Abstract

Introduction

In the setting of social distancing measures during the coronavirus 2019 (COVID-19) pandemic, pediatric hospitals have reported lower pediatric patient volumes across hospital settings.^1–5 In response to these changes and in an effort to minimize resident exposure, residency programs have altered resident schedules.^6,7 We sought to evaluate the impact of the COVID-19 pandemic on pediatric interns’ exposure to different types and care settings of pediatric diseases, at the onset of the pandemic and amidst the initial surge. We hypothesized that pediatric interns evaluated fewer patients and that these patients had a different spectrum of disease during the COVID-19 pandemic.

Methods

Results

Median (interquartile range) patient encounters per intern per two-week block declined by 28.0% on the PHM service (37.5 (36.0-43.0) vs 27.0 (22.0-36.0), p < 0.001) and by 35.5% on the ICU step-down service (29.0 (21.5-35.0) vs. 18.75 (14.0-22.0), p = 0.004) during the pandemic as compared to the year prior (Figure 1A). Median patient encounters per intern per two-week block were not significantly different before versus during the pandemic in the ED (63.0 (57.0-71.0) vs. 40.5 (32.0-57.0), p = 0.06; Figure 1A). The median number of patient encounters per intern per shift declined in the ED (6.7 (6.3-7.1) vs. 4.5 (3.2-5.7), p = 0.04) and in the ICU step-down service (2.7 (2.0-3.5) vs. 1.8 (1.6-2.2), p = 0.03), while encounters per shift were not significantly different for interns on the PHM service during the pandemic (3.5 (3.3-4.2) vs. 3.3 (2.7-3.9), p = 0.13; Figure 1B). Importantly, the number of shifts worked per intern per two-week block was significantly less during the pandemic on the PHM service, while there was no significant difference observed in the ED and the ICU step-down service (Figure 1C).

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Figure 1:

Box and whisker plot of (A) patient encounters per intern per two-week block, (B) patient encounters per intern per shift, and (C) shifts worked per intern per two-week block in the emergency department (ED), pediatric hospital medicine (PHM), and intensive care unit (ICU) step-down settings before vs. during the COVID-19 pandemic.

The mean number of patient encounters per pediatric intern with a given diagnosis is compared before versus during the pandemic in Figure 2A–C. In the inpatient and ED settings, there was an increase in mean encounters per intern per two-week block for the CCSR code, “exposure, encounters, screening or contact with infectious disease”. On the PHM service, the average intern saw 80% fewer patients with “acute bronchitis” during the pandemic (Figure 2B), and reductions in encounters for respiratory illnesses were observed across all three settings. In the ED, there was also a 55% decrease in mean encounters per intern for abdominal pain (Figure 2A).

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Figure 2:

Encounters associated with common CCSR codes before vs. during the COVID-19 pandemic for the (A) emergency department (ED), (B) pediatric hospital medicine (PHM), and (C) intensive care unit (ICU) step-down settings. Values reported as mean encounters by CCSR code per intern per two-week block. Common CCSR codes were identified by the top 10 CCSR codes by setting for both the pre-pandemic and pandemic cohorts. *Indicates statistically significant difference between the pre-pandemic and pandemic cohorts (p < 0.05).

Discussion

During the COVID-19 pandemic, pediatric interns at a large pediatric residency program were exposed to fewer patients and worked fewer shifts in the inpatient and ED settings. Our findings are supported by several recent studies demonstrating reduced pediatric patient volumes across settings nationwide.^4,5,10–15 We observed declines in encounters for respiratory illnesses in support of other recent studies documenting similar trends.^10,11 While there have been few published studies documenting the impact of COVID-19 on resident patient exposure, one study of an emergency medicine residency in Taiwan demonstrated that ED residents saw less than half the typical patient volume.¹⁶ Although our study reflects a single residency program’s experience, early on in the pandemic, declines in pediatric patient census have been documented nationwide. Similarly, residency programs in other specialties have reported on reduced clinical schedules.^7,17 Therefore, it is likely that pediatric interns across the country saw significantly fewer pediatric patients and worked reduced shifts on pediatric clinical services during the early COVID-19 pandemic.

These changes have heightened concerns among residency program leadership and trainees about whether reduced patient exposure may impact clinical competency.^7,18 In a study of radiology residents assessing the impact of exposure on performance, residents who interpreted more radiographic films had improved performance as measured by accuracy of their diagnostic reads.¹⁹ In two other studies evaluating family medicine and internal medicine residents, residents who saw more patients scored higher on in-training exams.^20,21 Given this association between exposure and competency, it is therefore important for residency programs to consider tracking resident-level patient exposures during the pandemic. It is also important to recognize that concerns about competency may impact intern confidence in medical decision-making, particularly as they gain additional autonomy at the end of intern year. Acknowledging these concerns and addressing gaps in the clinical experience may alleviate this anxiety and provide interns with the tools to feel more confident and comfortable in their decision-making.

Throughout the pandemic, residency programs in specialties across the country have developed innovative strategies to augment resident clinic experience. Radiology and surgical programs have developed simulations to mimic regular work days for residents.^6,24 Our program developed a virtual work from home option for residents with heightened individual or family health risks.²⁵ While these strategies do not replace in-person clinical interactions, virtual learning and patient care play fundamental roles in advancing resident training while also minimizing infectious risks.

Our study has several important limitations. Our findings represent a single residency program’s experience during a 3-month period at the onset of the pandemic and amidst a surge of cases within the community and therefore may not be generalizable to all institutions. However, given documentation of widespread reductions in pediatric patient volumes during the pandemic, pediatric residency programs across the country likely experienced similar trends. We were also unable to assess intern patient exposure during rotations outside the main study hospital which provided important additional training opportunities that were not quantified in this study. Next steps include evaluating intern’s clinical exposure through the 2020-2021 academic year as the pandemic has progressed and also assessing national trends outside of our single institution.

In a large pediatric residency program, the onset of the COVID-19 pandemic was associated with reductions in overall clinical exposure to patients and the breadth of pediatric disease. We identified a disproportionate decrease in patient exposures for respiratory and abdominal symptoms, common complaints that are key complaints for pediatrics residents to gain experience diagnosing and managing. If the COVID-19 pandemic or future pandemics continue to negatively impact pediatric patient volumes, it will be important for residency programs to track intern patient exposures and assess whether reduced volumes impact competency and attainment of professional milestones during training. In addition, identifying reductions in patient exposures by specific setting or disease processes, as we have done in this study, would allow programs to develop targeted interventions through simulation or virtual teaching curricula to supplement the clinical experience.

Acknowledgements

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Footnotes

References