To the Editor:

Many residency and fellowship programs have multiple training sites, which provide several advantages, such as an opportunity for trainees to access a wider range of training experiences and faculty experts. Spreading limited resources across multiple sites can also be taxing on a program, however, and potentially lead to lack of cohesion and consistency in training. Faculty and trainee travel between sites is an additional burden.

One of the challenges of a geographically disparate fellowship is finding ways to create community across a long-distance and split-campus program. The Statewide/Columbia University Geriatric Psychiatry Fellowship has two separate tracks: a New York City (NYC) track with rotations at Rockland Psychiatric Center, New York State Psychiatric Institute, and New York Presbyterian Hospital (Columbia Campus) and an upstate track based at the Greater Binghamton Health Center, located 175 miles from NYC (approximately 3 h by car), with rotations in community programs in Binghamton and Ithaca, New York. While each site has faculty present, the core teaching faculty is based in NYC, and before the COVID-19 pandemic, they would travel regularly to various sites to teach. This approach was choppy and did not lend to a unified experience for the total fellow complement, who often did not know each other, rarely met, and frequently were the sole student present for a didactic presentation.

Prior to the pandemic, our fellowship had been looking for ways to unify our geographically disparate sites, increase the interactions between the fellows, encourage collegial learning, be more cohesive, and strengthen our didactic curriculum. Our initial plan was to embark upon a program of remote didactics, taught over Zoom, to allow all fellows to join together for classes regardless of their placement site. This approach would unify the curriculum and allow all the fellows to be taught together instead of individually, as had happened in the past. We began teaching didactics over Zoom in January 2020.

The COVID-19 pandemic brought sweeping changes to graduate medical education in March 2020, with psychiatry training programs quickly pivoting to telepsychiatry [1] and remote didactics and conferences [2, 3]. While these changes were necessitated by the need for social distancing, they accelerated the unification of our program through increased connections among our sites, fellows, and faculty. Weekly virtual classes rapidly progressed to virtual case conferences, supervision, and grand rounds across our geographically diverse sites. Via telehealth, the fellows were able to broaden their education though exposure to clinical sites and clinicians to which they did not physically rotate. We were able to recruit a larger and more diverse faculty pool, both for teaching and conducting case conferences, because they could now join these activities remotely, instead of committing to a 6-h drive roundtrip to a distant site.

New clinical training included a weekly telehealth nursing home consultation program, staffed by all the fellows, regardless of geographic proximity. The consults occur via a Zoom platform that is compliant with the Health Insurance Portability and Accountability Act. An on-site nurse practitioner or social worker presents the case, and the patient is interviewed virtually by the team. This approach was important as most nursing homes did not want extra in-person visitation during the pandemic, yet they needed help with patients that had been transferred out of hospitals because of the pandemic, and it provided a useful training experience to the fellows. As COVID waned, the fellow who was most proximate to the site could attend in person and present the case to the others.

A collaborative care clinic in NYC also moved to remote treatment. While the NYC-based fellows attended this clinic weekly, the upstate fellow, who had previously only been able to attend occasionally when physically in NYC, could now attend weekly via telehealth, increasing the clinical services provided.

Although the pandemic has started to wane and restrictions have been lifted, we have continued these elements because of the added value these opportunities provide. Group supervision of all fellows has provided additional collegial and collaborative opportunities. Due to these increased opportunities for collaborative learning, the upstate and NYC fellows now know each other better than previous fellows, even when they are not able to meet in person frequently due to the geographic separation of our sites. They have more opportunities for discussion and to learn from each other, as well as from the faculty. The fellows have also personally shared that they feel less isolated and more collegial. Our future goals are to keep the fellowship sites tethered via virtual education, clinical conferences, and faculty/fellow supervision. We will continue to refine the experience with higher quality platforms at our upstate location and within the state hospital system.

During the pandemic, necessity forced us to find creative ways to bring separate sites and trainees together. Our experience may provide a model for increasing cohesiveness for residents in programs that have a geographic spread. It could also be a model for how smaller, more rural programs with fewer resources could partner with larger academic medical centers (which is how our fellowship was originally designed). Now that many programs have begun offering didactic learning online (e.g., supervision, classes, case conferences), it may be more feasible to imagine programs partnering together to maximize the limited resources that are available.