Effect of COVID-19 on training and mental health of oral medicine residents in North America.

OBJECTIVE: The objective of this study was to assess resident and faculty perception of the effect of the coronavirus disease 2019 pandemic on the training experience, education, and psychological well-being of oral medicine (OM) residents. STUDY
DESIGN: An anonymous 16-item online questionnaire was e-mailed to faculty and residents of all Commission on Dental Accreditation-accredited OM residency programs in North America. Survey questions asked about the pandemic's effect on resident educational, clinical, and research activities and the well-being of the residents. Survey data were collected using Qualtrics XM.
RESULTS: Forty participants (52.5% residents and 47.5% faculty members) responded to the survey. Regarding the effect on clinical activities, 67.5% reported 50% or less reduction in patient volume seen by residents at its worst during the pandemic. With respect to educational activities, most reported a complete switch of didactic training (85.3%), academic examinations (60%), and off-site resident rotations (45%) to a virtual platform. Research activities were affected the most; 55% reported complete cessation for some time. Thirty-three percent perceived a negative effect, 18% perceived no effect, 11% perceived a positive effect, and 38% were unsure regarding the effect of coronavirus disease 2019 on resident morale. Despite the interruptions in the clinical, research, and educational activities, 62.5% expected on-time resident graduation.
CONCLUSION: Despite constraints due to the pandemic, OM residency programs successfully continued clinical activities, didactic training, and research productivity through virtual means and a hybrid delivery care model while supporting their residents' morale.

The oral medicine residency programs of North America demonstrated resiliency amidst the pandemic through adoption of a hybrid patient care model and virtual education platforms that ensured successful continuity of residents’ didactic, clinical, and research training while supporting their morale.

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The recent coronavirus disease 2019 (COVID-19) pandemic has had a significant effect on oral health services and clinical education, in part because these entail working in close proximity to oral secretions and the use of aerosol-generating devices. , Additionally, strict isolation strategies such as social distancing and stay-at-home orders affected the delivery of patient care and clinical and didactic training and adversely affected faculty and trainees’ mental health and well-being.2, 3, 4, 5

At the beginning of the pandemic, in order to limit severe acute respiratory syndrome coronavirus 2 transmission and also to conserve personal protective equipment for those on the frontline offering medical care to patients severely affected by COVID-19, the American Dental Association recommended most dental education institutions limit dental services to emergency care only. , In contrast to general dental practice, the specialty of oral medicine (OM) is the discipline of dentistry primarily entailing diagnosis and management of oral mucosal abnormalities as well as oral manifestation of systemic and infectious diseases and thus does not routinely involve aerosol-generating procedures. To maintain continuity of care, several OM practices were successful in adopting a hybrid model with telemedicine services and the provision of in-person visits when necessary. ,

In most postgraduate dental residency programs, didactic activities transitioned to virtual academic sessions, national educational/research conferences were postponed or canceled, and the procedure of standardized examinations was modified to adopt remote technology. , The disruption of educational activities, the challenge of training in an uncertain environment of constantly evolving quarantine, patient care and travel guidelines along with sudden social isolation, and fear of contracting the virus/fear of infecting family members may have also affected resident psychological well-being. The actual effect and degree to which these restrictions affected OM programs are largely based on anecdotal experience from a single institution or a small groups of institutions. The aim of this study was to assess the effect of the COVID-19 pandemic on the training experience, education, and psychological well-being of OM residents. Specifically, we investigated the experiences and perceptions of the residents and the faculty members from all Commission on Dental Accreditation (CODA)–accredited OM residency programs in North America during the COVID-19 pandemic.

Materials and Methods

Study population

We conducted a survey-based study to assess resident and faculty perceptions of the effect of the COVID-19 pandemic on the training, education, and well-being of residents in the CODA-accredited OM residency programs in North America. This study was approved by the Massachusetts General Brigham Institutional Review Board (Protocol No. 2020P003806).

Survey instrument and data collection

A 16-item online survey questionnaire was developed using Qualtrics XM (Seattle, WA). The survey was e-mailed to the faculty and residents of CODA-accredited OM residency programs in North America. To maintain anonymity, no identifiers, including the Internet protocol address of the participants, were collected. All participants gave their implied consent through participation in the study. The survey was open from January 23, 2021, through April 23, 2021.

The study endpoints included the evaluation of the pandemic's effect on the education (both clinical and didactic) of the OM residency programs and its perceived effect on the mental well-being of the residents. Questions asked about the demographic characteristics of the respondents; characteristics of the OM residency programs; faculty member/resident perceptions of the effect on resident educational, clinical, and research activities; and overall well-being of the residents. Some questions allowed for free-text answers. The detailed survey questionnaire is available in Appendix SI.

Data analysis

Descriptive statistics, including quantitative analysis of the valid responses, were analyzed. For the multiple-choice questions, the missing responses were omitted and the valid responses were included in the final sample for that question; as a result, the total sample/n varied for different questions. For the free-text answer questions, the content of each response was reviewed and summarized.

Results

Respondents’ characteristics

A total of 40 individuals (52.5% residents and 47.5% faculty members) from CODA-accredited OM programs in North America responded to the online survey. Most of the participants belonged to a dental school–based OM program vs a hospital-based setting (57.5%; n = 23). Most respondents were from programs had 4 to 6 residents (40.0%; n = 16), followed by larger programs with 7 to 9 residents (37.5%; n = 15) and smaller programs with 1 to 3 residents (22.0%; n = 9) (Table I ).

Table I

Demographic characteristics of 40 survey respondents and their oral medicine programs

Demographic characteristics (N = 40)	n	Percentage
Role in the programProgram directorFacultyResident PGY-1 levelResident PGY-2 levelResident PGY-3 level or higher	7121065	17.530.025.015.012.5
Training environment of the programDental school settingHospital-based settingOther	23161	57.540.02.5
Program size1-3 residents4-6 residents7-9 residents	101614	25.040.035.0

PGY, Postgraduate Year.

Effect on resident educational, clinical, and research activities

Most of the respondents (67.5%; n = 27) reported <50% reduction in the patient volume seen by their residents (including both in-person and virtual consultations) at its worst during the pandemic. At no point was there a total interruption in clinical activity in any of the programs (Table II ). By April 2020, didactic training was switched to a virtual platform by most of the respondents’ residency programs, with 85.3% (n = 35) reporting a complete switch, 10% (n = 4) reporting a partial switch, and only 2.5% (n = 1) declining the shift to a virtual platform as didactics continued in person. A similar trend was seen in the administration of academic examinations. In lieu of social distancing, 60% (n = 24) of respondents reported shifting of all academic examinations/assessments to a virtual platform, 32.5% (n = 13) reported a hybrid model of both virtual and in-person examinations, and 7.5% (n = 3) reported no change in the process of in-person examinations (Table II).

Table II

Effect of the COVID-19 pandemic on residents’ educational, clinical, and research activities

Effect on resident activities (N = 40)	n	Percentage
Didactic activitiesRemain unchanged, continue in-personConducted partially in-person and partially through virtual platformCompletely switched to virtual platformOn hold indefinitely	14350	2.410.085.30.0
Academic examinations and assessmentsRemain unchanged and continue in-personConducted both in-person and virtuallyConducted through a virtual platform onlyOn hold indefinitely	313240	7.532.560.00.0
Clinical activitiesRemain unchanged, continue in-personResidents involved in both in-person and telehealth consultationsResidents involved in telehealth consultations onlyResidents not assisting with clinical activities	73300	17.582.50.00.0
Reduction in patient volume seen by residents (at worst)No reduction in clinical patient interactionsDecrease in <50% of clinical patient interactionsDecrease in 51%-75% of clinical patient interactionsDecrease in >75% of clinical patient interactions	62734	15.067.57.510.0
External rotationsRemain unchanged, continue in-personConducted partially in-person and partially through virtual platformCompletely switched to virtual platformOn hold indefinitely	172183	42.55.045.07.5
Research activitiesRemain unchangedHeld for some period but resumed nowDelays in research activitiesOn hold indefinitely	622120	15.055.030.00.0

COVID-19, coronavirus disease 2019.

Whereas 55% (n = 22) of participants, including 9 of 19 faculty members and 13 of 21 residents, reported a halt in resident research activities for some time with subsequent resumption, 30% (n = 12; 5/19 faculty, 6/21 residents) continued to report delays in the research activities at the time the survey was completed. With respect to the external/off-site resident rotations, 7.5% (n = 3) reported an indefinite hold, 42.5% (n = 17) reported continued in-person external rotations, and 45% (n = 18) reported completing off-site rotation requirements through virtual platforms (Table II). Despite the interruptions in the clinical, research, and educational activities, 62.5% (n = 25; 10/19 faculty, 15/21 residents) expected on-time graduation of the residents and the remaining cohort either expected a delay in graduation or was unsure (Figure 1 ). Of the 10 respondents who were unsure of the timely graduation of the residents, half witnessed a <50% reduction in patient volume and the other half reported a 50% to 75% reduction in patient volume. On the other hand, the reduction in patient volume was found to be variable for the 5 respondents who perceived a delay in graduation.

Fig. 1

Perception of the coronavirus disease 2019 pandemic's effect on resident graduation.

Perceived effect on resident morale

When asked about the effect of COVID-19 on the morale of the residents, 38% (n = 15) of the respondents expressed uncertainty and 33% (n = 13) acknowledged a negative effect of the pandemic (Figure 2 ), with a mean negative effect score of 3.75 (on a 1-10 sliding scale, where 1 denotes a minimal effect and 10 denotes the maximal effect). Among factors negatively influencing resident morale, the fear of loved ones contracting the COVID-19 virus ranked the highest (27.6%), followed by the fear of residents contracting the virus (21%) and the feeling of isolation (17%) (Table III ). The 3 most common factors positively influencing resident morale during the pandemic included the support of fellow residents (25.4%); support of family, friends, or community (23.5%); and support and guidance from the program's leadership (19%; Table III). Most of the respondents (57.5%; n = 23) indicated adequate resident access to mental health resources, 10% (n = 4) reported limited access, 2.5% (n = 1) reported no access, and 27.5% (n = 11) expressed uncertainty. Among the mental and well-being resources available to the residents, virtual counseling services were the most predominant (Figure 3 ).

Fig. 2

Perception of the coronavirus disease 2019 pandemic's effect on resident morale.

Table III

Factors influencing resident morale during the COVID-19 pandemic (respondents selected all that apply; total responses = 76)

Survey choices (option of multiple selections) (N = 76)	No. of responses	Percentage
Factors negatively influencing resident moraleFear of contracting the virusFear of loved ones contracting the virusFeeling of isolationFinancial insecurityLack of guidance from departmental leadershipFear of hiring freeze for graduating residentsOther (free-text response)Priority of vaccination given to medical residents instead of dental residentsLower quality of trainingClosed librariesChanging research projects	1621139584	21.027.617.111.86.510.55.2
Factors positively influencing resident moraleSupport of family, friends, or communitySupport and resolve of fellow residentsSupport and guidance from program leadershipInternal motivation to lead in difficult timesEfforts at maintaining personal well-beingOther (free-text response)Sense of mission and teamwork	24262016151	23.525.419.615.614.70.9

COVID-19, coronavirus disease 2019.

Fig. 3

Mental health and well-being resources available to residents during the coronavirus disease 2019 pandemic.

Discussion

In this study, we report on the effect of the COVID-19 pandemic on training experiences and the perceived mental well-being of OM residents across North America. Quarantine restrictions imposed to limit virus transmission during the pandemic led to a substantial decrease in patient visits to OM clinics in hospitals, dental schools, and private practice settings. , A multicenter study conducted to evaluate the effect of the COVID-19 pandemic on cancer center–based OM practices in Brazil, Canada, and the United States showed a 51.5% reduction in patient volume in hospital-based OM clinics. Our study also showed a decline, with 67% of respondents indicating a 50% or less reduction in patient volume seen by residents.

Amidst the challenge of maintaining regular OM services while limiting the risk of exposure to COVID-19, OM programs across North America were relatively quick to shift to a virtual platform for carrying out most patient-related activities. , This shift provided residents with the opportunity to continue to be actively involved in the patient history intake/interview process (including obtaining a history of present illness and past medical history) and to contribute to patient workup (including virtual examination, arriving at a differential diagnosis, and formulation of an appropriate treatment plan, where possible). In comparison to other dental specialties, it may have been more feasible for OM to adapt to telehealth principally because the patient interview for diagnosis and management of conditions such as dry mouth, burning mouth syndrome, or craniofacial pain remains the same. However, for conditions involving soft tissue or tooth pathology, the virtual clinical examination process may be suboptimal, impeding the ability of the residents to learn the necessary skill of comprehensive tactile assessment. , Moreover, patients may still require in-person procedures for definitive diagnosis, including biopsies of oral mucosal conditions.

A hybrid model of patient care (combination of telemedicine and in-person consultation) was adopted, and 82% of our study respondents reported continuous active involvement of residents in both telehealth and in-person consultations. Telehealth allowed for continuity of patient care, the ability to triage and prioritize patients’ needs, and continuation of resident clinical activities without complete cessation at any point during the pandemic. ,

The COVID-19 pandemic led to significant changes in didactic training and examination practices in the medical and dental education curriculum through embarkment on virtual academic platforms. , Our survey results showed a similar shift in the OM academic training, with 85% of the respondents reporting a complete switch of the didactics to virtual platforms, mainly by March to April 2020. One of the advantages of virtual didactic training included inviting expert guest speakers from across the globe and recording lectures/conferences. A study conducted to evaluate the effectiveness of webcast lectures in comparison to live lectures in medical education showed that medical students in the 2 groups performed equally on the written examination but those in the webcast group performed better in the objective structured clinical examination tests, indicating that lectures given through virtual platforms may be equally or more effective than live lectures. However, the virtual didactic courses cannot replicate certain important facets of traditional classroom format such as in-person class discussions and the development of interpersonal connections. The virtual learning platform may have its fair share of pros and cons, but it appears that the virtual didactic training in part made it possible for residents to potentially meet their graduation requirements. This is evident from our survey results indicating that the majority felt that the pandemic would not interrupt the timely graduation of the residents, a result similar to that of an observational study on COVID-19 pandemic's effect on medical residents within the Western Connecticut Health Network.

The aspect of OM resident training that appeared to be most affected by the pandemic was residents’ research activities (lab-based experiments, clinical research, electronic health records, thesis submission, defense, etc.). There were delays and interruptions in the research activities, with more than half of our study respondents reporting complete cessation of research activities for some period. Changing research projects possibly because of feasibility issues also seemed to be a factor negatively affecting resident morale. The development of quality virtual learning experiences and remote research practices including virtual research meetings may be one of the important considerations for many OM residency programs during the pandemic.

Several studies have shown negative economic, social, and psychosocial effects on dental residents. , , The qualitative survey questions also sought to determine the effects on OM resident morale and mental well-being. One-third of respondents perceived diminished resident morale due to the pandemic. The most substantial concern included the risk of being exposed to the COVID-19 virus, especially the fear of a loved one contracting the virus, a concern that was also shared by residents of other dental specialities. , Support, on the other hand, appeared to be an important factor for resident well-being during the pandemic. Residents felt supported by their fellow residents (25.4%), by loved ones and community (23.5%), and by their program leadership (19.6%). An internal motivation to lead in difficult times (15.6%) and efforts at maintaining personal well-being (14.7%) positively influenced morale. It was surprising to note, however, that 38% of our survey respondents expressed uncertainty about the effect of COVID-19 on residents’ morale, which could potentially reflect a lack of open discussion of mental health issues between residents and faculty members due to the associated stigma. Regular, transparent communication between program leadership, faculty, and residents is important in decreasing stress during difficult times such as during a pandemic. ,

The importance of psychological support to health care workers during the pandemic has been well documented. , Our survey showed widespread access of OM residents to mental health resources, self-care, fitness services for residents, including counseling services, virtual individual/group fitness resources (e.g., subsidized/free membership to fitness websites, institutional fitness resources, etc.), and virtual social interactions, but it is interesting to note that one-fifth of respondents were not aware of these available psychosocial support resources. These survey results reinforce the need for increased awareness in residency programs about available psychosocial support programs.

There are some limitations to this study. Firstly, because the survey was voluntary, the results may not be generalizable for all residents across all OM residency programs. Nevertheless, this study includes responses from every experience level of residency programs and may reflect the views of a representative sample. Secondly, as with any survey-based study, it may be subject to response bias. Residents who responded may have felt more strongly about the effect on their training experience during the pandemic. Lastly, this survey did not collect the geographic location of the respondents, so it is not feasible to make any inference about the pandemic's local severity effects.

Conclusion

Herein, we report on faculty and residents’ perceptions of the effect of the COVID-19 pandemic on the educational, training, and research experiences of residents enrolled in OM residency programs in North America. Despite constraints, the pandemic provided an opportunity for faculty, residents, and the program leadership to continue clinical activities, didactic training, and research productivity through virtual means and a hybrid delivery care model while maintaining resident morale through resources, support, and sense of comradery within the residency program.