Residents warn of burnout as COVID-19, medical exams clash

It started with a tickle in the throat one morning last August and quickly progressed to headaches, muscle aches and fevers. That’s when Zack Singer, a third-year internal medicine resident in Saskatoon, knew he had COVID-19.

“I got it in the workplace, seeing a high-risk patient in the emergency department on high-flow oxygen,” says Singer. “I was trying to help him call his wife because he was declining and needing intubation. I was trying to put the patient first – then I got sick a few days later.”

Singer is one of many senior internal medicine resident doctors across Canada who were redeployed to the frontline COVID-19 wards. As a result, says Singer, the ability of senior residents to prepare for their specialty board exams has been seriously disrupted.

“Residents are responsible for the brunt of admissions to hospital,” says Singer. “With rising COVID cases and admissions, our workload increased.”

Now, many internist residents are frustrated that the Royal College of Physicians and Surgeons of Canada, which examines and certifies specialists, has refused their requests to modify the timing of their exams to accommodate for the pandemic.

Typically, third-year internal medicine residents write a final written exam in March composed of 300 questions over a two-day period and an oral exam in May involving 10 clinical assessments over three to four hours. Residents are required to pass both to obtain certification as internal medicine specialists.

Last month, the Canadian Association of Internal Medicine Program Directors (CAIMPD), on behalf of residents, asked the Royal College for the oral exam to be cancelled and the written component to be moved to its place in May.

The request was denied.

Susan Moffatt-Bruce, the CEO of the Royal College, says that the organization consulted a variety of stakeholders about the request, including resident organizations, medical regulatory agencies, internal medicine program directors and members of the college’s various internal medicine committees.

“A delay of the written exam to May would benefit some residents but negatively impact others,” she says. “Many have been studying and organized clinical rotations toward a March date.”

However, last year, the Royal College cancelled the oral exam and delayed the written component to the fall due to the pandemic.

“What bothers me is the inconsistency,” says Tara Swami, another third-year internal medicine resident in Saskatoon: “They cancelled the oral exams the year before us.”

And, she says, this year has been even busier and more difficult for the 59 internal medicine residents spread across Saskatoon’s hospitals.

When Swami started her residency in 2018, the internal medicine team at Saskatoon’s Royal University Hospital had an average of 70 patients at any given time. During the past few months, she says, the average has been more than 120 patients. On top of the usual wards, there have been two additional COVID units to cover but with the same number of residents.

“Overnight, there are only two junior residents and one senior resident for all of those patients,” she says.

Swami says residents work 10 to 12 hours a day, on top of longer 26-hour call shifts every four days that often include working on weekends. Then, after work, she spends five to six hours studying for her exams.

Moreover, says Singer, if residents come down with COVID-19 and have to quarantine, it detracts from their education and increases the burden on other residents, who have to work longer hours to cover for them.

“We have to put our personal lives on hold in case someone gets sick and … someone else needs to come in,” he says. “Meanwhile, we’ve been unable to see friends and family. It’s been harder to unwind and decompress.”

One senior internist resident in Toronto, who wished to remain anonymous because of concerns about possible backlash from Royal College examiners, says her partner, also a resident, suffered cardiac complications of COVID-19 and was admitted to hospital with myocarditis. Some of her colleagues had to cope with family members dying from COVID-19.

The Royal College’s refusal to modify exams was released the day after Bell’s Let’s Talk Day, during which the Royal College tweeted in support of resident mental health. The irony of the situation set off a social media firestorm among internal medicine residents across Canada.

“This is total disregard for our sanity and wellbeing. It’s almost laughable,” says Swami.

Of the need for the oral exam, Moffatt-Bruce says, “The Royal College … is here to serve the public good. We are entrusted to ensure that all specialists in Canada practice under a common standard of competence.”

She adds that the oral exams were cancelled last year only because the Royal College was not equipped at the time to deliver virtual exams but that technology is now readily available.

Both written and oral exams will be held in hotels across Canada, “located in each city with a medical school, to limit the need for travel.” Each site will implement cleanliness protocols and candidates will be assigned to individual hotel rooms equipped with computers and with on-site technical support.

And, says Moffatt-Bruce, “Candidates who cannot travel to a hotel site can choose to take their written exam online at their home or office using their own computer with remote proctoring and invigilation.”

However, a third-year internal medicine resident in Ontario who wished to remain anonymous points out that the oral exam will be shortened this year to one hour with only four stations.

“You’re still asking people to travel to one location during a pandemic for this exam,” he says. “It’s worth asking if it’s worth doing this one-hour exam on the grand scale and if it really accomplishes the overarching vision of the Royal College to thoroughly train and examine trainees for independent practice.

“Right now, in Ontario, there’s a stay-at-home order unless travel is essential. But we’ll be travelling for this exam.”

Olivier Fortin, president of the Fédération des médecins résidents du Québec (FMRQ), says both of Canada’s resident organizations – his and the Resident Doctors of Canada (RDoC) – were approached by the Royal College for opinions. But during the ensuing discussions, he says, it seemed the Royal College officials “had made their minds up already and just didn’t want to take the fall for their decision.”

In a letter to the CAIMPD, Esther Kim, president of RDoC, wrote that “across the country … we have heard universally a plea that the Royal College not include the oral exam component in this year’s exam ….  We have encouraged the College to remove this year’s oral exam component on a non-precedent setting basis.”

Reached for an interview, Kim wrote in an email that she could not discuss details of the situation publicly but that “RDoC is actively advocating for residents and (is) continually listening to their concerns.” She added that she “very much sympathize(s) with the current internal medicine residents, particularly in the cities that are hit the hardest due to COVID.”

In the meantime, Fortin says, “Our residents are stretched and showing signs of burnout. That’s been clear in surveys we’ve had across the province – there’s emotional distress and work overload, and mental-health issues are clearly prevalent right now.”

Fortin, who is a pediatric neurology resident in Montreal, says that some hospitals have been able to alleviate the workload for internal medicine teams by redeploying residents from other specialties.

“Every specialty has to put one resident on the backup call list for COVID wards, from internal medicine to family medicine to neurology and pediatric neurology. At McGill (University hospitals), this has been happening all year.”

Other hospitals, however, have relied entirely on internal medicine residents, sometimes even without an attending physician on site.

“It shouldn’t be residents only, and definitely not internal medicine residents only, and definitely not only the third-year residents preparing for exams,” says Fortin.

Adds Swami: “I think the pandemic has really exposed the inadequacies in our healthcare system and how truly reliant we are on residents. It’s really residents at the end of the day who … have to suffer that. We’re all at the beginning of our careers and nobody wants to be complaining but there’s only so much you can take before you burn out.”