On May 28, Wilmer Eye Institute, Johns Hopkins Medicine hosted a Grand Rounds panel discussion titled “Academic Ophthalmology in the Age of COVID-19.” Guest panelists included Columbia University Residency Program Director Royce Chen; Massachusetts Eye and Ear Residency Program Director Alice Lorch; University of Michigan Vice Chair for Clinical Sciences and Learning at the Kellogg Eye Center Shahzad Mian; and University of Washington Residency Program Director Parisa Taravati. Representing Wilmer was Residency Program Director Fasika Woreta. Wilmer Assistant Chief of Staff Tom Johnson moderated the discussion.
Each panelist described how the pandemic affected their particular institution and how their departments and programs adapted clinical activities to accommodate social distancing and mitigate transmission. They shared some of the challenges they encountered and what they found effective. Mian said that knowing about the experience of peers in places like Seattle, New York and — in the original SARS pandemic, Singapore and Hong Kong — helped inform his center’s own responses and practices.
A vital issue for all was how to support the needs of the hospitals while protecting the health of residents. Chen said his group, in hard-hit New York City, struggled with how to decide who would be redeployed to other areas, particularly to the ICU. Ultimately, they met with a hospital ethicist to examine this question, which Chen said was helpful in weighing issues of need, competency and safety.
Lorch described how her department was forced to take the situation very seriously early on, as they had a number of residents and faculty members who were COVID-positive. “We had to think about how we were going to protect our workforce, moving forward. We put together a new schedule for our residents, where they were just covering emergency visits and inpatient consults, to really isolate them from each other,” she said.
Taravati pointed out that the first documented case originated in Washington state and noted that there was initially a sense of disbelief. “We quickly tried to change the criteria for ophthalmology consultations in order to protect residents as much as possible,” said Taravati, “and we modified criteria for higher specificity, in order to address the large number of consult requests we were receiving.” As was the case in all of the academic settings, the department implemented extensive cleaning protocols and the use of slit lamp face shields and mandatory masking.
Other effective adaptations included establishing triage hotlines to determine who actually needed to be seen in the emergency room, and creating diversion clinics to channel patients with urgent eye problems away from the emergency room, thereby reducing the number of patients gathered in the ER.
Witnessing a Virtual Revolution
Telemedicine was discussed in detail and appears to be gaining near-universal acceptance as a necessary and inevitable tool in ophthalmology. The departments all saw a trend toward hybrid visits, which allow patients to visit testing centers at suburban sites for things like glaucoma, retina, vision and pressure testing. Those results are then later interpreted by physicians during a virtual visit. The panelists discussed the need to build workflow around using testing imaging devices and educating patients on home use.
Chen shared details of a study he and his colleagues undertook that examined the impact of COVID-19 on resident physicians. Among other findings, ophthalmology was confirmed to be one of the higher risk specialties; quarantine and redeployment were deemed major disruptions to the resident workforce; and, not surprisingly, most residents felt that the pandemic had adversely affected their educational experience. (The paper has since been accepted for publication in the Journal of Clinical Investigation.)
One thing stressed by all the panelists was the challenge of keeping resident surgical training robust. Some programs shortened their rotation schedules to help ensure equitable training time for residents. Many residents used IC surgical simulators, and some centers tried virtual wet labs. Others found surgical video conferences helpful for preparing the cognitive aspect of training.
Lorch raised the prospect of live-streaming surgeries in the future, to allow more residents to watch and perhaps even ask questions in order to simulate aspects of the live experience. Woreta emphasized the need to make surgical training, especially for the PGY3 residents, a priority during ramp-up.
One of the biggest challenges now, the panelists agreed, will be helping patients feel safe in coming back to the clinics. Temporarily restructuring to allow more patients to be seen at satellite clinics may help facilitate a transition to the new normal, they said.
View the entire Panel Discussion: Academic Ophthalmology in the Age of COVID-19.