key: cord-308409-0n2ysgsa
authors: Pawlak, Katarzyna M.; Kral, Jan; Khan, Rishad; Amin, Sunil; Bilal, Mohammad; Lui, Rashid N.; Sandhu, Dalbir S.; Hashim, Almoutaz; Bollipo, Steven; Charabaty, Aline; de-Madaria, Enrique; Rodríguez-Parra, Andrés Felipe; Sánchez-Luna, Sergio A.; Żorniak, Michał; Walsh, Catharine M.; Grover, Samir C.; Siau, Keith
title: Impact of COVID-19 on endoscopy trainees: an international survey
date: 2020-06-11
journal: Gastrointest Endosc
DOI: 10.1016/j.gie.2020.06.010
sha: 
doc_id: 308409
cord_uid: 0n2ysgsa

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The coronavirus disease 2019 (COVID-19) pandemic has had a profound impact on the provision of GI endoscopy services worldwide, with the radical curtailment of elective procedures to restrict disease transmission. 1 Consequently, multiple gastroenterology and endoscopy societies have published rigorous recommendations on triaging endoscopy procedures, appropriate use of personal protective equipment (PPE) and postprocedure decontamination for GI endoscopy during the pandemic. [2] [3] [4] [5] Surveys from Italy and North America have reported over 75% reductions in procedure numbers in many centers. 6, 7 As institutions attempt to limit periendoscopic exposure to COVID-19 and conserve PPE, this will inevitably impact trainee engagement in hands-on endoscopy procedures.

The COVID-19 pandemic creates challenges for endoscopy trainees for several reasons. For trainees who are in direct contact with patients, providing clinical care during a pandemic can evoke fear and anxiety regarding personal safety and viral transmission. 8, 9 Trainees also face social isolation due to restricted contact with their families and friends. 10 These concerns can be further exacerbated by inconsistency in scheduling, both due to trainees being quarantined and redeployment to other services. 11 Finally, trainees may be concerned about delays in competency acquisition and future job security.

Novice endoscopists must become proficient in a range of diagnostic and therapeutic modalities during a training period, often of finite duration. As it remains unclear when endoscopy units will fully resume regular activities, endoscopists-in-training may be concerned about attaining and maintaining competence in procedural skills. Additionally, trainee exposure to inpatient and ambulatory GI patients may be significantly reduced if institutions are limiting contact between consulting services and inpatients and cancelling non-essential office visits. Shortages of PPE could worsen these issues because trainees may be the first to be excluded when there is inadequate PPE.

Despite these issues, there are no published data on the impact of the COVID-19 on endoscopy training and trainee well-being. Therefore, in this international survey, we aimed to assess the impact of the COVID-19 pandemic on endoscopy trainees, including procedure numbers, barriers to training, and the physical and emotional well-being of trainees. We also aimed to explore variation in this impact internationally.

A 37-item survey (Appendix 1) was developed through consensus by an international group of representatives from 10 countries with expertise in endoscopy training and education.

The survey was conducted using the SurveyMonkey platform (SVMK Inc, San Mateo, Calif, USA) and was structured into the following domains: 1) Demographics, including age, gender, country of training and specialization;

2) Monthly endoscopy volumes before and during COVID-19;

3) Training and availability of personal protective equipment (PPE); 4) Impact on physical, mental and emotional well-being. 

The primary outcome studied was the percentage reduction in the monthly volume of hands-on endoscopy procedures performed by trainees as a result of COVID-19. This was studied using 2 methods: (1) as a comparison over two 30-day periods before and during the COVID-19 pandemic, and (2) as a categorical variable according to trainee indication of an overall reduction in procedure volume. Endoscopy procedures studied comprised esophagogastroduodenoscopy (EGD), colonoscopy, EUS, ERCP, and upper gastrointestinal bleed hemostasis (included within the EGD numbers), for supervised, unsupervised and total numbers. Secondary outcomes comprised: 1) Barriers to hands-on training and the impact on residual training opportunities;

2) Changes to institutional case volume 3) Trainee concerns regarding competency development and prolongation of training; 4) Anxiety, assessed using the Generalized Anxiety Disorder-7 (GAD-7) scale, 12 and rates of burnout, measured using the single item burnout scale. 13 For each outcome, analyses were compared across continents to denote international variation in survey responses.

At the beginning of April 2020, the EndoTrain survey was distributed to trainees both directly and indirectly via program directors, trainee representatives, and to representatives within national and international societies (Supplementary Table 1 ). The survey was open for three weeks from April 11 to May 2, 2020.

All continuous variables were subjected to normality assessment (Shapiro-Wilk) and

presented as medians with interquartile ranges (IQRs) or means and standard error (SE) as appropriate. For each procedure, trainees who did not indicate any procedures in a given modality over the 2 comparison periods were excluded from analyses to identify active trainees for each procedure category. Pairwise comparisons of procedural numbers were performed at trainee-level between pre-COVID-19 and COVID-19 periods using Wilcoxon signed-rank tests. Nonparametric data across procedure types and continents were compared using Kruskal-Wallis, followed by Dunn's test for pairwise comparisons.

Continuous variables were compared across continents using one-way analysis of variance (ANOVA). Categorical data were compared using the Pearson Chi-square test.

Binary logistic regression analysis was performed for univariable and multivariable analysis of factors associated with anxiety in endoscopy trainees. The GAD-7 outcomes were stratified into 2 groups by composite score: <5 and ≥5 (indicating at least mild anxiety). A forward stepwise approach to factor selection was used and outcomes presented as odds ratios (OR) and 95% confidence intervals (95% CI).

Statistical analyses were performed using SPSS v26 (Arkmont, NY, USA: IBM Corp) and Prism v8 (San Diego, Calif, USA: GraphPad Corp), with P<0.05 considered statistically significant.

In total, 1199 respondents participated in the international training survey. After excluding incomplete responses (N=429, 35.8%), 770 trainees from 63 countries within six continents (Supplementary Table 2 and Supplementary Fig. 1) were included for analysis. Trainee characteristics and the differences across continents are presented in Table 1 

Overall, 770 trainees (93.8%) reported a reduction in their monthly endoscopy case volume attributable to COVID-19. By procedure type, the differences in estimated monthly volumes before and during COVID-19 are presented in Figure 1 , with significant (P<0.0001) decrements over the two 30-day periods. Across all modalities (Figure 2) , the median percentage reduction in procedural volume was 99% (IQR 85%-100%). This did not vary significantly by trainee specialty (P=0.658), or whether procedures were performed under supervision or independently (P=0.614), but varied by procedure type (P<0.001). On subgroup analysis, percentage reductions were greater for colonoscopy (median 100%, IQR 88%-100%) compared with ERCP (median 100%, IQR 60%-100%; P=0.003) and upper gastrointestinal bleeding (UGIB) procedures (median 100%, IQR 50%-100%; P<0.001). This outcome also varied across continents (P<0.001), with significantly greater percentage reductions observed in Europe (median 100%, IQR 91%-100%) and North America (median 99%, IQR 88%-100%) compared to Asia (median 87%, IQR 75%-97%) and South America (median 91%, IQR 70%-100%).

Of the 770 (93.8%) trainees who reported a reduction in endoscopy procedural volumes during the COVID-19 study period, the reasons cited included: changes to institutional policy to exclude trainees from procedures (79.9%); lack of cases (58.3%); shortage of available PPE (28.8%); redeployment to another clinical area (24.0%); and personal reasons (10.2%).

Access to endoscopy training remained accessible on an ad hoc basis to 60.5% (N=466) of trainees, with rates varying internationally ( Table 2) . Of these, 36.1% (N=168) could perform endoscopy on patients at low risk or negative for COVID-19, and 7.9% (N=37) on unsupervised procedures only. 46.7% (N=359) reported access to ad hoc emergency cases and 15.4% (N=119) to intensive care unit (ICU) cases. Only 6.2% (N=29) reported no restrictions on their endoscopy privileges.

Reductions in institutional endoscopy case volume due to COVID-19 were reported by 98.2% of trainees, with 73.5% of trainees reporting a decrease of ≥50% and 3.6% reporting the cancellation of all endoscopy activity.

Regarding PPE, 73.7% (N=520) received training on the use of PPE for COVID-19 patients.

50.5% (N=356) received training specific to managing COVID-19 in their endoscopy unit. This was mainly delivered through face-to-face teaching (34.0%, N=121), virtual teaching (22.4%, N=80), or written communication (43.5%, N=155). The level of PPE used within the endoscopy unit was felt to be adequate in 67.6% (N=476), but this varied internationally (P<0.001) ( Table 2) . 47.0% (N=331) believed that a lack of PPE was contributory to reductions in institutional endoscopy case volume. Endoscopy-specific practice guidelines on PPE use were available for 89.2% (628) of respondents. PPE policy within the endoscopy unit was predominantly directed by national guidelines (47.4%), individual unit/hospital policy (33.0%), or international guidelines (19.6%).

Trainees were asked to rate their level of concern regarding the impact of COVID-19 on the outcome of their endoscopy training (Table 3; Figure 4 ). Concerns with competency development were raised by 90.1% (N=629) of trainees across continents (P=0.844).

Concerns regarding the need to prolong specialty training to reach the required competency were raised by 71.9% (N=502) of respondents. This concern varied internationally (P<0.001), with the lowest proportion of concerned trainees in North America (49.5%). In total, 68.9% (N=472) of trainees believed that existing national/international guidelines should be modified to better support endoscopy training during the COVID-19 pandemic.

Concerns of acquiring COVID-19 were expressed by 79.3% of trainees (Figure 4) . In total, 23.9% (N=168) reported taking time off work for COVID-19 related reasons; 76.8% (N=129) took time off for themselves and the remaining 23.4% (N=39) for a household member. Of trainees affected, 14 .7% (N=19) tested positive, 52.7% (N=68) negative, 30.2% (N=39) were not tested, and 2.3% (N=3) preferred not to answer.

Anxiety and burnout were assessed in 695 trainees ( Table 3 ). The following anxiety levels were reported according to GAD-7 criteria: no anxiety (47.6%, N=331), mild (33.2%, N=231), moderate (14.2%, N=99) and severe anxiety (7.8%, N=54). On multivariable analysis ( Table   4) 

To our knowledge, this is the first study to comprehensively evaluate the impact of COVID-19 on endoscopy trainees. Survey responses from 770 trainees across 63 countries indicate that COVID-19 has had a profound adverse effect on endoscopy volume worldwide, with reductions in training opportunities for the majority of trainees (93.8%), and a drastic median reduction in case volume of 99% (IQR, 85%-100%). This has raised concerns among trainees in regard to competency development (90%) and the potential need to prolong training to achieve endoscopic competence (72%). These concerns were among the cited factors leading to COVID-19 associated anxiety (52.4%) and burnout (18.8%) among trainees. These results highlight the urgent call to action for institutions, training programs, GI societies, and accreditation councils to address the 2 overarching issues identified: (1) reductions in endoscopic training opportunities and (2) the emotional welfare of trainees.

The emphasis on minimum endoscopy procedure numbers as a competence safeguard is ubiquitous across international training settings. 14 These serve to indicate readiness for certification, credentialing, and program completion. Although training in all procedures was disrupted by COVID-19, the decrement was most pronounced for colonoscopy and less so for emergency procedures (ERCP and GI bleeding). This is important as colonoscopy is regarded as a core endoscopic skill. Over 50% of trainees estimated a reduction in institutional endoscopy volumes of 75% or more, in line with international recommendations to curb elective procedures. However, the exclusion of trainees was another major barrier, with PPE shortages and redeployment being contributory. The significant impact of COVID-19 has raised doubts among trainees over whether endoscopic competence in various procedures is realistically achievable within the duration of their training, with a substantial proportion expressing concerns that training will need to be prolonged. Addressing these issues could potentially have disruptive implications at many levels: restructuring of training curricula and schedules, redistribution of endoscopy cases between junior and senior trainees, delays in entering the workforce, financial strain and negative effects on trainees' mental well-being.

Indeed, relatively little has been published on the physical and mental well-being of endoscopy trainees, even before COVID-19. From our survey, COVID19 affected trainees beyond reductions in endoscopy training opportunities: 79.3% had concerns of acquiring COVID-19 and a significant proportion of trainees had to take time off work for COVID-19 related reasons. Inadequate PPE was raised as a concern by a third of respondents and was independently associated with increased anxiety. Overall, 52.4% of trainees met criteria for at least mild generalized anxiety, with 22.0% reaching a threshold score of ≥10, which has 89% sensitivity and 82% specificity for clinically significant anxiety. 12, 15 Predictors of anxiety included female gender (consistent with population-based studies), 16 concerns regarding prolongation of training, inadequate PPE, and a lack of emotional and mental health support. Anxiety levels positively correlated with burnout which was identified in 18.8% of trainees. Burnout is a consequence of unmitigated chronic stress which requires urgent intervention as it can lead to emotional exhaustion, depersonalization, negativity and impaired professional performance, 17 including suboptimal medical care and medical error. 18, 19 The association between the availability of emotional support and lower anxiety levels suggests that training programs should strongly consider implementing support strategies to proactively address anxiety and burnout in trainees and promote their wellbeing. Formalized interventions to improve trainee well-being, such as group stress management and resiliency training (SMART) may also play a positive role in improving job satisfaction and well-being. 16, 21, 22 There is additional need for attending gastroenterologists to proactively engage with trainees to discuss their learning gaps and career development and devise individualized curricula.

Internationally, there was significant heterogeneity in survey responses for both primary and secondary outcomes (Tables 1-3) . These may be partially explained by locoregional differences in severity and the phase of the COVID-19 pandemic during the survey period.

Nearly 50% of respondents were from the United States, United Kingdom, and Spain, which were in the acceleration to plateau phase in the 30 days leading up to the survey. 23 This is likely to account for the reductions in exposure to endoscopy training, institutional caseloads, uptake of PPE and time off work from COVID-19. It is possible that, as COVID-19 caseloads subside, training opportunities will slowly resume, although trainee exposure is still likely to be impacted due to prolonged turnaround times for decontamination and Our study has several limitations. Surveys are vulnerable to bias and misinterpretation inherently. Data validation was performed by excluding respondents who provided incomplete responses of primary outcome data, did not indicate a training modality, and where endoscopy numbers performed each month in a given modality exceeded 100. It was also not possible to estimate the response rate as the survey was disseminated through multiple national and international societies and organizations. Not all countries and specialties were represented which might affect the generalizability of findings. Next, our data provide a snapshot of training in time and was not matched to regional differences in pandemic activity. Our completion rate was limited at 65%, with a further dropout rate of 11% for completing all survey questions. Contributory factors include the length of the survey, complexity of individual questions, and dissemination only in English, which may have affected comprehension. Additional data, such as unit-level information and lifetime procedure counts were not collected. Finally, baseline data for anxiety and burnout could not be retrospectively captured in a valid manner and therefore, the high rates of anxiety cannot be directly attributed to COVID-19 alone.

The effects of COVID-19 are projected to persist until at least 2022. 24 As such, an urgent review of endoscopy training is warranted to adapt accordingly and provide direction. In our survey, 68.9% of respondents indicated that guidelines should be modified to support training. Training programs should openly recognize that minimum procedural numbers may not be achievable in some countries and adopt mitigation strategies. First, emphasis should shift toward maximizing gains from evidence-based, hands-off training interventions. For beginners, simulation-based training can be used to develop technical skills, 25, 26 nontechnical skills, 27 and accelerate time to achievement of competence. 28 Although simulation training requires performance feedback to be optimally effective, 29 selfassessment with benchmark videos and computerized feedback are viable alternatives. 30, 31 For all trainees, cognitive competencies can be developed through distance education using educational resources, webinars, and open access social media education, such as structured conversations on Twitter. 32 All 3 major American GI societies have high-quality, expert-led, endoscopy training videos; notably the American Society for Gastrointestinal Endoscopy (ASGE) with its catalogue of education materials in GI Leap, its online learning platform. 32, 33 Second, determination of competence should rely less on attaining minimum numbers and more on the use of objective and validated methods of competency assessment. This is best achieved through the use of objective performance tools with strong validity evidence, such as ACE (Assessment of Competency in Endoscopy), 34 DOPS (Direct Observation of Procedural Skills), [35] [36] [37] and GiECAT (Gastrointestinal Endoscopy Competency Assessment Tool), 38 which can allow trainers to target feedback provision in a formative manner, and to benchmark global competence for summative sign-off. 35 Despite these measures, it may be necessary for some trainees to extend their endoscopy training. 39 Additionally, it will be important for institutions and private practices to ensure that new faculty are closely mentored to promote continued skills development. With meaningful application of evidence-based training paradigms, the GI community can mitigate the ongoing impact of COVID-19 on trainees and ensure that they achieve the cognitive, technical, and integrative competencies needed for independent endoscopic practice.

The recent literature on the impact of COVID-19 on trainees stems from individual experiences and expert opinion. 10, 33 Our trainee-centered survey has now quantified the impact of COVID-19 on procedural volumes and on the well-being of endoscopy trainees, and shown how this varies internationally across different continents. As countries engage in collaborative endeavors to tackle the global impact of COVID-19, it is hoped that our findings will help to inform future strategies to mitigate the impact of the pandemic on endoscopy training. In this article, we aimed to assess the impact of COVID-19 on procedural volumes and the emotional well-being of endoscopy trainees worldwide. Our study showed that the COVID-19 pandemic has led to drastic reductions in endoscopic volumes and restrictions on endoscopy training, with detrimental effects on trainee well-being, including high rates of anxiety and burnout among trainees worldwide. Therefore, existing curricular requirements and delivery of endoscopy training should be urgently reviewed and adapted to support the educational and emotional needs of trainees during the COVID-19 pandemic. 

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