The impact of the COVID-19 pandemic on gastroenterology trainees in Australia.

To the Editor,

We read with interest the review article by Lui et al. on the coronavirus disease 2019 (COVID‐19) global pandemic and its impact on our speciality particularly in relation to endoscopy COVID‐19 has necessitated fundamental changes to the way endoscopy is conducted. To reduce the risk of infection to patients and healthcare workers, and to prioritize the use of personal protective equipment (PPE), outpatient attendances and elective surgical and endoscopic procedures have been significantly restricted. Little is yet known about the secondary impacts of COVID‐19 on the training and well‐being of gastroenterology trainees. Lui et al. acknowledge the well‐being of healthcare professionals (including psychological distress, fatigue, and burnout) as an important issue during COVID‐19. In addition, we wish to highlight trainee concerns relating to reduced endoscopy training as another negative effect of COVID‐19, which may impact their psychological health and quality of training. We present the results of our recent survey of Australian gastroenterology advanced trainees (ATs).

In Australia as of May 23, 2020, there have been 7095 COVID‐19 cases and 101 related deaths. Although Australia has been highly successful in “flattening” the curve, public health measures implemented to control COVID‐19 have come at significant cost to the economy, healthcare systems, and the daily lives of citizens.

Gastroenterology training in Australia is a standardized 3‐year program with at least 2 years of core training. An anonymous online survey of Australian gastroenterology ATs was conducted during the peak of the local epidemic to assess the impacts of COVID‐19. Between April 15 and 29, 2020, Australian gastroenterology ATs were contacted via email and invited to participate. Eighty‐three ATs (of 149 nationally; 56%) took part with representation across all states and years of training (Table 1).

Table 1

Survey responses from Australian gastroenterology advanced trainees

	N = 83 (%)
Year of training
1st	26 (31)
2nd	37 (47)
3rd	20 (24)
State
New South Wales	34 (41)
Victoria	22 (27)
Queensland	13 (16)
South Australia	8 (10)
Western Australia	3 (4)
Tasmania	2 (2)
Australian Capital Territory	1 (1)
Attitude to impact of COVID‐19 on training
Not at all concerned	0
Not very concerned	9 (11)
Neutral	8 (10)
Concerned	48 (58)
Very concerned	18 (22)
Greatest area of COVID‐19 impact
Endoscopy	72 (87)
Clinic experience	4 (5)
On‐call experience	1 (1)
Career progression	2 (2)
No impact	4 (5)
Median number of gastroscopies per week (IQR)	2 (0–4)
Median number of colonoscopies per week (IQR)	1 (0–3.5)
Satisfaction with telehealth
Very unsatisfied/unsatisfied	17 (20)
Neutral	34 (41)
Satisfied/very satisfied	31 (37)
Not doing	1 (1)
Anticipated readiness for independent practice at completion of training
Yes	32 (39)
No	24 (29)
Not sure	27 (33)
Preferred solution
Additional endoscopy training	37 (45)
Extended duration of training	30 (36)
No changes required	15 (18)
Other	1 (1)
RACP decision to allow progression into advanced training without passing clinical examination
No concerns	2 (2)
Do not agree	51 (61)
Concerns but the best option available	30 (36)
Impact of RACP decision on quality of advanced training
No impact	0
Minor	4 (5)
Moderate	49 (59)
Severe	30 (36)

COVID‐19, coronavirus disease 2019; IQR, interquartile range; RACP, Royal Australian College of Physicians.

The majority (66/83, 79.5%) of ATs reported concern regarding the impact of COVID‐19 on training with limited access to endoscopy training being the greatest concern (72/83, 87%). A higher proportion of first‐year trainees were concerned compared to more senior trainees (24/26 vs 42/57, P = 0.05). The majority of ATs (57/83, 69%) reported that endoscopy services had reduced by more than 75% at their institution due to COVD‐19 restrictions on elective endoscopy, only performing a median of two gastroscopies and one colonoscopy per week (Fig. 1). Twenty‐five ATs (30%) were prohibited from performing emergency endoscopy due to safety concerns. This is in line with guidelines from several international societies, , which recommend emergency procedures be performed by the most senior available person to limit the number of staff exposed and PPE used.

Figure 1

Percentage reduction in elective endoscopy due to coronavirus disease 2019 as reported by Australian gastroenterology advanced trainees. , 100%; , 75–99%; , 50–74%; , 25–49%; , < 25%; , 0%.

Almost all ATs (82/83, 99%) were involved in telehealth consultations, and most reported positive or neutral experiences with this service (65/82, 79%). The majority expressed concern that they may not be ready for independent practice at the completion of training due to COVID‐19 (24/83 responded would not be ready and 27/83 unsure), and most were in favor of either additional “catch‐up” endoscopy training (45%) or extended training duration (36%).

Compounding the above issues, recently, the Royal Australian College of Physicians (RACP) canceled the FRACP clinical examination scheduled for July 2020. Normally, basic physician trainees (BPTs) are required to pass this examination prior to commencing advanced training. The RACP has recommended that BPTs progress provisionally into advanced training and attempt the clinical examination in 2021 during their first year of specialist training. The majority of gastroenterology ATs (51/83; 61%) disagreed with this decision. All reported that from their own experience, it would be difficult to simultaneously study for the clinical examination and work as a gastroenterology AT (89% very difficult and 11% somewhat difficult) and that this may comprise the quality of advanced training and impact gastroenterology departments more broadly.

This survey highlights that COVID‐19 has raised significant concerns for Australian gastroenterology ATs particularly in relation to endoscopy training. As a procedural speciality, gastroenterology may be more affected than other specialities. Our findings may not be generalizable to other nations due to regional differences in training and the local severity and duration of the COVID‐19 crisis. Indeed, it is likely that in nations more severely affected by the COVID‐19 pandemic, the impact on trainees may be longer and more profound. In conclusion, we hope our survey can help to inform and guide modifications to training during the COVID‐19 pandemic.

Declaration of conflict of interest

David S Prince, Ken Liu, Gokulan Pavendranathan, Simone I Strasser, Steven Bollipo, and Ria Kanazaki have no conflicts of interest or relevant financial disclosures to declare.