Impact of COVID-19 on Hematology-Oncology Trainees: A Quantitative and Qualitative Assessment.

PURPOSE: Graduate medical and research training has drastically changed during the COVID-19 pandemic, with widespread implementation of virtual learning, redeployment from core rotations to the care of patients with COVID-19, and significant emotional and physical stressors. The specific experience of hematology-oncology (HO) fellows during the COVID-19 pandemic is not known.
METHODS: We conducted a mixed-methods study using a survey of Likert-style and open-ended questions to assess the training experience and well-being of HO fellows, including both clinical and postdoctoral trainee members of the American Society of Hematology and ASCO.
RESULTS: A total of 2,306 surveys were distributed by e-mail; 548 (23.8%) fellows completed the survey. Nearly 40% of fellows felt that they had not received adequate mental health support during the pandemic, and 22% reported new symptoms of burnout. Pre-existing burnout before the pandemic, COVID-19-related clinical work, and working in a primary research or nonclinical setting were associated with increased burnout on multivariable logistic regression. Qualitative thematic analysis of open-ended responses revealed significant concerns about employment after training completion, perceived variable quality of virtual education and board preparation, loss of clinical opportunities to prepare for independent clinical practice, inadequate grant funding opportunities in part because of shifting research priorities, variable productivity, and mental health or stress during the pandemic.
CONCLUSION: HO fellows have been profoundly affected by the pandemic, and our data illustrate multiple avenues for fellowship programs and national organizations to support both clinical and postdoctoral trainees.

INTRODUCTION

The COVID-19 pandemic dramatically altered postgraduate medical and research training, with rapid changes to educational and clinical environments and professional development opportunities. Beginning in March 2020 with the widespread implementation of social distancing, graduate medical education (GME) programs turned to virtual education via video conferences to continue core didactic lectures.[1-4] Many clinics and consult services converted to telehealth teams to minimize direct patient contact and potential spread of COVID-19.[5,6] Elective surgeries were indefinitely delayed and resulted in a precipitous drop in surgical resident case volume,[7] with one study of trainees in New York City finding a 74% decrease in cases at the height of the pandemic.[8] Trainees in COVID-19 hotspots across the country were removed from their regular rotations and redeployed to the care of patients with COVID-19.[8,9]

In parallel, hematology and oncology (HO) research groups experienced reduced staffing capacity, laboratory shutdowns, lost research animal colonies, funding limitations, and travel restrictions. In response to the drastic changes in training during this public emergency, the American College of Graduate Medical Education developed a Three Stages guidance statement, which loosened or suspended several core program requirements.[10] Per the statement, postgraduate training requirements that remained in place included adequate resources and training, adequate supervision, work hour requirements, and fellows functioning in their core specialty. However, these recommendations primarily addressed program accreditation concerns rather than trainee-generated issues.

Trainee responses to the dramatic changes within GME have only been sporadically reported, with some trainees noticing a decline in teaching and other trainees finding virtual education to be beneficial. However, a growing body of research suggests that trainee mental health has been negatively affected during the pandemic, with increased rates of burnout and anxiety that merit urgent mitigation.[11-13]

HO fellows represent a unique group of trainees who were directly and indirectly affected by the pandemic. From redeployment to COVID-19 services, to decreased outpatient cancer visits, to witnessing the devastating impact of COVID-19 on patients with cancer, HO fellows experienced dramatic changes to their practice, education, and research training.[14,15] The American Society of Hematology (ASH) and ASCO conducted a survey of all trainee members to understand the multifaceted impact of the pandemic on the well-being, education, research, and clinical training of postgraduate HO trainees.

METHODS

Survey Design

A survey to assess trainee pandemic-related experiences was developed by the ASH Committee on Training and the ASH Trainee Council and approved by the ASH Executive Committee. Demographic information included questions on sex, degree, year in training, country of residence, and visa status. Questions were in Likert-scale, multiple choice, and open-ended text formats; the full survey is available in the Data Supplement (online only). We used a single item from the Maslach Burnout Inventory that has previously been validated in medical personnel and comparable to the Maslach Burnout Inventory-Emotional Exhaustion single-item measure.[16] The electronic survey was created in the QuestionPro online survey software (Survey Analytics LLC, Austin, TX). Respondents received a $10 gift card for completing the survey. Topics explored included the following.

Baseline demographics: Sex, credentials, country of residence, type of training program, visa status, year of fellowship, and board certification plans.

Impact on training: Type of work, telemedicine, redeployment, professional activities, productivity, and career plans.

Trainee well-being concerns: Burnout, research funding, clinical competence, salary reductions, grant opportunities, loss of networking, loss of job opportunities, career changes, and family well-being.

Open-ended questions were incorporated to allow trainees to offer advice for other fellows and suggestions for how fellowships, institutions, and professional societies can support trainees.

Study Population and Survey Distribution

Survey invitations were e-mailed to all trainees listed as MD (clinical fellow) and PhD (postdoctorate) members of ASH and ASCO. Trainees not listed as members with an active e-mail address were excluded from the study. The survey was open for responses from May 26, 2020, to August 19, 2020.

Data Analysis and Outcomes

Primary outcomes of interest were the prevalence and scope of impact of COVID-19 on two major areas: training logistics (clinical work, redeployment, telemedicine, education, and professional activities) and well-being (burnout, worry about funding, productivity, grant opportunities, career, and family). A qualitative analysis of trainee-provided feedback was also conducted.

Responses were analyzed using descriptive statistics. Univariable and multivariable logistic regressions were performed to evaluate the effect of demographics and COVID-19–related work on burnout. Quantitative analysis was performed using STATA Version 16 (StataCorp, 2019. Stata Statistical Software: Release 16. College Station, TX: StataCorp LLC). Qualitative analysis of open-ended responses was performed using a general inductive approach with NVivo software (Version 12, QSR International Pty Ltd, 2018).[17] Thematic analysis revealed broad themes and subthemes from responses.

Institutional Review Board Approval

The institutional review board at Mayo Clinic (Rochester, MN) found this study to be exempt from review.

RESULTS

A total of 2,306 surveys were distributed to fellows by e-mail during the study period, of which 620 (26.9%) participants responded and 548 (23.8%) completed all survey components required for inclusion in the analysis. Demographic characteristics of survey respondents are displayed in Table 1 and reveal an even distribution of sex among study participants, 84% with a clinical doctorate, 90% currently in a clinical fellowship, and the majority in adult HO. First-, second-, and third-year fellows were evenly represented. Almost one fifth of respondents were currently holding a visa.

TABLE 1.

Demographic Characteristics of Study Participants

Quantitative Analysis of Fellows Surveys

Participant answers to Likert five-point scales for the survey questions are summarized in Figure 1.

FIG 1.

Summary of Likert five-point scale answers to survey questions. PPE, personal protective equipment.

COVID-19–Related Work

Of the 548 participants, 25% (137 of 548) reported being involved in COVID-19–related clinical work, whereas 8% (42 of 548) reported being involved in COVID-19–related nonclinical work (COVID-19–related work that does not involve seeing patients face-to-face). As shown in Figure 1, only 65% of participants agreed or strongly agreed that they had received adequate personal protective equipment (PPE) during the COVID-19 pandemic.

Career Concerns

Survey respondents were concerned about obtaining a job offer (58%, 316 of 536) because of the pandemic and were also concerned about lower starting salaries (68%, 365 of 537; Fig 1). Most trainees reported concern about the availability of networking events for mentorship and job opportunities (73%, 391 of 538). Eighteen percent (93 of 534) of participants reported considering changing their career plans and 7% (39 of 548) had already changed career plans because of COVID-19 (data not shown).

Fellowship Training Concerns

Worry about the quality of education and clinical training was expressed by 54% of participants (291 of 539) during the pandemic (Fig 1). Fewer trainees were concerned about passing their board examinations (29%, 155 of 536) or completing training on time (23%, 125 of 538). However, 43% of participants (233 of 539) expressed concern about their clinical competence.

Research and Productivity Concerns

Reduced research productivity during the pandemic was a concern for 59% (321 of 539) participants (Fig 1). Additionally, 35% (191 of 540) worried about research funding, and 43% (229 of 536) about the success of future grant applications. Approximately 47% (251 of 539) of participants felt less productive during the pandemic, and Figure 2 summarizes respondent reasons for reduced productivity, with the majority attributing it to pandemic-related stress or anxiety.

FIG 2.

Reasons for reduced productivity during the pandemic. Survey finds COVID-19 pandemic associated with reduced research productivity & burnout in hematology-oncology trainees.

Mental Health and Burnout

A sense of inadequate mental health support during the pandemic was expressed by 39% (214 of 539) of survey respondents (Fig 1). Moreover, 22% (93 of 426) of participants who reported no burnout symptoms before COVID-19 reported new symptoms of burnout since the pandemic began. The majority of survey trainees did, however, agree or strongly agree (54%, 293 of 539) to feeling connected with their colleagues, despite the pandemic (Fig 1). Family well-being was also a concern for most participants (75%, 402 of 537).

Predictors of symptoms of burnout among study participants were analyzed in logistic regression models (Table 2). Pre-existing burnout before the COVID-19 pandemic was associated with a much higher odds ratio (OR) of burnout during the pandemic (OR, 10.7; 95% CI, 6.38 to 18.2; P < .001) in the multivariable analysis. The multivariable analysis also revealed that involvement in clinical COVID-19 work (OR, 2.33; 95% CI, 1.42 to 3.82; P = .001) and working primarily in a research nonclinical job (OR, 2.54; 95% CI, 1.13 to 5.68; P = .023) were also significantly associated with worse burnout during the pandemic compared with no additional COVID-19 word or working primarily in a clinical job. The univariable analysis revealed a higher odds of burnout for women and fellows in their third-or-higher year of training, although these did not remain significant in multivariable analysis.

TABLE 2.

Univariable and Multivariable Logistic Regression of Variables Associated With Burnout Among Study Participants

Country of Work and Visa Holders

Approximately 96% (528 of 548) of respondents were from the United States, with the majority of non-US respondents (3%, 16 of 548) located in Canada. Nearly 20% of respondents were visa holders, with 29.2% (31 of 106) visa holders reporting issues with their visa during the pandemic.

Qualitative Analysis of Fellow Surveys

Of 621 completed surveys, 534 included responses to the open-ended questions. The broad themes identified in survey responses included concerns about finances, education, professional and career development, research activities, overall productivity, mental health, and institutional and programmatic support. Subthemes within each broad theme were identified and are summarized in Table 3 with representative survey quotations included. Table 3 also includes recommendations that fellows provided on how concerns could be addressed by their institutions or national organizations such as ASH and ASCO.

TABLE 3.

Broad Themes and Subthemes in the Qualitative Analysis of Open-Ended Responses, Including Representative Quotations and Fellow Recommendations on How Their Concerns Can Be Addressed

Financial Concerns

Overall, financial constraints affected multiple facets of fellows' personal and professional lives. For some trainees, financial support for master's programs and research summer programs had declined because funding was prioritized for other departmental expenses. Furthermore, budget cuts jeopardized faculty positions for the graduating fellows, particularly for fellows who are visa holders, and funding for travel and conferences had been suspended.

Educational Concerns

Most fellows indicated that COVID-19 clinical responsibilities superseded routine clinical rotations, and fellows expressed uncertainty about whether they would be allowed to take time out of the elective portions of the fellowship to complete core clinical rotations in the future. At some institutions, fellows were redeployed to general medicine inpatient services, including night shifts for up to two to three months, during which time essentially all specialty-related education ceased. Furthermore, fellows reported being excluded from outpatient rotations, with limited opportunities for oncology-specific telemedicine clinics. First-year fellows frequently expressed concerns about missing core learning opportunities, as well as physical and emotional exhaustion because of redeployment.

Didactic lectures and journal clubs were dramatically curtailed and even canceled during the pandemic. Remaining educational activities, such as didactics and board review sessions, were moved to virtual platforms like Zoom. Although virtual meetings maintained some educational continuity during the pandemic, many fellows perceived the overall quality of virtual learning to be low, because of a lack of robust discussions in the virtual environment and technological challenges with navigating online educational resources.

Although tumor boards continued online, fellows often did not have time to participate because of inpatient responsibilities. Moreover, fellows felt that it was difficult to not have cofellows around to talk about cases. The pandemic posed a unique challenge for some third-year fellows, who were not allowed to do pretending weeks where they could develop team leadership skills by acting as an attending physician.

Professional and Career Development Concerns

The pandemic disrupted all activities related to professional development. For some fellows, programmatic budget cuts during the pandemic reduced available funding for ASCO and ASH memberships, which curtailed access to many resources available through these professional organizations. Many professional meetings and conferences were moved to virtual platforms. Some programs were canceled, including the ASCO Education Scholars Program and some leadership training courses. The majority of fellow respondents indicated that losing in-person conferences curtailed opportunities for professional networking and job interviews, with a deleterious effect on their job prospects after fellowship.

Additional clinical responsibilities significantly reduced board preparation time, and many fellows expressed concerns about whether they would take board examinations during the year at all. Several fellows expressed serious concerns about attaining sufficient clinical competence in specific domains by the end of their training, such as medical oncology, benign and malignant hematology, and bone marrow transplantation.

Research Activity Concerns

Fellows reported severe impacts of the pandemic on research activities. With many laboratories closed and stay-at-home orders issued, research activities across the spectrum were put on hold. Fellows working on wet laboratory and basic science research projects reported complete cessation of many of their research projects. Clinical research projects of some fellows had significantly slowed because of the unpredictability of their mentors' schedules and responsibilities in a changing clinical environment. In addition to these restrictions, increasing clinical duties for fellows in the absence of residents and hospitalists also reduced time for research activities. Fellows expressed concerns about lost research time affecting grant opportunities as well as job applications in the future.

Overall Productivity Concerns

Fellows reported both positive and negative dimensions in regard to the question of how the pandemic affected productivity. With the majority of fellows working from home whenever they did not have clinical duties, some fellows discussed using virtual learning opportunities and working from home to catch up with the literature and complete writing projects. These fellows reported that working from home was more productive than in-person interactions in the office owing to additional flexibility, time saved from not commuting to work, and the ability to complete more tasks.

However, many fellows expressed concerns over their declining productivity during the pandemic. Major hurdles for productivity included increased responsibilities for domestic care and childcare, reduced hours at work, and distractions in the home environment that affected both the quality and quantity of their work. Male and female fellows had similar responses to this question (data not shown). In addition to domestic responsibilities, fellows reported that the overall pandemic atmosphere influenced their emotional and motivational levels at work.

Mental Health Concerns and Stress Responses

The drastic changes in the learning environment and clinical redeployment, as well as ongoing changes in schedules because of COVID-19, made the work and life of fellows more difficult and stressful during the pandemic. As many fellows reported, the fear of unknown outcomes in COVID-19–positive patients, and serious concerns about the health of fellows and their families, generated considerable distress. In addition to concerns about safety and wellness, fellows also lamented information overload related to COVID-19, including numerous e-mails, townhall meetings, and GME meetings. These stressors, as well as uncertainty regarding continual changes in workflow, also influenced fellows' mental health. However, some reported improved resilience amid stressful conditions as the pandemic progressed.

Institutional and Programmatic Support Concerns

Most fellows reported that their programs were helping them to navigate clinical and educational activities during the pandemic, including virtual educational and professional development activities. Fellows reported that program directors regularly asked them about their physical and mental health. Overall, fellows reported that their programs attempted to maintain normalcy through regular virtual meetings to provide updated information about institutional policies, COVID-19–related procedures, and fellows' roles and expectations. However, transparency within fellowship programs was not ubiquitous. Several fellows raised serious concerns about their safety and well-being during the pandemic. They wanted to ensure adequate access to PPE, which had been a significant concern in some regions during major COVID-19 surges. Some programs did provide a hazard allowance for fellows.

DISCUSSION

These data demonstrate that most HO trainees had significant concerns about career planning, research funding, productivity, educational quality, and ability to finish training because of the COVID-19 pandemic. In one of the largest studies of postgraduate trainees in the United States, we identified potential avenues for individual institutions and national organizations to better support HO trainees.

Worsening mental health was a significant concern among survey respondents, with 22% of trainees without burnout symptoms before COVID-19 reporting new symptoms of burnout since the beginning of the pandemic. COVID-19–related work, whether clinical or nonclinical, was a significant predictor of burnout in the univariate analysis, as well as pre-existing burnout, female sex, and first-year of fellowship. These findings mirror results in studies of other types of trainees, including a survey of Saudi ophthalmology trainees in which only 6% of respondents reported no effect from COVID-19 on their mental health[18] and another study of Pakistani residents, which found that two thirds reported complete psychologic abandonment within their departments.[19] Frontline trainees have previously reported worse burnout and stress during the pandemic compared with nonfrontline trainees,[12,20] with our study additionally finding that nonclinical COVID-19 work may also contribute to trainee burnout. Multivariable analysis of burnout risk factors found a strong association of pre-existing burnout (OR, 10.7) with development of burnout, as well as clinical COVID-19 work and research or nonclinical primary work setting. Pre-existing mental illness is a known risk factor for worse mental health in health care workers during the COVID-19 pandemic.[21,22] However, the observation that nonclinical fellows are at risk for burnout is an important finding, as the COVID-19 literature has demonstrated mixed findings with respect to mental health among medical versus nonmedical health care workers.[12] Several studies of women trainees and physicians have demonstrated increased risk of work-related burnout[23,24]; factors such as workplace bias or harassment and home or childcare responsibilities may contribute. Previous studies examining mental health during the COVID-19 pandemic have demonstrated that physician trainees are at least similarly[25] if not more affected[26] by the pandemic in several domains of mental health. In HO, first-year fellows may also be more susceptible to burnout at baseline because many fellowships are structured to make the first year the most clinically intense year, thus placing first-year fellows on the frontlines of COVID-19 care. As seen in the qualitative analysis in Table 3, fellows described the relatively higher workload on first-year fellows compared with senior fellows who were able to do research at home.

Our survey revealed concerns about the quality of trainee education during the pandemic, with the transition to virtual learning being met with mixed responses. Some studies have found positive responses to virtual learning among trainees, including a survey of first-year HO fellows at Dana Farber Cancer Institute, which found higher attendance rates and more interactive sessions with virtual conferences compared with in-person lectures.[27] Similarly, the majority of HO fellows at MD Anderson felt that an online-based lecture program was as effective as in-person learning and considerably more flexible.[28] However, not all training programs were able to transition seamlessly to virtual learning. As summarized in Table 3, many fellows described complete cancellation of didactic and board preparation lectures for some portion of the pandemic, as well as inherent limitations in learning on a virtual platform because of technical challenges and lack of interaction among cofellows.

It is well known from studying health care workers during the SARS epidemic of 2003 that clear, supportive, and consistent communication from leadership contributes to both organizational resilience as well as improved mental health.[29,30] These initiatives suggest that proactively addressing the well-being of trainees is a vital component of a successful trainee program response to the pandemic. It is important to note that 14% of fellows reported inadequate access to PPE, as lack of access to adequate PPE has been associated with worsening mental health in several studies in the COVID-19 era.[12] Institutions have reported on efforts to improve the experience of HO fellows during the pandemic.[27] Because of the surge in Boston, Dana Farber fellows were pulled from various outpatient rotations to cover COVID-19–related services. However, fellows were rotated 4 days on and at least 4 days off to distribute the work more evenly, and COVID-19–related updates were given to fellows on a weekly basis, which was well received among first-year fellows. Additionally, the fellowship converted all didactics to interactive biweekly virtual teaching sessions to compensate for lost time in outpatient clinics. In other postgraduate settings, switching to an online curriculum was met with positive feedback when accompanied with emphasis on peer support and the provision of confidential therapist sessions for trainees.[31] Other trainee recommendations from our survey, such as advocacy for practical supports including childcare and hazard pay, have also been demonstrated to be helpful for the well-being of health care workers.[12,32]

Although virtual didactics have received mixed feedback, trainees have reported that clinical training significantly suffered across specialties. Survey respondents described being removed from core and elective rotations during the height of the pandemic, risking not being able to complete required rotations for graduation as well as not completing rotations needed for autonomous and independent practice after graduating. During the initial COVID-19 surge, many fellows were required to cover COVID-19 inpatient services. Redeployment to COVID-19–related work may have had an impact on hematology-oncology trainee formation; 18% of survey participants reported considering changing their career plans because of the pandemic, and a majority were concerned about the quality of their education and clinical training. This concern was similarly highlighted in a study of neurology trainees in Italy; 34% of respondents believed COVID-19 had or would have a positive impact on their formation as general clinicians, but almost 70% believed it either had or will have a negative impact on their formation as neurologists.[33] Published analyses of surgical and procedural specialties have noted dramatic decrease in elective procedures and opportunities for hands-on training.[20,34] Although HO is not a procedurally heavy specialty, follow-up analyses assessing the impact of COVID-19 pandemic on graduating HO fellows' level of comfort with procedures such as bone marrow biopsy and lumbar puncture are necessary.

The impact of COVID-19 on HO trainee research activities varied on the basis of the type of research work being performed. Lack of patient access for clinical research and inability to access laboratory facilities for bench research were major barriers (Table 3), with significant challenges for laboratory-based fellows who expressed concerns about inadequate qualification for grant funding because of lack of research productivity. Similar concerns about trainee research productivity were reported for allergy and immunology trainees in United States and Canada, in which 38% were concerned about finishing their research before the end of fellowship.[35] With reductions in grant opportunities, there were numerous requests by fellows for ASCO and ASH to intervene to create more flexible submission requirements and deadlines (Table 3). Similar requests to expand funding opportunities, increase K-award pay-lines, and extend award durations have been published by trainees in other specialties.[36] Given HO fellow concerns about transition to independence in the post–COVID-19 era, implementation of such initiatives may benefit trainees in HO.

Job availability was a major concern for fellows because of lack of in-person job networking opportunities at national conferences, hiring freezes limiting faculty positions for graduating fellows, and concerns about visa requirements. Most fellows were concerned about obtaining a job offer after the pandemic, which is of particular concern, given that 76% of survey respondents were concerned about finishing training on time. Lack of in-person networking opportunities seemed to be a major concern as well, suggesting the important role these opportunities may play for meeting mentors and obtaining a post-training job.

There are several limitations to our survey-based study. First, our survey response rate was only 24%; although this response rate is lower than that of other surveys of trainees during the COVID-19 pandemic, this was also the first nationwide trainee survey addressing the impact of COVID-19, whereas other studies were focused on specific geographic areas or institutions, which may have been easier to survey. Additionally, since we did not collect data on demographics such as race, ethnicity, or program location, there may be subsets of trainees that are more vulnerable to the negative impact of COVID-19, which were not captured by our analysis. Furthermore, as the survey was distributed electronically through ASCO and ASH, fellows who are not members of these organizations are not represented in this analysis. Given that survey collection concluded in August 2020 and this study was cross-sectional in nature, the analysis does not capture changes in the training experience with subsequent waves of the pandemic. Finally, we used a 1-item measure to assess burnout in our population. Although this tool has been validated in health care personnel, it is limited in its ability to fully assess the breadth and depth of burnout in this population when compared with more thorough tools such as the Maslach Burnout Inventory.[16]

In conclusion, our quantitative and qualitative analysis of a large cohort of HO trainees enabled the description of the major concerns from the initial months of the COVID-19 pandemic, including trainee-generated recommendations for fellowship programs and national organizations to better address trainee needs. HO fellows were significantly affected by COVID-19 in all aspects of training and career development, and there were deleterious effects on the mental health of trainees with identification of several at-risk subgroups. Although we do not yet know the long-term effects that this pandemic will have on the future of HO education, this study provides a critical foundation to develop programs as well as policy interventions to improve the trainee experience as the pandemic progresses.