Lessons Learned From the Effects of COVID-19 on the Training and Education Workflow of Radiology Residents—A Time for Reflection: Perspectives of Residency Program Directors and Residents in Canada

Abstract

French

Purpose:

The coronavirus disease 2019 (COVID-19) pandemic has led to widespread changes in all health care settings including academic radiology departments. The purpose of this survey-based study was to investigate the impact of COVID-19 on radiology resident training and education workflow in Canada in terms of the nature, scale, and heterogeneity of the changes, preparedness and adaptation, and perceptions of the present and future of radiology training.

Methods:

A 30-question web-based survey was sent to 17 radiology residency program directors across Canada. A separate 32-question survey was sent to 460 residents currently enrolled in a radiology residency in Canada. These surveys were open for 3 weeks.

Results:

We received responses from 16 program directors and 80 residents (response rates 94.1% and 17.4%, respectively). Most respondents agreed that objectives were being met for knowledge and interpretation but less so for case volumes and technical skills. Less time was allotted for on-site activities (eg, readouts) with more time for off-site activities (eg, videoconferencing). Daytime rotations were at least partly cancelled. Most respondents felt these changes were met with enthusiasm by both faculty and residents. However, there were perceived challenges including lack of training on virtual platforms for delivery of teaching and decreased staff–resident interaction, with short- and long-term anxiety reported.

Conclusions:

The coronavirus disease 2019 has dramatically changed radiology resident training in Canada, with increased virtual learning at the expense of cancelled rotations and the resultant reduction in case volumes and staff–resident interaction. Although adopted with enthusiasm, these changes present substantial challenges and anxiety regarding the future of radiology resident education.

Keywords

COVID-19 internship and residency surveys and questionnaires radiology distance education

Introduction

The coronavirus disease 2019 (COVID-19) was declared pandemic by the World Health Organization on March 11, 2020. This declaration was accompanied by advice regarding personal protection, including physical distancing, leading to dramatic and widespread changes in the workflow in all health care settings including academic radiology departments.^1
-3 The changes included curtailment of on-site clinical and educational activities, heightened digital delivery of clinical and educational activities, redeployment of staffing to areas of need, and increased attention to social isolation and mental health issues.⁴ Every radiology residency program is dealing with the downstream effects of the changes in different ways.^5
-7

We conducted a survey to investigate the scale and heterogeneity of the impact of COVID-19 on radiology resident training in Canada during the reintegration phase. It was conducted at a time when the number of cases had declined and lockdown measures had been lifted in most of Canada. Most of the residency programs had integrated fully in the radiology departments. A similar survey was conducted earlier on in the pandemic in a previous study.⁸ Our survey was conducted during the calmer reflective phase rather than the reactive disorienting phase of the pandemic, giving respondents the opportunity to reflect on the outcomes of the response to the crisis.

We aimed at understanding the perspective of 2 major stakeholders in the residency program, the program directors (PDs) and the residents. The leadership of PDs is crucial for the successful transition of residency programs into a “new normal.” The high response rate among PDs bears testimony to their commitment and many expressed an interest in the outcomes of the survey. Working towards a common goal and incorporating perspectives of both PDs and residents are crucial for the success of the residency program. This survey aimed to identify the common perspectives and explore any differences in the outlook as it may influence the recovery strategies.

Methods

The project was approved by our institutional research ethics board. Two separate English-language web-based surveys were designed on the SurveyMonkey (SVMK Inc.) platform, the first targeting PDs and the second targeting residents, comprising 30 and 32 questions, respectively (Online Appendix 1 and 2).

The design of the survey was based on the best available information consisting mostly of commentaries and expert opinion as there was no available validated radiology questionnaire on the subject at the time. The surveys underwent 3 revisions following review by 3 senior colleagues actively involved in radiology education and pilot testing with chief and senior residents at our institution.

The PD-specific survey was sent via email to the PDs of all accredited residency programs across Canada, with subsequent distribution by the PDs of the separate resident-specific survey via email to all residents within each program. The surveys remained open for 3 weeks, until July 12, 2020, during which time 2 reminders were sent. Only 1 response per computer IP address was allowed. Voluntary and anonymous consent to participate in the study was obtained.

The primary outcomes of the survey were achievement of training objectives, educational adaptation, safety measures, communication during COVID, and well-being and anxiety related to the situation from the perspective of the residents and PDs. The responses were tabulated and plotted in Microsoft Excel following the end-date of the survey.

Results

Demographics

A total of 16 PD responses (response rate 94.1%, 11/16 finished the entire survey) and 78 resident responses (response rate 17.0%, 47/78 finished the entire survey) were received. The representation of different resident levels of training ranged from 12% for Postgraduate Year 1 (PGY1) to 28% (PGY5) (Table 1). In total, 71% of the residents were male, and 95% were enrolled in English-speaking residency programs.

Table 1.

Demographics.

Residents	n (%)
Gender
Male	55 (70.5%)
Female	20 (25.6%)
Other/choose not to answer	3 (3.8%)
PGY
1	9 (11.5%)
2	11 (14.1%)
3	18 (23.1%)
4	18 (23.1%)
5	22 (28.2%)
Language of residency program
English	74 (94.9%)
French	4 (5.1%)
PDs	n (%)
Number of residents in program
Less than 30	6 (37.5%)
30-39	6 (37.5%)
40-59	2 (12.5%)
60 or more	2 (12.5%)
Language of residency program
English	15 (93.8%)
French	1 (6.2%)

Abbreviations: PD, program director; PGY, postgraduate year.

Meeting Training Objectives

Among the different domains of radiological expertise, most residents agreed that objectives were being met for knowledge base and interpretation (median “moderately agree” and “mildly agree,” respectively), with fewer agreeing objectives were being met for volume of cases and technical skills (median “mildly disagree” for both; Figure 1). Program director responses demonstrated a similar trend. With regard to the various CanMEDS roles, PDs tended to report more opportunities for leadership and professional roles than residents (Online Supplemental Figure A.1).

Educational Methods

Residents tended to report less total educational time spent on in-hospital activities during COVID compared to before. The proportion of residents reporting greater than a quarter of their time given to on-site didactic teaching was 5.3% during COVID versus 46.6% before; similarly, 24.6% versus 77.2% for readouts and 15.8% versus 57.1% for technical skills (Online Supplemental Figure A.2).

Residents tended to report greater time dedicated to virtual didactic teaching and independent study during COVID (66.7% during vs 7.0% before and 51.8% vs 28.6%, respectively) with a similar trend among PDs.

Residents tended to report more video conferenced and recorded lectures during COVID compared to before (55.8% vs 23.1% and 88.4% vs 13.5%, respectively) with a similar trend among PDs (Online Supplemental Figure A.3). The 3 most common platforms for videoconferencing were Zoom (89.6% of residents and 83.3% of PDs), Microsoft Teams (60.4% of residents and 50% of PDs), and Webex (47.9% of residents and 50% of PDs) (Online Supplemental Figure A.4).

Audience participation in teaching rounds was most commonly encouraged by asking a volunteer to take a case or answer a question (83.7% of residents and 83.3% of PDs) or directing a question specifically to a named student (75.5% of residents and 66.7% of PDs), similar to before COVID. Quizzes/polls and games were more commonly reported by PDs than residents during COVID (75% of PDs vs 46.9% of residents) (Online Supplemental Figure A.5). The majority of residents reported higher attendance for synchronous activities during COVID compared to before (58% reported “much more than” or “more than”) (Online Supplemental Figure A.6), as did 50% of PDs.

Safety Measures

A total of 58.3% of residents reported the cancellation of all clinical rotations compared to only 9.1% of PDs (Figure 2). Daytime clinical rotations were most commonly reported to be cancelled with supplementation with off-site live didactic teaching (59.6% of residents and 27.3% of PDs). In total, 45.5% of PDs reported supervised remote Picture Archiving and Communication System readouts are used, compared to only 10.4% of residents (Online Supplemental Figure A.8). Only 3 residents (6.4%) and 1 PD (9.1%) reported redeployment to nonradiology rotations.

Respondents most commonly reported that case volumes will be resumed when routine clinical activity recommences (52.1% of residents and 54.5% of PDs) or that volumes have been substituted with didactic teaching sessions (35.4% of residents and 45.5% of PDs; Online Supplemental Figure A.9).

None of the residents or PDs reported cancellation of on-call duties.

Response to Change

The majority of respondents felt that the radiology faculty have adopted changes with enthusiasm (resident median “moderately agree,” and PD median “mildly agree”). Likewise, the majority of residents and PDs felt that the residents have adopted changes with enthusiasm (median “moderately agree” for both). Among the residents themselves, however, there was a divide on whether they liked the changes; 51.1% agreed (at least mildly), whereas 17.8% were not sure and 31.1% disagreed (at least mildly).

Communication

Both residents and PDs commonly reported implementing regular virtual huddles during COVID, 84.4% and 81.8%, respectively, compared to only 15.6% and 9.1%, respectively before COVID (Online Supplemental Figure A.12). Accordingly, regular face-to-face interaction tended to be reported less during COVID (4.4% during vs 71.1% before, according to residents).

While the majority (81.8%) of PDs reported being in communication 100% of the working week and weekends if necessary, only 29.8% of residents reported the same (Figure 3). Furthermore, none of the PDs reported being in communication less than 25% of the working week, compared to 27.7% of residents.

Well-Being

Multiple well-being resources were available to residents during COVID, with university resources the most commonly reported (90.9% of residents and 100% of PDs; Figure 4). Across all categories of wellness resources, more PDs reported availability during COVID relative to before, whereas fewer residents reported availability during COVID relative to before.

Challenges

The most commonly reported challenge resulting from the changes to educational workflow was lack of training for faculty on how to teach using a virtual platform (67.5% of residents and 100% of PDs; Figure 5). Program directors reported most commonly that no training was offered (36.4%) or that faculty had to engage in self-learning, either through YouTube (18.2%) or not (36.4%). Additionally, 60% of PDs reported financial constraints to going virtual, compared to only 5% of residents.

Looking to the Future

Going forward, the majority of both residents and PDs felt that residents will be supported with their training by adopting more virtual teaching and less traditional teaching (53.2% and 54.5%, respectively; Figure A.13). Regarding the immediate future over the next 1 year, residents overall felt anxious, with 78.7% being at least a little anxious about their future and only 10.6% being excited (Figure 6). Similarly, 72.7% of PDs reported being at least a little anxious about resident training and education in the immediate future. Regarding the more distant future beyond 1 year, 56.5% of residents reported being at least a little anxious compared to only 10% of PDs.

Overall Best and Worst

When asked about the best thing for radiology education that has come out of the COVID situation, the most common responses by residents related to increased virtual resources and opportunities and increased time for studying (n = 18 and 9, respectively; Table 2). Program directors, on the other hand, tended to focus on the benefits related to faculty and the program as a whole, including increased attendance and increased flexibility for staff (n = 3 for both).

Table 2.

What Is the One Best Thing for Radiology Education That Has Come Out of the COVID Situation?

	Residents (n = 43)	PDs (n = 9)
More virtual resources and opportunities	18	1
Time for studying	9	1
Improvement in ability to adapt and use technology	6	2
Break/time to recharge/well-being	4	0
Convenience of online lectures	3	0
Nothing	3	1
Time for research	2	0
Increased attendance	0	3
Increased flexibility for faculty	0	3

Abbreviation: PD, program director.

In terms of the worst thing for radiology education, both residents and PDs raised concerns about missed rotations and decreased case volumes (reported by 23 residents and 5 PDs), with decreased staff–resident interaction also commonly reported (Table 3).

Table 3.

What Is the One Worst Thing for Radiology Education that Has Come Out of the COVID Situation?

	Residents (n = 41)	PDs (n = 9)
Missed rotations/time on service, decreased volumes	23	5
Less interaction with staff/residents	13	2
Decreased personal knowledge growth	6	0
Isolation	4	1
Less procedural practice	3	0
Concern around exams	2	3
Difficulty staying motivated	2	1
Decreased networking	2	0
Less clinical/patient interaction	2	0
Effect on graduation/licensing	1	0
Abuse of power, neglect, intimidation, and harassment	1	0
Awkwardness of virtual rounds	1	0
Concern around call preparation	1	0
Lack of infrastructure for remote reporting	1	0

Abbreviation: PD, program director.

Discussion

The overall findings of our study, including less on-site activity (and consequently less case volumes and procedural skill practice) with a shift to virtual clinical and educational activities, are not surprising.^4
-6,8

In terms of meeting training objectives, residents and PDs alike agreed that technical skills and case volumes have suffered the most during the pandemic with uncertainty or mild or moderate concerns raised by both PDs and residents about their role as medical experts. This was a common scenario across radiology and nonradiology specialties.^2,3,8 This was offset to some extent with access to home reporting solutions and simulation studies.^9,10 Reintegration of the residency programs into normal rotations since the end of May/June will hopefully address the concerns about low clinical volumes and procedural skills.

There was less of an impact on knowledge base or interpretation, similar to other recent studies within the field of radiology¹¹ as well as in other specialties.^12,13 Residents commented on “the shift to academic work and education ahead of case work,” “lots of time to catch up on reading,” “more guidance on learning,” and increased access to online learning resources. Free online activities were provided by several larger programs and societies similar to other specialties.⁹

One positive consequence of this pandemic was the increased adoption of technology, which has been reported in the medical literature more broadly.^9,14

-17 This was described by 6 residents and 2 PDs as the best thing for radiology education that has come out of the COVID situation.

Overall, there was less time allotted for on-site activities such as in-person teaching, readouts, and technical skills, and more time allotted to off-site activities such as live lectures through videoconferencing, recorded teaching sessions,⁹ and independent study. Residents and PDs reported greater use of videoconferencing platforms during COVID, with Zoom being the most popular choice. The shift to virtual education has been received with some degree of enthusiasm by most of the residents. However, there was variability among residency programs; for example, one resident commented that “any presentation given [during COVID] is resident led only,” whereas another commented that “there was much less teaching pre-COVID. Our curriculum improved because of COVID” and “I wish online lectures remain forever as appropriate.” Attendance at these sessions increased during COVID, which was reported by 3 PDs as the best thing for radiology education that has come out of the COVID situation.¹⁸

The most frequently reported challenge of this virtual transformation, by the residents and PDs, was the lack of training of faculty on how to teach using a virtual platform, which is a common phenomenon in medical education. Every program would need to build resources on this, including radiology-specific faculty and resident training courses.^19,20

Strategies used to ensure the safety of radiology trainees and their teachers included internal redeployment to a call-only model and complete or partial cancellation of all rotations except interventional radiology, rotations replaced by readouts from home and if not possible by documented self-directed learning, and a “one week on, one week off” model, similar to previous recommendations by Chong et al, Slanetz et al, and Li et al.^5,6,21 These trends are common themes across all specialties.^2,3,13
-15 Redeployment of radiology residents occurred in a minority of radiology programs.

Both residents and PDs noted a substantial increase in communication through regular virtual huddles/town hall meetings, which has been a key factor in preparedness for other specialties.¹⁴ Of concern is the fact that up to a quarter of residents reported that they were in communication with their colleagues/PDs less than 25% of the week.

A number of innovative wellness resources were made available to residents during the pandemic, most commonly through the universities. One of the residents commented that their program incorporated a “wellness hour,” during which they performed documented daily wellness activities, which could be used toward obtaining their credits for the day.

Both residents and PDs reported varying degrees of anxiety around the immediate future. Sources of anxiety for residents went beyond exposure to the disease itself,^8,7 with residents commonly reporting concerns around uncertainty related to a “second wave” of the pandemic, future performance due to missed training, and stress around examinations and fellowships.

There were some common themes with the only other Canadian survey⁸ in that both confirmed disruption of daytime schedules more than on-call duties, decrease in case volumes, and increase in off-site learning activities, mainly through Zoom and provision of additional educational resources. Both studies revealed low redeployment rate to nonradiology units, although our study suggested a slightly higher redeployment rate.

Program directors and residents concurred on several major issues, as outlined in the discussion above. There were some apparent differences in perception of the CanMEDS roles between the two. Program directors reported more opportunities for resident leadership and professionalism, likely related to the increased team-building responsibility of chief residents and the support provided by residents to staff with digital technology. As one of the PDs put it, “the residents educated us,” similar to Slanetz et al.⁶

Surprisingly, more residents reported the cancellation of all clinical rotations than PDs. Additionally, fewer residents reported remote readouts and the use of quizzes/polls and games during teaching than PDs. This divergence on objective measures is difficult to explain. Perhaps this may be explained by different interpretations of the questions or different expectations between the 2 groups. It is likely that the PDs’ perception of provision of more remote readouts and interactivity through quizzes and games was not matched by the residents’ expectations.

The deeper understanding of administrative logistics may account for PDs reporting lack of infrastructure and financial constraints in moving over to a virtual platform more than the residents. Program directors also reported that a greater portion of their week was spent in communication with their colleagues/residents than residents, likely reflecting their leadership role.

Residents and PDs seem to diverge on the availability of wellness resources relative to the pre-COVID period, with PDs reporting more resources being available during the pandemic and residents reporting fewer. It may be that the residents are not fully aware of the available resources. Less resident communication with colleagues/PDs and less awareness of resources are sources of concern. Additionally, regarding the distant future beyond 1 year, residents tended to report greater anxiety than the PDs.

The limitations of our study include the low response rate by residents and partial completion rate, which may be related to the lengthy survey format without compensation, as well as potential “survey fatigue” during this time of mass questionnaires. There was also potential response bias as a result of the predominant multiple-choice question format, although most questions provided an opportunity for additional open-text commentary. This survey was largely opinion-based and did not study the outcome of educational modifications (eg, competency or examination results), and this could be a potential area for further research. Additionally, this was a cross-sectional study and responses related to the times before and during COVID were acquired at the same time. Finally, the survey provided in an English-only format, which may have contributed to decreased response among French-speaking residency programs.

Our study highlighted a few areas as being important in preparedness for the “second wave” and the long road to recovery beyond.

First, it highlighted the need for faculty development courses in virtual education. Each training program would need to put together training resources that facilitate virtual transformation.

Second, the residents reported being less connected with their colleagues/PDs and less aware of the locally available wellness resources compared to PDs. While some of this will be mitigated by return to on-site activities, continued support for residents through communication and wellness resources should be on the radar of residency programs.

Third, the enthusiasm for virtual teaching and increased attendance at these rounds need to be balanced with concerns about low clinical volumes and lack of exposure to procedural skills. A hybrid part-on-site and part-off-site model may be a consideration for reintegration.

Fourth, the PDs responses about anxiety about the future beyond 1 year are encouraging and crucial to leading the slightly more anxious residents into the post-COVID future.

In conclusion, the COVID-19 pandemic has led to dramatic changes in radiology resident training and education workflow in Canada, with increased virtual teaching and learning at the expense of cancellation of daytime rotations with reduced case volumes and staff–resident interaction. The changes have been met with enthusiasm by residents and faculty, despite substantial challenges and anxiety around the future of radiology resident education.

Supplemental Material

Supplemental Material, Appendix_1_-_PD_Survey - Lessons Learned From the Effects of COVID-19 on the Training and Education Workflow of Radiology Residents—A Time for Reflection: Perspectives of Residency Program Directors and Residents in Canada

Supplemental Material, Appendix_1_-_PD_Survey for Lessons Learned From the Effects of COVID-19 on the Training and Education Workflow of Radiology Residents—A Time for Reflection: Perspectives of Residency Program Directors and Residents in Canada by William Warnica, Alan Moody, Linda Probyn, Eric Bartlett, Navneet Singh and Mini Pakkal in Canadian Association of Radiologists Journal

Supplemental Material

Supplemental Material, Appendix_2_-_Resident_Survey - Lessons Learned From the Effects of COVID-19 on the Training and Education Workflow of Radiology Residents—A Time for Reflection: Perspectives of Residency Program Directors and Residents in Canada

Supplemental Material, Appendix_2_-_Resident_Survey for Lessons Learned From the Effects of COVID-19 on the Training and Education Workflow of Radiology Residents—A Time for Reflection: Perspectives of Residency Program Directors and Residents in Canada by William Warnica, Alan Moody, Linda Probyn, Eric Bartlett, Navneet Singh and Mini Pakkal in Canadian Association of Radiologists Journal

Supplemental Material

Supplemental Material, Supplemental_figures - Lessons Learned From the Effects of COVID-19 on the Training and Education Workflow of Radiology Residents—A Time for Reflection: Perspectives of Residency Program Directors and Residents in Canada

Supplemental Material, Supplemental_figures for Lessons Learned From the Effects of COVID-19 on the Training and Education Workflow of Radiology Residents—A Time for Reflection: Perspectives of Residency Program Directors and Residents in Canada by William Warnica, Alan Moody, Linda Probyn, Eric Bartlett, Navneet Singh and Mini Pakkal in Canadian Association of Radiologists Journal

Footnotes

Acknowledgments

The authors graciously acknowledge the assistance of Gary Cronin in the assembly and distribution of the web-based surveys. The authors also thank the trainees involved in the pilot testing and feedback on the resident survey, including Drs Jamil Addas, David Wang, Mary Tao, and Emmad Qazi.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Navneet Singh, MD, PhD, MPH

Supplemental Material

Supplemental material for this article is available online.

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