Pediatric residency programs must ensure residents achieve competence, despite disruptions from the coronavirus disease 2019 (COVID-19) pandemic.1,2 We conducted a national survey of pediatric program directors (PDs) to determine the extent of disruptions in pediatric resident training and frequency of resident redeployment and COVID-19 illness.
Methods
We performed a national cross-sectional, electronic survey of pediatric PDs from May to July 2020. We received Institutional Review Board approval from the University of Oklahoma Health Sciences Center.
We developed our survey after literature review, cognitive interviews, and pilot testing.
In our survey, we included questions about program characteristics, pandemic emergency stage, impact on patient care, and resident illness and exposure. The Accreditation Council for Graduate Medical Education established 3 pandemic emergency stages, in which some or most educational activities are suspended in stage 2 or 3.3
We analyzed data using descriptive statistics (displayed as count and percent), Pearson’s χ2 tests for categorical measures, and median and Wilcox rank tests for continuous measures. For calculations, we used R (version 4.0.3).
Results
A total of 55% (110 of 199) of PDs responded. There were no differences between respondents and nonrespondents (Table 1). Most (89%) programs reported operating at pandemic emergency stage 2 (56%) or 3 (33%).
The Demographic Characteristics of Responding US Pediatric Residency Programs Compared With Those of Nonresponding Programs
| Variable | Respondents (N = 110), n (%) | Nonrespondents (N = 89), n (%) |
|---|---|---|
| Program size | ||
| Small (≤30 residents) | 35 (32) | 38 (43) |
| Medium (31–60 residents) | 42 (38) | 29 (33) |
| Large (>60 residents) | 33 (30) | 21 (24) |
| Location9 | ||
| Northeast (New England, New York, Mid-Atlantica) | 37 (34) | 33 (37) |
| Midwest (Mid-America and Midwesta) | 31 (28) | 21 (24) |
| South (Southeast and Southwesta) | 26 (24) | 24 (27) |
| West (Western) | 16 (15) | 11 (12) |
| Residency program setting | ||
| University based | 52 (47) | 32 (36) |
| Community based and university affiliated | 47 (43) | 42 (47) |
| Community based | 8 (7) | 7 (8) |
| Military | 0 (0) | 6 (7) |
| Other | 3 (3) | 2 (2) |
| Primary site of clinical care | ||
| Children’s hospital inside a hospital building that also cares for adults | 43 (39) | — |
| Free standing children’s hospital within a hospital system that also cares for adults | 35 (32) | — |
| Free standing, independently operating children’s hospital | 19 (17) | — |
| Community hospital, military hospital, or other | 13 (12) | — |
| Variable | Respondents (N = 110), n (%) | Nonrespondents (N = 89), n (%) |
|---|---|---|
| Program size | ||
| Small (≤30 residents) | 35 (32) | 38 (43) |
| Medium (31–60 residents) | 42 (38) | 29 (33) |
| Large (>60 residents) | 33 (30) | 21 (24) |
| Location9 | ||
| Northeast (New England, New York, Mid-Atlantica) | 37 (34) | 33 (37) |
| Midwest (Mid-America and Midwesta) | 31 (28) | 21 (24) |
| South (Southeast and Southwesta) | 26 (24) | 24 (27) |
| West (Western) | 16 (15) | 11 (12) |
| Residency program setting | ||
| University based | 52 (47) | 32 (36) |
| Community based and university affiliated | 47 (43) | 42 (47) |
| Community based | 8 (7) | 7 (8) |
| Military | 0 (0) | 6 (7) |
| Other | 3 (3) | 2 (2) |
| Primary site of clinical care | ||
| Children’s hospital inside a hospital building that also cares for adults | 43 (39) | — |
| Free standing children’s hospital within a hospital system that also cares for adults | 35 (32) | — |
| Free standing, independently operating children’s hospital | 19 (17) | — |
| Community hospital, military hospital, or other | 13 (12) | — |
—, not applicable.
The regions in parentheses refer to Association of Pediatric Program Directors–designated regions.
The majority (>95%) of programs reported decreases in in-person clinical care in nearly all areas except the NICU and newborn nursery, with simultaneous increases in telemedicine (Figure 1).
The effect of the COVID-19 pandemic on the volume of patients cared for in-person and via telemedicine across different healthcare settings by region.
To create the left half of this figure, the answer choices were on a 5-point Likert-type scale, ranging from very decreased to very increased. Each answer choice was assigned a value: −2: very decreased; −1: decreased; 0 unchanged; 1: increased; and 2: very increased. The programs were sorted by region, and the mean score for programs in that region is presented. ED, emergency department.
The effect of the COVID-19 pandemic on the volume of patients cared for in-person and via telemedicine across different healthcare settings by region.
To create the left half of this figure, the answer choices were on a 5-point Likert-type scale, ranging from very decreased to very increased. Each answer choice was assigned a value: −2: very decreased; −1: decreased; 0 unchanged; 1: increased; and 2: very increased. The programs were sorted by region, and the mean score for programs in that region is presented. ED, emergency department.
One-quarter of programs (26%; 29 of 110) reported their residents were redeployed. Most (62%; 18 of 29) redeployment was mandatory and occurred within their own hospital network (93%) to care for adults (69%) who were critically ill, hospitalized, and/or in the emergency department. Residents in community-based programs were more likely to be redeployed (69%; 9 of 13 vs 21%; 20 of 97; P < .003).
Almost all programs (95%) reported some residents missed work because of the COVID-19 pandemic, with nearly one-half (47%; 52 of 110) reporting >10% of residents had missed work. The majority (66%; 73 of 110) of programs reported residents missed work because of a personal COVID-19 infection, whereas 84% (92 of 110) reported at least 1% to 10% of their residents missed work because of COVID-19 exposure. Even in the Midwest, where disease burden was low at time of survey completion, 52% (16 of 31) of programs reported residents missed work because of COVID-19 illness. Nearly all (>98%) programs who reported having pregnant, immunocompromised, or other high-risk residents made some clinical accommodations.
Discussion
Early in the COVID-19 pandemic, programs reported a decreased volume of in-person pediatric care, increased telemedicine, and resident redeployment to care for adults. Almost all programs reported some residents missed work. To accommodate high-risk residents, PDs often modified resident schedules or clinical experiences.
The long-term impact of decreased clinical volume2 and telemedicine4,5 in the absence of in-person visits on the clinical competence of pediatric trainees remains unclear. A reduction in clinical experiences may be further pronounced for residents whose experiences were modified because of illness, diversion to care for adults, or to accommodate high-risk conditions. Given training disruptions, it will be critical that resident competency is assessed frequently. PDs will need to fill gaps in important, direct care experiences to help trainees develop competence, including through simulation and new competencies around telemedicine.6 In the long-run, PDs will need to carefully consider the future of pediatric residency training, depending on how typical pediatric patterns of care remain affected, and, as a result, what types of experiences contribute best to achieving competence in general pediatrics.7 Future research focused on assessing the impact of the pandemic on achievement of competency-based milestone metrics may help better understand the relationship between clinical volume and achievement of competence.
Our study has several limitations. This study was early in the pandemic, did not include resident perspectives, and did not ask PDs to assess the pandemic’s effect on the 6 core competencies.8 It is possible that, although the pandemic had negative effects on some competencies, others may have been more positively affected. This is an important area for future study.
Pediatric clinical volume dramatically decreased in the initial phase of the COVID-19 pandemic across pediatric residency programs, concomitant with a substantial rise in telemedicine visits and significant redeployment of residents to care for adults. Residency programs will need to determine how to ensure clinical competence, given the potential for further alterations in clinical experiences, as the pandemic evolves nationally and internationally.
Acknowledgments
We acknowledge Janis Campbell, PhD, for her help in gathering the COVID-19 disease burden data and Kendra Sikes, CCRP, CCRC, for her editorial assistance. We also acknowledge the Association of Pediatric Program Directors and Dennis West for their support in facilitating this project, the Association of Pediatric Program Directors Research and Scholarship Learning Community for their review of the survey, and all of the PDs who participated by completing the survey.
Dr Naifeh conceptualized and designed the study, designed the data collection instrument, drafted the initial manuscript, and reviewed and revised the manuscript; Drs Stevenson, Abramson and Li helped with critical review and drafting of the data collection instrument, drafting of the manuscript, and review and revision of the manuscript; Dr Aston conducted data analyses and participated in review and revision of the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
FUNDING: No external funding.
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