Article Item

Impact of COVID-19 on the Acute and Chronic Pain Educational Experience

May 1, 2021

Jeffrey Grzybowski, MD, University of Wisconsin; Sarah Schroeder, MD, Vanderbilt University; and Jody Cimbalo Leng, MD, MS, Stanford Hospital and Clinics
COVID-19
COVID impact and possible solutions

Introduction

The COVID-19 pandemic has had an overwhelming impact on healthcare systems across the country. In addition to the patient-care related ramifications, this catastrophe has placed an unforeseen burden on residency and fellowship training programs and forced them to immediately adapt. In the early days of the pandemic, trainees found themselves as vulnerable frontline workers compelled to persevere despite a paucity of knowledge on our invisible viral enemy, an uncertain supply of personal protective equipment (PPE), and a lack of standardized protocols at a hospital systems level. Soon, numerous daily emails would flood inboxes with updates on the ever-evolving logistical changes that occurred throughout our hospitals. Scheduling flexibility, sacrificed educational opportunities, and possible redeployment of house staff to care for COVID-19-infected patients became hot-button and hotly debated issues. These represent only a sample of the difficulties that trainees experienced throughout the pandemic. Obviously, individual experience varied depending on the geographical area and the specialty involved. In this article, we explore the novel experiences encountered by anesthesiology residents and fellows in acute and chronic pain medicine programs in the early phases of the COVID-19 pandemic.

Impact on Resident Rotation Structure

Anesthesiology residents within the 160 Accreditation Council for Graduate Medical Education- (ACGME-) accredited residency programs in the United States are typically required to spend a minimum of one month of their training rotating in each of the following during their 36-month clinical anesthesiology residency training: acute perioperative pain management, assessment and treatment of inpatients and outpatients with chronic pain, and regional analgesia.1 Rotations in the latter two are often completed in the last two years of training to first allow for generalized understanding and competency in principles of caring for a variety of patients in the perioperative period and in intensive care units. This rotation timing also allows residents to develop procedural and ultrasound skills. The training that residents receive in pain medicine allows them to perform various interventional pain management procedures and gain an unmatched understanding of multimodal pain medications. These pain management skills are becoming increasingly important in addressing the current opioid epidemic as they offer the promise of non-opioid analgesic alternatives. Additionally, the current emphasis on enhanced recovery after surgery (ERAS) protocols has made fluency with regional anesthesia a coveted skill to decrease pain in the acute perioperative setting and expedite recovery, and ultimately, discharge from the hospital. Residents are required to meet criteria for minimum numbers of procedures and pain consults performed prior to graduation. The ACGME has established a minimum requirement of caring for 40 patients undergoing surgical procedures with spinal anesthetics, 40 patients for whom peripheral nerve blocks are used as part of anesthetic technique or perioperative analgesic management, and 20 patients presenting for initial evaluation of acute, chronic, or cancer-related pain disorders.1


Education in most fields has been significantly impacted by social distancing measures, and education of residents and fellows in regional anesthesia and pain medicine is no exception. 

In Spring 2020, many outpatient elective surgeries were cancelled to decrease the spread of the virus and ensure adequate available personnel and physical space to care for anticipated surges in COVID-19 positive patients. Orthopedic surgeries made up a large portion of the cancelled elective surgeries, and, therefore, the peripheral and neuraxial blocks that anesthesiology trainees would typically perform on these patients as part of their perioperative care also were cancelled. The number of procedures performed by residents during these early months of the pandemic was greatly diminished in volume. Moreover, residents who would normally have had acute and chronic pain rotations during this time may have encountered difficulties performing the required number of procedures needed to graduate. This would require them to find time during other rotations in future months to gain additional experiences before graduation.

The disparity in individual residents’ experiences often was exacerbated by the hospital system’s structure. Many high-volume orthopedic surgery centers, which typically provide a significant number of regional and acute pain interventional opportunities to trainees, were compelled to temporarily cease all operations due to the uncertainty of the pandemic and the often elective nature of their procedures. Additionally, necessary redeployment of anesthesiology residents from their usual rotations to either critical care or other adjunct roles impacted residents’ participation in regional rotations. Depending on a training institution’s organizational structure, exposure to sub-groups of patients appropriate for the application of perioperative regional anesthesia may have been limited, if not eliminated. For example, residents at the University of Wisconsin rotate for a month on regional anesthesia during their CA-2 year at a largely ambulatory/short-stay orthopedic hospital and during their final (CA-3) residency year at a tertiary hospital system. The senior resident rotation focuses on experience with thoracic epidurals in surgical and trauma patients, paravertebral blocks for oncologic breast surgery, newly described fascial plane blocks, and more. Given the proximity to graduation, many of these trainees were unable to hone these valuable skills prior to graduation in the last academic year.

Impact on Regional Anesthesia and Acute Pain Medicine Fellowship Training

In addition to the impact that these changes had on residents, regional anesthesia and pain medicine (multidisciplinary) fellowship programs also had to adapt to changes brought on by the pandemic. Many regional anesthesia and acute pain management fellowship programs currently operate under a non-ACGME-accredited model, which is subject to the needs and regional opportunities available at a given institution. Typically, such a fellowship offers a combination of experiences in both the personal performance and staffing of residents in acute pain procedures and medical direction of residents and clinical anesthetists in various clinical settings. Some of the various ways in which the pandemic has affected the fellowship experience include lower block volume-to-learner ratio, an emphasis on outpatient procedures, changes in call structure, and continuing efforts to maintain appropriate social distancing.

Individual experiences over the past year have likely been incredibly variable and impacted by geographic location and fellowship accreditation status. In some cases, reduced operating room volume and increased numbers of regional anesthesia resident learners, both due to originally scheduled rotations and those making up for missed time during the nadir of redeployment, may have resulted in significantly decreased opportunities to personally perform regional anesthesia procedures. Although trainees were largely able to exhibit competency with peripheral and neuraxial regional procedures and obtain the necessary numbers for graduation, they may have struggled to perfect their skills to the same degree as previous trainees. In addition to the reduced volume of procedural opportunities, increased numbers of trainees made appropriate social distancing challenging. This restriction prohibited even the observation of select novel procedures.

For the non-accredited regional anesthesia fellow, where time was also spent in the operating room as a general anesthesiologist, additional challenges have been encountered. Due to an increased critical care burden and need for expertise securing airways in hospitalized patients requiring mechanical ventilation, it is likely that many institutions have had to assess their ability to respond to emergent airways in a timely fashion and made staffing or call changes to cope with this demand. Many institutions made the decision that an experienced anesthesiologist, nurse anesthetist, or resident who was trained on appropriate PPE would perform all intubations. This added coverage meant increased demand on these team members. Coverage of this new role by non-accredited fellows acting as faculty is a reality that, arguably, detracts from other regular medical direction opportunities that would normally be a valuable component of their fellow year. As an aside, this also resulted in other providers who need to become proficient in airway management skills in critically ill patients, namely critical care fellows, being unable to perform this imperative skill.

Despite the many challenges, not all changes due to the pandemic have been negative. As a result of the restructuring that was forced to occur to accommodate COVID-19 patients, providers were forced to brainstorm and change practices to continue to provide excellent care that minimized risk to the non-COVID-19 patient. Trainees and new faculty were involved in these discussions, which led to increased interdisciplinary teamwork and necessary adaptations. This also led to new opportunities both for surgical and anesthesiology teams. For example, many surgeons were encouraged to discharge their patients following their operation to limit the number of hospitalized patients. Therefore, discharge criteria were structured so cases that would typically require one night of hospitalization postoperatively were now allow to be discharged home immediately following the procedure. Regional anesthesiology teams also were encouraged to change their practices to allow for this adaptation, which included measures such as faster spinal block offset and varying use of peripheral nerve catheters that patients could remove at home.

Impact on Chronic Pain Medicine Fellowship Training

Clinical fellows specializing in chronic pain also encountered dramatic changes to their typical training. First, given that many clinics and elective procedures were cancelled altogether and many healthcare systems were not yet equipped with telehealth options, fellows were forced to complete their fellowship training with a significant decrease in the number of procedures and consults compared to their predecessors. In addition, given that they were left without work to perform, they were asked to help in other areas of the hospital, namely critical care units.

The restructuring of healthcare systems involved major changes in many predominantly outpatient specialties, including interventional pain management. The majority of these procedures are deemed elective and, therefore, in the midst of a pandemic, were forced to cease for a period of time. Accredited chronic pain fellowships are one-year programs with a large amount of information and skill-acquisition that needs to occur. Pandemic-related changes compelled fellows to adapt and become proficient and assimilate this material with three fewer months of in-person education. Depending on the program and need for assistance elsewhere within the hospital system, numbers of procedures were decreased by at least 25% for the year. Neuromodulation, in particular, is a group of advanced procedures that may have been impacted by the reduction in fellowship training opportunities. To assist with this gap in knowledge and experience, an online curriculum created and named “Pain Rounds” allowed fellows to supplement their knowledge through lectures, interview discussions, lab demonstrations, and more.5

In addition to procedural skills, fellows also are expected to diagnose and manage typical pain ailments through consultations. As telehealth technology developed, outpatient consults returned but were notably different given an inability to perform in-person physical examinations that are important in appropriately diagnosing painful conditions. While treatment options certainly vary depending on the practice of a specific academic institution, some balance generally exists between interventional therapies and medication management. However, in a time where hospital policies precluded performance of elective procedures, focus was instead given to medication management and therapies that could be performed at home. Providers were forced to find creative solutions for their patients, such as YouTube videos for physical therapy and yoga practices. Overall, these changes proved to be a challenge but provided opportunities for creative solutions in an unprecedented time. This impact was primarily on the fellows graduating in 2020 as elective procedures and in-person visits were again allowed by the end of the academic year and largely normal for the 2020-2021 fellows.

Fellows were placed in an interesting position with the concomitant decline in interventional pain educational opportunities and a peak in critically ill patients with limited number of providers to manage. Chronic pain fellows have a range of backgrounds ranging from anesthesiology, physical medicine and rehabilitation, and neurology. Those fellows with a background in anesthesiology were well equipped to manage critically ill patients with respiratory ailments. Therefore, in many areas of the country with a significant surge in cases, pain fellows were asked to assist in critical care areas. In locations like Boston and New York, fellows staffed these units for several months. This poses additional challenges such as increased risk of COVID-19 infection to themselves and family members, especially with a national shortage of PPE.

Considerations in Caring for COVID-19 Patients

In the early days of the pandemic, emphasis on flattening the curve among the general population to reduce the stress on the healthcare system at large was of paramount importance. Many hospital systems found themselves to have a woefully inadequate amount of PPE for the anticipated surge of COVID-19 patients. Anesthesiologists, residents, anesthetists, and other ancillary support staff awaited further direction as to proper PPE protocols as well as information on best practices with regard to the reuse of contaminated PPE for preservation purposes based on one’s institutional supply. The adaptations made were not unique to anesthesia departments but were required across the healthcare worker spectrum.

Anesthesiologists come across a variety of aerosol-generating procedures including mask ventilation, tracheal intubation, extubation, tracheostomy, emergency front of neck access, non-invasive ventilation, disconnection of ventilatory circuits in use, cardiopulmonary resuscitation, bronchoscopy, and tracheal suction without a closed system.2 ASRA and European Society of Regional Anesthesia and Pain Therapy have published a joint statement on practice recommendations on neuraxial anesthesia and peripheral nerve blocks during the COVID-19 pandemic.3 The statement provides recommendations for many practical aspects of regional anesthesia including but not limited to proper PPE for a given situation, minimizing contamination of common rooms and shared equipment, minimizing risk of conversion from spinal to general anesthesia by avoiding short-acting local anesthetics, optimizing systemic analgesia where appropriate, caution with pre-procedural sedation dosing, and choosing blocks and medications least likely to interfere with respiratory function.3

In addition to these considerations, anecdotal efforts to reduce healthcare worker exposure to COVID-19 as well as improve patient care and safety are numerous. Use of liposomal bupivacaine in select patients, for example, can significantly prolong the duration of peripheral nerve and fascial plane analgesia and reduce the need for additional rescue blocks in COVID-19-positive patients. Certainly, reducing redundant block team personnel (extra technicians, nurses, students, residents) to only those necessary for completion of the block is a prudent strategy. Changes to typical block team function at a large academic institution also can reduce health care worker exposure by employing in-room anesthesiologists to perform their own regional techniques, where appropriate, in COVID-19-positive patient rooms. Counterintuitively, increased use of mepivacaine (relative to use of bupivacaine) in spinal anesthetics is a simple change that could be employed to streamline elective total joint replacements (knees and hips) into outpatient procedures. A recent study found that patients receiving mepivacaine spinals were more likely to ambulate sooner and be discharged the same day than patients receiving either hyperbaric or isobaric bupivacaine.4

As elective outpatient surgeries and procedures began to resume, questions arose on how to appropriately manage patients who were coming in from the community for their procedures given the possibility they were infected but asymptomatic. Surgical procedures, such as stimulator implants, required that patients have a negative COVID test just prior to their procedures. However, this was not the case with shorter procedures. Instead, patients received a phone call prior to their procedure to ensure they were not experiencing any symptoms consistent with COVID-19 and had no recent infectious contacts. A questionnaire, temperature check, and face masking were required prior to their visits. These changes to clinic operating procedures impacted the entire team but allowed patient care to resume in-person.


Didactic and Conference Adaptations

Education in most fields has been significantly impacted by social distancing measures, and education of residents and fellows in regional anesthesia and pain medicine is no exception. In most if not all institutions, in-person education sessions that would normally occur in medium to large groups have been moved to a virtual format. Technological pitfalls and the decreased interactive nature of discussions present a hurdle to having optimally enriching sessions. In addition to educational adaptations on a local or institutional level, the pandemic led to cancellation of the 2020 Spring ASRA meeting and forced the 19th Annual Pain Medicine Meeting to change to an all-virtual format this past November. While a virtual format increases accessibility to information and decreases necessity for and costs of travel to an in-person conference, networking and educational workshop events have been understandably limited. Coupled with institution-imposed travel restrictions, these changes may have resulted in decreased interest and engagement amongst trainees interested in submitting interesting cases, studies, or other education projects. Time will tell if this will be reflected in the number of submissions or overall interest among trainees in entering the field.

We would be remiss to not mention the impact the pandemic has also had on board exams. Anesthesiology trainees typically will take their written exam the summer following graduation and their oral board exam the spring of their first year following graduation. This means that both acute and chronic pain fellows spend a significant amount of time in the spring of their fellowship year preparing for this often stressful exam. Unfortunately, the majority of these exams were cancelled mere days or weeks before the scheduled test and often after trainees had already spent weeks to months dedicating time for review. Although one can argue that this ultimately will improve their overall ability to perform their duties as anesthesiologists, it also meant that they spent time studying that could have been directed elsewhere and that those impacted will now be distracted by board examinations as they attempt to launch their careers.

As virtual journal clubs, didactic sessions, conferences, and even the American Board of Anesthesiology (ABA) Applied exam have been birthed out of necessity, it remains to be seen which adaptations may be here to stay. Improved access to educational content is undoubtedly a positive development. Improved trainee-directed learning through YouTube videos, applications such as Anesthesia Toolbox and “Pain Rounds” are options to complement typical clinical education. The ABA has recently communicated to board-eligible physicians their intention to continue with virtual exam administration through the Fall 2021 exam dates beginning in July, following successful virtual examinations of more than 500 candidates. The ABA cited that the pandemic still posed too great a risk to the health and safety of examinees. The communications also have indicated an eventual return to in-person examination in Raleigh, NC. The merit of electively conducting future board examinations in a virtual format or reserving this as an accommodation in extreme circumstances is certainly up for debate.

Summary

Since the arrival of the COVID-19 pandemic, regional anesthesiologists and pain medicine physicians have adapted in countless ways to continue to provide excellent analgesia, safe care to patients with and without COVID, and education and practice in the safest ways currently possible. The above examples and suggestions are just some of the anecdotal experiences of the authors and are by no means all-inclusive solutions for every provider at every institution. As time goes on and more is learned about the virus and effective measures to combat it while educating the next generation of physicians, we can reflect on which strategies have worked well, which could be improved, and what else we can do to remain flexible and effective caregivers for our patients.


Dr. Jeffrey Grzybowski
 
Jeffrey Grzybowski, MD, is a regional anesthesiology and acute pain medicine fellow in the department of anesthesiology at the University of Wisconsin in Madison.

Dr. Sarah Schroeder
 
Sarah Schroeder, MD, is a chronic and interventional pain fellow in the department of anesthesiology at Vanderbilt University in Nashville, TN.

Dr. Jody Lenz
 
Jody Cimbalo Leng, MD, MS, is a clinical assistant professor of anesthesiology and the director of regional anesthesiology and acute pain medicine at VA Palo Alto and the associate program director of the regional anesthesiology and acute pain medicine fellowship at Stanford Hospital and Clinics in Stanford, CA.

References

  1. Accreditation Council for Graduate Medical Education. ACGME Program Requirements for Graduate Medical Education in Anesthesiology. 2020; June 13. Available at: https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/040_Anesthesiology_2020.pdf?ver=2020-06-18-132902-423
  2. Tran K, Cimon K, Severn M, Pessoa-Silva CL, Conly J. Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review. PLoS One. 2012;7(4):e35797. https://doi.org/10.1371/journal.pone.0035797.
  3. Uppal V, Sondekoppam RV, Lobo CA, Kolli S, Kalagara H. Practice recommendations on neuraxial anesthesia and peripheral nerve blocks during the COVID-19 Pandemic: a joint statement by the American Society of Regional Anesthesia and Pain Medicine (ASRA) and European Society of Regional Anesthesia and Pain Therapy (ESRA). 2020, March 31. Available: at https://www.asra.com/guidelines-articles/original-articles/article-item/legacy-b-blog-posts/2020/04/01/practice-recommendations-on-neuraxial-anesthesia-and-peripheral-nerve-blocks-during-the-covid-19-pandemic
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