Impact of the COVID-19 Pandemic on Nephrology Fellow Training and Well-Being in the United States: A National Survey.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic's effects on nephrology fellows' educational experiences, preparedness for practice, and emotional wellbeing are unknown.
METHODS: We recruited current adult and pediatric fellows and 2020 graduates of nephrology training programs in the United States to participate in a survey measuring COVID-19's effects on their training experiences and wellbeing.
RESULTS: Of 1005 nephrology fellows-in-training and recent graduates, 425 participated (response rate 42%). Telehealth was widely adopted (90% for some or all outpatient nephrology consults), as was remote learning (76% of conferences were exclusively online). Most respondents (64%) did not have in-person consults on COVID-19 inpatients; these patients were managed by telehealth visits (27%), by in-person visits with the attending faculty without fellows (29%), or by another approach (9%). A majority of fellows (84%) and graduates (82%) said their training programs successfully sustained their education during the pandemic, and most fellows (86%) and graduates (90%) perceived themselves as prepared for unsupervised practice. Although 42% indicated the pandemic had negatively affected their overall quality of life and 33% reported a poorer work-life balance, only 15% of 412 respondents who completed the Resident Well-Being Index met its distress threshold. Risk for distress was increased among respondents who perceived the pandemic had impaired their knowledge base (odds ratio [OR], 3.04; 95% confidence interval [CI], 2.00 to 4.77) or negatively affected their quality of life (OR, 3.47; 95% CI, 2.29 to 5.46) or work-life balance (OR, 3.16; 95% CI, 2.18 to 4.71).
CONCLUSIONS: Despite major shifts in education modalities and patient care protocols precipitated by the COVID-19 pandemic, participants perceived their education and preparation for practice to be minimally affected.

The coronavirus disease 2019 (COVID-19) pandemic is challenging every aspect of kidney care, research, and education.[1] Nephrologists have faced higher rates of AKI,[2] challenges in dialysis delivery,[3,4] and increased mortality in patients with concomitant COVID-19 and kidney dysfunction.[5-8] Health care workers overall have faced increased anxiety and depression during this pandemic.[9,10] Caring for complex patients with COVID-19 and kidney dysfunction likely worsens provider stress and increases risk for mental health diagnoses. Additionally, the pandemic has brought about major changes in the delivery of nephrology care, including the adoption of preparedness checklists,[11] increased use of telemedicine,[12,13] and an emphasis on critical care nephrology.[14] Nephrology will learn from these lessons in attempts to deliver improved care in the future, with or without a pandemic.

Although the COVID-19 pandemic has likely created lasting changes in nephrology care delivery, it has also created educational challenges and opportunities to meet these clinical demands. Before the pandemic, nephrology faced low recruitment,[15] adverse perceptions of the field,[16-18] and significant trainee burnout.[19] Whether the pandemic has changed these perceptions is unclear.

In a national survey, we explored the effects of the COVID-19 pandemic on nephrology fellows’ educational experiences, preparedness for practice, and personal wellbeing.

Methods

The American Society of Nephrology (ASN) Data Subcommittee (the manuscript’s coauthors; chaired by the senior author) developed a research survey instrument to assess the effects of the COVID-19 pandemic on the education and wellbeing of current fellows and recent graduates who completed training during the initial US COVID-19 outbreak in early 2020.

Since 2014, the ASN has conducted an annual survey of current nephrology fellows to capture the demographics of the incoming workforce, fellows’ perceptions of their training and the specialty, and leading indicators of the status of the local and national nephrology job market.[20] Although the 2020 survey (to be distributed in May) was canceled, as the pandemic accelerated there was a need for information on how the pandemic was affecting fellows-in-training. A customized survey—that included select questions from the annual instrument for longitudinal data collection—was distributed in August 2020 to measure COVID-19’s effect on fellows’ education, professional development, career trajectory, and personal life. Psychologic distress was evaluated using the Resident Well-Being Index (RWBI), which “…correlates with quality of life (QOL), fatigue, recent suicidal ideation, burnout, the likelihood of reporting a recent major medical error, and meaning in work.”[21] The RWBI’s distress threshold (RWBI score ≥5; score range 0–7) is associated with a three-fold higher risk of poor mental QOL and a four-fold higher risk of burnout, a “psychological syndrome emerging as a prolonged response to chronic interpersonal stressors on the job.”[22] A known occupational hazard among health care providers, burnout comprises “exhaustion, feelings of cynicism and detachment from the job, and a sense of ineffectiveness and lack of accomplishment.” The final survey instrument, including the RWBI, was validated and distributed via Qualtrics (see Supplemental Material I).

The survey frame was drawn from three sources. Participant rosters for ASN’s In-Training Examination (an annual board certification preparatory test administered each spring) were reviewed to identify current (academic year 2020–2021) second- and third-year adult nephrology fellows and recent (2020) graduates. Contacts for pediatric and adult/pediatric fellows were provided by the American Society of Pediatric Nephrology. Lastly, first-year fellows (who began nephrology training in July 2020) were retrieved from the ASN’s membership database and provided by training programs. Respondents’ demographic characteristics, including education status (international medical graduate [IMG] versus US medical graduate [USMG] versus US citizen graduate of an international medical school [US IMG]), were compared with the most-recent data from the Accreditation Council for Graduate Medical Education (ACGME) for representativeness.

Email invitations with unique survey links were distributed on August 4, 2020. The target audience was incentivized to participate by an opportunity to win one of 12 prizes (two complimentary registrations to ASN’s Board Review Course and Update and 10 1-year ASN memberships). Dissemination was timed to: (1) mitigate recall bias of fellows’ experiences during the initial surges in March and April 2020; (2) occur after the start of the academic year and completion of the new-fellow onboarding process (which started July 1, 2020); and (3) conclude before the typical onset of influenza season (the survey closed after 41 days on September 14, 2020). To evaluate how surges in patients with COVID-19 may have affected response, participants were geolocated and aggregated by the Morbidity and Mortality Weekly Report (MMWR) week of their survey completion date. Then, participants were mapped against the corresponding mean patient with COVID-19 hospitalizations aggregated by state for each MMWR week the survey was open.

Participants’ educational, professional, and personal experiences during the COVID-19 era were evaluated for any intercohort differences between fellows and recent graduates (using chi-squared test for independence or Fisher’s exact test). It was hypothesized that any observed differences could be a potential surrogate indicator of changing educational and practice approaches during the pandemic’s course. Potential associations between fellow and graduate demographic variables and aspects of personal wellbeing (the exposures) and occupational distress (the outcome, measured using the RWBI) were evaluated by univariable (both exposures) and multivariable (demographic variables) analyses using logistic regression.

The pandemic has increased demands on many physicians’ time. We considered this when designing our instrument. Our priority was to query broadly about a range of topics rather than pursue granularity on a few. Therefore, most questions were either developed or reframed as closed end. Although the number of open-ended questions were purposely underweighted in an attempt to reduce participant burden, participants had the option to provide free-text responses via an “Other (please specify)” option in 17% of questions (12 out of 69 total). (Note that, on the basis of their responses and question relevance, participants were not exposed to every question.) This limited the volume of free-text responses, which were manually reviewed and collated for representative data only. No formal qualitative analysis was performed.

Where appropriate, summary statistics are reported as median (interquartile range; IQR) or mean±SD. Logistic regression results are reported as odds ratios (ORs) with 95% confidence intervals (95% CIs). Statistical tests (chi-squared test for independence, Fisher’s exact test, or logistic regression) were conducted at α=0.01. The research was reviewed and deemed exempt by Johns Hopkins University Institutional Review Board (IRB00205206) with the caveat that respondents could skip questions they preferred not to answer. Thus, percentages reported were calculated using question-specific total responses in the denominator. Statistical analysis was conducted using R (R Foundation for Statistical Computing, Vienna, Austria. https://www.R-project.org/).[23-25]

Results

The survey audience comprised 1005 nephrology fellows-in-training and recent graduates, 110 specializing in pediatric nephrology and 895 in adult. In total, 436 participated and 11 were censored for nonresponse, yielding 425 responses (response rate 42.3%). Overall, 68% (n=291) were current adult, pediatric, or adult/pediatric fellows (first years, n=56; second years, n=193; and third years or beyond, n=42), and 32% (n=134) recent graduates (98.5% in adult and 1.5% in adult/pediatric nephrology).

Respondent demographics (Table 1) were representative of adult and pediatric trainee populations per ACGME data.[26] Overall, participants were geographically representative of the US population by Census division. However, there are disproportionally more fellowship programs (35% of total) located in the Middle-Atlantic and New England divisions, leading to overrepresentation of these regions (24% and 9%, respectively). Participants were located in multiple states with high COVID-19 hospitalizations (mean 608–1075 hospitalized-patients/state per MMWR week during the survey period) (Figure 1, Supplemental Material II: Supplemental Figure 1).[27,28]

Table 1.

Characteristics of participating nephrology fellows and recent graduates

Characteristic	Current Fellows (n=291) a	Graduates (n=134) a
Fellowship, n (%)
Adult nephrology	230 (79)	132 (99)
Pediatric nephrology	57 (20)	0 (0)
Adult/pediatric nephrology	4 (1.4)	2 (1.5)
Educational status, n (%)
USMG	143 (49)	61 (46)
IMG	130 (45)	65 (49)
US IMG	18 (6)	8 (6)
Median age in yr (IQR)	32 (4)	33 (3)
Race, n (%)
White	124 (43)	51 (38)
Black	16 (6)	6 (5)
South Asian	80 (28)	40 (30)
East Asian	30 (10)	6 (5)
Southeast Asian	14 (5)	11 (8)
Pacific Islander	0 (0)	1 (1)
Multiple	6 (2)	4 (3)
Other	17 (6)	14 (11)
Ethnicity, n (%)
Hispanic	30 (10)	18 (13)
Sex, n (%)
Male	146 (50)	87 (65)
Female	145 (50)	46 (34)
Prefer not to answer	0 (0)	1 (0.7)
Citizenship status, n (%)
Native-born US citizen	129 (44)	55 (41)
Naturalized US citizen	42 (14)	27 (20)
Permanent resident	30 (10)	15 (11)
H-1, H-2, or H-3 visa (temporary worker)	23 (7.9)	17 (13)
J-1 or J-2 visa (exchange visitor)	64 (22)	19 (14)
Other visa	3 (1.0)	1 (0.7)
Median educational debt in US$1000s (IQR)	161 (257)	213 (298)

Percentages may not total 100% due to rounding.

Figure 1.

Respondent locations (circles) overlaid on a map showing cumulative patients with COVID-19 as of the survey open date (August 4, 2020). COVID-19 data from COVID-19 Data Repository by the Center for Systems Science and Engineering at Johns Hopkins University.

We first looked at COVID-19’s effect on educational conferences and patient rounding. The pandemic precipitated a massive shift in nephrology education. Before COVID-19, half of respondents had “never” or “rarely” used remote learning, but by the initial outbreak most conferences were entirely online (76% overall; fellows 74%; graduates 81%). Since the pandemic’s start, educational settings have evolved, with 22% of current fellows’ conferences a mix of online and small in-person groups (P<0.01, Fisher’s exact test) (Figure 2).

Figure 2.

Changes to nephrology conference settings for nephrology fellows and recent graduates during the COVID-19 era—ASN COVID-19 Fellow Survey.

Beginning March 6, 2020, telehealth access expanded under an 1135 Waiver that reimbursed telemedicine at the same rate as in-person patient visits.[29] Telehealth was adopted in a majority of nephrology consults for inpatients (52% of fellows and 56% of graduates seeing “some” or “all” patients via telehealth) and outpatients (91% and 90%, respectively) (Figure 3). Differing proportions of fellows and graduates using telehealth for “some” and “all” consults was observed; 44% of recent graduates managed all outpatients via telehealth compared with 15% of current fellows (P<0.01, Fisher’s exact test). Half of the 2020 graduates were withdrawn from outpatient dialysis services versus 13% of current fellows. Respondents observed the increase in telehealth volume had reduced the outpatient missed-appointment rate.

Figure 3.

Telehealth utilization by patient care setting for nephrology fellows and recent graduates in the COVID-19 era—ASN COVID-19 Fellow Survey. *Fisher's exact test, P<0.01.

Most participants (64%) did not consult on COVID-19 inpatients in person. Rather, these patients were managed entirely by telehealth (27%), by attending faculty in person without fellows (29%), or with another approach (9%). Only 36% said both attending faculty and fellows comanaged patients with COVID-19 in person (Figure 4) (see Supplemental Material III: Supplemental Tables 1–4 geographic variation in rounding and management of patients with COVID-19). Adoption of management approaches for patients with COVID-19 were similar between recent graduates and current fellows. “At the very beginning, I saw all patients with COVID and refused to allow my attendings to accompany me [because I felt I was safer] as I was younger and double exposure was stupid,” one fellow said. “Now the process is mostly one exam early in the admission, with mostly virtual care afterwards with further exams only when clinically relevant.” Respondents said the preferred management strategy for patients with COVID-19 was telemedicine in concert with the primary care team’s assessment, unless an in-person dialysis-access or patient-volume evaluation was required.

Figure 4.

Management approaches used for inpatients who were COVID-19 positive—ASN COVID-19 Fellow Survey.

Beyond telemedicine, fellows reported implementing iPad rounding, team collaboration on Doximity, and visual patient inspection behind glass or using intensive care unit (ICU) video feeds when consulting on patients with COVID-19 in isolation. Emergent peritoneal dialysis for patients with COVID-19 in the ICU and with kidney failure was among the dialysis modalities respondents used to manage the early 2020 surge in the volume of patients with COVID-19. Other modalities included sustained low-efficiency dialysis, prolonged intermittent RRT, shared continuous RRT (1 day on and 1 day off), and in-room dialysis. In total, 47 fellows (11%) were redeployed, mainly to either the general medicine inpatient service or ICU.

Despite the many pandemic-influenced modifications in educational modalities and patient care approaches that trainees experienced, most indicated the changes had minimal effects on their professional development. Although a quarter of respondents perceived their case variety and clinical experiences (24%), preparation for board certification (25%), and ability to complete research (28%) had been impaired by the pandemic, fewer said their knowledge base (13% indicating “worse” or “much worse” since the start of the pandemic) or readiness for unsupervised practice (15%) had been negatively affected. Whereas 24% overall said their career goals and trajectory were adversely affected by the pandemic, less than one fifth of those preparing to enter practice (second-year adult or third-year pediatric fellows) reported their job search was complicated regarding geographic location (17%) or practice setting (14%). In total, 18% said COVID-19 worsened their ultimate job selection process, and 37% of graduates had difficulty finding a nephrology position they were satisfied with, most of whom were IMGs (72%). Yet, one third of respondents felt their mentor relationships and sense of community within their training program had improved (“better” or “much better”) since the COVID-19 pandemic began (Figure 5).

Figure 5.

Effects of the COVID-19 pandemic on facets of professional development—ASN COVID-19 Fellow Survey. Prac., practice; Prep, preparation.

Regarding perceptions of professional development, most fellows (84%) and graduates (82%) “agreed” or “strongly agreed” that their fellowship programs were successful in sustaining their education during the pandemic (mean 4.2±0.9; median 4; IQR, 1; scale of 1–5 where 1 is “strongly disagree” and 5 is “strongly agree”). Most respondents—86% of fellows and 90% of graduates—perceived themselves as prepared for independent practice on conclusion of their fellowship4. Most fellows and graduates (87%) would recommend nephrology to medical students and residents, up 9% from the 2019 ASN fellow survey.[20]

Of the 412 who completed the RWBI, 15% met the distress threshold (RWBI score ≥5)—16% of current fellows (n=46) and 12% of graduates (n=15) (chi-squared test for independence, P=0.28). The proportion of respondents meeting the RWBI distress threshold (15%) and mean RWBI score observed (2.04±2.03) was lower than the original RWBI validation cohort of 1700 residents and fellows (20% and 2.64±1.98, respectively).[21] Median RWBI scores (overall median RWBI score 2; IQR, 3) were similar between adult (2; IQR, 3.25) and pediatric (2; IQR, 4) fellows, but slightly higher for women (2; IQR, 4 versus 1; IQR, 3 for men) and USMGs (2; IQR 4, versus 1; IQR, 3 for IMGs). Univariable and multivariable analyses found no significant associations between any demographic variables and an RWBI score meeting the distress threshold (P≥0.06) (Table 2), which could be due to substantial class imbalances in some subgroups. However, there was an increased risk for the distress threshold outcome (RWBI ≥5) in respondents who perceived the pandemic had impaired their knowledge base (OR, 3.04; 95% CI, 2.00 to 4.77), board certification preparation (OR, 2.17; 95% CI, 1.54 to 3.12), or career trajectory (OR, 2.02; 95% CI, 1.42 to 2.93) (all univariable logistic regression). Those perceiving their program had not sustained their education were also at increased distress risk (OR, 2.03; 95% CI, 1.53 to 2.72) (Table 3).

Table 2.

Association of distress (RWBI score ≥5) with demographic characteristics of nephrology fellows and recent graduates

Demographic Characteristic	Univariable a				Multivariable a
	N	OR	95% CI	P value	OR	95% CI	P value
Sex	412
Male		—	—		—	—
Female		1.48	0.86 to 2.56	0.16	1.76	0.95 to 3.28	0.072
Race	407
White		—	—		—	—
Black		1.47	0.40 to 4.39	0.52	1.79	0.46 to 5.74	0.35
East Asian		0.42	0.06 to 1.51	0.25	0.38	0.06 to 1.49	0.22
Multiple		0.69	0.04 to 3.95	0.73	0.51	0.03 to 3.33	0.55
Other		1.30	0.41 to 3.51	0.62	1.20	0.31 to 3.90	0.77
Pacific Islander		0.00		0.99	0.00		>0.99
South Asian		1.38	0.72 to 2.62	0.32	1.68	0.80 to 3.55	0.17
Southeast Asian		0.89	0.20 to 2.85	0.86	1.14	0.24 to 4.16	0.85
Hispanic ethnicity	411
No		—	—		—	—
Yes		1.98	0.91 to 4.05	0.071	2.50	0.95 to 6.27	0.054
Educational status	412
USMG		—	—		—	—
IMG		0.94	0.53 to 1.65	0.83	0.64	0.33 to 1.23	0.18
US IMG		1.02	0.28 to 2.89	0.98	0.44	0.09 to 1.50	0.23
Fellowship	412
Adult		—	—		—	—
Adult/Pediatric		0.00		0.99	0.00		0.99
Pediatric		0.78	0.31 to 1.72	0.57	0.52	0.17 to 1.45	0.23
Training yr	412
1st		—	—		—	—
2nd		1.48	0.65 to 3.83	0.38	1.21	0.50 to 3.30	0.69
3rd		1.14	0.34 to 3.73	0.82	0.92	0.23 to 3.58	0.91
Graduate		0.90	0.36 to 2.49	0.83	0.66	0.23 to 1.95	0.43

N, number of complete responses; —, reference level.

Logistic regression.

Table 3.

Association of worsening perceptions of professional and personal factors with distress (RWBI score ≥5) among nephrology fellows and recent graduates

Factor	N	OR a	95% CI	P value
Nephrology education
Knowledge base	411	3.04	2.00 to 4.77	<0.001 b
Board certification preparation	410	2.17	1.54 to 3.12	<0.001 b
Variety/breadth of clinical experiences	411	1.11	0.80 to 1.55	0.54
Ability to complete/advance research	411	1.23	0.91 to 1.68	0.18
Program successfully sustaining education during pandemic	392	2.03	1.53 to 2.72	<0.001 b
Career preparation
Focusing career trajectory	411	2.02	1.42 to 2.93	<0.001 b
Job search location	356	1.56	1.07 to 2.28	0.020
Job search setting	355	1.37	0.91 to 2.07	0.13
First postfellowship job selection	129	1.89	0.98 to 3.67	0.057
Preparedness for unsupervised practice	412	1.68	1.15 to 2.51	0.010
Professional relationships
Sense of community within training program	409	1.22	0.91 to 1.64	0.19
Relationships with mentors	409	1.09	0.79 to 1.52	0.60
Personal life experiences
Relationships with family	411	2.34	1.64 to 3.42	<0.001 b
Relationships with friends	412	1.97	1.39 to 2.87	<0.001 b
Work-life balance	412	3.16	2.18 to 4.71	<0.001 b
Overall quality of life	412	3.47	2.29 to 5.46	<0.001 b

N, number of complete responses.

Logistic regression.

P<0.01.

In contrast to the occupationally focused RWBI assessment, a higher percentage of respondents reported that training in the COVID-19 era took a toll on their personal lives. One third (33.1%) said their work-life balance and 42% their overall QOL was negatively affected (“worse” or “much worse” since the pandemic began; scale of 1–5 where 1 is “much better” and 5 is “much worse”) (Figure 6). This may have been exacerbated for the 13% of respondents reporting living with an individual at high risk for COVID-19 morbidity or mortality. On univariate analysis, all personal life factors examined were associated with an outcome of higher risk for distress. These adverse relationships included an increasingly poorer QOL or work-life balance associated with a three-fold higher risk of meeting the distress threshold outcome (RWBI ≥5) (OR, 3.47; 95% CI, 2.29 to 5.46, and OR, 3.16; 95% CI, 2.18 to 4.71, respectively). Worsening family relationships (OR, 2.34; 95% CI, 1.64 to 3.42) and friend connections (OR 1.97; 95% CI, 1.39 to 2.87) were also associated with an increased risk for a distress outcome.

Figure 6.

Effects of the COVID-19 pandemic on facets of trainees’ and graduates’ personal life—ASN COVID-19 Fellow Survey.

Discussion

Our nationally representative study of current (2020–2021) nephrology fellows and recent (2020) graduates’ training during the COVID-19 pandemic found a rapid uptake of telehealth and virtual learning on the pandemic’s onset. Two thirds of inpatient-assigned nephrology fellows did not perform in-person consults on patients with COVID-19. Despite these potentially disruptive changes, most respondents said their fellowship program was successful in continuing their education and most perceived themselves as prepared for independent practice upon completion of fellowship. The pandemic complicated respondents’ career trajectories, with 29% of graduates changing their plans due to limited employment opportunities, 37% having difficulty in finding a satisfactory position, and 18% noting COVID-19 complicated their ultimate job-selection process. A total of 15% of respondents met the distress threshold (associated with a four-fold greater burnout risk). Those who perceived the pandemic had made it difficult to maintain their knowledge base or had contributed to a poorer overall QOL, worsened work-life balance, or deteriorated personal relationships with friends and family were at higher risk for having an RWBI ≥5.

Regardless of discipline, there has been rapid adoption of distance learning in graduate medical education.[30-39] Virtual learning can be quickly adopted for didactics and scaled to meet demand. Henderson et al. [33] used an online platform to provide instruction for attending physicians at the pandemic’s onset, helping prepare faculty for redeployment outside their specialty. Yet, distance learning cannot replace the inpatient clinical experience and in-person exposure necessary for procedural competence.[34,35] Although lecture recordings are commonly used in medical schools, whether synchronous virtual learning in graduate medical education is as effective as in-person instruction in terms of attention, retention, and interaction is unknown, and should be studied. Clinical restrictions (e.g., removing fellows from dialysis service) may affect fellows’ progress to unsupervised practice and procedural competence given nephrology fellowship’s 2-year training window.[31,34,39] Similarly, with the pandemic’s course uncertain, it is unknown how programs can address staffing and educational demands if the management approaches reported in our study—shifting COVID-19 consults to telehealth or away from fellows to attendings—are continued.

One quarter of respondents said the pandemic had negatively affected their clinical experiences, board preparation, and research, lower than the 69% of cardiology fellows concerned about completing requirements.[36] Yet, most respondents perceived themselves as prepared for unsupervised practice on fellowship completion (fellows 86%; graduates 90%). This perception is not an objective measure of respondents’ true state of preparedness but may reflect programs’ successes in advancing their trainees to independent practice. In total, 84% believed their program had sustained their education during the pandemic, although substantial challenges remain. Fellows training in New York City saw their academic activities put on hold as they suddenly found themselves overwhelmed by COVID-19 in March 2020, and such disruptions may continue to recur on the basis of local positivity rates.[40] Whereas 11% of respondents were redeployed, this is lower than other subspecialty trainees and may change.[37] This situation could complicate fellows’ progress through their ACGME Milestones. Impairments to advancing their research reported by 28% in our study will likely remain in the near term in both the bench and clinic, as institutions prioritize safety measures for laboratory staff and patients.[38,41,42] However, the unexpected increase in respondents recommending nephrology (87% versus 72%–80% observed in 2014–2019)[20] may reflect the esprit de corps of a specialty on the front lines of a pandemic response.[35,40,43]

Respondents reported a broad adoption of telehealth in their fellowships to comply with social distancing and other safety requirements. Telehealth has been effective in providing nephrology care to patients in sparsely populated regions of the United States and Australia, where geographic distance is a barrier to accessing specialized care.[44] It can also help improve access for those with limited resources for travel and/or high disease burden and reduce barriers to the adequacy of disease management.[45] Although initial literature has shown comparable educational efficacy in medical school electives and clerkships,[46,47] it is unknown if telehealth can provide clinical experiences as effective as in-person interactions needed in graduate medical education.[48] Of the other new patient care approaches reported by fellows, the use of acute start peritoneal dialysis to manage patients with COVID-19 has also been reported in the literature.[49-51]

Our finding that a lower proportion of respondents met the threshold for distress than in the RWBI instrument’s validation cohort was unexpected. The observed prevalence was also lower than reported in other subspecialty fellows (50% of intensivist trainees screened positive for depression),[52] global residents/fellows (burnout range 39%–66%),[53] or health care workers in the COVID-19 pandemic (anxiety range 23.2%–44.6%; depression range 22.8%–50.4%).[9,10] The lower rate could be attributable to our survey frame, which comprised adult and pediatric fellows, the latter of whom have experienced lower volumes of patients with COVID-19 and demonstrated lower distress prevalence (13% versus 15% for adult fellows). With the substantial personal risk health care providers face in the pandemic, coupled with the fear of COVID-19 infection and transmission to their families, we anticipated a higher proportion of respondents would meet the distress threshold, especially given 13% lived with a family member at high risk for COVID-19 morbidity or mortality.[35] Although fellows’ health could also affect QOL and distress threshold, questions about personal risk status were excluded due to their sensitive nature. An RWBI ≥5 correlates with a four-fold increased burnout risk, yet our observed proportion of distress (15%) was substantially lower than the 30% of nephrology fellows meeting the Maslach Burnout Inventory criteria in a prepandemic survey.[19,52,53] Although the RWBI is a composite measure of physician distress that correlates with burnout and other factors, it may not be a directly comparable to the Maslach Burnout Inventory or other assessments.[52,53]

There were no significant associations between demographic variables and meeting the distress threshold. Although this may be due to the small numbers of respondents in demographic subgroups, it is possible distress is such a unique personal experience, it cannot be identified by such coarse demographic variables alone. The uneven geographic distribution and timing of virus surges could also account for the lower distress rate in aggregate. An increased sense of unity born from adversity in addressing a global pandemic[40] and the prominent role nephrologists have played leading to an increase in the perceived value of the specialty may also be factors. The improvements in sense of community and mentor relationships observed in our study may also contribute an ameliorating effect.

Despite the comparatively low level of occupational stress we observed, respondents reported higher incidences of personal stress that were adversely related to an outcome of meeting RWBI’s distress threshold. Because we chose not to ask detailed questions about home life and family structure, our measures assessing pandemic-related effects on personal life may not be sufficiently granular or comprehensive to accurately determine their contributions to distress risk. The prevalence of graduates having difficulty finding a satisfactory position (37%) was within the range observed in previous surveys (38%–61%), as was the higher proportions of IMGs (72%) experiencing adversity in their job search.[54] This is concerning, because IMGs comprise the majority of nephrology fellows—and internal medicine residents—and make important contributions to the US health care system. Furthermore, our survey was performed relatively early in the pandemic, and it is likely the continued personal and professional stresses of the pandemic will cause the level of burnout to increase as further surges occur. Continuing to monitor fellows for signs of distress should be a priority for training programs.

Our study has several limitations. Participants were representative of nephrology fellowship locations and demographic variables, yet our results may not be representative of those who were invited but did not participate, and thus may not generalize to the fellow or recent graduate population as a whole. This gap may have been exacerbated by the study’s emotionally sensitive topic area, inaccuracies in contact information, and survey invitations filtered by institutional firewalls. Although the survey was distributed 6 months after the initial COVID-19 surge in the United States, the results could still be tainted by recall bias. This likely accounts for some of the differences between graduates and current fellows on some responses. However, we cannot be certain that fellows working in regions with high hospitalization rates for patients with COVID-19 during the survey administration were less likely to experience recall bias. “Telehealth” was also not defined across patient care settings, which may lower the reliability of our results. Specifically, it is unknown how these items were interpreted and whether they accurately captured the mode of interaction for each setting. Finally, this study largely assesses fellows’ perceptions of their training. We cannot infer their true readiness for independent practice on the basis of these data. This study was not designed to assess evolution of modalities such as telehealth and remote learning over time. However, these data provide critical insight for designing future studies to measure the effectiveness of remote-learning modalities and telehealth.

This study also has several strengths, including the robust response rate, especially during the course of a pandemic when physicians’ time demands are intensified. Our response rate (42%) is higher than some other physician web-based surveys, which can be 10% lower than for the general public.[55,56] The survey was also timed to reduce recall bias among respondents who experienced the initial COVID-19 surge in March/April 2020 and be completed before flu season and anticipated surge coincident with seasonal changes. Finally, our study was nationally representative of current nephrology fellowship program locations and demographics.[26]

Our results indicate nephrology fellowships and their sponsoring institutions should closely monitor their trainees for distress and ensure they have access to adequate support infrastructure. Agrawal et al. [19] outlined strategies to address burnout, including faculty awareness, curricula on emotional wellbeing and communication skills, and providing access to mental health resources, especially as the pandemic’s path—and duration—remain unknown. Although 34% of respondents indicated their sense of community within their fellowship had improved since the pandemic began, and has brought forth a sense of unity among fellows, attendings, and allied professionals, strategies to bolster this esprit de corps should be implemented. Programs must continue to balance the needs for safety, service, and education, which will allow fellows to develop a foundation of clinical competency, institutions to fulfill their clinical missions, and the field of nephrology to advance through the scholarly and service work of fellows.

Disclosures

K.A. Pivert reports having an ownership interest in iShares Gold Trust ETF and is an employee of the American Society of Nephrology. H.H. Shah is an editorial board member of the American Journal of Therapeutics. J.S. Waitzman’s spouse is an employee of Takeda Pharmaceuticals. L. Chan reports receiving research funding from National Institutes of Health. S.M. Halbach reports honoraria from Horizon Therapeutics; and Other Interests/Relationships with UpToDate. All remaining authors have nothing to disclose.

Funding

L. Chan is supported by National Institutes of Health award K23DK124645. J.S. Waitzman is supported by National Institutes of Health award T32 DK007199 and by a Ben J. Lipps Research Fellowship from the American Society of Nephrology.