What is the Impact of the COVID-19 Pandemic on Emergency Medicine Residency Training: An Observation Study


 BackgroundThe coronavirus disease 2019 (COVID-19) pandemic has engendered difficulties for health systems globally; however, the effect of the pandemic on emergency medicine (EM) residency training programs is unknown. The pandemic has engendered reduced volumes of emergency department (ED) patients, except for those with COVID-19 infections, and this may reduce the case exposure of EM residents. The primary objective of this study was to compare the clinical exposure of EM residents between the prepandemic and pandemic periods. MethodsThis was a retrospective study of EM resident physicians in Taiwan. We performed a medical record review and retrieved data regarding patients seen by EM residents in the ED between September 1, 2019, and April 30, 2020. The number and characteristics of patients seen by residents were recorded, and the training schedules, including clinical working hours, of EM residents were determined. We compared the data between the prepandemic and pandemic periods.ResultsA total of 51,337 patients were managed by 36 EM residents during the 8-month study period. The mean number of patients per hour (PPH) seen by EM residents decreased significantly during the pandemic period. The PPH seen by residents in the adult ED decreased in all three hospitals during the pandemic. The average number of patients managed by residents decreased by 50% and 70% in the trauma ED and pediatric ED during the pandemic, respectively. The severity of patient illness did not change significantly between the periods. ConclusionsThe COVID-19 pandemic engendered a reduced ED volume and decreased EM residents’ clinical exposure. All portion of EM residency training were affected by the pandemic, with pediatric EM being the most affected. The patient volume reduction may persist and in turn reduce patients’ case exposure until the pandemic subsides. Adjustment of the training programs may be necessary and ancillary methods of learning should be used to ensure adequate EM residency training.


Introduction
Coronavirus disease 2019 (COVID-19) is a novel viral disease that has spread rapidly and become a global pandemic. Health care systems worldwide have struggled to cope with the pandemic and prepared for a surge of patients with respiratory tract infections. In Taiwan, the emergency department (ED) patient volume has dropped with the progression of the pandemic. Similar situations have been noted in several countries in Europe and some states in the United States. (1)(2)(3)(4)(5) This drop can be attributed to people's fear of being infected and being a burden on the health care system, as reported in multiple countries. (5) Studies have reported the effect of the COVID-19 pandemic on residency training programs in urology, surgery, and ophthalmology. (6)(7)(8)(9) The rapid decrease in clinical and surgical activities has posed challenges to residency training programs in several specialties. The pandemic has also affected the mental health of residents, which may further interfere with their clinical learning. (10,11) Emergency physicians have been at the frontline of the pandemic; nevertheless, according to our review of the relevant literature, studies have yet to be conducted on the effect of the pandemic on emergency medicine (EM) residency training. The reduced ED volume caused by the pandemic may affect EM residents' clinical case exposure, thus engendering insu cient clinical experience. The extent of case exposure reduction is unknown. To address this knowledge gap, the present study explored the effect of reduced ED volume on EM residency training; the ndings may provide suggestions to EM educators regarding the change in the learning conditions of EM residents during the pandemic.

Study design
This was a retrospective study of EM resident physicians. The study was conducted at a university-a liated tertiary teaching hospital with a 3,600-bed capacity and an estimated annual ED volume of 180,000 patient visits. Two branch hospitals with an estimated ED volume of 48,000 and 78,000 patient visits were also included. The three hospitals are located in three different cities in northern Taiwan. The study was approved by our institutional review board (IRB no. 202000945B0).

Study setting and population
The ED has 63 board-certi ed EM faculty members and conducts an EM training program for 7-10 resident physicians annually. The training residents rotate among the three hospitals-namely one general hospital in Linkou and two branch hospitals in Taipei and Keelung-on a monthly basis. The general hospital in Linkou is a tertiary medical center, and the branch in Keelung and that in Taipei (Taipei branch) are regional hospitals. Table 1 presents the patient groups seen by residents enrolled in different courses. The general hospital has an adult ED (AED) and a pediatric ED (PED). The adult ED includes a medical ED (MED) and trauma ED (TED). The MED has care facilities for patients with triage acuity levels 1 and 2 and facilities for patients who require critical care. Residents enrolled in the AED course work and see new patients in the MED critical care area. For traumatology and pediatric training, residents enroll in TED and PED courses in the general hospital. EM residents in the training program see patients with trauma or nontrauma conditions in the AED when in rotations at the Taipei and Keelung branches. At the time of study, the EM residency program involved 3.5 years of training, including 2-month TED and 2-month PED courses, in the general hospital, according to the criteria stipulated by the Taiwan Society of Emergency Medicine. The study included data from September 1, 2019, to April 30, 2020. The electronic medical record system was queried, and a database with the following information was generated: patient gender, patient age, patient triage acuity level, the rst physician seen, and disposition. Only the data of patients who were rst seen by residents were included in the study. Resident shift schedules were reviewed, and working hours were calculated.
To evaluate the effect of the COVID-19 pandemic on EM residency training programs, we divided the study period into two periods: prepandemic and pandemic periods. The rst con rmed COVID-19 case in Taiwan was reported on January 11, 2020, and the larger outbreak began in February 2020. The EM training course is structured by month; therefore, the pandemic period in our study was de ned as spanning from February 1, 2020, to April 30, 2020. The EM training year began on September 1, 2019; hence, the prepandemic data were considered as those obtained between September 1, 2019, and January 31, 2020.

Outcome measurements
Data on new patients seen by residents during the prepandemic period were compared with those of patients seen by residents during the pandemic period. The main outcome was the average number of patients seen by residents per hour during the prepandemic and pandemic periods. The demographic characteristics and triage acuity levels of patients seen by residents were also compared. Data on different training courses were analyzed separately.

Statistical analysis
Data were analyzed using SPSS software (version 13.0 for Windows; SPSS Inc., Chicago, IL, USA). Regarding descriptive statistics, categorical variables are presented as numbers and percentages. The recorded patient visits during the prepandemic and pandemic periods were compared using the Mann-Whitney U test for continuous variables and Pearson's chi-square or Fisher's exact tests for categorical variables. A p value of < 0.05 was considered statistically signi cant.

Results
The data collected from the three hospitals for the 8-month study period comprised more than 175,000 ED visits. Figure 1 presents the number of ED visits in each month. Figure 1a shows the patient volumes of the three hospitals. The ED volumes of the three hospitals exhibited similar trends, namely decreased volume since February 2020. We observed that the average patient volume per month decreased by more than 30% in all three hospitals during the pandemic period. The volumes of different EDs at the general hospital are presented in Fig. 1b; similarly, we noted a reduction in patient volumes. The patient volumes of the MED, TED, and PED decreased clearly during the pandemic period. The patient volume during the pandemic period was nearly half and one-third of that during the prepandemic period in the TED and PED, respectively. Table 2 lists the patients per hour (PPH) seen by residents. In the AEDs of the Taipei and Keelung branches, the mean number of patients seen by residents during the pandemic period decreased relative to that during the prepandemic period. The PPH seen by residents in the Taipei and Keelung branches differed signi cantly between the prepandemic and pandemic periods. We observed similar analysis results for the general hospital. The average PPH seen by residents in rotations in the MED critical care area, TED, and PED during the pandemic period were signi cantly lower than those recorded during the prepandemic period.  Table 3 presents the demographic characteristics of patients seen by residents in the Taipei and Keelung branches. In these branches, the percentage of patients with triage acuity levels 1 and 2 was higher during the pandemic period than it was during the prepandemic period. The admission rate during the pandemic period relative to that during the prepandemic period was substantially higher in the Keelung branch but only slightly higher in the Taipei branch. Table 4 lists the demographic characteristics of patients seen by residents in the general hospital. In this hospital, the percentage of patients with triage acuity levels 1 and 2 did not differ between the two periods in the MED critical care area, but the admission rate increased during the pandemic period. Similar results were obtained for such patients in the PED. In the TED, no signi cant difference was noted in the percentage of patients with either triage acuity level or the admission rate between the two periods.   (14,17,18) The PPH for residents in the AED decreased signi cantly during the pandemic period relative to that during the prepandemic period.
However, if the pandemic persists, the long-term effect of the change in patient volume on resident training is unknown. Although the ED volume was lower during the pandemic period, the severity of illness in patients visiting the ED did not increase signi cantly as expected. Training in the management of critically ill patients is essential for emergency physicians, and the training would be affected by the number of patients seen during the pandemic period. (19) Accordingly, a monitoring system for assessing residents' case exposure regularly is necessary during the COVID-19 pandemic. (13) Our study revealed that the pediatric patient volume was most affected during the pandemic period. The volume of patients seen by residents during the pandemic period was less than half of that observed during the prepandemic period. The acuity level of patients remained unchanged during the pandemic period. Fear of having COVID-19 or getting infected by the virus in the hospital could be a reason for parents not bringing their children to the hospitals. The importance of pediatric training in EM residency programs has been mentioned in previous reports, but the su ciency level of training is inconclusive. (16,20,21) Previous surveys have revealed that EM faculties perceived that they were less prepared to manage pediatric patients than they were for managing adult patients. (22)

Conclusions
The COVID-19 pandemic engendered reduced ED volume, thus reducing the clinical exposure of EM residents during their training. All portions of EM training were affected by the pandemic; the effect of the pandemic on pediatric EM was the most severe because of a profound decrease in pediatric patient volume. If the COVID-19 pandemic persists, its effect on residents' training could lead to poorer EM educational outcomes compared with the outcomes observed during the prepandemic period. The learning conditions of EM residents must be regularly monitored and assessed. Adjustments to EM residency training programs may be necessary, and ancillary methods of EM learning would be helpful in the scenario of a prolonged pandemic.  Figure 1 a ED visits to the Linkou general hospital and the Taipei and Keelung branches. b ED visits in different ED departments of the Linkou general hospital.

Supplementary Files
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