Fellowship Training in Adult Cardiothoracic Anesthesiology: Navigating the New Educational Landscape as a Result of the Coronavirus Crisis

Abstract

THE severe acute respiratory syndrome coronavirus-2 has spawned a pandemic from the resultant coronavirus disease-19 (COVID-19) that is now a worldwide crisis.1Yang X. Yu Y. Xu J. et al.Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: A single-centered, retrospective, observational study.Lancet Respir Med. 2020; (Accessed April 10, 2020)https://doi.org/10.1016/S2213-2600(20)30079-5Abstract Full Text Full Text PDF Scopus (5955) Google Scholar, 2He Y. Wei J. Bian J. et al.Chinese Society of Anesthesiologists expert consensus on anesthetic management of cardiac surgical patients with suspected or confirmed coronavirus disease 2019.J Cardiothorac Vasc Anesth. 2020; 34: 1397-1401Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar, 3Bhatraju P.K. Ghassemieh B.J. Nichols M. et al.COVID-19 in critically ill patients in the Seattle region – case series.N Engl J Med. 2020; (Accessed April 12, 2020)https://doi.org/10.1056/NEJMoa2004500Crossref PubMed Scopus (1595) Google Scholar The spectrum of COVID-19 includes acute lung injury that may progress to acute respiratory distress syndrome, circulatory shock, renal failure, and death.3Bhatraju P.K. Ghassemieh B.J. Nichols M. et al.COVID-19 in critically ill patients in the Seattle region – case series.N Engl J Med. 2020; (Accessed April 12, 2020)https://doi.org/10.1056/NEJMoa2004500Crossref PubMed Scopus (1595) Google Scholar, 4Peng P.W.H. Ho P.L. Hota S.S. Outbreak of a new coronavirus: What anaesthetists should know.Brit J Anaesth. 2020; 124: 497-501Abstract Full Text Full Text PDF PubMed Scopus (245) Google Scholar, 5Guan W.J. Ni Z.Y. Hu Y. et al.Clinical characteristics of coronavirus disease 2019 in China.N Engl J Med. 2020; 382: 1708-1720Crossref PubMed Scopus (17399) Google Scholar, 6Huang C. Wang Y. Li X. et al.Clinical features of patients with 2019 novel coronavirus in Wuhan, China.Lancet. 2020; 395: 497-506Abstract Full Text Full Text PDF PubMed Scopus (27644) Google Scholar The surge in health care demands for patients with severe COVID-19 across the United States has been overwhelming as a result of multiple factors, including viral transmission, patient volume, patient acuity, and the requirements for strict infection control.7Swerdlow D.L. Finelli L. Preparation for possible sustained transmission of 2019 novel coronavirus: Lessons from previous epidemics.JAMA. 2020; 323: 1129-1130Crossref PubMed Scopus (69) Google Scholar,8Chopra V. Toner E. Waldhorn R. et al.How should US hospitals prepare for coronavirus disease 2019 (COVID-19)?.Ann Int Med. 2020; (Accessed April 14, 2020. [E-pub ahead of print])https://doi.org/10.7326/M20-0907Crossref Scopus (101) Google Scholar The purpose of this freestanding editorial is to highlight the significant effects of the coronavirus crisis on fellowship training in adult cardiothoracic anesthesiology across the United States. This perspective describes this landscape and suggests solutions for the program leadership to navigate this crisis successfully in a flexible and resilient fashion. The references provide additional detail for program directors and their teams to manage the demands of the pandemic in their respective fellowship programs. The severity of a health system's response to the COVID-19 crisis has been classified into 1 of 3 stages by the Accreditation Council for Graduate Medical Education (ACGME) (full details available at: www.acgme.org/covid-19). Stage 1 has been termed “business as usual,” reflecting a period during which the health system is not significantly affected by the coronavirus crisis. In this stage there is little disruption of patient care or fellow educational activities, but the hospital and departmental leadership have begun planning for the anticipated increased clinical load. Although the fellowship is still governed by the usual common and specific program requirements, certain ACGME activities will be suspended, including surveys, the self-study, and site visits.9Trombetta C. Capdeville M. Patel P. et al.The program evaluation committee in the adult cardiothoracic anesthesiology fellowship – harnessing opportunities for program improvement.J Cardiothorac Vasc Anesth. 2020; 34: 797-904Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar,10Goldhammer J. Herman C.R. Heitz J.W. et al.ACGME accreditation guide for the adult cardiothoracic anesthesiology fellowship.J Cardiothorac Vasc Anesth. 2018; 32: 2395-2401Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar The duration of the first stage is determined by the local trajectory of the pandemic in a given health system and region.11World Health Organization. Clinical management of severe acute respiratory infection when novel coronavirus (2019-nCoV) infection is suspected - interim guidance. Available at: https://www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected. Accessed March 29, 2020.Google Scholar,12Driggin E. Madhavan M.V. Bikdeli B. et al.Cardiovascular considerations for patients, health care workers, and health systems during the coronavirus disease 2019 (COVID-19) pandemic.J Am Coll Cardiol. 2020; (Accessed April 14, 2020)https://doi.org/10.1016/j.jacc.2020.03.031Crossref Scopus (1240) Google Scholar As the number of infected patients and subsequent clinical demands increase, the health system enters stage 2, during which period some educational activities are suspended and some fellows are shifted to patient care duties outside of their fellowship area to help shoulder the clinical burden of the health system's pandemic response. Although the fellowship continues to be governed by the existing common and specific program requirements, the ACGME has added some qualifiers, including the provision of adequate resources and training, adequate supervision, the maintenance of professional standards, and the preservation of existing work hour limits (www.acgme.org/covid-19). Board-eligible fellows may apply for and receive emergency credentialing from their respective health system so that they may function as attendings in anesthesiology to further aid in managing the increased clinical workload. However, the amount of time they spend outside the clinical area of their fellowship may not exceed 20% of the fellowship year. Although surveys, self-study, and site visits are suspended in stage 2, fellowship programs should do their best to continue with educational activities while adhering to adequate social distancing and other local rules and policies regarding the size of meetings or gatherings. Thankfully, there are a variety of technology-based solutions that allow for the continuation of educational activities under such restrictions, including remote video- and audio-conferencing technology, internet-based resources, and similar innovative tools. As clinical demands surge along with the local COVID-19–positive population, the health system enters stage 3. ACGME has termed this phase “pandemic emergency status,” which it defines as the deployment of most fellows to patient care areas outside the normal fellowship scope and the suspension of most educational sessions (www.acgme.org/covid-19). In this crisis mode, the fellowship is governed by the following 4 overriding requirements: respect for work hour limits, the provision of adequate resources and training, maintenance of adequate supervision, and the potential for fellows to function as attendings in their core specialty of anesthesiology. The other requirements for stages 1 and 2, and for the fellowship subspecialty, are waived during stage 3. This road map provided by the ACGME allows the health system to plan a phased response to the COVID-19 pandemic depending on its local intensity. The fellowship leadership then can synchronize accordingly at all levels, as outlined in the following sections. The designated institutional official graduate medical office will lead the navigation through the response phases to the pandemic as outlined by the ACGME and thus serve, as always, their vital central oversight function across the training landscape at a given institution.13Capdeville M. Hargrave J. Patel P.A. et al.Contemporary challenges for fellowship training in adult cardiothoracic anesthesiology: Perspectives from program directors around the United States.J Cardiothorac Vasc Anesth. 2020; (Accessed April 14, 2020)https://doi.org/10.1053/j.jvca.2020.02.011Abstract Full Text Full Text PDF Scopus (10) Google Scholar, 14Sorbello M. El-Boghdadly K. Di Giacinto I. et al.The Italian coronavirus disease 2019 outbreak: Recommendations from clinical practice.Anaesthesia. 2020; (Accessed April 14, 2020)https://doi.org/10.1111/anae.15049Crossref Scopus (235) Google Scholar This central leadership from the institutional graduate medical education team likely will consider the following recommended principles to engage and support the graduate medical community through the COVID-19 crisis: a clear strategy to cope with patient volume and acuity, protecting and supporting the fellows on the front lines of patient care, a transparent and fair strategy for allocation of health care resources, and the deployment of an adaptable and open communication policy with weekly townhall-style meetings that take advantage of innovative platforms such as remote conferencing technology.8Chopra V. Toner E. Waldhorn R. et al.How should US hospitals prepare for coronavirus disease 2019 (COVID-19)?.Ann Int Med. 2020; (Accessed April 14, 2020. [E-pub ahead of print])https://doi.org/10.7326/M20-0907Crossref Scopus (101) Google Scholar The fellowship program director should be very familiar with all of this content to guide the fellowship faculty and trainees successfully through the ups and downs of the coronavirus crisis with focused planning, training, and teamwork in a fashion consistent with the phased ACGME response to COVID-19.8Chopra V. Toner E. Waldhorn R. et al.How should US hospitals prepare for coronavirus disease 2019 (COVID-19)?.Ann Int Med. 2020; (Accessed April 14, 2020. [E-pub ahead of print])https://doi.org/10.7326/M20-0907Crossref Scopus (101) Google Scholar,9Trombetta C. Capdeville M. Patel P. et al.The program evaluation committee in the adult cardiothoracic anesthesiology fellowship – harnessing opportunities for program improvement.J Cardiothorac Vasc Anesth. 2020; 34: 797-904Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar The director and broader leadership team of the fellowship program should strive to maintain consistent and transparent communication not only with the educational leadership at the institutional level but also at the departmental level. This includes the leader of the core anesthesiology residency program, other fellowship directors, the vice-chair for education, and the departmental chair.8Chopra V. Toner E. Waldhorn R. et al.How should US hospitals prepare for coronavirus disease 2019 (COVID-19)?.Ann Int Med. 2020; (Accessed April 14, 2020. [E-pub ahead of print])https://doi.org/10.7326/M20-0907Crossref Scopus (101) Google Scholar,15Black S. Capdeville M. Augoustides J.G. et al.Clinical competency committee in adult cardiothoracic anesthesiology – perspectives from program directors around the United States.J Cardiothorac Vasc Anesth. 2019; 33: 1819-1827Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar This regular dialogue will facilitate a seamless synchronization of the adult cardiothoracic fellowship with the department's integrated response to COVID-19, especially in stages 2 and 3. This communication will help to ensure that the fellows have adequate training in the clinical area to which they are deployed, are appropriately credentialed, and receive the necessary supplies and equipment to protect themselves as they aid the department and health system in caring for COVID-19–positive patients.11World Health Organization. Clinical management of severe acute respiratory infection when novel coronavirus (2019-nCoV) infection is suspected - interim guidance. Available at: https://www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected. Accessed March 29, 2020.Google Scholar,16He H. Zhao S. Han L. et al.Anesthetic management of patients undergoing aortic dissection repair with suspected severe acute respiratory syndrome coronavirus-2 infection.J Cardiothorac Vasc Anesth. 2020; (Accessed April 14, 2020)https://doi.org/10.1053/j.jvca.2020.03.021Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar, 17Madjid M. Safavi-Naeini P. Solomon S.D. et al.Potential effects of coronaviruses on the cardiovascular system: A review.JAMA Cardiol. 2020; (Accessed April 14, 2020)https://doi.org/10.1001/jamacardio.2020.1286Crossref PubMed Scopus (1104) Google Scholar, 18Clerkin K.J. Fried J.A. Raihelkar J. et al.Coronavirus disease 2019 (COVID-19) and cardiovascular disease.Circulation. 2020; (Accessed April 15, 2020)https://doi.org/10.1161/CIRCULATIONAHA.120.046941Crossref Scopus (976) Google Scholar The normal fellowship timeline with its goals and activities should be managed as best as possible in stages 1 and 2, but will have to be largely sacrificed in stage 3, depending on the intensity of the local COVID-19 outbreak, as outlined by the ACGME.19Capdeville M, Ural KG, Patel PA, et al. The educational evolution of fellowship training in cardiothoracic anesthesiology – perspectives from program directors around the United States. 2018;32:607-20.Google Scholar,20Xiong T.Y. Redwood S. Prendergast B. et al.Coronaviruses and the cardiovascular system: Acute and long-term implications.Eur Heart J. 2020; (Accessed April 14, 2020)https://doi.org/10.1093/eurheartj/ehaa231Crossref Scopus (424) Google Scholar This dynamic educational landscape offers multiple opportunities to mentor educational leaders, including aspiring program directors, to develop creative and collaborative solutions for the challenges of the coronavirus crisis for both the graduating and incoming fellows.19Capdeville M, Ural KG, Patel PA, et al. The educational evolution of fellowship training in cardiothoracic anesthesiology – perspectives from program directors around the United States. 2018;32:607-20.Google Scholar, 20Xiong T.Y. Redwood S. Prendergast B. et al.Coronaviruses and the cardiovascular system: Acute and long-term implications.Eur Heart J. 2020; (Accessed April 14, 2020)https://doi.org/10.1093/eurheartj/ehaa231Crossref Scopus (424) Google Scholar, 21Capdeville M. Hargrave J. Foshee C. et al.Mentoring aspiring program directors in adult cardiothoracic anesthesiology – perspectives from program directors around the United States.J Cardiothorac Vasc Anesth. 2018; 32: 2381-2394Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar The phased response to the crisis intensity at the departmental level will be greatly enhanced with an integrated response from the fellowship leadership.21Capdeville M. Hargrave J. Foshee C. et al.Mentoring aspiring program directors in adult cardiothoracic anesthesiology – perspectives from program directors around the United States.J Cardiothorac Vasc Anesth. 2018; 32: 2381-2394Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar, 22Zheng Y.Y. Ma Y.T. Zhong J.Y. et al.COVID-19 and the cardiovascular system.Nat Rev Cardiol. 2020; 17: 259-260Crossref PubMed Scopus (1923) Google Scholar, 23Ross S.W. Lauer C.W. Miles W.S. et al.Maximizing the calm before the storm: Tiered surgical response plan for the novel coronavirus (COVID-19).J Am Coll Surg. 2020; (Accessed April 15, 2020)https://doi.org/10.1016/j.jamcollsurg.2020.03.019Abstract Full Text Full Text PDF PubMed Scopus (77) Google Scholar The program leadership should endeavor to maintain an open and approachable leadership style with the faculty and fellows. The interpretation and implementation of the information and policies from the ACGME, institutional graduate medical office, and the department leadership can be led and facilitated at the fellowship level by the program director.13Capdeville M. Hargrave J. Patel P.A. et al.Contemporary challenges for fellowship training in adult cardiothoracic anesthesiology: Perspectives from program directors around the United States.J Cardiothorac Vasc Anesth. 2020; (Accessed April 14, 2020)https://doi.org/10.1053/j.jvca.2020.02.011Abstract Full Text Full Text PDF Scopus (10) Google Scholar,15Black S. Capdeville M. Augoustides J.G. et al.Clinical competency committee in adult cardiothoracic anesthesiology – perspectives from program directors around the United States.J Cardiothorac Vasc Anesth. 2019; 33: 1819-1827Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar,19Capdeville M, Ural KG, Patel PA, et al. The educational evolution of fellowship training in cardiothoracic anesthesiology – perspectives from program directors around the United States. 2018;32:607-20.Google Scholar A regular series of townhall-style meetings will allow the fellows to be heard and express their concerns and ideas for addressing the effect of the coronavirus crisis, including the clinical, educational, and emotional considerations.2He Y. Wei J. Bian J. et al.Chinese Society of Anesthesiologists expert consensus on anesthetic management of cardiac surgical patients with suspected or confirmed coronavirus disease 2019.J Cardiothorac Vasc Anesth. 2020; 34: 1397-1401Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar, 3Bhatraju P.K. Ghassemieh B.J. Nichols M. et al.COVID-19 in critically ill patients in the Seattle region – case series.N Engl J Med. 2020; (Accessed April 12, 2020)https://doi.org/10.1056/NEJMoa2004500Crossref PubMed Scopus (1595) Google Scholar, 4Peng P.W.H. Ho P.L. Hota S.S. Outbreak of a new coronavirus: What anaesthetists should know.Brit J Anaesth. 2020; 124: 497-501Abstract Full Text Full Text PDF PubMed Scopus (245) Google Scholar,24Brooks S.K. Webster R.K. Smith L.E. et al.The psychological impact of quarantine and how to reduce it: Rapid review of the evidence.Lancet. 2020; 395: 912-920Abstract Full Text Full Text PDF PubMed Scopus (7683) Google Scholar Of note, fellows should be reassured that the clinical minimums set by the ACGME are a means to evaluate programs themselves, not individual fellows. Thus, the decision as to whether an individual fellow will graduate from a training program is up to the program director and larger clinical competency committee, irrespective of whether all minimum case numbers have been met.10Goldhammer J. Herman C.R. Heitz J.W. et al.ACGME accreditation guide for the adult cardiothoracic anesthesiology fellowship.J Cardiothorac Vasc Anesth. 2018; 32: 2395-2401Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar,13Capdeville M. Hargrave J. Patel P.A. et al.Contemporary challenges for fellowship training in adult cardiothoracic anesthesiology: Perspectives from program directors around the United States.J Cardiothorac Vasc Anesth. 2020; (Accessed April 14, 2020)https://doi.org/10.1053/j.jvca.2020.02.011Abstract Full Text Full Text PDF Scopus (10) Google Scholar,15Black S. Capdeville M. Augoustides J.G. et al.Clinical competency committee in adult cardiothoracic anesthesiology – perspectives from program directors around the United States.J Cardiothorac Vasc Anesth. 2019; 33: 1819-1827Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar The ACGME also has stated that the COVID-19 crisis and its effects on fellowship case logs will be taken into account when program reviews eventually restart (www.acgme.org/covid-19). Other aspects that program directors must take into consideration are the psychological and emotional consequences of quarantine.24Brooks S.K. Webster R.K. Smith L.E. et al.The psychological impact of quarantine and how to reduce it: Rapid review of the evidence.Lancet. 2020; 395: 912-920Abstract Full Text Full Text PDF PubMed Scopus (7683) Google Scholar,25Maunder R. The experience of the 2003 SARS outbreak as a traumatic stress among frontline healthcare workers among frontline health care workers in Toronto: Lessons learned.Phil Trans R Soc Lond B Biol Sci. 2004; 359: 1117-1125Crossref PubMed Scopus (264) Google Scholar The psychological effects of quarantine are significant and may affect fellows who are quarantined because of exposure to or infection with COVID-19 or who are well but live in an area of community lockdown with social distancing to minimize the risks of viral transmission.24Brooks S.K. Webster R.K. Smith L.E. et al.The psychological impact of quarantine and how to reduce it: Rapid review of the evidence.Lancet. 2020; 395: 912-920Abstract Full Text Full Text PDF PubMed Scopus (7683) Google Scholar,25Maunder R. The experience of the 2003 SARS outbreak as a traumatic stress among frontline healthcare workers among frontline health care workers in Toronto: Lessons learned.Phil Trans R Soc Lond B Biol Sci. 2004; 359: 1117-1125Crossref PubMed Scopus (264) Google Scholar These effects include confusion, anger, depression, burn-out, and posttraumatic stress disorder.24Brooks S.K. Webster R.K. Smith L.E. et al.The psychological impact of quarantine and how to reduce it: Rapid review of the evidence.Lancet. 2020; 395: 912-920Abstract Full Text Full Text PDF PubMed Scopus (7683) Google Scholar Given the significant effects of quarantine on psychological well-being, program directors should be aware of these issues and be constantly vigilant for their signs in the fellowship class. Additional stressors that fellows or faculty may be facing include known psychiatric conditions such as anxiety and depression, which are commonly exacerbated during times of crisis. Additional factors that may aggravate stress include marital status, number of children, and perceived level of exposure, although the evidence is not consistent about these issues.24Brooks S.K. Webster R.K. Smith L.E. et al.The psychological impact of quarantine and how to reduce it: Rapid review of the evidence.Lancet. 2020; 395: 912-920Abstract Full Text Full Text PDF PubMed Scopus (7683) Google Scholar, 25Maunder R. The experience of the 2003 SARS outbreak as a traumatic stress among frontline healthcare workers among frontline health care workers in Toronto: Lessons learned.Phil Trans R Soc Lond B Biol Sci. 2004; 359: 1117-1125Crossref PubMed Scopus (264) Google Scholar, 26Roberston E. Herschenfiled K. Grace S.L. et al.The psychosocial effects of being quarantined following exposure to SARS: A qualitative study of Toronto health care workers.Can J Psychiatry. 2004; 49: 403-407Crossref PubMed Scopus (193) Google Scholar Clinical investigation about factors that may negatively affect psychological well-being during periods of quarantine has revealed several triggers, including the duration of quarantine, anxiety levels about infection, levels of frustration and boredom, inadequate supplies and personal protective equipment, and disordered communication.24Brooks S.K. Webster R.K. Smith L.E. et al.The psychological impact of quarantine and how to reduce it: Rapid review of the evidence.Lancet. 2020; 395: 912-920Abstract Full Text Full Text PDF PubMed Scopus (7683) Google Scholar, 25Maunder R. The experience of the 2003 SARS outbreak as a traumatic stress among frontline healthcare workers among frontline health care workers in Toronto: Lessons learned.Phil Trans R Soc Lond B Biol Sci. 2004; 359: 1117-1125Crossref PubMed Scopus (264) Google Scholar, 26Roberston E. Herschenfiled K. Grace S.L. et al.The psychosocial effects of being quarantined following exposure to SARS: A qualitative study of Toronto health care workers.Can J Psychiatry. 2004; 49: 403-407Crossref PubMed Scopus (193) Google Scholar, 27Reynolds D.L. Garay J.R. Deamond S.L. et al.Understanding, compliance and psychological impact of the SARS quarantine experience.Epidemiol Infect. 2006; 136: 997-1007Crossref Scopus (565) Google Scholar After quarantine has ended, ongoing stressors that may slow psychological recovery include financial losses and the effects of social stigma.24Brooks S.K. Webster R.K. Smith L.E. et al.The psychological impact of quarantine and how to reduce it: Rapid review of the evidence.Lancet. 2020; 395: 912-920Abstract Full Text Full Text PDF PubMed Scopus (7683) Google Scholar Because the effects of quarantine may occur through all phases of the COVID-19 response, program directors should consider processes to recognize and manage these issues in their fellows. Interventions that may minimize the effects of quarantine and social distancing include a focused approach to the fellows with regular, open communication; frequent information sharing; adequate supplies and personal protective equipment; and an emphasis on collective responsibility and teamwork.24Brooks S.K. Webster R.K. Smith L.E. et al.The psychological impact of quarantine and how to reduce it: Rapid review of the evidence.Lancet. 2020; 395: 912-920Abstract Full Text Full Text PDF PubMed Scopus (7683) Google Scholar, 25Maunder R. The experience of the 2003 SARS outbreak as a traumatic stress among frontline healthcare workers among frontline health care workers in Toronto: Lessons learned.Phil Trans R Soc Lond B Biol Sci. 2004; 359: 1117-1125Crossref PubMed Scopus (264) Google Scholar, 26Roberston E. Herschenfiled K. Grace S.L. et al.The psychosocial effects of being quarantined following exposure to SARS: A qualitative study of Toronto health care workers.Can J Psychiatry. 2004; 49: 403-407Crossref PubMed Scopus (193) Google Scholar, 27Reynolds D.L. Garay J.R. Deamond S.L. et al.Understanding, compliance and psychological impact of the SARS quarantine experience.Epidemiol Infect. 2006; 136: 997-1007Crossref Scopus (565) Google Scholar The fellowship team can manage these challenges with due cognizance of these factors in concert with departmental, institutional, and national guidance. The coronavirus crisis has challenged fellowship training in adult cardiothoracic anesthesiology. The magnitude of this challenge is proportional to the intensity of the COVID-19 crisis. The program leadership should coordinate its strategies in concert with input from the institution, department, faculty, and fellows. The successful navigation of this crisis should focus on patient care and the physical and psychological safety of the fellows.