How did the Fellowship Program Respond to COVID-19?
The COVID-19 pandemic really forced all of us to consider returning to our guiding principles. When making the following policy and procedural changes, our fellowship program thoughtfully considered the following guiding principles:
We believe strongly that fellows should be doing procedures or clinical rotations with utmost safety considerations. We carefully considered how fellows would take care of patients with COVID-19 or persons under investigation (PUIs). We wanted to balance fellow physical safety and mental well-being, as well as concerns about availability of personal protective equipment (PPE). We wanted to ensure adequate procedural education, and also minimize risk to fellows, and preserve the principle that the most experienced provider should do the majority of procedures.
Given these considerations, during different rotations, we thoughtfully made policies that we iteratively revised with fellow and faculty feedback to decide how fellows would staff rotations and be involved in procedural training. Since these policies are constantly changing with the caseload in San Francisco, we made detailed surge planning.
We wanted to come up with a “deep bench” of fellows and faculty to be on standby in case of a big surge in San Francisco. Our fellows and faculty generously volunteered to be in a robust jeopardy system, thereby ensuring that nobody would feel concerned about workload. We wanted to thoughtfully ensure safe staffing as well as “right staffing” – where we would flex up or flex down fellows on rotations appropriately.
For example, we saw a large number of cases at our ZSFG MICU, necessitating creation of a new COVID MICU rotation, staffed by separate faculty and fellows, and adding in-house night coverage. We asked for volunteers to staff this unit, and F2s and F3s volunteered to work here. Once the case load declined, we carefully de-escalated the staffing to ensure adequate fellow numbers and preserve fellow autonomy without being overstaffed.
We realize that fellows may have a number of reasons why taking care of COVID-19 patients may not be within their goals. For example, fellows or their families may have pre-existing conditions, and we wanted to be sensitive to these issues. For that reason, no fellow was mandated to work with COVID-19 patients, we had a generous opt-out policy with “no questions asked” and a robust jeopardy back-up system. Fellows did not have to disclose the reason why they did not want to work with this patient population.
During the pandemic, we realized that fellows’ well-being would definitely be impacted, since fellows and faculty are truly on the front-line working in ICUs and pulmonary consults. Therefore, we wanted to be keenly aware of fellows’ wellbeing. We started regular fellow Zoom happy hours with program leadership to check in on how fellows were doing. We continued our leadership ‘open-door policy’ and invited fellows to schedule Zoom check-ins one-on-one with us anytime. We proactively reached out to fellows to check in on the busier rotations.
COVID-Related Curricular Changes
During the pandemic, we wanted to preserve fellow education and a sense of community. We converted our existing Monday clinical case conference to a community COVID-19 discussion. The first hour, our Divisional leadership discussed clinical and policy updates in the Division. This included sessions such as: brainstorming how to safely reopen clinics, hearing from colleagues who had volunteered in NYC, discussing clinical trajectories of our cohorts of COVID-19 patients, etc. The second hour of the conference was dedicated to COVID-19 related research updates. We had “flash talks” by investigators who had pivoted to COVID related research activities, and had Division-wide brainstorming for collaborations to ensure avoiding redundancy.
Our other existing educational conferences continued seamless, all virtually. For example, pre-clinic conference, interstitial lung disease conference, Fellow Friday conference, and journal clubs, all continued via Zoom. Our fellows rotating in critical care created a new COVID-19 journal club didactic curriculum with guest speakers. The critical care conferences also all continued via Zoom.
Our continuity clinics continued uninterrupted with almost complete conversion to remote Telehealth. We did fully virtual precepting, where patients, fellows, and faculty preceptors all logged into Zoom from their homes to ensure social distancing and avoid incurring any unnecessary risks. Clinic patients thus were able to access uninterrupted care and were satisfied with the experience.
Policy & Clinical Rotation Changes
Given the temporary closure of our pulmonary function lab during the pandemic, our PFT fellow was redeployed to the ZSFG COVID MICU. Given the temporary halting of elective surgeries, our OR fellow was redeployed to a novel interventional pulmonary rotation. Rotation needs are continually assessed to enable ongoing fellow education and preservation of fellow safety.
UCSF Fellowship Program operated in agreement with other national policies by the ACGME. For example, our in-service exam was converted to a virtual remotely proctored exam. Our ACGME survey this year was deferred per national guidelines. Our Clinical Competency Committee met virtually and discussed graduating fellows.
We worked with fellows to ensure ongoing research-related productivity. We followed university policy of social distancing to enable all fellows to work remotely from home. We assisted fellows with getting more technology to help improve their access to clinical telework as well as research telework. We helped provide funds for new monitor set-ups, headphones, etc. We helped fellows use funding from canceled conferences toward other educational and research-related activities.
Our faculty Dr. Maya Kotas, Dr. Michael Peters, Dr. Michelle Yu, Dr. Michael Lipnick, Dr. Michael Podolsky, Dr. John Metcalfe traveled to COVID-19 hotspots in New York and Navajo Nation to volunteer their efforts as they were much more heavily impacted than San Francisco. While they were gone, our Divisions sent them care packages and moral support. On their return, they spoke at multiple conferences to share lessons learned from their experience.