COVID-Proofing the Class Rheum

There’s a learning curve to this.

Rose, A Colleague

We had to change the way we conduct training as restrictions continue to be in place against #COVID19PH. We cannot do our usual activities or at least in the manner we used to do them.

But how did we evaluate our trainees pre-COVID?

The teaching-learning activities of our rheumatology trainees rotated around actual patient care, conferences, consultant interactions, and self study. We adapted using best practices shared by other units, exploration of available technologies, and customizing tools to our Section’s needs. It wasn’t that easy and up to know we continue to review what we’re doing and implement changes to our system. I’d say our system is far from being perfect but we’re slowly getting there.

Before, our fellows would document their activities through their portfolios which we regularly reviewed (portfolio-based evaluation). Each fellow would have their individual census of referred in-patients and managed out-patients (with a section on learning points: answers to questions raised by consultants while attending to patients), a procedure checklist, an exemplary case report (a patient managed from which the fellow learned a lot), a reflection paper, evaluations of all conferences they gave, written exams/ quizzes, and an evaluation of their performance in the OPD & wards. I’d go over each fellow’s portfolio and leave comments or instructions on what to do. Their census and checklists were important for us to determine if they were meeting the minimum number of cases required to attain competence. The deadline was the 5th of every month.

I’d usually review the portfolios around the second week of each month, sit down with the fellows to discuss their portfolio, and refer the fellow to their mentor should the need arise.

But with COVID, we could no longer do just that. For one, not all consultants can report to the hospital per IATF protocols. There are also restrictions to the number of people who can occupy a room (particularly our own small room in the OPD). Our fellows also get assigned to the COVID floors for a week and it would be problematic to have them complete their portfolios should they be assigned there near the time of the deadline. And lastly, mobility is not that easy anymore. I’d have to get several rides from our place to the Medical Center as my usual modes of transport remain limited.

How did the Section adapt?

First, we looked at a platform that everyone in the Section could use for training-related announcements. The UP-PGH Section of Rheumatology had started using Google Classroom for theirs. And several other consultants were familiar with it (being used for their kids’ classes). They volunteered to put one up. Soon, all fellows were asked to upload links to their presentations at our G Classroom.

Part of the training of our fellows was to prepare them as educators. One of us consultants with exposure to test construction was asked to collaborate with the fellows for their Kelley’s Hour. It’s a dedicated time of the week that fellows spend studying a particular rheumatic disease. Weekly, a fellow is assigned to produce a quiz for the given topic. He makes one using Google Forms and posts the link at the G Classroom. The fellows also soon started making pre- and post-tests for the didactic conferences. The other goal for these quizzes really was to expose them to different types/ styles of questioning in preparation for the subspecialty (PSBR) boards.

Since we were gradually building our confidence in using Google apps, we soon started using Google Docs for the fellows’ submissions. The nice thing was we could post these submissions as assignments in our G Classroom. Templates (with some instructions) for the patient census, procedure checklist, exemplary case report, and reflections were made. These were then posted at intervals in the classroom (complete with due dates) with the settings set for individual submissions so that only the consultants can read what they submit. The advantage here is that both fellows and consultants need not be in the hospital for the portfolios – we can access them whenever and wherever there is an internet connection. Likewise, we can exchange comments which are tagged to specific entries (similar to what we do when reviewing manuscripts through Word).

A problem did arise when our two senior fellows graduated. Apparently, when you leave the classroom, you take with you all the submissions you made. Whether it be the portfolio entries or the links to reports and quizzes, everything one shares goes with him when they un-join a class. There’s no problem with this when it comes to the exemplary case report and the reflection papers which we consider personal. However, we needed to keep track of the census for accreditation purposes, This month, I created an excel sheet for this monitoring purpose.

Our section head recently started holding clinical reflection sessions (via zoom) to teach our fellows clinical skills and decision-making. She occasionally sends out assignments and uses the grading scheme for assignments also through G Classroom.

How about supervised patient care? For those of us still able to report to the hospital, we continue to do our service rounds but observing minimum health standards. For those of us unable to go to the hospital, Zoom has proven very useful. Fellows attend first to their patients then they open up zoom to connect with their consultants. They then proceed to discuss their cases and discover the nuances relevant to patient management.

The OPD clinic is a different case. Most of rheumatology practice is based in the clinics. So, the Section made it a point to ensure that at least one of use consultants is present for face-to-face OPD. Another consultant is available for tele-consultation.

Our schedule of activities had also drastically changed because of #COVID19PH. No longer are that troubled by traffic and parking as Zoom allows us to hold meetings at common times. In fact, I feel our meetings are more common now than during pre-COVID.

The desire to continue training physicians in rheumatology has lead our Section to compensate and to adapt – remaining steadfast to our goal of creating rheumatologists who will practice in government and public health institutions.

#COVID19PH is still here and we’re gradually learning to live and work with it. Here’s to more COVID-proof strategies in our class-Rheum.

COVID-19 and Medical Conferences

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COVID-19 is not only a public health epidemic. It’s a social pandemic as well – affecting how people relate and interact with each other. And medical training, as a social activity, is not exempt from it. Just look at how conferences are done nowadays.

Apart from hands-on patient care, medical conferences are the major teaching-learning activity for medical students, residents, and fellows in training. Presentors (often the trainee) discuss an assigned topic to consultants and colleagues. This may be in the form of a mortality audit (what could have been done to prevent this?), case management (how do we do things better?), or a topic conference (what’s new?). There was a pause in such activities when #COVID19PH started but things got back in May 2020.

The Philippine College of Physicians instructed training institutions to hold at least 2 major conferences per month out of consideration for the more important task of doctors nowadays, #DealingWithCOVID19. But the residency handbook defines a major conference as one where at least 2 members of the training staff are present. However, our Department holds DAILY COVID ward endorsements where 3-4 COVID subspec consultants, 1 attending physician, and 1 general medicine consultant are in attendance. So, I guess our unit’s doing pretty well in terms of major conferences.

From the feedback we got, our residents and fellows prefer attending the Daily COVID endorsements more than the non-COVID rounds for their learning. There they run-through and discuss each of the admitted COVID patients. They are challenged to present a brief update, discuss their cases, and analyze problems they encountered. They immediately get the inputs and feedback of the consultants present. They trainees feel the impact of having a team of consultants closely supervise them as they go about their duties.

Contrast this to what happens during non-COVID rounds. A consultant comes to do basically the same thing being done in the COVID-floors – review the course, assess problems, and update the management plans. Only difference is you got a team in COVID versus a point-person in non-COVID. I guess the team approach appeals to our residents in terms of the training it provides, the interaction between experts, and the impact it has on patient care.

Now that the department conferences had returned – the challenge is becoming a good #Zoom-tizen.

Since Zoom became the go-to service for virtual meetings, a lot of new challenges had cropped up. Not too often, someone would join the meeting with barking dogs, crowing chickens, or beeping car horns in the background. You’d hear a consultant engage a patient or their secretary in the clinic when the presenter’s in the middle of the discussion. (I remember overhearing one consultant while bathing her kid!) It can be amusing and annoying at the same time. On the other hands, we have hosts who appear to live their post and are unable to mute “noisy” participants or those moderators who forget that there’s such a thing called “chat” which they should check from time to time.

Some practices that we’ve tried to implement:

  • Mute all participants on joining
  • Make the moderator and those with special functions during the conference as co-host
  • Have the moderator read out the ground rules at the start of the meeting
  • Have an attendance picture at the end of the meeting

I’m not sure how this “misbehavior” is seen by our trainees. But I, for one, am indignant. It’s difficult enough dissecting a mortality and presenting the arguments that lead to a decision. We don’t need these distractions to prevent others from understanding the points being raised.

But I guess the bigger problem is Zoom is the opportunity for inattention. Given the slow internet speeds, many would join a meeting then turn off both their videos and mics for less lag or buffering of their stream. A resource person once said that this was a respectful gesture as this focused the meeting on whoever’s speaking and prevented her from being distracted. However, with this arrangement, how sure are we that they’re still there and part of the meeting? It’s happened several times that a co-participant would ask whether a question she posted (in the chat) had been answered. And when I’d say yes, they’d immediately respond that they temporarily stepped out so they weren’t able to catch it.

To me, the practice of turning off the video/ mic may present even with the chance to “sign-then-leave” (a practice we’ve observed pre COVID where participants would just sign the attendance sheet but never enter the conference hall).

“There’s a learning curve to this,” a colleague once told me. She was referring to another matter but I guess it also applies to how we’re adapting our activities to the challenges of #COVID19.

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