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Back to Basics: Changes to the Residency Curriculum
During a Pandemic
Alecsa Mackinnon Blair BMBS, Sagar Rohailla MD, and Alberto Goffi MD, Malika Sharma MD, FRCPC
About the Authors
Alecsa Mackinnon Blair, BMBS and Sagar Rohailla, MD are with the Department of Internal Medicine, St. Michaels Hospital, University
of Toronto.
Alberto Goffi, MD is with the Department of Critical Care Medicine, St. Michaels Hospital, University of Toronto.
Malika Sharma, MD, FRCPC, is with the Department of Infectious Disease, St. Michaels Hospital, University of Toronto.
Corresponding Author Alecsa Mackinnon Blair: blaira@unityhealth.to
Submitted: April 20, 2020. Accepted: April 25, 2020. Published: May 7, 2020. Ahead of issue. DOI: 10.22374/cjgim.v15i3.452
Abstract
In the height of the COVID-19 pandemic, prompt changes are required from medical systems.
Within Canadian academic institutions, this will mean a restructuring of residency programs of
all specialties and at all levels of training. Rapid training in critical care procedures and models of
patient care will be paramount to contend with the increasing numbers of critically-ill patients.
Flexibility from staff physicians, residents, and medical students will be required to fill gaps in
patient care. Finally, compassion for our co-workers throughout illness and isolation will be
necessary to provide emotional support for one another.
Resume
Au plus fort de la pandémie COVID-19, des changements rapides sont nécessaires de la part
des systèmes médicaux. Au sein des institutions universitaires canadiennes, cela signifiera la
restructuration des programmes de résidence de toutes les spécialités et à tous les niveaux de
formation. Une formation rapide aux procédures de soins intensifs et aux modèles de soins aux
patients sera primordiale pour faire face au nombre croissant de patients gravement malades. La
flexibilité des médecins du personnel, des résidents et des étudiants en médecine sera nécessaire
pour combler les lacunes dans les soins aux patients. Enfin, la compassion envers nos collègues
tout au long de la maladie et de l’isolement sera nécessaire pour se soutenir mutuellement sur
le plan émotionnel.
Canada confirmed its first case of the novel coronavirus (SARS-
CoV-2) causing coronavirus disease 2019 (COVID-19) on
January 25, 2020.
1
Forty-six days later, COVID-19 was officially
declared a pandemic by the World Health Organization. As of
April
15
th
, there were 23, 891 confirmed cases of COVID-19
in Canada, spread by both international travellers and local
transmission.
2
Many phrases have been used to describe this unprecedented
period in our healthcare, such as “all-hands on deck” or “the
calm before the storm. As residents, we await our call to action
with both excitement and trepidation. The lessons from SARS
are only accessible to us from our mentors. From these lessons,
and from our own experiences, we share some thoughts on how
post-graduate trainees can support the response to COVID-19.
Canadian Journal of General Internal Medicine
Volume 15, Issue 3, 2020 23
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A New Curriculum
Preparing for the pandemic has affected the structure of residency
programs nationwide. Licensing exams have been postponed,
many hospital services have been cancelled, and many residents
may be redeployed from career-focused electives. As a result,
many learners are seeing a narrower scope of their practice and
feeling apprehensive about their futures. Despite these changes,
the message from programs has been clear: things will eventually
return to normal. For now, the short-term goal of our curriculum
is to ensure that we are prepared.
We are learning from our colleagues in the United States,
Italy, and other countries deeply affected by this pandemic
that we need to rapidly expand our critical care capacity (e.g.,
beds, ventilators, monitors) and the number of healthcare
workers trained in intensive care.
3
While residents cannot
expect to become experts before the surge of COVID-19
cases occurs, we can develop our competency with additional
rapid training.
4,5
Currently, Toronto hospitals are quiet, but
this will not last long.
The need for expertise is essential in the management of patients
with COVID-19. Rapidly worsening hypoxemia paired with vigilant
personal protective equipment (PPE) use means that securing
an airway is done by the most experienced physician available.
Yet as we have seen in other parts of the world, COVID-19 has
created major challenges for the provision of critical care. Many
jurisdictions are recruiting multi-disciplinary support to meet
increased demands.
6,7
Herein lies an opportunity for ingenuity
in medical education to prepare junior doctors by developing
a curriculum that emphasizes the hands-on practical skills but
also focusses on equipping residents with an ICU-approach to
managing health emergencies.
An immediate solution to developing further competency is
implementing educational programming in collaboration with
other health care specialties. For instance, residents could spend
a week with a respiratory therapist to learn basic principles of
oxygen delivery systems, the management of ventilator settings,
and troubleshooting common ventilator problems. Residents
training in Canada are seldom taught how to draw blood and
insert peripheral intravenous catheters, skills we could start to
learn by shadowing our nursing and phlebotomy colleagues.
This planning phase is also an excellent opportunity to use
simulation labs to learn the basics of obtaining central venous
access, inserting an arterial line, or reviewing scenarios on
how to resuscitate critically ill patients. When the workload
increases hospital-wide, teams can be more effective if we share
our collective knowledge and skills.
Beyond the procedural skills, critical care experience introduces
residents to a unique care philosophy when treating patients
at their sickest while also supporting their families through a
period of intense vulnerability. Effective communication will be
necessary and frequently used skill during the pandemic in all
areas of healthcare. The ability to be clear and develop a rapport
will be even more challenging with the limitations of physical
distancing. However, we can learn from our ICU colleagues
on how they deliver difficult news, update a family member
or discuss the end of life care goals in order to be ready if the
pandemic moves beyond the critical care setting.
Examples of resources to prepare our front line staff are
already being developed with online training modules such
as www.quickicutraining.com. This free resource developed
through the collaborative efforts of clinicians, educators, and
scientists from across the University of Toronto and the Toronto
Academic Health Sciences Network (TAHSN) called the Critical
Care Education Pandemic Preparedness (CCEPP), will help
health care workers meet the potential demand.
Redefining Our Roles
Trainees play a key role in providing care. When the demand
is highest, we will need to be flexible. This may mean being
uncomfortable. Discomfort bolstered by a safe learning environment,
however, can be a powerful teacher. Junior residents from all
subspecialties (Psychiatry, Family Medicine, Internal Medicine,
and Surgery) can be moved to general medicine wards where
the bulk of the COVID-19 response will take place. This may
mean moving towards a more historical intern year, where
first-year residents apply their knowledge from medical school
to work in multiple disciplines with a focus on general internal
medicine and critical care.
We have seen a redefining of role already in undergraduate
medical education. Not able to receive clinical training at the present
time, many of our medical students have taken the initiative by
volunteering their time to support health care workers (HCW)
with everyday tasks including childcare.
8,9
In Calgary, medical
and nursing students have volunteered to help local public health
agencies with contact tracing, quadrupling Albertas capacity for
this essential public health task
10
. While non-conventional, these
solutions are exactly the kind of creativity we need when faced
with a novel problem within the health care system.
Compassion for Our Colleagues
A year ago, the idea that you “do not call in sick unless you are
dying in your bed” was not uncommon. However, residents are
now being told to stay home with even mild symptoms such
as sore throat and runny noses. This is the right thing to do to
keep patients, communities, and other HCWs safe; however,
this is not without its own burden. Staying at home with mild
symptoms, knowing your colleagues are covering your call shifts
during a pandemic can be agonizing.
Canadian Journal of General Internal Medicine
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Blair et al.
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We must remember these policies are not about the individual
and are not meant to be punitive. Public health starts in the
community and as healthcare workers, residents are part of that
community first and foremost. We are no different and need
to self-isolate when required. We can help prevent the spread
of the virus by being vigilant and judicious about PPE and by
coaching our colleagues’ donning and doffing. This not only
keeps us protected but also creates a community of support as
we care for each others safety.
Recently, a Toronto clinician highlighted the importance
of colleagues’ emotionally supporting one another during the
SARS pandemic.
11
The medical community needs to suspend
the reflex to blame our colleagues for staying home. Rather, we
must prioritize taking care of one another; we are all susceptible
to the emotional toll of this crisis stemming from self-isolation,
fear of infecting our families, and feelings of helplessness.
These are certainly unprecedented times. Training programs
have been challenged with the responsibility of keeping residents
safe as they fight this pandemic. We believe that we are safer if
we are trained and prepared. Many lessons will be learned from
this pandemic – years from now all HCWs will recount what
it was like during COVID-19, our generations greatest acute
public health crisis. Let us ensure that history looks back on us
kindly, knowing we did all that we could do.
Disclaimer
The opinions expressed in this submitted article are our own
and do not represent an official position of the University of
Toronto or of St. Michaels Hospital.
Conflicts of Interest
None.
Sources of Support
None.
References
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management of first case of COVID-19 in Canada: Lessons applied from
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the epidemics front line. N Engl J Med 2020.
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Canadian Critical Care Society; [Cited 2020 Apr 15]. Available from: https://
www.canadiancriticalcare.org/COVID-19-E-Learning.
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Infect Dis 2020.
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training. Lancet Respir Med 2020;8(4):e23.
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Response Team. [Internet]. Toronto, Canada. The Varsity; [Published 29 Mar
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9. Vendeville G. As COVID-19 battle escalates, U of T students offer busy
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Toronto; [Published 19 Mar 2020] [Cited 2020 Apr 3]. Available from: https://
www.utoronto.ca/news/covid-19-battle-escalates-u-t-students-offer-busy-
health-care-workers-help-home-front.
10. Cryderman K. Alberta enlists a non-traditional team of medical students,
nurses and others to aid with tracking COVID-19. Calgary, Ab., Canada. The
Globe and Mail; [Published 2020 Apr 3] [Cited 2020 Apr 10]. Available from:
https://www.theglobeandmail.com/canada/alberta/article-alberta-enlists-a-
non-traditional-team-of-medical-students-nurses-and/.
11. Detsky AS. What i learned from SARS in 2003 That Will Help Me Cope With
COVID-19 in 2020. J Hosp Med 2020.
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