By Martina Murphy, MD, Devika Das, MD, and Elizabeth Henry, MD

Running a training program is not for the faint of heart. As educators, we sought the field for a love of learning and passion for teaching. Leaders in oncology training programs routinely evaluate how to improve their educational offerings, developing innovative educational tools to meet learners where they are. In recent years, driven by adult learning theory and the generational changes of our trainees, there has been an evolving role of virtual learning formats in medical education. This spans the educational continuum from elementary education to graduate medical education (GME) and beyond. In an eerily prescient JAMA article, “The Inevitable Reimagining of Medical Education,” Dr. Ezekiel Emanuel highlights the growing role of online learning (as opposed to classroom learning) as a “gradual but significant change” occurring in the pre-clinical curriculum of many medical schools across the country.¹ The author makes a strong case for the role of online learning as a means to increase the reach and flexibility of educational content—a concept that is not unique to undergraduate medical education. Importantly, though, he is quick to point out that medicine is irreducibly personal and that for all of our technologic advances, the art of medicine is found in our personal interactions with our colleagues and our patients. In no other field does this resonate more than in hematology/oncology.

Suddenly, we find ourselves thrown into a world crisis at the hands of COVID-19. The need for hematology/oncology training goes on, though nearly every aspect of how we typically achieve that training has changed. Like us, our trainees help care for the most vulnerable patients at the highest risk for COVID-19–related complications and death. Like us, they are members of a highly necessary workforce that may be called upon to help fight this pandemic by working outside their comfort zones. Like us, they are scared. They have lives in progress and we are in charge of giving them thoughtful direction. How do we balance reassurance and continue their training in this swiftly evolving environment of uncertainty?

Like many others across the nation, the onslaught of rapidly changing information and guidance for health care workers related to COVID-19 is head-spinning. Assimilating this changing information into practical guidance for trainees is no small task. Oncology is a team sport. Our daily lives are ingrained with human connection that doesn’t always easily translate to virtual communication. We rely on regular face-to-face interactions with our colleagues in formats like case-based conferences and tumor boards to help facilitate the best decision making for our patients. Email and electronic medical record inbox discussions remain but are merely a useful adjunct to our in-person discussions. Does this all grind to a stop?

On many days, there seem to be more questions than answers: how will time off be calculated if you are on quarantine, will you still be eligible to take your boards, can you graduate on time? Faculty approach program directors with other questions: will we still have fellows with us on service, or in clinic? At many institutions, heme/onc training programs have opted to consolidate fellow teams to those working on essential inpatient services, with the rest staying at home for work study or research in an effort to preserve a workforce that may be called upon to help in other areas as this crisis develops. While doing so, fellows can help with e-consults or telehealth, though questions remain about how they can be supervised effectively.

It goes without saying that we are in unprecedented times. There is no template for the path forward—we are literally forging it together as we use our best judgment as medical educators and mentors. Program directors sit squarely between the interests of our faculty and the interests of our learners. The job on a good day is a tightrope walk, keeping training programs humming along without disrupting a homeostatic balance.

Professional Society Support

In an effort to help guide our decisions on behalf of our heme/onc trainees, the American Council of Graduate Medical Education (ACGME) has developed a new conceptual framework from which graduate medical education can effectively operate during this pandemic.² Institutions are grouped into one of three “stages” based on their current pandemic-related volume. Specific guidance with regards to training expectations are dictated by which stage each institution is currently experiencing. Institutions in Stage 1 (“business as usual”) will follow all relevant accreditation requirements, while institutions in Stage 3 (“pandemic emergency status”) are allowed more flexibility in work assignment and other core program/specialty specific training requirements for 30 days.

The ASCO community of program directors has recently increased the frequency of group calls to help offer support to those leading heme/onc training programs. Through these calls, program directors are able to share ideas for maintaining educational opportunities for our trainees despite a sudden disruption in our collective workflow. Because we are all faced with many of the same challenges, discussions have started to include crowdsourcing educational content to share between programs. While programmatic schedules differ, this would offer a high-quality repository of educational content to be used by all fellowship programs moving forward. In this model, fellows at all institutions could learn from national experts and not be limited to the expertise of faculty at their own institutions. A live option could be maintained which would allow for inter-programmatic networking and potentially, future collaboration. ASCO has been very helpful to this extent and discussions are under way to make this user-friendly for all involved, both among program directors and among ASCO’s community of division chiefs and department chairs. (To learn more or get involved, visit the online communities on ASCO myConnection or email professionaldevelopment@asco.org.)

Distance Learning Modalities

In the United States, we are only a few weeks into social distancing and most of us seem to already be experts at online meeting platforms like Zoom or WebEx. Many programs are using these to continue to conduct regularly scheduled educational conferences and meetings like tumor board. They are also being used to conduct virtual rounds so as to prevent congregation of inpatient teams while keeping the semblance of regular rounds with teaching presentations and decision making, short of a thorough physical exam.

Some programs, already adept at the use of simulation for medical education, have been able to transition some elements to a virtual platform. This represents an opportunity for innovation within heme/onc programs. Other distance skill-building opportunities abound. One example is the program VitalTalk, which can be used to help develop communication skills needed to have the most meaningful discussions with our patients. Videos and other resources are available online, including a new section on communicating with patients about COVID-19.³

Social media remains a powerful way to transmit information in real time but can also be used to facilitate heme/onc-specific medical education. One example is the @HOJournalClub Twitter feed, which hosts a monthly virtual journal club via tweet chat. An article is chosen on a relevant topic and a guest expert invited to participate. Trainees from around the world can participate in real time and converse with national experts on a given heme/onc topic and could choose to do so in an asynchronous manner if necessary. Additionally, #distancemeded is a new movement on Twitter aimed at amplifying mini-lectures and quizzes from educators in all fields.

This embrace of virtual learning has had previously unrealized advantages—didactics are less constrained by the time and space of all the tasks in a usual workday. We are thinking more creatively about incorporating more frequent, shorter discussion sessions that in some ways may be higher yield than an hour-long lecture. Fellows can participate from remote sites or from the wards, which may be less disruptive to clinical work. That flipped classroom we've all been working to achieve can finally be fully realized—because we don't really have a choice anymore. Necessity is, after all, the mother of invention.

Maintaining Connection and Optimizing Mental Health

In an era of necessary social distancing, maintaining our human connections and relationships with one another has never been more important. Platforms like Zoom, WebEx, and others allow for group conferencing and other forms of interaction that may help mitigate the negative psychological effects of social distancing and isolation. Many educators are well versed in using these platforms for educational conferences and meetings. They can also be used for informal social gatherings like group exercise class, virtual happy hour, or faith-based meetings. While certainly not as fulfilling as in-person gatherings for fostering human connection, they can help bridge the gap until we can meet again. Other methods of maintaining connection to and between trainees include group chats using applications like WhatsApp or Slack. At several programs, heme/onc fellows are included on a group WhatsApp chat. The chat is used to share information and cut down on email burden—but more importantly as it pertains to mental health and maintaining meaningful connection with one another, to share weekly gratitude with one another. Fellows share photos of their children, their pets, or the delicious dish they made while in isolation. This form of communicating is not only a break from the grim daily onslaught of COVID-19 news and information, it is grounding in the here and now. It is incredibly easy to let uncertainty-related anxieties spiral out of control and this method of communication helps, in some small way, to mitigate this tendency.

There are plenty of ways to stay connected to trainees and mentees in challenging times. Some ideas:

• Encourage faculty to reach out to trainees via email or text simply to offer a supportive word. Many trainees live away from their families of origin and are now distanced from colleagues and friends. A quick note of encouragement can go a very long way.
• Schedule regular “check-in” meetings via Zoom or another online platform. No agenda is necessary, but this offers a space for trainees to see one another and their program directors and to ask questions or share concerns.
• Larger programs may benefit from a “buddy system”—pairing a senior fellow up with a more junior fellow and encouraging a daily check-in.
• Some program directors have found it helpful to schedule “office hours”—essentially, time in a given week where interested trainees can log into Zoom or another online platform and chat outside of regular conference times or email communications.
• Ask trainees what would be most helpful. This is an easy, and often overlooked, method of encouraging wellness. While program directors are a thoughtful bunch who care deeply about their trainees, those trainees often have wonderful ideas about what might best help the group.

In many ways, this crisis may ultimately draw us nearer to our patients through a lived experience of uncertainty and mortality. Our patients with cancer diagnoses face uncertainty and their own mortality every single day. We can find a teachable moment about empathy here, both for our trainees and for ourselves.

Our trainees are resilient and, like us, will rise to this challenge. On days when we worry that this sudden shift in our usual educational offerings will rob them of essential learning, we remember that they are watching us. They are watching us navigate wholly uncharted waters with our patients, our colleagues, and our families at the forefront of all we do. There may be no better professional development we could ever offer.

Dr. Murphy is a clinical investigator and medical educator specializing in gynecologic cancer. Her research focuses in the study and reduction of health care disparities and inequity as it pertains to patient-related outcomes in cancer care as well as workplace and training environments. She is the program director for the hematology/oncology fellowship program at the University of Florida. Follow her on Twitter @DrMMurphy.

Dr. Das is a clinical assistant professor at University of Alabama at Birmingham and the section chief of oncology at the Birmingham VA. She focuses primarily on thoracic oncology and health care quality and safety. She is also the associate fellowship program director for the affiliated hematology oncology fellowship. Follow her on Twitter @DevikaDasMD.

Dr. Henry is an associate professor specializing in genitourinary cancers. Her clinical research focuses on novel therapeutic strategies in bladder and prostate cancers. Her medical education research focuses on the use of social media as a novel platform in medical education, and strategies to build community and reduce grief and empathy loss amongst medical trainees in oncology. She is the program director for the hematology/oncology fellowship program at Loyola University Medical Center. Follow her on Twitter @DocLHenry.

References

1. Emanuel EJ. The Inevitable Reimagining of Medical Education. JAMA. 2020;323:1127-8.
2. Accreditation Council for Graduate Medical Education. ACGME Response to Pandemic Crisis. Available at: https://acgme.org/COVID-19. Accessed March 31, 2020.
3. VitalTalk. COVID Ready Communication Playbook. Available at: https://www.vitaltalk.org/guides/covid-19-communication-skills/. Accessed March 31, 2020.

ASCO has developed and compiled resources to support oncology professionals during the COVID-19 pandemic. Resources include evidence-based answers to Frequently Asked Questions (FAQs) about clinical care of patients with cancer, a centralized collection of links to credible sources, the latest decisions about impacted ASCO meetings and programs, and oncologist-vetted information for patients. This page will be updated regularly as the COVID-19 public health situation evolves.