Hi, I'm Marion Vaughn-Mischewski. I'm an associate professor of critical care at MD Anderson Cancer Center in Houston, Texas. Today I'm going to talk about how to build resilient trainees during a pandemic. This is a skill that none of us were aware we really needed three or four years ago and as always, hindsight's 20-20 and now we understand how we can better continue to educate our trainees and keep them safe, both physically and emotionally during a pandemic. We all know the general challenges for working in an ICU and the things that we have to teach our trainees for them to become critical care practitioners. There's religious or cultural disparity that may affect how our patients come to see us as well as how they expect to be treated. Due to knowledge of a patient's total diagnosis, there may be conflicting expectations of outcomes between care teams and family members and patients themselves. Also, all of these patients need a continuously high level of care without significant respite for the care teams. But what did the pandemic bring us? It brought new stressors, stressors that were particularly difficult for trainees who are new to the healthcare environment and particularly new to the critical care setting. First, we had a fear of the unknown. Initially, the first thing we knew was there was a virus that was spreading rapidly and that people were dying from it, and there were high levels of healthcare needed. Many of our trainees were sent home to avoid any potential exposure to them and to allow those who had the technical expertise to maintain care of patients. Their education continued in a virtual manner without actual patient contact and that education was initially very difficult to maintain as we had to quickly adopt our technological standards and capabilities both for the students and for teachers in order to continue. A new environment was established, one which required wearing PPE on a continuous basis, even utilizing new equipment such as PAPRs and face shields, which no one was comfortable with wearing initially, and making sure that N95s were fit. They also had to learn how to utilize this equipment appropriately, as well as function in the equipment. So new skills were needed. Our staff needed to learn how to perform CPR, how to place lines, and do lab draws wearing this increased level of PPE, as well as effectively communicate with patients while wearing face masks and face shields, and other things that could muffle the voice. They also had to learn how to conduct virtual visits from outside the room at times to monitor patients or use video screens and cameras in order to watch patients. New staffing models were developed. The first, the tiered staffing model was discussed and utilized in many settings, which sometimes caused more tears than avoided them. Then responsibilities had to be shared and personnel had to step out of their comfort zone in order to maximize a visit into an isolation or negative pressure room. So others might have been asked to draw labs or adjust patients, or provide services that weren't usually within their job description. Treatment strategies were ever changing as different modes of pharmaceutical treatment, ventilator management, positioning, and other modes of therapy were discussed, evaluated, and then moved to the wayside. We moved from an era of evidence-based medicine as much that everyone had practiced and had proven was thrown in the trash, and we utilized more of the aisle of hopes and dreams to determine future treatment strategies. This was particularly confusing to trainees who had been reading the most current literature regarding therapy of critically ill patients. Next, they face social isolation, not only from social distancing and an inability to be close to co-workers, or eat near them in break rooms or at work. They weren't able to be near family members because of fear of contaminating them. Friends were off limits. Any forms of entertainment, even prior to the stay home initiative. Most meetings and educational conferences were turned to a virtual setting. Therefore, the camaraderie of being with their trainee group especially for those new in the year was lost. Most trainees found themselves with increased responsibility as they juggled patient care, talking to family members over the telephone and over video, and learning as much as they could. Many hours of the day and working both day and night shifts, sometimes having to add additional responsibility for supervision and decision-making. All the while, they were preparing for the next wave, the next surge of coronavirus. We've always talked about burnout, but let's really look at how this affected our trainees. Again, high levels of emotional exhaustion from dealing with the unknown day in and day out, especially in our critically ill population who required a lot of interventions. Some with poor results even from the outset being known, which then caused another emotional burden. High levels of depersonalization as patient volumes increased so that it was difficult to develop relationships. Family members were at home, so those caregiver ties weren't available. Even the PPE wearing made it difficult to maintain that contact as masks and shields and other things really muffled communication and minimized eye contact and personal touch. The low levels of personal effectiveness that may have been felt from some of the care that required so much effort but yielded poor results. So what have we learned at this point? So we've learned that in the pandemic setting, we know what we need to support our trainees and what we want to do. We want to avoid fatigue, burnout, and conflict among our trainees and between other members of the medical team. We want to mitigate their mental strain due to emotional dissonance and that providing all you can though knowing the outcome will be bad. And the strain due to all of the challenges, both physical and mental, during care. And also, we want to decrease that turnover of trainees and other healthcare professionals as they exit from healthcare due to the strains and to the low levels of satisfaction seen during this period. So how can we do that? We have many strategies that we've developed over the last two years. And there are some we need to specifically address in order to keep our trainees in the healthcare setting. On-site support's important. And one of the strategies that's been shown to work are paired relationships, buddy systems for daily check-ins with someone who's in that similar environment. So, and there are two types here to consider and to implement. And that's with trainees, with those same backgrounds who experience the same challenges, but also with different members of the healthcare team. So perhaps not someone with the same background and the same vocation, but someone who's taken care of the same patients and has had that shared experience of a patient and the caregivers. Conducting regular debriefing sessions and including the trainees in that and then making sure to encourage the use of virtual resources. Debriefing sessions have always been a key piece of critical care. In the setting of COVID-19, we wanted to make sure that we emphasize wins as well as losses. Because the wins are there, but haven't been as prominent at times. They're taken for granted. Where it promotes self-awareness of the positive impacts and contributions, regardless of patient outcomes, the benefits of the teamwork there. It provides a way to discuss the stressful aspects of care as well and try to develop strategies for future cases. And then we've seen the need to develop some discussions for special topics, young adult patients, and even those older adolescents that have had challenges. The cultural norms anticipated both from healthcare disparities and backgrounds. How to conduct verbal de-escalation with family members and patients demanding certain treatments. And again, sharing those strategies of self-care during times of stress. The most important factor for our trainees are their mentor relationships. We want to establish smaller mentor-to-trainee ratios to support more frequent in-person meetings and to have those visual, physical check-ins. And provide an honest exchange of what stressors have been seen by both the mentor and the mentees and the coping mechanisms. It's another place to really reinforce that use of virtual wellness resources and to reinforce a trainee's ability to maintain their own safety and patient safety and minimize error by stopping the line. Even in extreme situations, we want to make sure that that's a capability that is maintained and it's understood that it's maintained. And then we need to continue to focus on education that's still an educational setting. We want to make sure that the opportunities are maintained and that the mentor is able to confirm that that trainee is continuing the educational aspects. We talked about virtual resources. And a lot of times, trainees either aren't aware or don't feel inclined to utilize them. But it's important to emphasize employee assistance programs. The resources provided by graduate medical education groups specifically aimed towards wellness as this has been recognized as an important factor of training. And then offerings by other medical and professional societies to manage burnout and stress associated with these symptoms, with these situations. As well as educational resources that may be available to specifically address management of these patients. The most important thing that we need to do for our trainees is to maintain the education. As we sent some personnel home and tried to keep them safe by keeping them out of those interactions with the pandemic patients, they were also affected by closures of healthcare facilities in order to better service and focus all resources on the COVID-19 patients. But we need to maintain both their educational activities, conferences, research, pieces like that. And we need to make sure that they're allowed to not only take care of those pandemically affected patients, but patient care outside of that. The patient care that may have dropped off. So not only does it affect our patient outcomes, it affects the training because we need those basic skills. And then it's also important to match the responsibilities of the trainee to the appropriate level of training. This, although this is a time of need for heightened care, it's important to remember that a trainee success is going to depend on their preparation and they should only be asked to perform at the appropriate level. By addressing all of these aspects, we really want to encourage the sustainability of all of our healthcare professions and focus on longevity, not just the current situation and the current panic. So we want to focus on an entire career. So maintaining that space for vacations and educational conferences, encouraging other interests, family, hobbies, other things to to to have that mental break from work and then engage in some of the other pieces of health care that include leadership, the business of medicine, legal interactions, as well as internal and external and even governmental policy development as an added piece of medical practice. There will likely be more development of rebel work for trainees. And then also we need to maintain this recognition even outside of an emergency situation of a need to support mental health issues and recognize stress and not expect our trainees to continue to work extended hours or to volunteer to do extra work or extra things and to understand that they may need to debrief after difficult situations or even after those that weren't anticipated to be difficult before. And this will maintain our workforce because they'll feel that they're safe and their needs are all being met. In conclusion, I want to say something to the audience here. As critical care educators, remember that they're going to be watching what we do. So it's really important to not only teach the lessons I've discussed here, but to make sure that you're taking care of them yourself, because one of the biggest ways that our trainees learn is by watching what we do and how we respond. Thank you for your attention. I'm Marianne von Mishevsky.

resilient trainees

pandemic challenges

virtual education

mentor relationships

work-life balance