New beginnings in post graduate medical education. Latin American Medical Education Leaders Forum

Introduction: The consequences of the Covid-19 epidemic have been catastrophic for Latin America in 2021. This study explores experiences, lessons learned, and practice changes during this critical time in post-graduate medical education in Latin America. Methods: A panel of 53 post-graduate medical education leaders from 8 Latin American countries and Canada was invited to participate in the 2021 Latin American Medical Education Leaders Forum to share their experiences, lessons learned, and main educational practice changes given the Covid-19 pandemic scenario. Participants were selected following a snowball technique with the goal of obtaining a diverse group of experts. Small group discussions were conducted by bilingual facilitators based on a semi-structured questionnaire. The plenary session with the main conclusions of each group was recorded and fully transcribed for a thematic analysis using a framework methods approach. Results: Participants ́ profiles included 13 experienced clinician-educators, 19 program directors, and 23 deans or organizational representatives. Seven specific themes emerged. They followed a pattern that went from an initial emotional reaction of surprise to a complex collective response. The responses highlighted the value of adaptability, the application of new digital skills, a renovated residents’ protagonism, the strengthening of humanism in medicine, the openness of new perspectives in wellness, and finally, an unresolved challenge of assessment in medical education in a virtual post-pandemic scenario. Conclusion: A diverse panel of medical educators from Latin America and Canada identified changes triggered by the Covid-19 pandemic that could transform postgraduate medical education in the region.


Introduction
The consequences of the Covid-19 epidemic have been especially In this scenario, local communities have experienced an unbearable amount of suffering, medical services have been surpassed in most countries, and health care teams have been overstressed. Postgraduate medical programs had to navigate in this critical context and to adjust to conditions that have been never experienced before (Chasset et al., 2021).
The pandemic period found Latin American medical education in a very particular scenario. The region has experienced a significant increase in new medical schools and residency programs during the last decades. About 15% of medical schools worldwide are from Latin America (Duvivier et al., 2014). Most of the residency programs are yet to start to systematize their training models (Duvivier et al., 2014;Hoyl et al., 2019) Despite the high proportion of medical schools and residency programs in Latin America, there is a lack of information on the effects of the Covid-19 pandemic on post-graduate medical education in the region. In the systematic review conducted by Chasset et al. (2021) on the consequences of the Covid-19 pandemic on residents and medical students, the authors identified over 1400 references and included 60 articles in their final analysis; none of these articles were from Latin America. Similarly, Tolu LB et al. (2020)  Forum is an international encounter where medical education leaders from Latin America and Canada discuss relevant trends and changes that could improve post-graduate medical education in the region. The Forum offered an opportunity to reconnect a community that has been strongly hit by the pandemic and allowed participants to analyze what experiences and themes have emerged and could make a significant impact on the organizations and communities they lead.

Study setting and participants
The IMELF-LA Forum was organized by the Centre of Medical Participants split into eight groups, and each of them was conducted by a bilingual facilitator who took field notes and summarized the information gathered during the discussion. Each group presented their reflections and conclusions at a plenary session. The plenary session was audio-video recorded and fully transcribed for the analysis.

Analysis
The analysis of the information was based on field notes taken by organizers and group facilitators, a review of the recorded sessions, and plenary session transcripts. A framework methods approach (Ritchie & Lewis, 2003) was used to analyze the information. This approach is recommended when analyzing qualitative information explored within a specific topic. It has been used previously in similar contexts . Key concepts were coded and clustered in common themes that were included in the general framework of the discussion that focused on the lessons learned in residency education given the pandemic scenario. The information was charted in a concept mapping developed to summarize the main findings.
The report was sent to all participants for their review. General comments on the document and specific suggestions or additions related to the results of this report were considered and included in the final version.

Results
The 2021 IMELF-LA Forum gathered 53 participants from 9 different countries. The first group of experienced clinician educators included 13 participants. The second group of senior academic coordinators, postgraduate and medical school directors, integrated 19 participants. The third group included 12 deans, four vice-deans or associate or assistant deans, two pro-rectors or vice-rectors, and three presidents or vice-presidents of national or international institutions. The participants' profile is presented in Table 1.
The results of the information were grouped into seven main themes. Each theme expressed a cluster of key-related concepts expressed during the discussions. Table 2 summarizes the themes and key concepts that emerged during the discussions.

From surprise to chaos:
The majority of groups expressed that the pandemic generated a first surprised reaction among their clinical and academic communities.
It was a sudden event that appeared unexpectedly and irrupted in unprepared residency programs. Most teams had the idea that this was an acute event that would last a couple of weeks, and that was not going to affect them strongly. The sense of surprise turned into uncertainty, disorganization, and chaos in most programs. The exceptional event was transitioning into a permanent "abnormal" Participants emphasized the teamwork approach of different medical specialists. They tried to contribute from their expertise, adapting their actions to the social reality. This experience revealed professionals as public servers, capable of responding in a non-familiar environment, distant from their specific work field.

New digital skills:
There was consensus among participants on the essential role of digital technology for enhance residency training. The pandemic crisis uncovered the opportunities and capabilities of technology to improve residency training, making it more effective and (4) (3) (4) (1) (3) (2) (4) efficient. Application of digital technology to retake clinical consultations and supervision through telemedicine, workshops, and webinars via zoom for topic discussions and distant simulation training with virtual feedback were some of the digital education strategies mentioned by participants. Some of them emphasized that good traditional educators were also good digital educators, and therefore, educational principles remain the same. However, most participants agreed that digital skills were essential to take full advantage of technology and that there was a high, probably generational, variability in those skill levels among faculty. Many faculty gave examples of residents helping them to use technology appropriately. There was agreement that faculty should have consistent digital skills for residency training and that many will need to improve them in the new scenario after the epidemic.
Participants highlighted that technical information and communication (TICs) skills are here to stay in medical education and that the pandemic triggered this change. The change was "announced" years ago, but the pandemic boosted it in a short period and allowed the programs to sustain medical education during the crisis.

New role of residents as protagonists:
The traditional learner-centered approach acquired a new dimension during the pandemic scenario. Residents' less specific professional development allowed them to serve better as generalists in different highly demanded scenarios such as emergency care, community services, or primary care. In some cases, residents of a specific specialty (e.g., intensive care, primary care) had to supervise specialist faculty helping with clinical work in areas that were not of their and residents emerged in many cases during the epidemic crisis.

Humanism in a new dimension:
Most participants mentioned that the community burden associated with the epidemic, not only for patients but also for health teams, peers, family, and close friends, highlighted the humanistic dimension of medicine. There was a consensus that life has changed for everybody. The traditional paternalistic and vertical approach of taking care of patients as part of the medical commitment was twisted (once again) by the epidemic that generated a sense of a vulnerable community that included patients and health care teams, family, friends, students, and faculty. Empathy and collaboration were translated from principles to practices, given the need for mutual care.

Wellness, new strategies required:
The relevance of wellness in residency education was emphasized by many participants in the Forum. However, there was agreement

Assessment, an unresolved challenge:
Most participants highlighted that virtual educational strategies were going to remain in a post-pandemic scenario, but there was concern on how to improve assessment of clinical and non-clinical competencies in this context. The evaluation of residents' skills in uncertain real clinical scenarios respecting patients´ privacy, the interaction of residents with real health teams as well as the assessment of procedures in real contexts was seen as relevant components in residency training that are not fully captured yet in virtual education.
Academic dishonesty was an important concern raised by some participants that emphasized the higher risk of dishonest behaviors when evaluating the competencies of residents in virtual (synchronic or asynchronous) scenarios. Advances in educational technology, enhancement of self-centered learning strategies, and the need to strengthen self-responsibility and professionalism were some of the elements mentioned to improve assessment in virtual scenarios. However, there was consensus that this remains an unresolved challenge, and more experience and research is needed in this area for post-pandemic times.

Discussion
The diverse group of leaders that participated in the 2021 IMELF-LA Forum identified profound changes in post-graduate medical education triggered by the pandemic. These changes were probably initiated before the epidemic but were activated and amplified by the catastrophic consequences of the Covid-19 disease. The changes identified were so profound that they predict a new beginning in post-graduate medical education in Latin America.
The sense of initial chaos (khaos) in residency training that emerged as a strong theme in the discussion of our Forum has also been highlighted in several editorials, commentaries, and reviews as an initial effect of the Covid-19 pandemic (Lucey et al.,2020;Rose et al., 2020;Trevor et al., 2020;Papapanou et al., 2021). It has been described as disruption and sudden confusion. Our panel added on the concept of disorganization, the image of a storm and the sudden (súbito) effect of the crisis. The concept of chaos (khaos) emerged in the discussion connected with its original Greek meaning i.e. as an obscure abyss, as "an emptiness that existed before things came into being" (Merrian Webster, 2021).
Our panel identified an empowering effect of residents due to the pandemic that was expressed in very concrete experiences. One example is their leading role in helping their faculty use digital technology effectively to improve educational activities. Virtual education strategies have been extensively described in many reports as an immediate response to maintaining medical education activities (Tolu et al., 2020;Chasset et al., 2021;Papapanou et al., 2021). However, the protagonist role of residents in this process has been less described. Another example is the resident´s role in helping their faculty in general care practices required during the pandemic where residents had more recent experience due to their undergraduate training. This empowering effect of the pandemic, on residents could help to change a vertical tradition of medical education and enhance medical professionalism in Latin America .
Medical humanism expressed by empathy, compassion, and collaboration in critical scenarios was highlighted as an essential value of medicine that was uncovered during the pandemic. Many Latin American faculty and residents participated as "frontline workers." Our panel identified the relevance of this experience to (re)connect with the core values of medicine but also recognized the mental health consequences of it. Exhaustive clinical work, new virtual educational scenarios, and physical distance were identified as strong risk factors for mental health problems.
These factors have been described elsewhere (Papapanou et al., 2021). Given this scenario, the panel highlighted the need for new wellness strategies such as screen breaks, healthy pauses, and virtual support meetings to face these new challenges.
There was agreement that humanism in medicine was not only an essential value to serve others with dignity but also a value that required self and collective care.
This study has some limitations that are important to address.
First, it is a report from a selected panel of experienced medical educators and academic directors that might not represent the variety of experiences in residency education of the large Latin American community. To face this limitation, a snowball technique was used that aimed to include a diverse group of participants. A group of Latin American medical education leaders that has previously collaborated with the research team facilitated this process . Second, the analysis of the information was based on secondary data from the reports of the group discussion and open plenary. Specific primary information from participants within the group discussion might have been missed using this strategy. However, a systematic approach using a semi-structured questionnaire to gather the information and a framework analysis approach to analyze the information was applied to standardize ARS MEDICA Revista de Ciencias Médicas Volumen 46 número 4 año 2021 the information shared by participants. Credibility was ensured by member checking. All participants received a full report of the Forum and had the opportunity to review and make changes to it after the encounter.
This study opens new perspectives in post-graduate medical education. Future research should explore better assessment strategies in virtual clinical scenarios and look for innovative support interventions to enhance wellness in residency programs. In addition, the study highlights the relevance of conducting new research to understand better the way adaptability could be developed and assessed as competency in residency education.

Conclusion
The 2021 Latin American Medical Education Leaders Forum gathered a diverse group of experts and leaders in postgraduate medical education that highlighted seven key themes that emerged strongly during the covid-19 pandemic and anticipate a new beginning in residency education in the region.