The Impact of COVID-19 on Pulmonary Fellowship Training in an Irish Setting.

To the Editor:

We read with interest the recent Perspectives piece by Çoruh entitled “Flattening the Curve: Minimizing the Impact of COVID-19 on a Pulmonary and Critical Care Medicine Fellowship Training Program” (1). The authors explored multiple potential disruptions to fellowship training programs caused by the coronavirus disease (COVID-19) pandemic and highlighted the actions undertaken to mitigate the effects in their center, a hospital that “experienced moderate strain.” We report how fellowship training has been affected in an Irish hospital. Multiple different fellowship training programs exist internationally, which have varying formats and expectations for both attending physicians and fellows and all have experienced change owing to the effects of the COVID-19 pandemic.

St. Vincent’s University Hospital is an 836-bed academic health center in Dublin, Ireland, which was significantly affected during the peak of the crisis in Ireland, operating at surge capacity for 8 weeks, with 150% occupancy of the intensive care unit during this time. Fellows were redeployed from pulmonary and other specialist training posts to a ward-based internal medicine service that faced increases in patient caseload, on-call frequency, and working hours. Consequently, pulmonary fellows saw a decreased number of specialty pulmonary patients, resulting in decreased opportunities for detailed assessments and investigations. Before the pandemic, 389 patients were reviewed per month through 11 weekly outpatient clinics in this hospital, the national referral center for adult cystic fibrosis and the largest tertiary referral center for interstitial lung disease and sleep medicine. These clinics were changed to telemedicine “virtual clinics,” which further reduced the capacity for engagement with subspecialty-specific cases and the training opportunities that these consultations afford.

Because of the recognition of bronchoscopy as an aerosol-generating procedure (2, 3), the decision was made at the outset of this crisis for these to be performed by attending physicians to minimize exposure to multiple clinicians, preserve personal protective equipment, and observe social distancing guidelines. Pleural procedures, including thoracentesis and pleural catheter placement, were preferentially undertaken by interventional radiologists for the same reasons. Routine pulmonary function and cardiopulmonary exercise testing was postponed, with only urgent cases being performed, further impacting pulmonary fellows’ training in their performance, interpretation, and reporting. Lack of access to these procedures and investigations raises the possibility that fellows may not be able to achieve procedural competence. Although the pandemic has allowed for this to be acceptable to central training bodies, this could impact trainee confidence and competence in these skills (4).

Formal delivery of education, which previously included specialty-specific case-based conferences, journal clubs, teaching conferences, and research meetings, has decreased as the demands on service provision have increased. The impact of this on trainees has been offset somewhat by the conversion of institute-wide teaching sessions to virtual lecture series accessible to all users (5). However, exposure to teaching by attending pulmonologists is a core component of fellowship training and was largely unavailable because of the increased demand on attending physicians.

Physician burnout is common in medical trainees and can be influenced by several factors (6, 7). The multiple increased demands on fellows combined with the reduction of access to core components of pulmonary training programs have the potential to increase burnout rates. This is compounded by the societal impact of COVID-19 restrictions, with many fellows unable to access the usual support networks they may rely on to ameliorate burnout.

Fellowship training has been significantly affected by the COVID-19 pandemic as outlined above and in the Perspectives piece by Çoruh (1). Although steps may be taken to mitigate many of these factors, these actions are dependent on the individual institutional setup and clinical demands. It is critical to prioritize strategies to optimize training in times of increased service demand, such as during the COVID pandemic, and planning for this is especially important, as we face the possibility of a second wave and other novel viral infections in the future.