Cancer Topics - COVID-19’s Impact on Oncology Trainees

In this episode of the ASCO Education Podcast, moderator Dr. Annie Im speaks with fellows and training program directors about oncology training during the COVID-19 pandemic. Featuring Drs. Kathryn Bollin (director), Farah Nasraty (fellow), Jonathan Berry (fellow), Nino Balanchivadze (fellow), and Nishin Bhadkamkar (director). Subscribe: Apple Podcasts, Google Podcasts | Additional resources: elearning.asco.org | Contact Us

Air Date: 5/26/2021

 

TRANSCRIPT

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SPEAKER: The purpose of this podcast is to educate and inform. This is not a substitute for medical care, and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.

ANNIE IM: Hello, and welcome to ASCO's podcast episode focused on the impact of the COVID-19 pandemic on oncology fellows and training programs. My name is Dr. Annie Im. And I'm an associate professor of medicine and the Fellowship Program Director at the University of Pittsburgh. I am pleased to be joined by our five guest speakers today.

NINA BALANCHIVADZE: Hello my name is Nina Balanchivadze. I'm a second year fellow at Henry Ford Hospital in Detroit, Michigan.

JONATHAN BERRY: Hi, my name is Jonathan Berry. I'm a first year fellow at Beth Israel Deaconess in Boston, Massachusetts.

NISHIN BHADKAMKAR: Hi, I'm Nishin Bhadkamkar. I'm an associate professor in the departments of general oncology and gastrointestinal medical oncology. I'm at MD Anderson Cancer Center. And I'm the Program Director of the Hematology Oncology Fellowship Program.

KATHERINE BOLLIN: Hello, everyone. I'm Katherine Bollin. I'm the Associate Program Director for Hematology Oncology at Scripps MD Anderson Cancer Center in San Diego. And I'm also the Wellness Chair for the GME Division of Physician Wellness, and a medical oncologist specializing in cutaneous oncology.

FARAH NASRATY: Hi, Everyone. I'm Farah Nasraty. I'm a third year hematology oncology fellow at Scripps Clinic MD Anderson in San Diego, California.

ANNIE IM: Thank you. So let's get right into it. First, let me ask how are training programs adjusted at your institution during the COVID-19 pandemic? What was the impact on learning? What adjustments did your institution make? And what has worked well that you can share with the treating program community? Let's start with Dr. Bhadkamkar.

NISHIN BHADKAMKAR: When the pandemic hit us, we obviously had to rapidly make changes to our clinical and educational programs. I think the first change that came about was transitioning to telemedicine for many of our outpatient visits. And obviously this had an impact on outpatient rotations for our trainees. At the same time, we also changed all of our didactic programming to the virtual format. And this also had to be done fairly quickly to meet institutional requirements.

And what we found in making these changes was first and foremost on the clinical side that trainees on outpatient rotation definitely had a perception that their learning would be adversely impacted by having less in-person interactions. And so we really relied on our rotation coordinators to make sure that fellows were involved in the telemedicine platforms to talk about decision making, and to interact with the patients. Obviously, there's no way to completely recreate the interaction. But we wanted there to be the element of fellow talking to patient, than fellow talking to the attending, and then all three again coming together to talk about the treatment plan.

With regard to education, we certainly found that there was a social element that is important to learning that it was more difficult to recreate on a virtual platform. However, there were certainly advantages to the virtual setting in the sense that it allowed people to connect from different campuses. It allowed some people to participate who perhaps in a live setting would be less likely to speak up. And so using chat features and other elements, we found that there was a segment of our trainees who actually were participating more than they would have in our normal format. So clearly there were advantages and disadvantages. But I think overall it was a necessary change, and one that I think trainees in the end embraced and were able to make the most of.

NINA BALANCHIVADZE: We had a lot of the similar changes as described. And I would say that what worked the best was clear communication and clear messages from the program leadership. One of the important things that our program did was we had a town hall like meeting where all fellows got together with program leadership and faculty, and we discussed going forward. And we discussed what changes will be made. And fellows this way felt empowered. We had our voice, and we were part of a decision.

As you all know, the pandemic brought shock. And as the pandemic unraveled, in particular, Detroit was one of the hardest hit cities. Therefore, all of these changes I would say got to us before too many places. Another thing that worked well was splitting up the fellow group in three separate groups, which allowed two week blocks. So a group of fellows did inpatient hematology and oncology related work such as consults. In the same groups, there was a fellow who covered the clinic, and saw patients that could not be seen virtually.

There was another group that covered the COVID wards. That was the group that was deployed to take care of patients at the front lines. And a third group of fellows were actually at home, and participated in remote and telemedicine type visits. So the way the structure went-- two weeks of being at home doing remote didactics. Then two weeks doing hematology oncology related work. And then two weeks doing COVID related work. Therefore, after kind of going through these phases, it allowed all the fellows to kind of have a time to decompress and decongest. So I think that really worked well for our program.

KATHERINE BOLLIN: So we did many of the same things that have been highlighted already and shifting didactics online, and multidisciplinary conferences. And also clinic visits became mostly telemedicine. And we were able to institute technology within the hospital wards to facilitate interactions that may not have been in person being a consultative service as well. So those things went fairly smoothly at our institution where the impact of COVID initially was relatively low compared to other institutions across the country. So we were able to maintain a safe and functional environment.

But what's been interesting is that, yes, we've been nimble in making this kind of transition, but now our eyes are open to the advantages of working and functioning in a virtual world. And we're looking at how we might carry this over in a post COVID way. I think that remains to be seen. But it's been wonderful having fellows at different centers coming together over a virtual format not just within our own cancer center from different satellite clinics, but also in combining with other cancer centers. And sharing didactic and multidisciplinary conferences and the like.

So I think that the strain and the impact of COVID on our fellowship has been tricky and difficult in many ways. But it's open the door to really facilitating living in a virtual world in the future.

ANNIE IM: We know this pandemic has affected everyone in some way. Regarding your personal life and well-being, would you like to share what was particularly challenging during this pandemic? What has been helpful through difficult times?

NINA BALANCHIVADZE: I think that pandemic has been challenging on various levels, particularly in personal lives. A lot of the fellows live away from their families or extended family and have children. So the quarantine, and being at home, daycares being closed, I think affected a lot of fellows. In addition, having virtual visits, having teleconferences, is difficult if you have a toddler running around the house. And I think this also puts a whole new layer and dimension to the stress that fellow experienced during this time.

And then there was the stress of am I going to get infected? Am I going to infect my children? How am I going to cope? And I believe that these were the questions that everybody had and went through. Personally, what helped me was collaborating and talking to other fellows. I created a Facebook page where I had included a lot of the fellows I knew not only from hematology oncology but as well as from other specialties. So I also took up a hobby. I started gardening and I started taking care of flowers and flowering. And trying to do things that were more family centered to try to get through this difficult time.

FARAH NASRATY: I would agree with that. I think COVID of course now we're a year into it, but it brought so many challenges with it all at once. Maybe we were used to dealing with a challenging patient interaction or interpersonal interaction. But it just brought everything together. Not seeing your family, your friends. Not being able to see patients or your co-fellows.

And then as we have talked about, just your own fear of getting sick and dying. Or your family member or co-worker getting sick. And so it was just a lot to take all at once. And I think anyone could kind of crack under that pressure almost. And so I kind of used that period initially as a stopping point for myself to kind of regroup, and see where I have resiliency skills or strengths. And where I could build upon that.

And at Scripps, at my clinic, we had just recently gone through a resiliency course. So I kind of had those tools ready. But I also spent part of the beginning of COVID taking an online course called The Science of Well-being. It's a free course, it's offered through Yale available online at Coursera. And that was a really helpful tool for me to use then, and to continue to use now. Because I think as medical professionals we had an idea of the handwashing, and the masks, and social distancing. But I think in terms of emotional support, and in terms of our being, I think that also took a hit. And we really needed additional support there.

And the course I took online and our course at Scripps, there wasn't necessarily anything you didn't already know. Just general reminders. But I think sometimes that's what we need. Right. Like excess use of social media is bad. Increased sleep is good. But it also opened my eyes to some other ideas that even through such a dark time as COVID something like keeping a gratitude journal, which for me is just like in the Notes app on my iPhone. But just little things like that. What are the small positives I could find in the day when I was going through such a hard time.

And I think taking that course, taking the resiliency tools I had, and trying to actively remind myself of that, which I hadn't ever done in the past going through medicine, I think that really helped me kind of get through the day to day struggle. And I still use it today. So it's been really helpful.

JONATHAN BERRY: So I actually started fellowship last summer. I'm just in my first year. And so we were already several months into the pandemic by the time we entered our hemog fellowship. And I think the most important kind of support in my personal life was really our program thinking about how we as first year fellows can support, and encourage, and be there for each other. So historically, prior to our year, the first year are almost all in the clinic. And so they share what could probably be best termed a very cozy office or a large closet, which of course, did not meet social distancing rules under the normal kind of new standards.

And so there is was great advocacy to get us a different office where we could all be at the same workspace appropriately kind of spread out. But be able to support each other as we go through the challenges of starting this new year, and all of the ups and downs of hemog fellowship. And so that was absolutely huge was having that support at work. And on the same way, having my partner and having my close friends that we only saw each other for the first few months. I think just having those people around who are able to remind you of the world outside of medicine whenever things are really challenging was by far the most important part.

And the ways in which we couldn't have those interactions that we would have normally had with far more people were some of the hardest parts.

ANNIE IM: Next, I want to ask, how have you coped with remote instruction and limited in-person interaction with peers, patients, and mentors? Any lessons learned from this experience that you'd like to share with others?

JONATHAN BERRY: So I think one of our big concerns as I was a new fellow in hemog was with the total change of everything moving to online education, and having less in-person interaction locally and at conferences-- national conferences, which obviously also were happening online-- there is this worry of how this would affect our learning in this pivotal first year. And I think that's something that's continued to be a question. And to be honest, I think I still have some areas where I feel like I might have learned this a lot better if I was able to sit with colleagues around a table, and talk about it in person as opposed to online.

But that being said, I think there's definitely been some developments. Some things that I've learned and some things that our program has learned about how to make remote instruction as effective as it can be. I think any time we can get people talking and interacting-- like was mentioned earlier, whenever there is educational sessions that are structured in such a way that they're not just one way conversations, but they're kind of small group conversations, or they have interactive elements, or use breakout rooms effectively, those things are extremely helpful at making remote instruction stick a lot better. I think the other aspect is there are types of conferences and types of lectures that actually seem to work a lot better online.

So I found that things like grand rounds and having these speakers who often I would be intimidated to approach in person to ask a question, having them online and being able to pose a question in a chat format is significantly less intimidating. And then we also have the ability of bringing in anyone at any time for grand rounds. You don't have to deal with thinking about travel, and housing, and hotels, and things like that. And so I think some of those sorts of things like invited speakers, the online format of instruction has actually worked a lot better. And I anticipate that some of that might actually stick around. Although hopefully, we will still travel from time to time and see each other at conferences and in each other's institutions as well.

NISHIN BHADKAMKAR: I think that each fellowship class experienced the pandemic in a different way. And I think that it was very important for program leaders to think carefully about that the first year fellows who started last July didn't know when they applied they didn't know that they were going to be in the midst of a pandemic. And so there was a different type of experience that they had being apart from their families sometimes unexpectedly compared to other fellowship classes. And we found that it was important to try to maintain social connections within the classes and also among the three classes as much as we could.

With regard to virtual instruction, the engagement and interactivity piece became even more critical. When you have in-person instruction, there's a natural flow and the natural dynamic to the learning that I think is conducive to fellows education. And when that piece was lost, it was important that we try to include as many interactive elements using small group sessions, using multidisciplinary sessions, to try to engage fellows in virtual platforms.

NINA BALANCHIVADZE: I believe that a pandemic did change our outlook on medicine. And general medicine as well as on our subspecialty training. A lot of us felt lost because some of the procedures were not being done. There was a feeling of, am I going to get enough instruction? Am I going to see enough procedures? And on the flip side, we've all felt that we have had acquired additional points in our training that was important for the future, such as triaging patients better. Which before pandemic, I would have never thought that a patient with cancer on cytotoxic chemotherapy can be seen virtually. And now we had to triage which patients were safe to be seen via televisit, and which patients had to come in.

We also honed on our skills on some of the basic general internal medicine issues. And I also think that having this experience and going through deployment opened our eyes to what is it like to be in the shoes of other specialists, such as hospitalists, and emergency room physicians, the infectious disease physician. So I think this period was important for team building. And it was important to further our respect for different subspecialists. So carrying that forward, I think, will be very important for me as a physician and as a specialist.

ANNIE IM: What has been the impact of the pandemic on your clinical training?

FARAH NASRATY: At my institution, we were relatively spared or fortunate in that they really didn't need a lot of us to come to the inpatient medicine and ICU services, which is different from some of the other colleagues on the call. But I think our biggest change, of course, was the move to telemedicine. I think we're all pretty adept with the internet and computer visits. And that wasn't really the challenge-- the visit itself. I think for me and my co-fellows, it was the loss of the interaction with our attendings that I think was tough.

Of course, the educational aspect changed a bit. You were looking up things by yourself. And reading articles by yourself versus doing that with your attending. But I think there's also the loss of that kind of casual back and forth with your attending about your interests, your career goals, maybe mentorship. And just those little pieces that you didn't really have necessarily when you weren't together in the office. Or the same conversations that were lost somewhat with your co-fellows. But I think just as we've all had to do with everything else related to COVID, we adapted to the online situation also.

And Dr. Bollin, Dr. Costantini, our program directors, they really made a point to have us carve out some time with our attendings to chat about our patients via email. Or to just call each other on the phone or text each other just to check in and talk. Kind of what we had done in the office. And it was kind of in a different format. But I think we were able to gain back that human interaction that we were all missing, and that we were all craving. So we really made an adjustment to using telemedicine, and to have it kind of be a positive for us at this point.

NINA BALANCHIVADZE: In addition, I think, as a first year fellow I was already struggling delivering bad news in person. And now I had to do that in a telemedicine setting was particularly challenging for me. And not having a senior attending physician right there with me made things even more challenging. So I think we all had to navigate. We all had to lean on our attending physicians on some advice. And learn from experiences.

And there were days where I would worry as I delivered bad news over the telephone who was with the patient, and how they were going to react with this news. And did they have the support system to take the news? So I think there was a lot of provider angst, and that really added a whole new dimension to the pandemic.

ANNIE IM: Doctors Bollin and Nasraty, your institution offers resiliency training. How does has that benefited trainees at your institution?

KATHERINE BOLLIN: So the genesis of our implementing the ASCO resiliency course actually came about after I attended the last in-person ASCO Annual Meeting in 2019. Along with experiencing all the wonderful things that we all experienced when we attend that conference with meeting with colleagues from around the globe to learning cutting edge data, et cetera, I also became acutely aware of a phenomenon that before I wasn't really alerted to, which was several of my colleagues were experiencing some pretty interesting signals or signs of burnout. So I became aware of these signals through some different interactions while I was there

I came home. Wrote an essay about it. And spoke about this phenomenon with my program director for the fellowship, Dr. Costantini. And she had actually become aware of the resiliency course as a pilot program. So I looked into that. Did some research. Spoke to folks and fellows that had participated in the pilot. And wondered if it was something that we could use at our institution as a proactive means to help people recognize signs of burnout, and address them during their early career and training phase.

So that's what we did. I brought in Dr. Nasraty and another one of our fellows to review the outline of the course, which addresses about eight different topics over eight weeks. And we tweaked it a little bit to their liking in ways that we felt could really address topics at hand that we see daily in the clinic. And then we brought in someone from outside of our institution who's a social worker that specializes in relationships. And ended up being a perfect match for leading this course with our fellows.

So we implemented this program actually before COVID. And we did pre-surveys, post-surveys, and then we've run the course now another couple of times since COVID. And have been able to look back over time, and see the response among fellows that have repeated the course and those that have been taking it for the first time. And so far, the data is showing us that one of the key takeaways from the course, is that people are much more aware now of the notion of self care and wellness, and the different tools that we can use to help us develop resiliency skills. And now all of us are acutely aware of the physician burnout pandemic since the COVID pandemic. This is something that I think as a tool for physicians in training has great value. And I'll let Dr. Nasraty speak to the specifics on what she and some of the other fellows have gleaned from this course.

FARAH NASRATY: So I have a couple different points. I'll start with the first one, I guess. I love our resiliency course. I've taken it a couple times since it started. And I think it's just such a special opportunity that we have. And I would encourage everyone, if they could have that opportunity, to develop their own unique to their program. But one of the things I'd mention is that our instructor had handed out a sheet on the foundations of mindfulness. Just basic concepts.

But I've actually since COVID and until this point today, I keep it in my desk within arm's reach. And so when I'm having a tough time, I always refer to that and just look through the sheet. And I think about what she's told me during our course. And a lot of other fellows do that too. We kind of text back and forth about it. So it's not a cure all to have these type of courses. It doesn't take away all stresses that you have in the clinic and at home. But it just creates almost a safety net that now you know what tools you have. And where you can get extra support.

And when I think about how it's benefited us as a group, I think from the fellow standpoint, the course really opened my eyes and our eyes to seeing that our peers experience the same struggles that we do. And I think that sounds pretty simple. But I think it's actually a really important point because I think in medicine everyone feels a sense that they always have to be the best version of themselves. And I know I feel that way. And even during COVID felt that way. And I think that's pretty unrealistic to always want to be the person who doesn't make any mistakes, and who doesn't second guess their clinical decisions.

And this course kind of opened my eyes to that. That working through the course, we kind of realize as a group that we might need to temper our expectations a bit. And that we need to allow ourselves some grace, especially during COVID. But even after that. And that we need to remind each other and uplift each other that we're doing a good job, and doing good by our patients. And I think we all experience challenges at work and at home during COVID. And in that protected space in our course, we could really discuss these concerns openly with each other, and provide honest feedback to each other. And I think we helped to support and encourage each other.

And I've personally left the course feeling inspired to continue to work on myself, and to continue to uplift my colleagues which I think is just as important. So it's been really beneficial to me.

ANNIE IM: Finally, I want to ask an important question as we move forward. Do you anticipate that any of the changes implemented to oncology fellowship training during the pandemic will continue in the post-pandemic era?

JONATHAN BERRY: So we've talked about telemedicine a good amount here. And I think that that is certainly something that is here to stay. I think thinking of telemedicine as an option for our patients just gives us such a wealth of opportunities to really provide patient centered care. I think as trainees and as oncology fellows it'll be imperative to learn how, as others have discussed, to triage patients and figure out who's appropriate for telemedicine and who's not.

But when you consider that so many cancer centers are in major urban centers, and patients may come from hours away to come see us, figuring out when we can spare them a long drive particularly if they may be nearing the end of their life or on hospice care and yet still be able to check in on them and provide the care we need to provide from a distance, I think is just such a wonderful and crucial tool. And so while we look forward to welcoming more and more of our patients back into our clinics again, seeing them in person, giving them hugs, celebrating the wins, I think we'll also continue to connect with them over the phone and over the computer for years to come.

NINA BALANCHIVADZE: In addition to incorporating some of the telemedicine visits in our everyday practice. I think teleconferences could stay, and would be welcome. I found myself attending more tumor boards, multidisciplinary tumor boards, because as I'm driving into work I'm able to listen in. And I find that there are a lot more conferences that I can actually attend virtually that I couldn't go to in person. Also, just echoing back to some of the resilience training, and of the things that we do now to learn about caring about ourselves as physicians. And our program, we are developing a position. And we are going to have a fellow who will be the Wellness Director.

So therefore, this fellow will be in charge of trying to help create some opportunities for fellows, and get togethers, and some social events for collaboration as well as promote wellness for all the fellows.

FARAH NASRATY: I just have one really short point to kind of reiterate what Jonathan said. But I would say that I don't anticipate telehealth to be my future practice every day all day. But I actually did enjoy somewhat getting to see patients in their home environments where they're comfortable. And there's something about them being with their dog, or their family, with their blanket, and kind of in their comfort space. Because they're always coming into our clinic into our sterile environment. And it's never as comfortable as being at home. And I like that part, and kind of learning a little bit about our patients just beyond what we're talking to them about in the clinic.

So I do hope that stays around. And especially, as Jonathan said, for our patients that are coming from hours away to give them this opportunity to have better access to health care I also think is really important. So I hope that sticks.

KATHERINE BOLLIN: Sure. One comment I was going to make. I think stemming from what we've experienced as physicians and training programs during the pandemic will be truly a lot more attention on physician well-being. So we think there will be a setting where we can implement resiliency courses across the board at institutions or similar kinds of programs to emphasize-- to put attention onto this need.

NISHIN BHADKAMKAR: I'm certainly hoping that we are able to maintain some of the initiatives and the lessons that we learned over the last year. I think as others have mentioned, I think the pandemic really forced us to think carefully about the incremental value of in-person interaction. Whether it's in the clinic or in educational activities. And I think we've learned that, yes, there is value with in-person interactions. But perhaps in some situations we overestimate what that value is. And we underestimate what the virtual platform allows us to do.

So in terms of conferences for example. As we've all turned to remote conferences, it's hard to say that the educational value of the conference has been diminished. I would say that there's a social element and a networking element to conferences that certainly can't be reproduced virtually. But I think that the ASCO Annual Meeting and the subspecialty meetings are a great example of how we've been able to maintain that educational component for trainees, faculty, and others in the midst of restrictions on in-person activity.

ANNIE IM: That's all the time we have for today. I want to thank you all so much for joining us. It will be really important for our community moving forward to continue to share our best practices as we move into this post-pandemic training era. I want to thank all of our wonderful guest speakers for sharing your experiences with us today, and for participating in this episode of the ASCO Education Podcast.

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