Differences between fellows and fellowship program directors in their perception of the impact of the COVID-19 pandemic on gastroenterology training: results from a nationwide survey in Greece

Introduction

Caused by an extremely virulent pathogen, with a potential for developing into a devastating pneumonia, COVID-19 has forced most countries to enact strict social distancing programs, or even complete lockdown of non-essential commercial activity. Nearly all affected countries have stopped performing elective endoscopy, with the majority of emergency procedures undertaken by certified endoscopists with minimal staff presence [1]. Countries more affected by the pandemic have allocated their staff, including those in training, to the service of units dealing with COVID-19 patients [2]. Greece, while having only a moderate disease burden that never exceeded the healthcare system’s capacity, has postponed nearly all elective medical and surgical procedures since March 23, 2020. Many of the hospitals that served as gastroenterology training centers acted as tertiary referential centers for COVID-19 patients. In other countries this measure led to a re-allocation of gastroenterology fellows to other clinics, with a detrimental impact on their training [3]. In view of the controlled restart of elective activities, the Governing Board of the Hellenic Society of Gastroenterology (HSG) decided to perform a survey to assess the perceptions of fellows and their fellowship program directors on the effects of the lockdown on gastroenterology training.

Materials and methods

Results

Participants’ characteristics

A total of 77 of 128 fellows and 18 of 28 fellowship program directors completed the survey (response rates 64.3% and 60.1%, respectively). Among fellows, 32 (41.6%) of them were in the 2 first years of the fellowship. The monthly diagnostic endoscopy volume performed by fellows during the COVID-19 outbreak significantly decreased compared to that prior to the pandemic: median: 10 (IQR 2.5-20) vs. 50 (IQR 30-75), P<0.001. As far as fellowship program directors are concerned, they had practiced gastroenterology for 25.8±5 years and had served for 9.8±6 years as fellowship program directors. The demographic characteristics of the participants are shown in Table 1.

Table 1 Participants’ demographics, n (%)

Study endpoints

Participants’ perspectives of COVID-19 outbreak impact on gastroenterology training

The majority of fellows conveyed that the COVID-19 pandemic would exert a negative impact on their training in gastroenterology overall, while fellowship program directors retained a more conservative attitude: 63 (81.8%) vs. 10 (55.6%), P=0.038, Table 2, questions 1-8. Supplementary Table 2 summarizes the distribution of answers among both respondent groups according to their baseline demographic characteristics. Regarding the overall impact of COVID-10 pandemic on gastroenterology training, no difference was detected among fellows (P≥0.205) and program directors (P≥0.188) according to their main demographic characteristics. Significantly more trainees in departments with more than 7 fellows expressed their concerns that the lack of protective equipment in the context of the COVID-19 pandemic might affect their training compared to departments with <7 fellows (94.7% vs. 65.5%; P=0.029).

Table 2 Differences in perceptions of trainees and trainers regarding the impact of COVID-19 outbreak on different fields of gastroenterology fellowship programs

Factors associated with negative impact on training

Overall, there were no significant differences between fellows and program directors regarding factors potentially associated with a negative impact on training (P=0.274; Fig. 1A). Both groups agreed that the unknown timeframe of measure implementation (87.0% and 83.3%), the cancellation of scheduled endoscopic procedures (83.1% and 66.7%), the reduction of endoscopies performed by fellows (62.3% and 44.4%), the redeployment of fellows in a COVID-19 treating department (20.8% and 22.2%) and the reduction of training time in the outpatient clinic (10.4% and 27.8%) were the main factors that could negatively affect fellows’ training (Fig. 1A). However, more fellows than fellowship program directors identified the lack of time due to potential involvement with COVID-19 patients, as well as the lack of protective equipment, as additional contributors that negatively affected training: 60 (77.9%) vs. 9 (50%), P=0.036, and 56 (72.7%) vs. 6 (33.3%), P=0.003, respectively.

Figure 1 (A) Factors negatively affecting fellows’ training during the COVID-19 pandemic (Question 6) and (B) Measures to improve fellows’ training after the COVID-19 pandemic (Question 20)

*Denotes statistical significance

ns, not significant; HSG, Hellenic Society of Gastroenterology

Participants’ perspectives of COVID-19 outbreak impact on training in specific fields of gastroenterology

Significantly more fellows than fellowship program directors expressed concerns about the negative impact of the pandemic on acquiring/maintaining endoscopy competence: 64 (83.1%) vs. 5 (27.8%), P<0.001. Although numerically different, none of the differences between the 2 groups regarding the other specific fields of gastroenterology training were significant (72.7% vs. 55.6%, P=0.167 for training in general gastroenterology, 64.9% vs. 44.4%, P=0.192 for training in inflammatory bowel diseases, and 62.3% vs. 44.4%, P=0.243 for hepatology training, respectively). The rates of negative, neutral and positive answers for each group are given in Table 2, questions 9-12.

Participants’ perspectives of COVID-19 outbreak impact on endoscopy subdomains

Significantly more fellows than fellowship program directors expected a negative impact of COVID-19 outbreak on achieving competence and maintenance of technical skills in endoscopy: 61 (79.2%) vs. 7 (38.9%), P=0.001. This difference between the two groups was also consistent as regards achieving competence in the performance of basic diagnostic and emergency procedures: 54 (70.1%) vs. 4 (22.2%), P<0.001, and 37 (48.1%) vs. 2 (11.1%), P=0.004, respectively. The difference regarding the impact on the cognitive domain of fellows’ endoscopy competence did not reach significance: 52 (67.51%) vs. 8 (44.4%), P=0.14, Table 2, questions 13-17. Interestingly, statistically significantly more fellows ≤30 years old considered that the COVID-19 pandemic would negatively affect their training, in acquiring or maintaining competence in the performance of basic diagnostic endoscopic procedures, compared to their older colleagues: 100% vs. 61.7%; P=0.013 (Supplementary Table 2).

Participants’ perspectives of COVID-19 outbreak impact on academic training

As shown in Table 2 (questions 18-19), there was no significant difference among fellows and their program directors regarding the potential impact of the COVID-19 pandemic on academic training. Interestingly, in both groups half or more of the participants considered that the pandemic would have either a positive or no impact on the fellows’ scientific [47 (61%) and 10 (55.6%) for fellows and fellowship program directors, respectively] and academic [44 (57.1%) and 9 (50%), respectively] training.

Discussion

SARS-CoV-2 outbreak resulted in an unprecedented disruption of gastroenterology specialty training worldwide [8-11]. The results of this first web-based nationwide survey present valuable data regarding trainees’ and fellowship directors’ perceptions of the impact of the COVID-19 pandemic on gastroenterology fellowship training in Greece.

Our survey highlighted the fundamental concern of Greek gastroenterology fellows about the overall negative impact on training exerted by the COVID-19 pandemic. This newly encountered phenomenon has been at the focal point of other researchers worldwide. While our data were under analysis, 3 similar survey studies were published. Specifically, one international study, involving 770 trainees from 63 countries [8], reported that the pandemic led to restrictions in endoscopic volumes (99%; IQR 85-100% reduction in all procedures) and endoscopy training, with high rates of anxiety and burnout, while a second questionnaire distributed to members of the Italian Young Gastroenterologist and Endoscopist Association and some European representatives, not including Greece [9], underlined the significant impact of the COVID-19 outbreak on gastroenterologists’ clinical activity. Siau et al [11], in a survey across the United Kingdom (UK), noted a significant reduction in monthly endoscopy volume (P<0.001). It should be noted, however, that each of the abovementioned studies aimed at a different primary outcome and used its own, uniquely designed questionnaire, while the educational characteristics of the participants were not uniform, rendering direct comparisons to our results difficult. It is perhaps even more interesting that, in our study, fellowship program directors believed that a break of some weeks within a 4-year training program might be ultimately associated with only a small decrement in fellows’ overall abilities [12]. This is corroborated by the fact that lack of time due to potential involvement with COVID-19 patients, as well as the shortage of protective equipment, were identified only by fellows as major contributors that negatively affected the quality of training.

A reduction in the volume of endoscopies has been a common finding among all studies that investigated this issue [8-11]. Procedural volume has been inextricably linked to procedural competence [4,13]; however, whether the same finding applies to the era of the COVID-19 outbreak remains to be seen, since such implications at present time with the pandemic still underway are yet to be defined. Similarly to their European colleagues [9], study participants recognized that deployment in a COVID-19 treating department and a reduction in outpatient clinic activities as factors with an adverse impact on training.

Our study presents for the first time a handful of interesting observations derived from the participants’ perspectives of the impact the COVID-19 outbreak will have on training in different fields of gastroenterology. Although statistical significance was not always reached, the proportion of fellows expressing concerns about the negative impact of the pandemic on endoscopy competence, as well on other specific fields of gastroenterology, surpassed that of the fellowship program directors. For all aspects of endoscopy (technical, diagnostic, emergency), fellows anticipated a statistically significant negative impact on their training, compared to their directors. Although short-term training breaks cause minimum disruption to fellows’ training [12], one cannot exclude that a prolonged period of COVID-19 measures, together with existing evidence for high rates of anxiety and burnout among gastroenterology fellows [14], may affect trainees’ perception about the impact of the pandemic on their endoscopic skills. On the other hand, directors showed fewer concerns about this matter, perhaps knowing that endoscopic competence needs a significant amount of time and procedural volume to be achieved; thus, the disruption would only be temporary and would not be able to influence training in its entirety.

Most of the fellows proposed prolongation of the fellowship training program, while fellowship program directors favored an increase in the daily workload. Training program prolongation could indeed be a potential measure; however, it is not without concerns (anxiety and burnout) for fellows, as was recently shown in a survey among UK gastroenterology trainees [11]. However, one should not forget that the UK and Greek healthcare systems are not directly comparable, since the two countries have not been equally affected by the pandemic. On the other hand, an increased workload further results not only in physical and emotional exhaustion, but also in fellows’ perception of inadequate training [14]. Gastroenterology fellows ask for modifications of existing guidelines on training [11], with reforming of training curricula and rearranging of training activities among institutions [15,16]. Although limited, respondents had a positive attitude towards medical education delivery through online teaching and webinars. However, these methods might never replace the “traditional” methods of teaching and endoscopy performance in real-world circumstances.

This study had the following strengths. First, it is the first nationwide report to assess the perceptions of trainees and trainers regarding the impact of the COVID-19 outbreak on Greek gastroenterology fellows’ training. Second, the examination of fellows’ as well as fellowship program directors’ perspectives on this important issue is considered a study asset. Finally, an equivalent response rate was achieved to those reported previously in similar studies [8,9].

Limitations of this survey include the possibility of results being susceptible to recall and self-report bias, as with all studies of this particular type. Moreover, there is no validated instrument or questions; however, the questionnaire was designed based on the existing literature. Another limitation associated with the study’s cross-sectional character might be considered the fact that these results just reflect a snapshot taken during the acceleration phase of COVID-19. Although a response rate of 60% could be considered as satisfactory, the fact that 40% of those initially invited did not return the questionnaire cannot not be overlooked. Finally, it should be underlined that the COVID-19 pandemic and its impact on education represent a dynamic process. Accordingly, conclusions should be viewed in the light that they may just reflect temporary and ephemeral opinions of the study’s participants.

To conclude, Greek gastroenterology fellows are convinced that the COVID-19 outbreak will have a negative impact on their training, while training program directors are less concerned. Accurately identifying training gaps will assist local and international scientific societies to pursue new measures in order to address the educational needs of fellows during and after the COVID-19 pandemic.