One year later: Reflections on clinical training during the COVID-19 pandemic

By Sahar. S. Eshtehardi, MS, MaryJane S. Campbell, MS, Kelly E. Rea, MS, Andrea L. Fidler, MS, & Clarissa Shields, MA

Roughly one year ago, psychology trainees across the United States began experiencing disruptions in their training as a result of the COVID-19 pandemic. Like a domino effect, classes started shifting from in-person to Zoom, research protocols were put on hold, and clinical training became scarce. What was originally thought to be a few indulgent weeks working from home quickly became a new way of life, one that neither trainees nor their laptops were quite prepared for. Since last March, many aspects of doctoral training have easily transitioned into a remote format, while some components, such as clinical training, have been far more nuanced. As a result of the COVID-19 pandemic, doctoral students have had clinical placements entirely adapted, on hold, or in some cases, eliminated due to limitations around telehealth services. Balancing their desire to accomplish training goals and preserve the health and well-being of not only themselves, but also their families, pediatric psychology trainees have had to make difficult decisions in relation to deciding what path to pursue. This opinion piece provides prospective from five pediatric psychology doctoral trainees across the United States and their experiences navigating clinical training since the onset of the COVID-19 pandemic.

Telehealth Training

Many trainees had their first experience delivering clinical services via telehealth during the COVID-19 pandemic. Students found that having clear telehealth policies at the clinic or department level helped ease the transition for everyone involved. Although many aspects of telehealth have been enjoyable, as discussed below, it is important to acknowledge some of the unique challenges of delivering care remotely. Technology glitches occasionally terminated sessions prematurely, interfered with effective communication, and invalidated results for neuropsychological assessments. Non-verbal cues can also be more difficult to read over video. Many trainees realized they had to be more effortful and intentional in maintaining engagement with some therapy patients, especially when sessions followed a long day of virtual schooling (Zoom fatigue is real!) or due to distractions in the patient’s home environment. Given the unique safety concerns related to seeing patients in a non-clinic setting, trainees appreciated having established risk mitigation protocols and being able to easily contact supervisors as needed.  It is important to note that telehealth is not universally accessible. Some families do not have video-enabled devices or space to talk freely at home. Similarly, it is unrealistic to expect that all trainees have access to a private space with adequate lighting and an appropriate background, as well as a stable internet connection. These challenges were amplified for trainees living together, particularly when roommates were trying to see patients at the same time. Despite these drawbacks, trainees also acknowledge the benefits of conducting a portion of clinical training virtually. Telehealth has increased the ease of accessing mental health services for certain families, including those in rural areas and parents who are typically unable to attend in-person sessions due to a lack of childcare. Moreover, the utilization of telehealth allows therapists to provide feedback on parent management skills in a real-world setting. From a training perspective, there is shared appreciation that supervisors can “hide” in the background of video sessions and provide live feedback via the chat function. Further, it can feel less intrusive to refer to an intervention manual during a telehealth session. Trainees also appreciated the reduced commute times and increased flexibility in scheduling.

In-Person Training

For some trainees, there was the option to resume clinical training entirely in-person, dependent upon institutional policy, the population served, and patient preference within clinical rotations. While many institutions and supervisors made clear that resumption of in-person clinical training was up to the trainee, many trainees struggled with feeling forced to decide between valuable and necessary experiences for their training and the health and safety of themselves and those within their homes. For those electing to return to in-person experiences, time spent in training settings prior to vaccine availability for healthcare workers while cases were steadily rising remained a constant concern. With regard to the provision of in-person services, there were several changes to the clinical training experience when compared to the pre-COVID-19 era that remain today. Meetings with caregivers and other healthcare providers are often virtual or socially distanced, which limits face-to-face opportunity to receive consults or critical information directly from caregivers and can result in trainees being excluded from rounds. Without the casual, unstructured opportunity to interact with caregivers and team members, critical information regarding collaborating on patient care may be missed or reserved for only the most urgent or acute cases. In addition, caregivers occasionally expressed specific frustrations with the regulations in place, including pushing back on visitor restrictions, mask requirements, and the need to transition some previously established in-person services to telehealth when cases of COVID-19 increased during the winter months.

Combination of Remote & In-Person Training

Perhaps the most optimal experience for trainees has been a mixture of remote and in-person experiences. From trainees’ perspective, this hybrid approach allowed for invaluable in-person clinical experiences, as well as increased competency in navigating telepsychology. Specifically, trainees have enjoyed the ability to interact with patients and interdisciplinary team members within a medical setting. Academic medical centers and hospitals significantly enhanced pediatric psychology student experiences when they adapted procedures for trainees to deliver remote services. This included providing trainees with a secure laptop and increased medical access to meet with patients and supervisors remotely. The gradual re-entry of trainees into medical settings also benefited student training needs, while still balancing their health-related needs. Combination of remote and in-person training also improved trainees’ well-being, particularly through decreased video-conferencing fatigue. The flexibility to choose in-person versus remote services also allowed children and their families to receive psychological services based on their needs and preferences. In some clinical situations, in-person services may be imperative (e.g., clinical assessment, inpatient settings). Further, in-person services may be more ideal for high-risk clients (e.g., those presenting with suicidal ideation) given safety monitoring that may be more challenging to assess via telehealth. A hybrid approach has also enhanced patient care given that interdisciplinary team meetings, school meetings, and assessment feedback sessions can involve more caregivers for a child.

Challenges Across Clinical Settings

Despite best efforts to optimize clinical training opportunities during these unprecedented times, challenges across both telehealth and in-person settings remain. Most notably, institutional social distancing policies have resulted in numerous barriers related to consultation and supervision. Across sites and regardless of the method of care delivery, many trainees are finding it more and more difficult to build rapport with interdisciplinary providers, which is instrumental to not only patient health outcomes, but also to the professional development of trainees. Further, students are having to be more effortful in seeking out support from other clinical supervisors and trainees. Prior to the COVID-19 pandemic, if a trainee experienced a challenging session, they could often debrief with other trainees in the clinic workroom within the context of a commonly shared space. Students now, more than ever, need to be more intentional with creating those opportunities. Failure to provide these shared spaces not only impedes trainees’ ability to learn from differing clinician perspectives, but also prevents important social support from interacting with other trainees. The many limitations that trainees face across care delivery have also been noted, including the requirement to wear masks, face shields, and goggles for those providing in-person services. As such, trainees have relied on subtle communication with body language, etc. – something that is prominent when providing services via telehealth.

Moving Forward Post-COVID

Upon reflection, there are aspects of the COVID-19 pandemic training environment that would be valuable to continue moving forward. Overall, trainees enjoyed the mixed format of remote and in-person remote training opportunities, noting that the mixture maximizes flexibility, efficiency, and quality of training opportunities. Specifically, continuing to provide virtual didactics and clinical workshops would be highly valued among trainees. Prior to the COVID-19 pandemic, these opportunities might have been inaccessible due to travel and time constraints (e.g., clinical placements located some distance away from home institution), but due to increased feasibility of virtual format lecture series and workshops, trainees were able to attend more of these opportunities. Relatedly, some trainees were able to participate in training opportunities at other institutions (e.g., interventionist for telehealth research) that previously would have been impossible. Such opportunities have given pediatric psychology trainees a wider array of experience with settings, populations, and supervisors that may not otherwise exist. Continuing to offer virtual opportunities in addition to in-person training would be highly valued by trainees going forward. Lastly, having an option for telehealth was particularly beneficial for trainees with unique challenges during the COVID-19 pandemic (e.g., immunocompromised persons, trainees with dependents at home). The reduced commute time allowed trainees to balance competing work and home demands, minimized time away from dependents, and prioritize health and safety.  In sum, while trainees experienced many challenges associated with clinical training during the COVID-19 pandemic, some things worked well and may be beneficial to continue in the months and years to come.