The Impact of COVID-19 on Gastrointestinal Endoscopy Training in the United Kingdom.

The coronavirus disease 2019 (COVID-19) pandemic has abruptly reduced gastrointestinal endoscopy activity worldwide. This has had a consequent impact on endoscopy training in the United Kingdom (UK). However, the impact on trainee procedure exposure has not been quantified. We conducted a UK-wide survey with the aim of quantifying the impact of COVID-19 on hands-on endoscopy procedures performed by trainees and on their emotional well-being.

Methods

A 37-item survey (Supplementary File) was developed as part of an international collaborative (EndoTrain). The survey was endorsed and disseminated to UK trainees by the British Society of Gastroenterology (BSG) and was open for a 3-week period (April 11–May 2, 2020). The primary outcome measured was the reduction in 30-day volume of hands-on endoscopy procedures during COVID (ie, 30-days leading up the survey) vs the average month before COVID-19. Endoscopic methods studied comprised esophagogastroduodenoscopy, colonoscopy, endoscopic retrograde cholangiopancreatography, endoscopic ultrasound, and upper gastrointestinal bleeding, which was included within the esophagogastroduodenoscopy numbers. These were measured for supervised, independent (unsupervised), and total numbers. Secondary outcomes comprised rates of anxiety, measured using the Generalized Anxiety Disorder-7 tool, burnout, and uptake of alternative training resources. For each endoscopic method, respondents who recorded 0 procedures over their pre–COVID-19 period were excluded to limit analyses to actively participating trainees.

Comparisons over two 30-day time periods were made using Wilcoxon’s signed rank tests and across methods modalities using Kruskal-Wallis with multiple comparisons Dunn’s tests. Statistical analyses were performed using SPSS 26 software (IBM Corp, Armonk, NY), with significance at P < .05.

Results

Respondents

The survey was completed by 132 respondents from the specialties of gastroenterology (101 [76.5%]), surgery (24 [18.2%]), and pediatric gastroenterology (7 [5.3%]). Trainees had received a median of 3 years of training (interquartile range, 1-5 years). The response rate of gastroenterology trainees was approximately 20%, and 53% of trainees performed ≥1 procedures without supervision.

Impact of COVID-19 on Trainee Procedures

All active trainees reported a reduction in monthly endoscopy volume due to COVID-19. For each method, there was a significant decrease (P < .001) in average monthly numbers of supervised and unsupervised hands-on procedures before and during COVID-19 (Figure 1 ). The mean percentage reductions for supervised, unsupervised, and all trainee procedures were 93.5% (SD, 23.6%), 96.3% (SD, 12.1%), and 96.0% (SD, 12.8%), respectively. This percentage reduction did not differ by level of supervision (P = .781) or specialty (P = .108), but varied across methods (P = .001), with a significant difference (P < .001) between upper gastrointestinal bleeding procedures (mean reduction, 78%; SD, 43.9%) and colonoscopy (mean reduction, 97.2%; SD, 12.4%).

Figure 1

Comparison of trainee-reported number of (A) supervised procedures, (B) independent procedures, and (C) total procedures in the 30-day period pre (PRE) and during COVID-19 (COVID). Symbols and error bars represent the median and interquartile ranges. ∗P < .05, ∗∗P < .001, ∗∗∗P < .0001. Colon, colonoscopy; EGD, esophagogastroduodenoscopy; ERCP, endoscopic retrograde cholangiopancreatography; EUS, endoscopic ultrasound; n, number of actively participating trainees; UGIB, upper gastrointestinal bleeding hemostasis.

Barriers to Training

The reasons cited for the reduction in opportunities comprised changes to institutional policy that excluded trainees from procedures (75.8%), lack of cases (56.8%), and redeployment to another clinical area (47.7%). Endoscopy training remained accessible on an ad hoc basis to 69.7%. Reductions in institutional endoscopy case volume were reported by 100%, with 96.0% reporting reductions in excess of 50%. Altogether, 21.2% (n = 28) of trainees were on an emergency endoscopy rota before COVID-19. Participation was stopped or reduced in frequency in 71.4% (n = 20).

Trainees’ Concerns

Competency development was a concern for 93.4% (n = 113) of trainees, and 82.6% (n = 100) were concerned with the possible need to prolong speciality training due to COVID-19. Modification of existing UK guidelines to support endoscopy training was endorsed by 56.7% (n = 68).

Anxiety and burnout were assessed in 120 trainees. Of these, 50% had anxiety based on Generalized Anxiety Disorder-7 criteria (35.8% mild, 9.2% moderate, and 5.0% severe), with 10.8% meeting criteria for burnout. Institutional provision of emotional support strategies during the COVID-19 pandemic was available to 90.8% of trainees.

Alternate Sources of Education

During the COVID-19 pandemic, 37.5% (n = 45) did not access any alternate educational resources for endoscopy training. At least weekly use was reported for social media-based education (29.1%), followed by endoscopy journals (15.8%), online courses from gastrointestinal societies (15.0%), and distant learning from institutions (9.2%).

Discussion

The COVID-19 pandemic has adversely affected endoscopy trainees in the UK, with a mean reduction in procedure count of 96.0%. This was mainly due to changes to institutional policies limiting trainee access, reduction in unit case volumes, and redeployment toward high-priority clinical areas. Such disruptions have led to concerns regarding competency development and the prolongation of training to achieve competence, which may be fuelling anxiety and burnout during this period.

Our survey had several limitations. Our survey had a response rate of 20%, a dropout rate of 9%, and did not include nurse endoscopist trainees. Regional data and lifetime procedural counts were not collected. The survey was a snapshot taken during the acceleration phase of COVID-19 and did not provide a dynamic assessment of procedural data in line with COVID-19 caseload. National Endoscopy Databases could be interrogated in the future for this purpose.

Like many countries, the UK places reliance on minimum procedure numbers as a competency safeguard. These are embedded within national certification processes for independent practice overseen by the Joint Advisory Group. The effects of COVID-19 are projected to persist until 2022, coinciding with UK Shape of Training reforms aimed at reducing specialty training from 5 to 4 years. This combination is likely to render minimum procedure numbers unattainable for many trainees. In response, the BSG is actively engaging in multistakeholder dialogue to discuss possible solutions:

First, learning curves for cognitive skills could be optimized by increasing access to hands-off training methods, including alternative educational-based training, while promoting access to ad hoc hands-on opportunities.

Second, summative evaluation could focus less on minimum numbers and more on validated competency assessment tools, , with consideration for distant assessment to conserve personal protective equipment.

Third, a defined period of mentorship could be adopted for those who complete specialist training without acquiring certification.

Finally, trainee well-being will also be prioritized on the BSG agenda. We hope that these measures can be incorporated with solutions from other societies to help provide much needed support to endoscopy trainees nationwide.