Practical Strategies to Ensure Trainee Well-Being During the COVID-19 Surge and Beyond

As the magnitude of the coronavirus disease 2019 (COVID-19) pandemic became clear and with it came unprecedented stressors for clinicians, specifically trainees, the program leadership for the Geriatrics and Palliative Medicine Fellowship at Mount Sinai Hospital quickly recognized the urgent need to focus on trainee well-being. From March to June 2020, program leadership focused on implementation of five core strategies to assess and meet trainees’ real-time physical and psychological support needs. To assess fellows’ opinions of these strategies, a formal survey was administered six months after the initial COVID-19 surge. Results found that more than 75% of fellows agreed on the high value of four specific interventions: (1) flexible scheduling with (2) a built-in backup system and (3) a safe environment with (4) adequate personal protective equipment. These well-being strategies are feasible and broadly applicable to other training programs across the country. They may also be useful outside the scope of the pandemic crisis.


INTRODUCTION
The Mount Sinai Healthcare System (MSHS) consists of seven acute care hospitals serving approximately 3.5 million patients in the New York metropolitan area. When coronavirus disease 2019 (COVID-19) surged throughout New York City, MSHS was hit hard. Between March 1 and May 10, 2020, 4,313 patients with confirmed positive COVID-19 were admitted to one of our hospitals. A total of 3,043 (70.5%) patients were successfully discharged, but 1,270 (29.4%) patients died during their hospitalization [1].
When it became clear that the virus disproportionately affected older adults [2,3] and was characterized by critical illness and high mortality rates, geriatricians and palliative care physicians emerged as essential clinical resources throughout the health system. When the number of hospital admissions increased relentlessly on a daily basis, the health system shifted into 'all hands on deck' mode, and our 27 geriatrics and geriatrics-palliative medicine fellows played a critically important role. With their expert knowledge of how to care for older and sicker patients, the fellows worked tirelessly on the frontlines, functioning uniquely as both learners and care providers.
As the magnitude of the COVID-19 surge became clear, treating a novel virus with unknown treatment options and uncertain outcomes left providers feeling powerless and out of control. Additional stressors for providers included anxiety over personal protective equipment (PPE) supply and concern for the health and safety of their colleagues and family members. Ensuring physical safety, preventing burnout, and maintaining trainee well-being became a high priority for leadership of the program and the department chair. Strategies were rapidly implemented to assess and meet trainees' real-time physical safety and psychological support needs during COVID-19.

METHODS
As they faced the challenge of ensuring trainee safety and well-being, department and program leadership quickly developed strategies in two categories of concern: promoting physical safety by limiting exposure to the virus and maintaining the psychological well-being of trainees by striving to prevent burnout, reduce anxiety and stress, and maintain resilience.
Within these two domains, five core strategies were devised: 1. Prioritizing trainee safety with adequate PPE and cleaning supplies.

2.
Decreasing clinical and academic workload and instituting flexible scheduling. 3. Increasing emphasis on burnout prevention and well-being. 4. Maintaining frequent, consistent, and efficient communication with trainees. 5. Ensuring that leadership was present on the clinical frontlines alongside fellows.
To assess fellows' opinions of safety and well-being strategies adopted between March and June 2020, a formal 11-item survey with Likert-scale and open-ended questions was administered to 21 geriatric and geriatrics-palliative medicine fellows six months after the initial surge. The response rate was 71%.

RESULTS
The top three challenges reported were burnout, uncertainty, and concern for loved ones' safety. Flexible work scheduling was the most helpful mitigation strategy, followed by a backup system, sufficient PPE, a safe environment, weekly meetings with the program director, and food availability. Well-being sessions and a 'buddy system' were ranked lowest (Figure 1). In openended questions that asked fellows to describe areas for improvement, three themes emerged. Workload: ensure fair scheduling, increase access to available workspaces, decrease rotation length, and decrease frequency of rotation switches among different hospital sites. Mental well-being: make professional help and one-on-one sessions available in addition to group 'emotional check-ins' with leadership; provide more assistance to cope with uncertainty, loss, and rapid change; and maintain a proactive focus on post-surge recovery. Academic growth: continue to support academic growth with scheduled lectures and structured academic time.

DISCUSSION
COVID-19 presented very stressful challenges for trainees in our fellowship program, with a sudden surge in work hours, redeployment to unfamiliar clinical sites, and fear for personal and family safety. There was insufficient time to implement system-level changes that addressed fellow well-being, so our fellowship program took a multipronged approach to optimize physical and emotional health during the pandemic on an individual level.
The needs and concerns identified by our fellows during this unprecedented pandemic were not unique [4]. While our training program is large and well resourced, many of the practical lessons we learned could be helpful to other fellowship programs. Using the feedback we obtained from the fellows after the surge, we have identified which of these feasible, low-cost, potentially high-yield safety and well-being strategies may benefit other programs as they seek to institute similar plans during this pandemic and for any future public health crisis.
More than 75% of fellows agreed on the high value of four specific interventions: (1) flexible scheduling with (2) a built-in backup system and (3) a safe environment with (4) adequate PPE. These goals were achieved primarily through strong leadership and consistent, effective communication. More than half of the fellows reported that weekly meetings with the program director and department chair eased concerns and reinforced that the department was committed to supporting trainee well-being.
Additional suggestions based on survey feedback included continuing weekly didactic sessions but also using the sessions for regular check-ins with program leadership. Trainees expressed a strong desire to be kept informed of rapidly evolving departmental and program initiatives. They also identified the need for a forum where their evolving concerns and needs could be shared with leadership. Empowering trainees to 'sign up' for backup coverage in a shared file may provide a sense of increased control over their schedules and may also promote transparency, flexibility, and responsibility in the area of clinical assignments during a pandemic.

CONCLUSION
Our fellowship program adopted pragmatic individual-level well-being strategies during the COVID-19 pandemic. These initiatives were effective and popular with trainees and successfully addressed their key concerns. Additional well-being suggestions from fellows are feasible and will improve our program going forward. We feel these strategies are broadly applicable to other geriatrics and palliative medicine training programs across the country. They may also be useful outside the scope of the pandemic crisis. While system-level interventions are undoubtedly the most effective tools for achieving a sustainable culture of physical and emotional support for learners, these simple interventions are easy to implement and can have profound impact on individual trainee well-being.