Introduction
The challenges posed by the COVID-19 pandemic reshaped the landscape of pulmonary and critical care (PCCM) fellowship training. PCCM trainees were unique because, as a group, they experienced higher rates of depression, distress, and burnout before the pandemic.1 During the pandemic, they were at the forefront of the response. They cared for sicker hospitalized patients for extended periods, facing a greater risk of exposure, a more significant workload, and moral dilemmas while dealing with a continuously changing clinical practice environment. These changes had a substantial impact on the roles, learning experiences, and well-being of PCCM fellows. Prior studies2–10 investigated the effects of COVID-19 on medical education and well-being; however, few studies have examined the impact on PCCM fellows. For example, Xia et al11 surveyed interventional radiology (IR) programs and concluded that the COVID-19 pandemic had a significant adverse effect on IR training and employment. However, these conclusions may not apply to PCCM. Additionally, most studies consisted of surveys,1,4,12,13 while these provided significant findings, questionnaires cannot delve deeply into perspectives and experiences. Moreover, few studies examined the effects of the pandemic from the perspective of the fellowship director (FD), information that could convey fundamental implications for training and education.
We conducted a quality improvement study to investigate the impact of the pandemic on various aspects of training for PCCM fellows from 2020 to 2021. We sought to understand trainees’ perceptions of both educational and operational factors, as well as their well-being, during the pandemic. We aimed to gain insight into how to support the learning and resilience of trainees in the event of a future pandemic.
Methods
As a quality improvement initiative whose intent was to collect aggregate anonymous data, the Syracuse VA Institutional Review Board exempted this study from full review. Nonetheless, all participants were informed about the purpose of the study and verbal informed consent was acceptable and approved by the IRB. The consent included publication of anonymized responses and direct quotes.
Setting
This research was conducted within an academic university-based PCCM fellowship program, where trainees undergo rotations at three hospitals: a university hospital, a Veterans Affairs (VA) facility, and a private community hospital. Rotations include pulmonary consultative services, outpatient clinics, procedures, and medical intensive care units (ICUs). The university and VA hospitals have a closed medical ICU model, whereas the community hospital maintains an open model. One fellow covers the university and private MICUs at night, while another covers the VA hospital. Notably, all three hospitals are situated within walking distance of one another.
Fourteen PCCM fellows from 2020–2021 participated in the study. Data collection started in January 2022. The analysis began in January 2023 and completed in December 2023.
Online Survey
We developed a handwritten pilot questionnaire and sent it to four fellows not involved in the study to assess the questionnaire before its full deployment. This pretesting identified issues with the questionnaire’s clarity, flow, and length, ensuring more accurate and reliable data. Through an iterative process, questions were refined. We then sent an electronic survey to PCCM fellows from 2020 to 2021 (supplementary material). Data were collected and managed using the REDCap electronic data capture tool hosted at SUNY Upstate Medical University. We collected demographics and included questions about program preparedness, satisfaction, communication, rotational changes, and education, which were assessed using yes-and-no questions, a Likert scale, multiple-choice questions, and semi-open-ended questions. No participant was identified in person, and the data are presented as aggregates. We used data from the electronic survey to inform our planning of questions for the interviews.
Qualitative Interviews
We used results from the electronic survey to formulate interview questions. We used pretested questions on four fellows, who provided feedback on the questions, process, and overall flow of the interview. We used these suggestions to modify the interview. We interviewed the fourteen participants whose training coincided with the 2020–2021 COVID-19 pandemic. To gain insight into the program’s perspective, we also interviewed the fellowship director.
Participants were informed that their responses would be anonymous, and trainees were allowed to withhold their PGY level or graduation date if they chose to do so. To minimize researcher bias, permission was obtained from the interviewees to record verbatim, anonymized written notes. Interviews were conducted over the phone.
Following published methods in qualitative research, we used a thematic analysis approach to analyze the data.14
Results
Online Survey
The mean age of the fellows was 35.5 ± 3.7 years, and 54% of the fellows had at least one child. The vast majority (92%) of the fellows expressed concern about spreading COVID-19 to their families, and 46% said that their personal lives were somewhat affected, while 38% reported that it was significantly affected. Due to the pandemic, 23% of fellows reported increased work hours. Additionally, 70% of fellows noted significant changes in their rotations, primarily in critical care rotations (77%), and over half (54%) believed these changes were voluntary. Over three-quarters (76%) of fellows felt that their education was impacted by the cancellation of conferences (77%) and remote learning (61%). All the fellows perceived a reduction in non-COVID procedures such as endobronchial ultrasound (EBUS). Although 100% of fellows felt they had adequate support from their program, 61% thought that support from other in-house residency/fellowship programs required improvement.
Thirty-one percent of fellows believed that the hospital was overwhelmed, 23% thought it was unprepared for the pandemic, while only 15% felt it was adequately prepared. Interestingly, 92% of the fellows did not believe that the program placed them at unnecessary risk for COVID-19 exposure, and 31% stated that one or more of their et.al tested positive for COVID-19. The overall fellowship experience was rated as “Very Good” by 31%, “Good” by 31%, and “Poor” by 8%. 58% of fellows were satisfied, 33% were very satisfied, and remarkably, none were dissatisfied with the program.
Semi-Structured Interviews
All trainees were comfortable providing their grade or graduation year despite being allowed to withhold this information.
We analyzed the interviews thematically following the approach initially described by Braun and Clarke14 and used by others15,16 Each interview was read and re-read closely by the authors independently so they would become familiar with the material and identify key patterns of meaning within and across transcripts. Similar findings were then grouped to form the initial codes. Using coded excerpts from each of the interviews, broader codes were interpretively analyzed and merged to form early themes. The merged codes and early themes were then re-examined in the context of the previously coded excerpts. Further refining led to the development of the following themes: emotional burden and physical demand, Loneliness and camaraderie, and Education. During this process, the authors met regularly to discuss progress and agree on the final themes. We describe the key themes and findings (Table 1).
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Table 1 Themes, Subthemes, Codes, and Related Quotations from Trainees
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Emotional Burden and Physical Demand
The need for a dedicated space became paramount for PCCM fellows during the pandemic, especially at the University Hospital. The fellow room emerged as the only area where fellows could be without personal protective equipment (PPE) and were able to take much-needed breaks, including lunch. Wearing PPE for extended periods in the ICU produced physical discomfort with skin tears and challenges navigating the hospital floors. Due to the critical condition of patients, fellows often had to be in the ICU for prolonged periods. The only permissible space to remove PPE was the fellows’ room since fellows hesitated to do so in shared break areas with nursing staff and other ICU staff, fearing potential COVID-19 transmission.
The small size of the break room had not been a concern previously. The size was amplified during the pandemic due to greater demand for space during the crisis. With many shifts spent in the ICU, fellows required more space for breaks and respite. Personal space became indispensable for the trainees working nights, as they needed access to their call rooms. Acknowledging these concerns, the hospital’s leadership responded by providing fellows with a larger break room. This adjustment demonstrated a commitment to addressing the unique challenges faced by the PCCM fellows during the pandemic, offering them a safer and more accommodating environment amidst the demanding circumstances they encountered daily.
The interviews revealed that a sense of instability and uncertainty prevailed, making it crucial for PCCM trainees to find safety and support. Initially, all fellows were concerned about the risk of infection. Uncertainty prevailed regarding the availability of PPE and the contagious nature of COVID-19. The anxiety extended beyond the workplace, with fears about spouses and children contracting the virus, amplifying the emotional burden on trainees. One fellow, grappling with the added concern for his pregnant wife, implemented strict precautions. He would change clothes before heading home, leave spare garments in the car, refrain from bringing work shoes indoors, and immediately shower upon arrival at his house. His wife gave birth three months later without complications. As protocols and understanding of the virus evolved, the anxiety about contracting COVID-19 decreased. It became clear that wearing a gown, gloves, and a mask provided adequate protection, gradually easing concerns among the trainees.
The emotional burden of coping with the substantial number of ICU deaths and the challenging and often distressing nature of dealing with the high mortality rate weighed heavily on the well-being of the trainees. Discussions about these distressing events became commonplace among the trainees—these involved conversations with peers, attendings, and family members. Witnessing numerous patients succumb to COVID-19 added a profound and challenging aspect to their professional experiences, contributing to the overall emotional toll. One trainee who grew up in Nepal likened the death toll in the ICU to the aftermath of an earthquake in Nepal, describing a scene of widespread loss: “There were people dying everywhere, and I have not seen so many people die before.”
Although palliative care services were available, they had little impact on alleviating the emotional strain. The fellows informed family members and discussed patients’ status, a responsibility shouldered neither by residents nor attendings. Family meetings often took place over the phone rather than in person, further complicating the challenge. Face-to-face visits were prohibited, and families were denied the opportunity to see their loved ones, making it challenging to understand the gravity of their family member’s condition. Establishing a personal connection with families was necessary but gruelling for the fellows. The lack of eye contact and facial expressions hindered meaningful interactions. Family meetings had become routine, with one trainee expressing, “It had become so routine that it felt like a cold call, and I had to get it done because I had 5–10 more families to call that day.” The impersonal nature of the communication exacerbated the emotional toll.
Another source of frustration for the PCCM fellows stemmed from the need to intubate numerous patients. The initial apprehension surrounding the aerosolization of the COVID-19 virus led to sparse use of non-invasive ventilation and high-flow nasal oxygen. This precautionary measure, while understandable, placed an additional burden on the trainees. There were many patients on ventilators, demanding heightened care, additional central lines, the use of sedatives, and numerous ventilator weaning trials. The physical exhaustion of the trainees was compounded by the lingering question of whether non-invasive ventilation might have sufficed in some. This uncertainty fueled the frustration as the fellows grappled with concerns about potentially harming their patients. This dilemma of whether they were doing more harm than good weighed heavily on their minds, highlighting the challenging ethical and medical decisions.
Loneliness and Camaraderie
The trainees experienced a paradoxical sense of loneliness and camaraderie in the ICU. They felt a profound loneliness while managing many critically ill patients, particularly during night shifts. One fellow highlighted the challenge of overseeing 50 patients at the academic hospital and an additional 50 at the private hospital, creating the impossible situation of being in two places at once. The trainees faced an added challenge during the pandemic as attendings took calls from home. The fellows were left with a profound sense of isolation, particularly when managing many patients during the night shift, as fellows navigated the complexities of patient care in an overwhelming environment.
Furthermore, PCCM trainees felt isolated and requested added support from the other subspecialties. While the cardiac ICU and surgical ICUs were filled with COVID patients, assistance from these specialties was erratic. Surgical residents occasionally assisted in central line placements, but cardiology fellows, not trained in critical care medicine, were less inclined to help. In one instance, a cardiology fellow declined to address an issue with a pacemaker for a COVID-19 patient, accentuating the PCCM trainees’ belief of insufficient collaboration. Despite these challenges, the PCCM fellows found support from anesthesia services for intubations and ENT for tracheostomies, highlighting a mixed experience of cooperation and isolation.
On the other hand, the loneliness experienced by the PCCM fellows during the pandemic fostered a deep sense of camaraderie. One fellow described it as “brothers and sisters in the trenches”, emphasizing that only other PCCM fellows understood their challenges. This shared experience forged a strong bond among the trainees. In a spirit of mutual support, the trainees extended helping hands to one another. Whether using the elective time to assist in the critical care unit or rearranging schedules to accommodate individual needs, they recognized the value of solidarity, acknowledging that they were in the “same boat.” Sensitivity to a fellow who was pregnant led to prioritizing outpatient telemedicine appointments and rearranging her ICU rotations to suit her circumstances better. However, there were also mixed feelings about this arrangement due to the added workload.
Despite the demanding circumstances, the trainees found solace in their faculty and fellowship director. They perceived their PCCM program as supportive, further contributing to a sense of unity and shared purpose.
Education
Given the overwhelming patient load in the ICU, it became an “all hands-on deck” situation, leading to a shift in most pulmonary rotations towards critical care. In response to the escalating demand at the university hospital, a third ICU was established as a step-down unit. Interestingly, the fellow in charge of this unit was also the pulmonary fellow responsible for inpatient pulmonary consults. Pulmonary medicine advice was sought in the medicine wards for COVID-19 patients. Fellows became frustrated as they dealt with the increased workload and were often consulted on ward patients with COVID-19. Even the emergence of treatment regimens such as remdesivir and steroids did not decrease the number of consults. Fellows considered these pulmonary consults unnecessary, as they added to their workload without providing educational benefits. One trainee even declined such consults, expressing to the attending physician in medicine, “I possess the same knowledge as you about COVID; why are these consults being requested?”
The first- and second-year fellows perceived a decline in the quality of their pulmonary education, as all pulmonary outpatient experiences and procedures were initially cancelled. On the other hand, the third-year fellows were adept at handling pulmonary issues and even engaged in board reviews.
The fellows were especially concerned about endobronchial ultrasound (EBUS) procedures, as these needed an additional set of skills for proficiency. EBUS appointments gradually resumed, but only for patients with cancer. By the end of the pandemic, fellows believed they could make up for lost ground in terms of pulmonary procedures.
Conversely, PCCM fellows became adept at treating acute respiratory distress syndrome, managing ventilators, and administering sedative and paralytic agents. They became experts in critical care procedures, including the placement of central lines, arterial lines, dialysis catheters, chest tubes, and intubation. One fellow even remarked, “There was an abundance of critical care procedures; we are doing so many.” Yet, another third-year fellow, now an attending, observed that certain aspects of critical care training had suffered. He noted: “Some fellows struggled with managing diabetic ketoacidosis, a condition that was once considered a straightforward critical care case.” Cancelling all trainees’ electives in areas such as transplant, radiology, and rotations in neurology and cardiac ICUs intensified the challenges of obtaining a comprehensive critical care education.
Lectures eventually resumed virtually, departing from the previous in-person sessions. Trainees were allocated a protected time between 7 and 8 am to attend such seminars. However, even virtual lectures were challenging for fellows assigned to the ICU. Despite the designated protected time, the high ICU patient load during the pandemic demanded extensive chart review and round preparation. This workload made it difficult for the ICU fellow to participate fully in the virtual lectures. While the trainees appreciated the convenience of the virtual format during the pandemic, allowing them to multitask and manage their time efficiently, it came at the expense of their ability to remain fully engaged in the lecture. The shift to virtual lectures resulted in the loss of more than just educational content; it meant the absence of personal contact and connections. Beyond the formal learning environment, the trainees missed the opportunity to interact with one another. The sense of camaraderie and shared experiences that typically accompany in-person interactions was perceived as a loss during this period of virtual learning.
Fellowship Director (FD) Perspective
We interviewed the FD for her perspective on the fellows’ concerns and how she managed the program during the COVID-19 pandemic. This was a single interview without thematic analysis; the results are presented in Table 2.
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Table 2 Themes, Subthemes, Codes, and Related Quotations from Fellowship Director
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The three main issues discussed that fellows discussed with the FD were: 1] The fear of contracting COVID-19 at the onset of the pandemic and the adequacy of PPE, 2] Concerns regarding their mental well-being and exhaustion due to the increasing demands in the ICU, and 3] Frustration with the overbearing workload since they shouldered most of the responsibility for managing critically ill patients without assistance from other services.
The FD made earnest efforts to address their concerns. The department convened ZOOM meetings three times a week to disseminate information about COVID-19, share treatment protocols, and, crucially, provide a platform for the fellows to voice their frustrations. The fellowship schedule was adjusted to alleviate the burden on the medical ICU fellow. Since electives were cancelled, fellows helped in the ICU or served as backup for the medical ICU. While the ICU schedule remained from 7 am to 7 pm, a third medical ICU opened to accommodate more stable, critically ill patients with the goal of reducing the census of the other two ICUs from 25–30 patients each, to fewer than 20 patients.
Managing the private hospital ICU and two medical ICUs in the academic hospital became overwhelming for the night fellow whose duties were changed to focus on the university ICU. An attending was required to manage the private hospital’s patients at night. Further efforts were made to enlist the assistance of surgical residents and fellows for procedures at night, but their participation was inconsistent. The FD became the fellows’ liaison with hospital leadership to secure additional support from other specialties, but encountered resistance. The FD noted that leadership “expressed concerns about diverting resources to the medical ICU as they were already stretched thin covering their services.”
All educational activities were suspended in the first two months of the pandemic, and conferences gradually resumed via Zoom. Much of the focus was on COVID-related topics, with presentations dedicated to sharing insights from other institutions to ensure alignment of practices. Lectures explored emerging data on proning and the use of airway pressure release ventilation.
When discussing the challenges of managing a fellowship program during the pandemic, the FD admitted feeling “very stressed out” due to the fellows’ discontent, which was vocalized to the FD in private and occasionally during the Zoom meetings. Disgruntlement arose following the decision to have third-year fellows assist in the ICU. Several fellows expressed frustration, feeling “they had paid their dues.” Nevertheless, their expertise was needed to support the MICU and mentor junior fellows. Resentment ensued when a pregnant fellow was reassigned from all MICU rotations to clinics. The PD noted that third-year fellows were more likely to express discontent than first- and second-year fellows.
Despite the tensions, the FD believed that the trainees displayed remarkable unity and resilience in navigating the pandemic and showed maturity in overcoming obstacles. Their collective efforts were essential for the hospital’s functioning, with the FD emphasizing that “the housestaff and fellows played indispensable roles.”
Discussion
This qualitative study delved into the multifaceted challenges faced by PCCM trainees during the COVID-19 pandemic. Through interviews, we provided a platform for reflection, enabling trainees to navigate and understand their experiences in depth. Three themes emerged: the pandemic’s emotional and physical toll, feelings of isolation fostering camaraderie among PCCM fellows, and how the pandemic influenced their education.
PCCM trainees prioritized fulfilling their physiological and safety needs before all others. Establishing a suitable rest area was crucial. At the onset of the pandemic, it became apparent that the existing break room was insufficient. In response, the facility expanded the workroom, providing additional workstations, food storage, and a dedicated call room for PCCM fellows.
Amidst the physical strain of the pandemic, the emotional toll was a recurrent topic. Given the frequency of encounters with death and critically ill patients, fellows sought outlets to manage their stress. Regular Zoom meetings provided a platform for trainees to express their frustration and afforded opportunities for reflection and debriefing. The presence of palliative care services did not alleviate the stress of dealing with very ill patients and their families. PCCM initiated and oversaw the vast majority of end of life discussions.
While fellows found solace in the support of their peers and the FD, there was a consistent call for additional support beyond their immediate circle. Many expressed a desire to recruit trainees from other specialties to share the burden of ICU responsibilities. This might have distributed the workload and alleviated the emotional strain experienced by PCCM fellows.
Other studies reported high levels of stress, increased workload, anxiety and fear of transmitting COVID-19 to family members, especially in the early phases of the pandemic.2,12,17–20 Our data contribute to the existing literature and offer additional insight. For example, the emotional toll of initiating and clarifying goals of care, the anger over scant support from other services, and importance to the rest area. A qualitative study21 using the appreciative inquiry technique in a UK tertiary medical center identified four themes: feeling safe, physical needs, emotional burden, and self-fulfillment. While these results were similar to ours, that study did not delve into the educational experience in detail.
The issues raised by PCCM fellows, whether positive or negative, align with Maslow’s hierarchy of needs.8,11,12,18,20–22 This motivational theory is consistent with a five-tier model of human needs, including physiological, safety, love and belonging, esteem, and self-actualization. Maslow’s theory suggests that fundamental needs, including physical well-being and safety, must be fulfilled before individuals can progress to higher-level needs, such as love and camaraderie, ultimately leading to self-confidence and self-actualization, including job satisfaction.
The enduring challenges stemming from the COVID-19 pandemic profoundly disrupted graduate medical education.6,7,12,18,20,22 A prior study concluded that the COVID-19 pandemic affected training, but its consequences were unevenly distributed across program types and regions of the country.12 In this study, we concentrate only on one program and one specialty. Our trainees overwhelmingly favored in-person lectures over virtual platforms, raising concerns about the efficacy of this mode of instruction. While fellows developed proficiency in critical care, there was a genuine apprehension regarding the adequacy of pulmonary education. Similarly, other studies found that certain limitations in training were temporary and improved in the latter stages of the pandemic.23 Research indicates that the pandemic has significantly influenced trainees’ perceptions of their education and sense of purpose in their work, directly affecting their overall well-being.2,8,10–13,17,19,20,22,24–27 Our study corroborates these findings and emphasizes the importance of addressing the broader implications of the pandemic on trainee education and professional fulfillment.
Even though there were conflicts and discontent amongst the PCCM fellows, the FD corroborated the subjective experience of the fellows, including the lack of support from other services. Meetings with the FD were frank and open with the fellows regarding the FD as fixer, advisor, arbitrator and point of contact.
Limitations and Strengths
This study was conducted at a single center, and the results may not be generalizable to other institutions. Our study included 14 participants, admittedly a sample of convenience. Yet, it was an exploratory study focusing on the lived experience of a homogenous group -fellows in the same speciality and program-. This type of study requires a small number of participants.14,28–30 We iteratively reviewed and refined data ensuring that no new patterns emerged. Thus, interviewing more fellows is unlikely to yield additional information.29,30 With its limitations, a notable strength of the study lies in our methodology. We provided a platform for trainees to engage in reflective practices, offering them a safe space to explore and gain deeper insights into the challenges they faced during a difficult period. Our findings contribute to previous research by acknowledging the importance of deliberative, reflective practice in fostering new perspectives and catalyzing change. The lessons derived from reflection are significant for organizational improvement.
Conclusions
While there was discontent amongst PCCM fellows in our program, our study found that the fellows valued the program’s communication efforts in keeping them informed and confided in the FD. In these stressful times, the fellows did not consult mental health services and relied on each other, some attendings and the FD. Most fellows were concerned about the lack of support from other services. Conflict amongst fellows arose when ICU rotations were added to the third year fellows’ schedule and when a pregnant fellow could not work in the ICU. While it was not possible to resolve these issues, the situation was improved by focusing on de-escalation and providing empathy. Our study implies that a place for rest is of utmost importance to a fellowship program and virtual lectures caused a loss of personal contact and connections with fellows much favoring in-person sessions. Overall, fellows became quite proficient in critical care, and while they were initially concerned about the pulmonary aspect, most felt they could compensate for the content.
Disclosure
The authors report no conflicts of interest in this work.
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