C.O.V.I.D.: A Survival Guide for GI Fellowship Training During the COVID-19 Pandemic
Authors: Tzu-Hao Lee, Cecelia Zhang, Richard Wood, Darshan Kothari
Journal: Clinical Gastroenterology and Hepatology (2020)

It was the best of times, it was the worst of timesA Tale of Two Cities, Charles Dickens The COVID-19 pandemic is an unprecedented event with significant implications on training environments in gastroenterology (GI).1American Society for Gastrointestinal EndoscopyGuidance for trainees during the COVID-19 pandemic.Gastrointest Endosc. 2020; S0016-5107 (0020): 34364-34367Google Scholar Local and professional regulations limit educational opportunities by reducing endoscopic procedures and in-person clinics.2Pawlak K.M. Kral J. Khan R. et al.Impact of COVID-19 on endoscopy trainees: an international survey.Gastrointest Endosc. 2020; 92: 925-935Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar,3Keihanian T. Sharma P. Goyal J. et al.TeleHealth utilization in Gastroenterology (GI) clinics amid coronavirus-19 (COVID-19) pandemic: impact on clinical practice & GI training.Gastroenterology. 2020; 159: 1598-1601Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar Furthermore, social distancing increases the feeling of isolation and impacts trainee wellness. However, the pandemic has given fellows a unique opportunity to adopt a new set of skills to learn in a safe and supportive environment. In this article, we describe our approach to fellowship education during the pandemic: community building, online learning, virtual communication, infection control, and destress activities (C.O.V.I.D.) (Figure 1). A sense of community provides the foundation for a safe and supportive learning environment. This sense of community is affected by measures limiting personal interaction. Pandemic social distancing policies limit the number of people in work areas and conference rooms. Safety requirements, such as mask-wearing, limit interpersonal interaction and make it difficult to create and maintain camaraderie. Fortunately, digital technology provides several innovative ways to remain connected from a safe distance. At our program, we are now using virtual weekly check-in meetings to allow fellows to have a direct conversation with cofellows and program leadership. This is crucial, given our program frequently makes adjustments to accommodate the rapid changes during the pandemic. Importantly, the video function provides our trainees a means to connect on a more personal level. These virtual meetings may be facilitated by ice-breaker games, team building activities, and educational exercises (eg, GI Jeopardy), allowing for networking and social engagement while adhering to social distancing regulations. To enhance learning and networking, we have created a virtual learning community of fellows and faculty using an instant messaging application to have interactive daily discussions on different GI topics. Through use of digital technology, we have maintained interpersonal communication within our community, a fundamental component of the training environment during this uncertain time. Although online educational resources are not new to GI, the pandemic has enhanced their use. The American Gastroenterological Association and other major GI societies made online resources available to fellows from the early stages of the pandemic, including live virtual lectures, recorded webinars, procedure videos, and question banks (Table 1). At a regional level, our program collaborated with other GI programs in North Carolina to create a series of faculty-led noontime lectures that allowed trainees from multiple programs to learn from content experts. These online resources have increased accessibility and expanded the scope of learning opportunities for each fellowship program. In fact, fellow and faculty attendance at our educational meetings has increased significantly since we adopted the virtual format by eliminating travel time to return to the main campus from various satellite sites for conferences. Despite increased participation in virtual learning modalities, challenges remain with learner engagement. To enhance learner engagement on virtual platforms, our program uses such features as real-time voting and annotation to increase interactions between the audience and speakers.Table 1Online Learning Resources for GI FellowsGI/Hepatology Professional SocietiesSociety (Twitter handle)Online sourcesContentAGA (@AmerGastroAssn)AGA UniversityWebinars, modulesDDSEPBoard review books, question banksGastroenterology (@AGA_Gastro)JournalClinical Gastroenterology and Hepatology (@AGA_CGH)JournalACG (@AmCollegeGastro)Education UniverseWebinars, modulesVirtual Grand RoundsWeekly online real-time lecturesAJG Author PodcastsPodcastsThe American Journal of Gastroenterology (@amjgastro)JournalAASLD (@AASLDtweets)Liver LearningWebinarsHepatology (@HEP_Journal)JournalASGE (@ASGEendoscopy)GI-LeapWebinars, procedure videos, question banksGastrointestinal Endoscopy (@GIE_Journal)JournalOther GI/Hepatology Groups and Hashtags on TwitterGroup/ThemeDescription#GITwitterTag for searching or marking GI-related contents#LiverTwitterTag for searching or marking hepatology-related contents@ScopingSundaysOnline discussion about endoscopy every Sunday@MondayNightIBDOnline discussion about IBD every Monday@TuesdayNightIBSOnline discussion about IBS first Tuesday of the month#TracingTuesdayOnline discussion about GI motility every Tuesday@GIJournalOnline GI/hepatology journal club every Wednesday@LiverFellowOnline hepatology learning resources for trainees@GIreviewOnline resources of GI and hepatology review articles and guidelinesAASLD, American Association for the Study of Liver Diseases; ACG, American College of Gastroenterology; AGA, American Gastroenterological Association; AJG, American Journal of Gastroenterology; ASGE, American Society of Gastrointestinal Endoscopy; DDSEP, Digestive Diseases Self-Education Program; IBD, inflammatory bowel disease; IBS, irritable bowel syndrome; Leap, learning platform. Open table in a new tab AASLD, American Association for the Study of Liver Diseases; ACG, American College of Gastroenterology; AGA, American Gastroenterological Association; AJG, American Journal of Gastroenterology; ASGE, American Society of Gastrointestinal Endoscopy; DDSEP, Digestive Diseases Self-Education Program; IBD, inflammatory bowel disease; IBS, irritable bowel syndrome; Leap, learning platform. In addition to these virtual resources, the evolution of social media, including Twitter, has allowed for both networking and educational opportunities.4Bilal M. Oxentenko A.S. The impact of Twitter: why should you get involved, and tips and tricks to get started.Am J Gastroenterol. 2020; 115: 1549-1552Crossref PubMed Scopus (19) Google Scholar On Twitter, learners, content experts, and members of professional societies interact by sharing "bite-size" material intended to convey knowledge in a streamlined manner using newly published data, clinical images, or review topics. For example, "Tweetorial" is an easy-to-digest presentation format that is effortlessly reviewed during a busy day on service. Additionally, several groups host interactive forums to discuss interesting topics on a regular basis (Table 1). Twitter also allows trainees to network with colleagues and experts in the field for mentoring and career opportunities. As a GI fellow, it is important to know how to use these online resources, especially while traditional education formats are disrupted by the pandemic. The shift in clinical interactions from in-person to virtual visits in the early days of the pandemic identified the importance of telehealth skills.3Keihanian T. Sharma P. Goyal J. et al.TeleHealth utilization in Gastroenterology (GI) clinics amid coronavirus-19 (COVID-19) pandemic: impact on clinical practice & GI training.Gastroenterology. 2020; 159: 1598-1601Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar,5Keswani R.N. Sethi A. Repici A. et al.How to maximize trainee education during the coronavirus disease-2019 pandemic: perspectives from around the world.Gastroenterology. 2020; 159: 26-29Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar According to a recent study, fellow participation in faculty clinics was reduced by more than 50% with telehealth because of challenges in preceptorship and limitations in clinic time, and more than one-third of fellows reported that outpatient GI training was compromised.3Keihanian T. Sharma P. Goyal J. et al.TeleHealth utilization in Gastroenterology (GI) clinics amid coronavirus-19 (COVID-19) pandemic: impact on clinical practice & GI training.Gastroenterology. 2020; 159: 1598-1601Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar These changes highlight the need for adequate training and planning by faculty and fellows as teaching clinics move to the telehealth platform. Furthermore, because we anticipate most research meetings, national conferences, and job interviews will be conducted virtually for the foreseeable future, it is important for fellows to have the ability to give formal presentations on a virtual platform. Our institution held several online workshops regarding virtual communication and interview skills for trainees and faculty. Fellows in our program also now give GI grand rounds through a virtual platform and receive direct feedback on their performance as a means to improve their skills. Given that COVID-19 is a highly contagious disease, it is vital to adopt appropriate infection control precautions into our daily practice, including routinely reviewing charts and discussing with the primary team about the probability of COVID-19 infection before seeing a patient. A well-planned, focused history and physical could help decrease the time spent in a patient's room and minimize exposure risk. At our institution, mobile smart devices are given to isolated patients that are COVID-positive to communicate with providers. We also adhere to society guidelines regarding personal protective equipment use during patient encounters and endoscopy procedures.6Sultan S. Lim J.K. Altayar O. et al.AGA Institute rapid recommendations for gastrointestinal procedures during the COVID-19 pandemic.Gastroenterology. 2020; 159: 739-758Abstract Full Text Full Text PDF PubMed Scopus (237) Google Scholar Last but not least, fellows should familiarize themselves with GI manifestations of COVID in addition to the common respiratory symptoms.7Sultan S. Altayar O. Siddique S.M. et al.AGA Institute rapid review of the gastrointestinal and liver manifestations of COVID-19, meta-analysis of international data, and recommendations for the consultative management of patients with COVID-19.Gastroenterology. 2020; 159: 320-334Abstract Full Text Full Text PDF PubMed Scopus (294) Google Scholar From a program perspective, adequate personal protective equipment and infection precaution training should be provided to the trainees and faculty to minimize exposure risk. There should also be a clear policy regarding COVID testing before endoscopy procedures and the role of fellows in cases that are COVID-positive. In our program, fellows are encouraged to participate in the care of patients who are COVID-positive via virtual communication but are excused from having direct contact or performing endoscopic procedures on these patients. It is also important to standardize the reporting process for COVID-related symptoms, so fellows feel comfortable reporting possible infection. The unpredictable nature of the pandemic has significantly increased the anxiety level among trainees; thus, it is important to learn effective coping mechanisms. GI fellows should be encouraged to find the best stress-reducing activities that fit into their daily life to prevent burnout. More dedicated and advanced resources, such as individual counseling sessions and an anonymous crisis hotline, are also provided to the fellows at our institution for their mental health. Adjustments to the rotation schedules during the pandemic should also be considered.8Palchaudhuri S. Gabre J. Prenner S. et al.Adapting a GI fellowship to a pandemic: novel approaches to accommodating a novel virus.Dig Dis Sci. 2020; 65: 1562-1565Crossref PubMed Scopus (9) Google Scholar At our program, we now divide all fellow rotations into essential services and nonessential services. The essential services include general GI or hepatology inpatient consultation rotations, which may carry a higher risk of exposure compared with the nonessential services, such as outpatient clinics or endoscopy rotations. In addition, we shortened the length of each rotation from 4 weeks to 2 weeks and had each fellow rotate between essential and nonessential services to help them destress between high-exposure rotations. Fellows are strongly encouraged to take their vacation time as scheduled to maintain work and life balance. Trainees with families may need additional support given potential conflicts and shared responsibilities at home. Fortunately, medical students in our institution who were excused from clinical requirements early in the pandemic volunteered to help house staff and their families with essential activities, including childcare and grocery shopping. Fellows with special considerations, such as childcare issues or pre-existing medical conditions, have also been encouraged to discuss their individual needs for accommodation with program leadership. The weekly meeting with program leadership also provided an important platform for destressing and debriefing. The current local and institutional conditions and coverage plans, such as an updated list of back-up fellows and indications for redeployment, should be discussed frequently with all fellows. Equitable distribution of the clinical tasks, transparent decision making, and direct communication helps reduce unnecessary angst and maintain trainee morale. The COVID-19 pandemic has transformed training and education in GI. Fellows in different training programs may face different challenges depending on local prevalence, institutional policies, and available resources. In our region in the Southeast, we were fortunate to have had a more flattened rate of infection and hospitalizations that allowed the leadership and trainees in our program more time to plan and adapt during the pandemic. This pandemic will continue to influence our educational system for the foreseeable future. Using our framework (C.O.V.I.D.), we believe trainees in all institutions can continue to learn in a safe and supportive environment. Ongoing effort is required from trainees and program leadership to achieve this goal. Future discussions at a national level are necessary to further augment engagement in online learning, improve preceptorship in telehealth, and ensure an adequate endoscopy experience for the fellows. It could be the worst time to be a GI fellow during a pandemic. However, this special time provides us with a good opportunity to learn and practice new skills that allow us to face challenges in the post-COVID era.