Introduction
Due to the growing complexity of health care, physician training has been modified
to include the skills necessary for new and constantly changing scenarios.[1]
[2] The coronavirus disease 2019 (COVID-19) pandemic represents one of the most important
health crises in recent human history. In medical education, these changes have forced
adaptations in curriculum design regarding new skills, interpersonal relationships,
teaching strategies, and the need for community interventions.[3]
[4] For physicians in training, such as medical residents, the pandemic has also led
to direct changes in work and leisure routines, social interaction, and their own
health care. In addition to the inevitable stress that arises from training in a medical
specialty, these young physicians are overwhelmed with concerns about how to address
the health care of the population and how to deal with the dangers of contagion, both
for themselves and those close to them.[5]
[6] In other words, in addition to resident burnout, which has already reached epidemic
levels in recent years, the pandemic has added a further destabilizing factor.[7]
[8]
[9]
[10]
Recently, professional identity formation has been studied as a crucial element in
the long trajectory of medical education.[11] Thus, becoming a doctor in such a disruptive and uncertain context may deserve greater attention by researchers
committed to medical education.
This study is part of a broader, qualitative research project that seeks to analyze
the formation of professional identity among gynecology-obstetrics residents in a
public hospital in Brazil. Medical residents and preceptors in this program were interviewed,
and their interviews were recorded, transcribed, and analyzed using NVivo software
(QSR International, Doncaster, Australia). This study was approved by the institutional
research ethics committee (protocol no. CAAE 27172919.6.0000.5327).
After some initial interviews, it was clear that the pandemic had definitely affected
this process.
Healthcare and Educational Changes in Brazil due to the Pandemic
Following its spread from China, the COVID-19 pandemic hit Brazil in late February
2020, with the first case confirmed on February 26, and the first death recorded on
March 17. Although there were enormous contrasts in the epidemiological characteristics
of the disease's progress, all regions of the country were severely affected, and
there were significant changes in the functioning of healthcare networks. In view
of this situation, the National Medical Residency Commission (CNRM, an organ linked
to the Ministry of Education that is responsible for regulating medical residency)
issued a technical note on May 2020 featuring recommendations regarding the development
of residence program activities during the COVID-19 pandemic.[12] In general, this document has guided the medical residency commissions of each institution
and the State Medical Residency Commissions (CEREMs) about how to make residency activities
more flexible to minimize the harmful effects to physicians during the specialization
process. At the same time, it called on medical residents of all specialties to actively
engage in health care activities aimed at the pandemic in their cities. In the same
vein, the Brazilian Federation of Obstetrics and Gynecology Associations (FEBRASGO),
a scientific entity that represents Brazilian gynecologists and obstetricians and
is involved in the training of specialists in the area, issued its own recommendations
seeking, among other points, to minimize the loss of surgical skills due to the pandemic.[13]
The Hospital de Clínicas de Porto Alegre, a university hospital, is one of the largest
centers for training medical specialists in southern Brazil. The institution had been
preparing for the pandemic since January 2020, establishing contingency plans with
staggered restrictions for assistance activities, including specific flows for each
stage according to criteria that considered the number of occupied hospital beds and
the spread of the disease in the state of Rio Grande do Sul and the city of Porto
Alegre, where this study was conducted. The first officially registered case of severe
acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection at the institution
occurred on March 11, 2020, and the first death, 2 weeks later.
Since residence programs generally begin in early March, the new residents arrived
at the height of all this activity. Although the official reception was still festive,
including hundreds of photos shared on social media, the hospital moved to its first
contingency level on March 15, limiting a number of assistance activities and the
circulation of people through the hospital, which affected the patients and the medical
teams. As the pandemic progressed, restrictions were implemented in residence program
teaching activities and, in conformity to local health regulations, bars, restaurants,
and other public places were closed to reduce crowds.
Professional Identity: The Case of Obstetrics and Gynecology Residency
This exceptional scenario has had repercussions even on specialties that are not traditionally
involved in epidemiological problems. Obstetrics and gynecology, for example, is essentially
a medical specialty in women's health. The competency matrix, which serves as a guide
for the almost 300 residency programs in obstetrics and gynecology in Brazil, was
defined through recent CNRM legislation.[14] This detailed document divides the competences to be achieved into several axes
of care according to each year of the residency. Although it does not establish a
minimum number of expected procedures, there is a clear indication that the resident
must master certain techniques, which presupposes having acquired such competence
through exhaustive training.
As in any other surgical specialty, it requires, in addition to knowledge and attitudes,
the development of a series of motor skills, which residents obtain through continuous
exposure to a significant and varied number of situations in which they can exercise
their clinical reasoning in an appropriate, independent, and safe way for their patient
and themselves.[15]
In this complex trajectory towards specialized medical practice, the interrelationship
of peers plays a crucial role. Although the formation of a physician's professional
identity involves an eminently individual path, it always occurs alongside others
who are undergoing the same situation. For newcomers, being accepted into a peer community
that has a structured professional identity can pose additional stress during the
transition from student to doctor. This is true among the residents and the health
team members they relate to professionally. In other words, becoming a doctor is also
directly linked to the process of appearing like a doctor to other people. Thus, forming
a group of residents has been a hallmark of medical residency since its beginning.[16] In other words, the formation of professional identity is a two-way street: from
the inside out (the doctor must feel like a doctor) and from the outside in (other people must see him or her as a doctor).
Although the millennials' way of learning has led to changes in teaching and medical
residency in recent years, some traits, such as group support, have remained equally
important despite generational differences and increasing technological sophistication.
Regardless of preparation, which can begin prior to entering medical school, the transition
from being a student to a resident is still a huge challenge in any specialty.[17] Despite previous familiarity with some of the activities of medical school, being
registered with state agencies and “having the seal”, that is, formal authorization
to practice medicine, puts professional activity in a different perspective.
Likewise, coexistence and relationships with new colleagues—some completely unknown
and others who were former competitors for a place in the program—is an important
element in this equation. Interaction between colleagues in outpatient clinics, in
the operating room, on duty and in seminars is not only inevitable, but it can also
help residents bear the moments of stress and emotional overload that occur during
the program. Often, it is this type of connection that allows young doctors to satisfactorily
reach the end of their journey toward obtaining the title of specialist after finishing
the residency program.
Following the rapid expansion of information, communication, and technology resources,
there seems to be no doubt that this generation has a different learning style than
its predecessors.[18]
[19]
[20] Nevertheless, despite such autonomous learning and skill development, interpersonal
relationships and collaborative work among peers remain among the most important pillars
in resident training, although different programs do not always recognize them in
the same way.[21]
The Particularities of Brazilian Programs
The medical field in Brazil reflects certain particularities observed in the country
as a whole. Deciphering Brazilian culture has, in itself, been a constant challenge
for generations of anthropologists. However, despite great regional diversity, we
can say that Brazilian culture has a more permissive tendency than many other countries,
both in romantic relationships and in friendships.[22] Among other characteristics, it is a culture marked by physical proximity; for example,
greetings with hugs and kisses are not unusual.
This greater permissiveness in interpersonal relations is also reflected in the work
environment. In medical residencies, for example, new friends are made quickly through
numerous social activities during the program, although mainly outside the formal
structure. The welcoming rituals for new residents, reception parties, and other informal
gatherings that occur in the first weeks of the program are good examples of this.
Such events, especially among residents of the same year, become habitual and strengthen
friendships and the feeling of belonging to the larger group. These feelings continue
even after the residents go their separate ways as trained professionals. The testimonies
of two final-year residents illustrate this dimension well:
“Towards the end of the first year, we start working together, with two first-year
residents and one second-year resident. But there was always this thing about ‘after
our shift, let's go out and get something to eat, after our shift let's go out and...’”
“To deal with stress, I talk to my fellow residents. We have a very good group, my
colleagues from the same year. We're pretty united. We try to help each other. Just
yesterday, two colleagues were going through some situations and we [said] ‘Let's
go have some coffee together, let's go have lunch together’, we help each other a
lot. And this is in addition to family support”
(these and the following quotes have been translated from Portuguese).
During a medical residency program, any activity can have an educational role, even
informal ones and those involving interpersonal and group relationships. It is also
in these environments that information about jobs, courses, publications, and articles
of interest are exchanged. As Bonet[23] notes in his study on the training of family physicians in Argentina and Brazil,
it is interesting to observe the different environments in which professional socialization
takes place. It is in these spaces that, more or less explicitly, the transmission
of values and performance standards occurs. Thus, the group of residents becomes the
space in which they share their personal stories and reveal their personalities in
a more open way, without the risk of being judged by preceptors. In fact, it is when
residents share their problems with the group, such as difficulties with patients
or conflicts within the staff, that they receive collective support. As a second-year
resident reports:
“I was having a very stressful month that was turned around by my great team. I had
an episode that I guess should be called burnout, in which I found myself yelling
at a patient. I understood I was in a bad environment. But my colleagues took me aside
and said: ‘What's going on? Let's sit down and talk.’ And then I was able to get myself
together, and the month ended very well.”
Obviously, the group dynamics depend essentially on how these relationships are established
and maintained over time. On one hand, there can be a spirit of camaraderie and cooperation,
but on the other, overexposure can be dangerous because it reveals weaknesses, faults,
or other behaviors that are considered out of step with the group's principles. These
discrepancies, if striking, can even compromise a resident's participation in the
group. This is because, despite theoretically enjoying independence, more flexible
limits, and their own set of values, groups of residents assume a position of relative
submission to the larger structure of the residency program. In other words, there
is a permanent tension between the central core of the program and the groups of residents
who, being the weak end, are “shaped” by the more consolidated and, therefore, more
powerful group.
Two residents' reflections about how a colleague abandoned the program the previous
year are very enlightening about this type of thinking:
“The eight of us who entered [the program] are progressing, for better or worse, by
leaps and bounds, but, when necessary, we get together and hammer things out. I think
the group we have now is very good, we help each other. Still, there are, of course,
differences, little intrigues, but I think that, in general, it is a supportive group.
There was a resident who requested a transfer to another state, and, recently, one
of our oldest residents gave up, taking a test for another specialty. And there was
another one who gave up at the beginning of the year and is doing another clinical
specialty. These people did not feel at home in our program.”
“Two colleagues ended up quitting the program. I think it was because of a number
of things. I think the first one gave up because she didn't really fit in; she gave
up in July. I think it's because she didn't really like what she was doing. But the
second one, I think, was because of built-up pressure. She had a sick relative and
the pressure her colleagues–her teammates–put on her was also great.”
Even in this environment, interesting changes have occurred more recently regarding
group formation. The growing and widespread use of technology has proven inexorable
in all dimensions of our lives. Interpersonal and intergroup communication should
be highlighted, especially during the pandemic, which has required physical distancing
as a way to reduce disease transmission. Communication through platforms such as Facebook,
Instagram, and applications—such as WhatsApp and Telegram—have become very popular,
especially among young people. With these tools, unlimited instant text and voice
messages, images, and videos can be exchanged virtually for free.
Thus, other forms of interpersonal communication had to be quickly created to ensure
a sense of interactivity and belonging, which is essential for medical residency.
“They [only] had 2 weeks of residency! Many people can't make it to meetings. For
example, what brought my group together was this: scheduling a happy hour to talk
trash about the professors together, call each outer out, to get together, we did
that a whole lot. So, now, we can very easily resolve our problems, trade shifts,
and admonish each other. [The new residents] often have to go before the full group
to ask to trade shifts.”
In this context, there was a rush toward online communication tools and virtual meetings.
Although most of these applications have been used routinely for several years, the
lockdown has intensified their use. What was formerly resolved in person began happening
online—even the most common questions. As one resident said: “WhatsApp saved us!” Nevertheless, she pointed out that “it's not the same thing, but you can still feel supported.”
The changes in these relationships seem to indicate adjustments in both form and content.
They were creative adaptations implemented very quickly during an uncertain situation
and an urgent need for interaction. Thus, a quick solution for a communication problem
has now assumed the characteristics of professional identity formation.
Assessing the real impact of these changes will require, in addition to a longer follow-up
time, a more comprehensive and careful perspective.
