Disrupting the disruption: Using digital tools to support psychiatry residency training in Singapore during the COVID-19 pandemic.

Dear Editor,

On 11 March 2020, the World Health Organisation (WHO) declared the 2019 coronavirus disease (COVID-19) to be a global health pandemic. As of 2 May 2020, more than 3.4 million confirmed cases and 239,000 deaths have been reported across more than 210 countries (Worldometer, 2020); in Singapore, 17,101 cases and 16 deaths have been reported (Channel News Asia, 2020). Singapore's aggressive efforts to limit human-to-human transmission through rigorous contact tracing has been commended by the WHO (The Straits Times, 2020). However, given its high density (large population in a small area), the country remains susceptible to and focused on curtailing cluster and community spread. On 7 February 2020, Singapore first raised the national disease outbreak alert level. On 7 April 2020, it implemented more stringent 'circuit breaker' measures, including mandatory work-from-home policies, prohibition of social gatherings, and closures of sports and recreational facilities (Ministry of Health Singapore, 2020).

The National Psychiatry Residency Program is a five-year program accredited by the US Accreditation Council for Graduate Medical Education-International (ACGME-I) and Joint Committee on Specialty Training (JCST), Singapore. The pandemic infection control measures, including social distancing and cross hospital movement restrictions, have created unprecedented challenges to training. Psychiatry residents cannot meet in groups, go outside of their current sites to do clinical work or attend educational activities, and ambulatory teams have halted home visits and day treatment programmes. However, in the process, other clinical learning opportunities have unexpectedly arisen. To help with shifting demands (e.g. psychiatric emergency and inpatient services), some psychiatry residents have been assigned to different services than the ones belonging to their rotations. Several residents have volunteered for deployment to medical facilities which are set up in the community, and are assisting medical teams in managing clinically ill patients. There are ongoing discussions between the residency program committee, central educational office and health authorities to ensure that requisite training rotations are being fulfilled as best as possible at the respective training sites. Some of the arrangements include switching the order of some of the rotations, and allocating buffer training periods to those who may be affected due to various deployments.

Prior to COVID-19, the last event that significantly disrupted training in Singapore was the Severe Acute Respiratory Syndrome (SARS) epidemic in 2003. This time, technological advancements such as videoconferencing have been implemented to reduce disruptions in residency training. When psychiatry residents and their clinical supervisors could not meet up due to movement restrictions, they switched to videoconferencing. In this way, residents continued to discuss clinical cases with their supervisors, and in turn, the supervisors continued to assess the clinical skills and competencies of their residents. One year ago, the residency program moved the resident evaluation process from a paper-based to an online platform. This change proved timely.

In-person academic activities such as clinical case presentations and topical discussions were initially stopped due to safe distancing measures. Some of these have since been reinstated using videoconferencing. Participation rates have been good. Faculty and residents, from the same and different sites, have attended sessions from offices and wards using a variety of electronic devices.

Psychiatry residents from all sites come together weekly to attend a didactic lecture series held at rotating institutions. Prior to the pandemic, the residency program started to support asynchronous learning by placing pre-recorded lectures on an online platform. During the pandemic, full access to learning material, anywhere and anytime, has been especially useful. To support continuous learning, some of the weekly didactic lectures are now being delivered online via videoconferencing, allowing residents on rotating shifts and at different sites to attend. Essential and compulsory courses (e.g., ACLS, medical ethics) have also leveraged the videoconferencing platform to maintain interactivity. Through the live chat function, residents may submit questions without interrupting the tutor, a process that is unavailable with the traditional lecture.

The Royal College of Psychiatrists (RCPsych) has cancelled the post-graduate examinations in March 2020 and May 2020. Residents are understandably worried about not being able to sit for their relevant intermediate or exit summative examinations in time to progress within their residency. However, they have been reassured that both the RCPsych and the local examination committees are actively exploring alternative dates and examination formats, including the use of virtual platforms. Senior residents preparing to take the local exit examinations have been organising online study group sessions through videoconferencing platforms such as Zoom or Skype.

Psychiatry residents are responding tirelessly despite increased clinical demands, considerable manpower constraints, and suspension of prolonged period of holiday. Risks include burnout, coupled with fears of contracting the virus and the risks to their loved ones in close contact (Fessel and Cherniss, 2020; Ripp et al., 2020). Clinical supervisors have been keeping tabs on residents’ emotional well-being and emphasising self-care. They update residents on changes in training schedules as they occur. While gathering feedback can be easily overlooked due to workload, disrupted schedules, and deployments, it is critical to keep up with such efforts in the long haul. The digital platforms described have made this possible.

Although the disruption to psychiatry residency training in the midst of the pandemic is severe, the innovative use of digital platforms is coming of age. This is the 'new normal' of training for residents, faculty, and administrators, in the upcoming months and longer. However, limitations of digital platforms need to be borne in mind. Compared to in-person meetings, differences with videoconferencing include the depth and spontaneity of individual and group interactions, the possibility of distractions especially when multitasking, as well as the narrower range and quality of patient responses that can be observed and assessed during clinical direct observation. A great deal of tolerance and flexibility is required of residents, supervisors, and administrators, in continuing to foster committed learning and teaching within a community of practice, during this current evolving pandemic.

Declaration of Competing Interest

All authors have no conflict of interest.