Pondering the Pandemic's Problems: A Program Director's Perspective.

The year 2020 was challenging for many fellowship programs with regard to training or even burnouts. In this article, I will reflect on being a new program director having to deal with new responsibilities amidst an evolving pandemic. I highlight ten takeaway reflections with the hope that others may find these relevant to their current situation as training program leaders and mentors.

Introduction

The year 2020 was strange and challenging, one that I will never forget. It was not just the beginning of my journey as a gastrointestinal (GI) fellowship program director (PD), nor was it simply the arrival of the COVID-19 pandemic that turned our lives upside down. It was the collision of both into my world, and the collateral damage I saw around me, that made me retrace my footsteps and reflect on the whirlwind of events and emotions of a year gone by more quickly than I have ever previously experienced.

When I took over as PD on January 1, 2020, COVID-19 had already made its way into East Asia, but little did I know how disruptive it would be as it bludgeoned its way into our healthcare system later that month. The preparations that I had made for changing the program were suddenly dwarfed by the task in hand of maintaining continuity of training while ensuring the welfare of my trainees who were working on the front lines. I hope that sharing my reflections as PD over the last year will help others in similar leadership positions faced with similar challenges.

Please note that this article is a sequel to my prior essay on fellow burnout exacerbated by the COVID-19 pandemic [1], the reading of which will likely increase your appreciation of this problem.

Reflection #1: Relationships Are Everything

Fundamentally, a training program is about people, from the trainees to the program coordinators. I started my first day as PD writing a long e-mail to all of my trainees in order to make myself accountable to them along with my commitment to work with them during their training. This latter became the foundation of a series of e-mails throughout the pandemic, supported by chats over online platforms that allowed an open channel of communication. The pandemic also forced social distancing and prohibited large gatherings, with the advantage that public places were quieter, facilitating communication with colleagues, providing opportunities to invest in the relationships that mattered. Beyond the assessment forms and portfolios, I found unique individuals to mentor. Understanding how their work fit into the grand scheme of their life was a winning recipe for coaching them toward success, rather than coaching them toward compliance. Spend time to build relationships and good things happen.

Reflection #2: Improving Communication Skills

In challenging times, clarity calms the storm, necessitating that all communications are effective, thorough, honest, and frequent. Effective communication encompasses written and oral communication, and with the sudden explosion of Zoom meetings, the loss of nonverbal communication emphasizes the importance of verbal communication skills. What I found equally as important was the ability to listen well, which itself is a part of effective communication. A podcast on deep listening [2] taught me the awareness and skillset to practice this important skill, which in turn revolutionized the way I listened to my patients and my trainees. The cornerstone to an effective mentoring relationship is the ability to actively listen to the trainee; using this skill helps you fight burnout and to incite change. Words are powerful, use them well, and use them for good.

Reflection #3: Keep Improving Yourself

Many academicians who serve as PDs or as other leaders never received proper training prior to assuming responsibility for the education and well-being of trainees. I was no different. Managing patients requires totally different skills than managing colleagues or trainees, who require specific training in order to grow into abler teachers, mentors, and leaders. Leaders need to have a positive outlook [3] regarding every challenge as an opportunity to improve, and every failure as an opportunity to reflect and then advance. The pandemic has produced many such opportunities to tap the available resources that others have shared [4], including literature beyond medicine, such as in the corporate world [5]. Leaders are made, not born.

Reflection #4: Be a Good Clinician First

Though it is challenging to juggle administrative, teaching, and clinical obligations, most physicians entered their profession as clinicians first, a belief that must be preserved within the soul of our being. It is difficult to have credibility in training a generation of residents when they do not respect nor believe in your clinical abilities. Therefore, it is important for healthcare leaders, especially in teaching positions, to keep up with the latest scientific developments, clinical advances, and guidelines so as to inspire and better educate our trainees. The pandemic further altered the importance of educators, who are now not just creators, but also moderators and curators [6] of the avalanche of online digital content. Harnessing the power of social media with #GITwitter and #MedEd [7-9] has helped me adjust to this new world; I encourage my trainees to do the same.

Reflection #5: Reflect on Your Situation

No one knows truly how long this pandemic will last nor will life ever revert to what it was like pre-pandemic. Amidst all the changes imposed, along with the challenges I faced as a new PD, it is important to constantly reflect on the situation, for this pandemic will not be the last of its kind and will certainly recur in some form in the near future. Therefore, I started my journey as PD endeavoring to journal, blog, or tweet frequently, with the intent to write down what happened now in order to learn from my mistakes and not repeat them, and to learn to celebrate success. Lessons in life will keep repeating until you learn from them and then alter your behavior and outlook accordingly.

Reflection #6: Be Nimble to Change

The effect of a pandemic on a fellowship program is unpredictable; it forces the PD to think of all the gears of the program and evaluate the necessity of its moving parts. In the leadership literature, some [10, 11] have suggested a strategy for implementation of change that constantly takes into account shifting circumstances, rather than an “action strategy” where leaders try to alter reality and people in order to fit the intended action. I have shared previously [1] on how my program had to dynamically adjust its curriculum, assessment, and teaching practices as national policies evolved during the pandemic. Nevertheless, this was also possible only by reading the medical education literature in order to contextualize the recommendations with the local situation and apply it accordingly. Never do things just because it has always been done that way unless there is good reason. Keep looking to adapt your program, improve things, evaluate, and then improve again.

Reflection #7: Have a Vision of the Trainee You Want

One of the biggest challenges to a PD is juggling the multiple stakeholders, including the departments, the junior internal medicine residency program, and ultimately, the public and the patients. As such, it is important to clarify our actions within our training program in order to nurture the type of trainee we want. With the pandemic, this goal is strained even more as compromises are made with regard to training, and therefore the program needs clarity from the leadership regarding which parts of training are essential. The “softer” aspects of the ACGME core competencies [12] are often neglected since they are difficult to evaluate and also are assumed to be present before fellowship and therefore difficult to alter. It is therefore important for PDs to place equal emphasis on these competencies. I have seen in our fellows during the pandemic resilience and professionalism that I would not have seen in a nonpandemic situation, qualities to be valued among our trainees. Character is a precious commodity compared with skills since the latter are often easier to teach. We need to treasure those trainees of exceptional character, yet never give up on those who at no time showed these traits, for perhaps one day they may. Role modeling is a good method to teach trainees who might have fewer of these traits than others.

Reflection #8: Never Believe Isolated Sources of Information

Many ultimately believe that every source of information about trainees emanating from all sources has to be relayed to the PD, data which can be overwhelming at times, as I painfully discovered. I have also learnt, through mistakes of my own, to never take action on information until I had heard the trainee’s version and further triangulated and verified that information. Trainees are vulnerable in many ways, and if we as PDs and faculty do not advocate for them, resentment, failure, and burnout can follow. I had trainees, who were struggling because of family members dying of COVID-19 or personal mental struggles, information which was manifest only by their performance deficiencies. Whenever possible, give trainees the benefit of the doubt, accommodate, clarify, and mitigate.

Reflection #9: Develop Your Trainee's Career as if It Was Your Own

Mentoring and coaching are privileges that are often undervalued until it is time to reflect on your career, when it will become apparent that the lives we influenced that will give us the greatest satisfaction. I spend a lot of time building relationships with my trainees by trying to understand who they are as a person outside of the clinical setting, and what matters to them, and the struggles they face. One of the responsibilities of a mentor is to harness their strengths in order to reinforce them while minimizing their weaknesses. It is amazing how we can live vicariously through the success of our trainees rendering the joy of celebrating success ever so much sweeter.

Reflection #10: Have a Balanced Life

In the midst of advocating for trainees and helping to fight burnout, many forget that the PD is also human, fallible and weak. I have sourced my strength from my faith, my family, and my hobbies by enjoying these more than my work. Though there can always be another PD, my family is unique and precious. Attention to self is the basis for having sufficient mental and physical energy to care for others.

Conclusions

It is an understatement to say that this year was difficult and that the only constant was change itself. Through the ups and downs, I have truly enjoyed my journey which has been bittersweet at times. I will always regard my trainees also as my friends and they will become colleagues or even my bosses one day. I hope to just be a part of their journey.