

The COVID-19 pandemic has disrupted the training of FMR. At the University of Toronto, both graduating and incoming residents were affected by reduced access to clinical environments, reduced patient volumes, and lack of opportunity to practise procedural skills. However, our thematic analysis highlights that the effects of the pandemic on clinical learning varied depending on the stage of residency training. This is consistent with previous literature suggesting that learning disruptions from the COVID-19 pandemic affect junior versus senior residents differentially.29

While graduating FMR reported statistically significantly lower confidence in their readiness to practise compared with those from previous years, this difference was small and of uncertain significance regarding overall competence.30 Overall, a large proportion appeared to graduate feeling confident and competent, also indicating that their family medicine experiences had prepared them well for their work during the pandemic. This likely reflects the fact that this cohort had completed the bulk of their core rotations before the pandemic hit (ie, 20 of 24 months of their training). However, graduating FMR highlighted the loss of tailored learning experiences at the end of their training, such as elective rotations.

In contrast, incoming residents—whose responses reflected their experiences during the first 3 months of residency and the last 3 months of clerkship—highlighted losses regarding the attainment of core skills, such as physical examination and procedural skills. While most reported feeling generally prepared, there were specific dimensions where they identified perceived deficits. This suggests that this group may be at higher risk of losing critical opportunities for attainment of competency in these areas due to the pandemic. Moreover, incoming FMR commented on limitations owing to a lack of face-to-face communication. This impacted their ability to build rapport with patients, as well as their ability to learn “via osmosis” from colleagues and role models. Unlike the graduating cohort, this group entered residency during the pandemic: they did not have a chance to consolidate their clinical skills or form relationships with their patients early in their family medicine training. As a result, these FMR had to build physician-patient relationships largely virtually, as opposed to maintaining existing ones.

Questions arising from our findings include the following: to what extent, if any, does the loss of early exposure to core and physical examination skills affect the incoming cohorts’ future competency as family physicians? To what extent, if any, does the loss of early face-to-face communication and subsequent relationship building with colleagues and patients impact family medicine residents’ identity and development?

As educators, how can we mitigate their losses? In what ways can family medicine residency programs be reimagined to provide adequate exposure to core skills, teaching, and clinical experiences during unforseen disruptions to clinical training such as a pandemic?

The University of Toronto Department of Community and Family Medicine made several curricular adaptations in an effort to minimize residency losses. These included enhancements to virtual care and virtual supervision, distribution of electronic modules to facilitate independent learning, and an intense focus on faculty development regarding virtual teaching and supervision of medical students and residents. An example of these efforts is the Virtual Care Competency Training Roadmap, a series of 6 case-based interactive online modules that was introduced to support the development of clinical reasoning during a virtual care interaction. Moreover, in cases where electives were canceled, many residents were provided with opportunities to volunteer for in-person care via redeployment. Others were able to participate in COVIDCare@Home electives, which were created to provide exposure to medical and psychosocial consequences of COVID-19.31

Working groups have also been created at the postgraduate evaluation committee level to address the procedural skills gap highlighted in this research.

Future directions may involve creative ways to learn procedural skills with “at-home kits,” supplemented with virtual teaching; using the family medicine competency-based curricula framework to self-identify skill gaps32; enhanced orientations, which may be especially important for FMR redeployed to other services33; and possible extension of the 2-year family medicine residency program.

Strengths and limitations

While our study represents data from one of the largest North American family medicine residency training programs, with an 81% average response rate, it may not be generalizable to all family medicine training programs.

The FMLS enabled the collection of comprehensive data through both Likert scale and open-ended, short-answer questions. Of note, our data were collected via self-report and are based on residents’ perceptions of their training, rather than an assessment of resident competency. Therefore, it remains to be seen whether skill acquisition has been affected. This paper might serve as a needs assessment based on residents’ perceptions of areas requiring additional program support.

Future directions

Our team is continuing to gather information from resident respondents via ongoing qualitative interviews and analyses. We are interested in how the COVID-19 pandemic affected their transition to practice as well as their professional identity.

Conclusion

The COVID-19 pandemic made unprecedented changes to family medicine residency programs, affecting both graduating and incoming resident cohorts. As subsequent waves of the pandemic have emerged since our data collection, the losses highlighted in this study have had only greater impacts on the training of FMR. Based on our results, residency programs can tailor solutions and modifications to address common themes across cohorts and facilitate optimal learning environments during pandemics.

NotesEditor’s key points

▸ This paper highlights the impact of the COVID-19 pandemic on family medicine resident (FMR) training in Canada, with data from one of the largest North American family medicine residency training programs.

▸ Both incoming and graduating FMRs were affected by reduced access to clinical environments, reduced patient volumes, and lack of exposure to procedural skills.

▸ The incoming FMR cohort reported on the loss of core skills, face-to-face communication, and relationship-building opportunities.

▸ The graduating cohort, despite feeling confident to begin practice, was impacted most by the loss of a tailored learning environment.

Points de repère du rédacteur

▸ Le présent article met en évidence les répercussions de la pandémie de COVID-19 sur la résidence en médecine familiale au Canada au moyen de données provenant d’un des plus grands programmes dans ce domaine en Amérique du Nord.

▸ Les nouveaux résidents et les finissants ont été touchés par un accès réduit aux environnements cliniques, une diminution des volumes de patients et un manque d’exposition aux actes techniques.

▸ La cohorte de nouveaux résidents en médecine familiale a signalé une perte au niveau des compétences essentielles, de la communication en personne et des possibilités d’établissement de relations.

▸ Malgré le fait qu’ils se sentaient confiants à l’idée de commencer à exercer leur profession, les membres de la cohorte des finissants ont été le plus touchés par la perte d’un environnement d’apprentissage personnalisé.

Footnotes

* Appendices A and B are available from https://www.cfp.ca. Go to the full text of the article online and click on the CFPlus tab.

Contributors

All authors contributed to the concept and design of the study; data gathering, analysis, and interpretation; and preparing the manuscript for submission.

Competing interests

None declared

This article has been peer reviewed.

Cet article a fait l’objet d’une révision par des pairs.

Copyright © 2023 the College of Family Physicians of Canada

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