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AUSTRALIA experienced its first coronavirus disease 2019 (COVID-19) surge with a small number of mainly introduced infections and a national stage 3 lockdown from March to June 2020. This was followed by a second surge of community-spread disease in Melbourne, resulting in a city-wide stage 4 lockdown from July 2020 until the time of writing in early September.
At present, the number of infected individuals is falling, but the form of restrictions and how long they will remain is unclear. Stage 3 required all those who could work from home to do so, and stage 4 allows only essential services to operate, just four reasons to leave home (work in essential services, the purchase of food or medicine, exercise, or to provide care), one hour of exercise outside the home, no travel outside a 5 km radius from home, as well as a night-time curfew.
Initially, the main sources of community transmission were from quarantined travellers, but more recently, they have been from health services, aged care facilities, and food processing and distribution centres. Internationally, up to one-quarter of people who have been infected are health care workers, and 70–80% of Victorian health care workers have acquired the infection at work.
During the pandemic, the whole Victorian health system has undergone major change. This, together with infection risk, have had a severe impact on medical student education (here, here and here), but also on training in the medical specialties. We describe here the consequences of the COVID-19 pandemic for medical specialty training in Victoria and the strategies implemented to mitigate these effects.
Stresses
Anxiety levels among some trainee doctors have been high, not only because of the risk of infection and potential personal protective equipment shortages but also because of uncertainty about teaching opportunities, examinations, career progression, 2021 training positions, and fulfilling Fellowship requirements.
Hospital experience
The hospital training experience has changed for many trainees during the COVID-19 pandemic. There have been fewer opportunities for non-COVID-19 training, with reduced patient numbers: there have been fewer hospital admissions, fewer patients in the emergency department, reduced surgery, fewer requests for pathology and radiology tests, and specialist outpatient clinics have been conducted almost exclusively by telehealth.
There have also been changes to rosters. Trainees have not necessarily worked in their expected rotation but instead have been assigned to COVID-19 wards or to help elsewhere (eg, in-reach aged care, testing and tracking, or covering staff who are furloughed, quarantined or ill). Early in the first surge, trainees were not allowed to move to other health services, such as rural rotations, since health worker movement represented a risk for COVID-19 spread. This decision was later rescinded. Thus, trainees may have had excellent experience in pandemic management and the care of patients with COVID-19, but this may have displaced a term in a possibly critical area of training such as cardiology or microbiology.
Teaching and supervision
Across the board, workforce limitations have been more significant than access to intensive care unit beds and ventilators. There have been fewer teachers available for teaching and less direct supervisor contact. Sometimes, this is due to supervisors being elsewhere, including working from home, or busy doing something else because of changed patient demand. Indeed, some trainees themselves are working from home. In some disciplines, the diversion of laboratory staff to COVID-19 testing has meant less teaching. Some teaching is undertaken remotely, from blood film morphology to general practice supervision, which is difficult for trainees starting out in the corresponding disciplines.
There has also been less time available for teaching. Teaching sessions, revision courses and practice examinations have been cancelled or moved online, and no bedside tutorials using patients who are not the team’s responsibility, or small in-person group tutorials are allowed. Trainees cannot even attend training courses within the same city, and these have all been cancelled. Tutorials must be carried out under COVID-19-specific restrictions, which usually means remotely.
Examinations
Examinations have generally been deferred, and there has been uncertainty about when and how some will be conducted. Trainees cannot travel interstate for examinations. Regional trainees in some colleges are unable to travel to Melbourne and must sit examinations in their home hospital or laboratory. College staff in interstate-based colleges cannot travel to Melbourne to help with supervision, which local Fellows must provide at multiple examination sites. Again, examinations must be held under appropriate infection control procedures, with physical distancing.
Some college examinations have been, or are planned to be, held under different circumstances; for example, in several modules via a videoconferencing platform. Others are in different formats, such a “long case” examination without a physical examination, and where the patient is rung and interviewed at home. Trainees then do not have access to “practice papers”, and their supervisors and past examinees cannot advise on successful strategies from past experience because they are not experienced with the new forms of examination.
Advanced training
Trainees, particularly in procedural specialties, may not be able to complete their training requirements (logbooks) with the requisite numbers of renal biopsies, gastroscopies, cataract surgeries etc. This potentially delays obtaining their Fellowships and establishing practices.
2021 training positions
Trainees who have not been able to sit for the examinations before the advanced training position “match” have been concerned about “bottlenecks”, where they are competing with trainees who passed the examination the previous year but were not appointed to a training position. Trainees are concerned that if they do not obtain an advanced training position this year without having passed the qualifying examination, there will be twice as many applicants next year.
Learnings and responses
Trainees have learned how to deal with a public health emergency. They have also gained experience in telehealth, participating in online meetings and webinars, providing care within the community, infection control and the use of personal protective equipment, and learning from simulation laboratories.
Advocacy from doctor groups has been strong and listened to. Victoria’s Premier and Chief Health Officer have provided daily updates. The Chief Medical Officers in each health service have also provided regular updates citing the number of new infections detected locally, the number of staff infected, available personal protective equipment supplies, and any changes to practice. There have been regular votes of appreciation from the administration, and acknowledgements from the Premier for health care workers. WorkCover (government-funded insurance) now applies to all health care workers who contract the virus, no matter where.
At least some of the colleges have accredited COVID-19 rotations as training. Some have used webinars to allow the examination committees to communicate directly with trainees to discuss their concerns and plans for changes to the examination system. Most have adapted to provide online written examinations and, in some cases, local examinations by a supervisor, or examinations with delayed but staggered timing, to allow more time for preparation and safe practices. Others that allowed only a fixed number of examination attempts have stated that a fail in 2020 will not count as one of those attempts. The exposure of candidates to patients in the examinations has typically been reduced.
All hospitals have moved rapidly to online meetings, which many have found convenient. Online teaching has been adopted widely, and new training courses developed to compensate for those that cannot be held. Health services that have been less affected by COVID-19 have taken a greater role in providing online revision for all trainees.
The Victorian Department of Health and Human Services (DHHS) has asked health services to appoint trainees based on merit, acknowledging that it was not their fault that the examinations have been deferred, but the trainees are still concerned. Can this process really be as fair as promised and the current trainees will not be disadvantaged? How understanding will their next year’s supervisor be if a trainee is appointed to an advanced training position but must concentrate on preparing for the qualifying examination for 6 months rather than learning their new specialty? And what if a trainee is appointed to an advanced training position but fails the examination?
Some colleges have indicated that candidates for Fellowship who have not performed the requisite number of procedures may ask for their individual circumstances to be taken into account.
In 2020, for the first time, the DHHS has supported centralised online interviews for junior doctor appointments (intern, PGY1 and PGY2) because trainees cannot attend interviews in other health services, and to deal with the shortage of available consultant staff. This has been successful, and it is likely that advanced trainee appointments will use a similar format.
Some health services have provided yoga or mindfulness sessions. Others have introduced reflective practice groups for staff, including trainees, which draw on psychological theories of adjustment and coping when exposed to heightened stress. Further programs that strengthen the caregiver–patient relationship and reinforce the motivation for working in health care are being considered.
The whole health sector in Victoria has performed with unprecedented collaboration and agility. However, the pandemic is not yet over. Our specialty medical colleges will need to continue to adapt and innovate to meet the training requirements of our medical trainees as well as the needs of our community now and into the future.
All of the authors are or have been involved in teaching and training. These are the private views of the authors, and not necessarily of the health services where they work nor their Colleges
Judith Savige is a Professor at the University of Melbourne and Foundation Professor of Medicine at Northern Health.
Professor Erwin Loh is national Chief Medical Officer and Group General Manager Clinical Governance for St Vincent’s Health Australia, the nation’s largest not-for-profit health and aged care provider. He is Honorary Clinical Professor with the title of Professor at the Department of Medical Education, University of Melbourne, Adjunct Clinical Professor at Monash University, and is Honorary Professor at Macquarie University at the Centre for Health Systems and Safety Research.
Kate Stewart is a Casual Lecturer in the Department of Clinical Pathology, University of Melbourne.
Associate Professor Merrole Cole-Sinclair is a haematopathologist, and currently Head of the Laboratory Haematology at St Vincent’s Hospital Melbourne.
Associate Professor Leeroy William is Clinical Director of Supportive and Palliative Care at Eastern Health Melbourne and is current President of the Australian and New Zealand Society of Palliative Medicine.
Dr Kerryn Rubin is Head of Adult Psychiatry at Peninsula Health Mental Health Service.
Caroline Clarke is Chief Medical Information Officer at the Royal Victorian Eye and Ear Hospital.
Dr Charlotte Elder is an obstetrician and gynaecologist at Mercy Hospital and specialist gynaecologist at Royal Women’s Hospital.
Dr Sarah Whitelaw is an emergency medicine physician at Royal Melbourne Hospital, and Director of the Victorian Doctors Health Program.
Dr Nam Le is an anaesthetics consultant at Royal Women’s Hospital.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.