The coronavirus outbreak has forced podiatric residency programs to examine their curricula and determine how best to adapt under these unprecedented circumstances. With this in mind, authors from one residency program share their institution’s transition to a remote learning model and offer suggestions on how other programs may implement such initiatives.
With the extraordinary circumstances surrounding the COVID-19 pandemic, shelter-in-place shutdowns nationwide have put residency training and education in an unprecedented situation. In addition to widespread outpatient elective surgery cancellations and postponements, we are unable to hold in-person meetings in order to adhere to responsible social distancing practices. While the traditional method of in-person meetings presents obvious advantages, these current circumstances forced an adaptation to web-based “virtual” meetings, revealing more benefits than we have previously considered.
Accordingly, we would like to share insights from our residency program’s transition to the virtual learning space. Our temporary accommodation of virtual-based learning may serve as a framework for residency programs interested in conducting similar meetings but view distance learning as a major barrier.
Recognizing The Immediate Impact Of COVID-19 On Residency Education
As outlined in the Council on Podiatric Medical Education (CPME) Document 320, curriculums in podiatric medicine and surgery residencies include completion of both clinical and academic milestones.1 Logging of surgical cases, biomechanical examinations, history and physicals, and other clinical encounters serve to satisfy such clinical minimums needed for graduation. In the midst of this pandemic, the CPME recognized the immediate disruption of training and accordingly decreased the minimum activity volume (MAV) by 15 percent across all categories for the residency graduating class of 2020.2
Nonetheless, required non-clinical contact hours, in the form of academic meetings, journal clubs, cadaver labs, research projects or other scholarly activity, have not been thoroughly addressed. Research shows these non-clinical contact hours to be effective and necessary for the podiatric resident learner.3-6 Though not anticipated, the suspension of hands-on activity secondary to the cancellation of surgeries through illness, scheduling conflicts or other unforeseen disruptions affects portions of each resident’s education.
Moreover, as was our experience with the COVID-19 pandemic, limitations on gatherings further restrict attendance to academic meetings. At our residency program, participants at these weekly meetings include attending physicians, fellows, residents, and medical student externs. To address this occurrence and limit its impact on surgical education and training, our residency program quickly adapted to web-based virtual learning opportunities.
Although collaborative learning via teleconferencing is not a new idea, previous reports do not exist as to the content outline of online web-based residency education. Currently used in many medical subspecialties, specifically in circumstances in which residents and faculty are spread across multiple distant training sites, teleconferencing can be a powerful tool in clinical and surgical education.7 Other than convenience, this method of communication potentially saves travel time and costs. Accordingly, we wanted to share what we learned in transitioning our weekly foot and ankle surgery academic meetings to a teleconferencing format so /interested residency programs could have a guide to making similar adjustments to holding regular academic meetings in a virtual setting.
One Residency Program’s Experience With Transitioning To Remote Learning
Through the authors’ hospital continuing education portal, Webex™ video conferencing, the meeting facilitator could quickly schedule and create a meeting room for multiple sessions. Participants do not need to download an application prior to entering the video conference room. Similar to most user-friendly video conferencing applications such as Zoom™, Skype™ and GoToMeetingRoom™, the WebEx facilitator, or host, has control of the screen sharing capability. Screen share allows the presenter to share documents or an application, such as Microsoft PowerPoint or Keynote from his or her own personal computer.
Each virtual session may involve multiple presenters, with only one presenter screen sharing at a given time. One can also play videos and animations within the screenshare feature. The participant has the option of connecting video and audio through smartphone and a toll-free, dial-in number if the participant experiences either connectivity issues with his or her computer and microphone. Up to 25 meeting participants are visible in one grid view. Other features include a chat box, poll taking, raise hand and note annotation from a non-presenting participant.
In our program, the chief resident was responsible for the distribution of meeting information including agenda, content outline, time, presenter responsibilities and a specific virtual meeting room uniform resource locator (URL) to all residents, fellows and attendings. She disseminated this information to the residency program one week and then one day prior to the start of the meeting. Residents compiled and presented lab lecture presentations and case studies as delegated from a designated rotation schedule.
Over a month-long period from March 18, 2020 to April 8, 2020, our program held eight academic meetings using Cisco Webex. The weekly academic meetings lasted 60 minutes and 180 minutes, on Mondays and Wednesdays respectively, on average. The content of the web conference meetings and lectures are listed in “An Overview Of Our Agenda For Academic Meetings.”
A majority of our resident participants joined in the virtual conference room utilizing either their home or our hospital wireless Internet network. Prior to starting every formal teleconference, the chief resident announced administrative updates regarding hospital policy changes. There was an average of 21 attendees at each meeting (with a range between 16 to 26).
The meetings were unrestricted and open to all resident members, teaching and associate faculty, and affiliated fellows of the OhioHealth Grant Medical Center Foot and Ankle surgery residency program. Only two residents experienced technical difficulties, one with video and the other with Internet connectivity error (see “A Closer Look At The Scheduled Web Conference Meetings”). The presenter occasionally experienced microphone scatter but this typically resolved by alternately calling into the teleconference over telephone.
Best Practice Etiquette For Effective Web Conferencing
There are certain keys to maximizing the effectiveness of web conferencing. Accordingly, we adapted some best practice tips on web conferencing from the Harvard Business Review and Stanford University, and modified them to suit the size of our residency program.8,9
Prior to a meeting …
- When using equipment or locations not regularly used for Web conferencing, test your meeting connections in advance.
- Establish online video conferencing connections several minutes before the meeting start time.
- Create a backup communication plan in case there is trouble connecting with remote participants. A backup plan can include asking on-site participants to connect to the meeting through their cell phones or via speaker phones
During a meeting …
- Have all participants share their video and audio. This prevents lurking residents and disengagement.
- Ensure all participants can see and hear all other participants as appropriate.
- Ensure location lighting does not limit a participant’s visibility (e.g., avoid backlighting from windows or lamps).
- Have participants mute their microphones if their location has excessive background noise or they will not be speaking.
- Have a meeting facilitator. This is often the person who called the meeting, whether it is the chief resident or the residency program director.
- The facilitator is responsible for providing an agenda to participants. Sending the agenda prior to the meeting is not absolutely necessary but should at least be distributed at the start of the meeting.
- When and if a presenter has technical errors uploading presentation slides or documents onto the shared screen, the presenter should email the facilitator the presentation files.
- The facilitator should allow verbal or visual cues, such as raising a hand (a feature on Cisco Webex), to indicate politely when someone wants to actively contribute verbally to the meeting.
- The facilitator should engage participants at all locations to ensure discussion understanding and alignment, limiting “side conversations” and multitasking to ensure all participants are made aware of that content.
- Make sure all participants have equal access to content by sharing all content within the video conferencing connection and using online tools (e.g., Google docs) whenever possible.
- Maintain an interactive environment by calling on resident participants and capture real-time feedback via polling systems as necessary to make sure all voices are heard. If the presenter is a senior resident, he or she engages the junior residents by calling on one particular resident to answer a case specific question. Call on specific residents and go down the line of participants to avoid long unwanted silences.
In many ways, virtual web-based education may allow more robust discussion and question and answer sessions as participants may not feel the stress of speaking in front of a large group as they might in person. On that premise, there should be an allotted time for audience questions, which is typically designated by the presenter at the end of a series of slides. The presenter should reiterate the relevance of learning points to each audience member. When a presenter displays content with a specific reference, the resident should be able distribute the content reference (i.e. websites, hyperlinks or journal citations) to all participants.
Open discussion allows residents, attending physicians and students to discuss the presented content and cases. It is crucial to remind residents to practice professionalism and challenge team members without humiliation at all times. The goal as educators is to teach and guide residents, not to discourage them from learning. Upon the conclusion of the open discussion, the facilitator should ask the audience if there are any questions, problems or concerns. This reinforces the commitment to teaching and the commitment to the team. It also allows an opportunity to revisit any forgotten questions or topics.10
Assessing The Pros And Cons After Holding Eight Virtual Academic Meetings
The attendance count for our program’s in-person meetings typically averaged 18 participants, comprising 13 residents, three attendings and two students. Recently, our residency program has experienced a twofold average increase in attending physician participation from three to six (range one to 11), during these virtual teleconference meetings. Whether this was due to the pandemic crisis slowing down private office practice schedules or the accessibility of web conferencing, this increase in participation presents as an opportunity for change and possibilities for more collaborative, engaged academic meeting forums.
In addition to the impact on resident learning, each of the nine podiatric colleges withdrew their medical students from their designated externships. This has additionally caused concern for students and residency programs as these externships contribute significantly toward the process of residency candidate interviews. To mitigate the negative effects of cancelling student externships, we concomitantly use web conferencing to include students, allowing them to showcase their knowledge, skills and personality.
The ability to have real-time interaction and discussion is a major advantage for distance learning programs based on teleconferencing, the benefit of which cannot be overstated during these unprecedented times. Self-directed, asynchronous e-learning and web-based learning can be advantageous. Free, educational webinars and podcasts for residents and attendings are widely available since the pandemic crisis. Namely, the American College of Foot and Ankle Surgeons recently created a series of recommended educational pathways to supplement student and resident education.11
However, these virtual lectures, online books and podcasts do not substitute for interaction between groups of residents and faculty, which is subjectively reported as being extremely beneficial in a resident's education.3,4,7,12,13 Shofler and colleagues noted that the most valuable evaluation for learners in podiatric residency derives from attending feedback.3
Having a larger residency program (15 total residents), we were easily able to transition to Web conferencing for our academic meetings. However, we recognize that smaller residency programs may have difficulty in doing so. Thus, we recommend collaboration with and synchronization of schedules between multiple residency programs when possible. We realize that not every hospital system and, therefore not all podiatric residency programs, provide access to a paid teleconferencing platform subscription. Additionally, we assume that all residents have access to computers with audio microphone capability.
There are inherent disadvantages to web conferencing. For example, non-engaged users may disturb such meetings through disruptive background noise. “Zoom bombing” incidents are a widely reported disruption by bad actors or Internet trolls since the beginning of social distancing precautions.13 Although this sort of incident is unlikely in the setting of a podiatric residency web conference, a facilitator can follow a number of tips and settings to streamline meetings.14,15 Failure of the host to bring in all participants without a given agenda or outline of the teleconference meeting can lead to severe disorganization and long periods of delay without conversation.13 Finally, effective learning heavily relies on the synergistic efforts of individual resident participation and preparation of educational content by the presenters and facilitator.
In summary, despite a few minor challenges in connectivity, our residency program was able to successfully transition, implement and sustain a distance education program while abiding by strict shelter-in-place government mandates. Successful meetings involve collaborative contribution as well as discussions of evidence-based medicine and shared surgical experiences. At a period of standstill for hands-on learning, web conference learning has kept our residents and attending physicians participating in active discussion and constructive feedback.
We attribute the success of this temporary transition to the availability of hospital resources, active resident and attending physician participation, coordination and preparation of scheduled presentations, and reliance on uninterrupted electronic communication. While this article recounts a pandemic-specific transition for one residency program, the availability of teleconferencing should be made known to and utilized by all educators and residency programs. Future studies should analyze perceptions of this technology among both podiatric residents and faculty. We urge all residency program directors, residents and faculty to stay intellectually proactive with this temporary modality shift.
Dr. Law is a Chief Resident at OhioHealth Grant Medical Center in Columbus, Ohio.
Dr. Casciato is a first-year resident at OhioHealth Grant Medical Center in Columbus, Ohio.
Dr. Hyer is the Podiatric Residency Program Director at OhioHealth Grant Medical Center in Columbus, Ohio and the Fellowship Director for the Advanced Foot and Ankle Surgical Fellowship at Orthopedic Foot and Ankle Center in Worthington, Ohio.
- Council on Podiatric Medical Education. Document 320: Standards and requirements for approval of podiatric medicine and surgery residencies. Available at: https://www.cpme.org/files/CPME/CPME%20320%20Updated%20June%202018.pdf . Published July 2018. Accessed April 13, 2020.
- Council on Podiatric Medical Education. CPME guidance on COVID-19 for residency and fellowship education. Available at: https://www.cpme.org/files/CPME/Guidance%20on%20COVID19%20-%20Residency%20and%20Fellowship%20Education.pdf . Published March 16, 2020. Accessed April 13, 2020.
- Shofler D, Chuang T, Argade N. The residency training experience in podiatric medicine and surgery. J Foot Ankle Surg. 2015;54(4):607-614.
- So E, Hyer CF, Richardson MP, Thomas RC. What is the current role and factors for success of the journal club in podiatric foot and ankle surgery residency training programs? J Foot Ankle Surg. 2017;56(5):1009-1018.
- Chu AK, Law RW, Greschner JM, Hyer CF. Effectiveness of the cadaver lab in podiatric surgery residency programs. J Foot Ankle Surg. 2020;59(2):246-252.
- Casciato DJ, Ead JK, Rushing CJ, et al. Podiatric medicine and surgery resident authored publications in the journal of foot and ankle surgery: a systematic review. J Foot Ankle Surg. 2020;59(3):550-555.
- Markova T, Roth LM. E-conferencing for delivery of residency didactics. Acad Med. 2002;77(7):748-9.
- Stanford University. Best practices for effective video conferencing. Available at: https://uit.stanford.edu/videoconferencing/best-practices . Published March 8, 2019. Accessed April 13, 2020.
- Frisch B, Greene C. What it takes to run a great virtual meeting. Harvard Business Review. Available at: https://hbr.org/2020/03/what-it-takes-to-run-a-great-virtual-meeting . Published March 5, 2020. Accessed April 13, 2020.
- Cook KD, Gutowski RB. Teaching during rounds. Clin Podiatr Med Surg. 2007;24(1):27-36.
- American College of Foot and Ankle Surgeons. ACFAS educational pathways. Available at: https://www.acfas.org/acfaseducationalpathways/ . Accessed April 13, 2020.
- Boatin A, Ngonzi J, Bradford L, Wylie B, Goodman A. Teaching by teleconference: a model for distance medical education across two continents. Open J Obstet Gynecol. 2015;5(13):754–761.
- Williams HC, Chalmers JR. How to teleconference effectively. Br J Dermatol. 2015;173(3):806–810.
- Morris DZ. Zoom meetings keep getting hacked. How to prevent ‘Zoom bombing’ on your video chats. Fortune. Available at: https://fortune.com/2020/04/02/zoom-bombing-what-is-meeting-hacked-how-to-prevent-vulnerability-is-zoom-safe-video-chats/ . Published April 2, 2020. Accessed April 13, 2020.
- Duffy J. How to prevent Zoom-bombing. PC Magazine. Available at: https://www.pcmag.com/how-to/how-to-prevent-zoom-bombing . Published April 10, 2020. Accessed April 13, 2020.