Statistical analysis
The reference population size was 497, and the confidence level was set
at 95%.
Statistical analysis was performed with STATA 13.0 (College Station, TX:
StataCorp LP). Continuous variables were reported as median and
interquartile range (IQR), and categorical variables were summarized as
frequency and percentage.
RESULTS
A total of 129 out of 497 (26%) Italian residents from 22 programs out
of 31 (71%) completed the online questionnaire and gave informed
consent. Considering a 95% confidence level, the margin of error
(confidence interval) was ±7.45. Participants’ demographics and
professional data are listed in Table 1. The great majority of residents
(119, 92%) worked in hospitals that admitted COVID-19 cases, and an
even greater percentage (127, 98%) reported changes in their daily
professional activities (Table 2). In particular, in 71% (91) of the
cases surgery was limited only to urgent cases, in 23% (30) the overall
volume of activity was reduced without case selection, in 5% (7) of
cases the ENT activity was shut down, and only 1% (1) reported no
changes. Suspension of all surgical procedures was reported by 23 (18%)
of responders, while urgent surgeries were still performed in 82%.
Swabs to determine COVID-19 infection were not performed in 25% of
cases prior to surgery.
Changes in resident’s weekly activities were reported by 127/129 (98%)
of residents. Further details concerning reduction of inpatients and
outpatients and surgical procedures are presented in Table 2.
Table 3 summarizes data about training, learning gaps and possible
solutions. In particular, 90% of residents thought that the changes
brought by COVID-19 negatively affected the regular course of their
residency. Indeed, a minority of ENT residents was directly involved in
the response to the pandemic either collaborating to the medical or
ventilator care of COVID-19 patients (25, 19%), or performing
tracheostomies (14, 11%). A similar percentage of responders (23, 18%)
was able to acquire new skills outside of the traditional ENT curriculum
(e.g. management of respiratory patients, ventilator care, etc.).
Finally, the overall perception of the quality of training by residents,
rated from 1 to 10 with a visual-analogue scale (VAS), decreased from a
median score of 7 before the outbreak to 4 during the pandemic.
Data concerning specific training on COVID-19, availability of PPE and
exposure to the virus are reported in Table 4. In particular, a median
score of 5 (VAS 1-10) was attributed to the fear of contracting
COVID-19. On the other hand, the reported median level of stress was
actually lower during the pandemic 5 (VAS 1-10) than before (6, VAS
1-10).
DISCUSSION
Roughly one-quarter of Italian ENT residents responded to the
questionnaire with a slight prevalence of males (54%) and with a
similar number of residents attending the first 2 years (67,5%)
compared with those in the last 2 years (62,5%) of residency.
Seventy-one percent of Italian programs (22/31), distributed all over
the country, were sampled. The analyzed sample is therefore fairly
representative of the Italian ENT residents’ population, with an
acceptable margin of error (±7.45). The vast majority of residents
reported reductions not only in surgical activity, but also in
outpatient visits, to an extent that is clearly significantly affecting
clinical exposure. Reduction of residents’ activities through rotation
of small teams to manage urgent cases has been put in place in many
residency programs to reduce the risk of infection and preserve a pool
of healthy colleagues to respond to hospital’s needs2,3. Interestingly, at the time of the survey, only a
quarter surgical cases were tested for COVID-19, possibly due to the
urgent nature of the cases managed during the pandemic. Also, senior
colleagues in charge of tutoring residents reduced surgical teaching,
further reducing practical learning possibilities. Nonetheless, they
were still available for consultation in the majority of cases. While
hospital reorganization and changes related to the pandemic can explain
the overall reduction of surgical procedures, it is unclear why roughly
half of residents reported that surgical teaching was halted altogether
in a time period in which some ENT surgeries were still being
performed4. One explanation might be related to the
necessity of speeding up oncologic procedures requiring resection and
reconstruction, in order to minimize the utilization of
anesthesiologists that were directly involved with the management of
COVID-19 patients admitted in intensive care unit
departments5. However regarding tracheostomy, the most
requested ENT procedure during the pandemic, it has been suggested that
expert surgeons would guarantee quicker and more effective procedures,
with the aim of reducing spread of droplets from the open
airway6. However, such claims are unsupported by
evidence, and it has been demonstrated that tracheostomies performed by
supervised residents are by no means inferior to those carried out by
senior colleagues7. Contrarily to surgical activities,
self-study followed an opposite growth trend for 80% of residents. On
the other hand, while in-person lectures were reduced or remained
unchanged due to the social distancing precautions, only a minority of
residents (23%) had access to online lectures. Development of consortia
dedicated to residents’ education in the US has considerably increased
the availability of materials for distance learning and it represents a
promising strategy to cope with the current situation, while also laying
the foundations of a structured high-quality national teaching
curriculum8,9. Apart from the implementation of online
lessons, to compensate for the reduction in clinical exposure, 41% of
residents favored a prolongation of their training or wished to be
reassigned to a COVID-free hospital (10%). Only a small minority saw
the necessity of additional theoretical training (4%), while the
majority of questionnaire responders (44%) advocated an increase in
hands-on training as the most fitting solution. However, due to the
present biological risk, reduced availability of cadaver specimens may
also obstacle the organization of dissection courses.
Still, in spite of the reduction of learning opportunities, roughly 20%
of residents reported that they were able to gain new skills and
received training in ventilator and pharmacological treatment of
COVID-19. Indeed, due to overall shortage of doctors, some hospitals
reallocated residents to the treatment of COVID-19 patients. In other
cases, residents volunteered to be assigned to the treatment of COVID-19
cases. While training in respiratory patient care is not part of the
traditional ENT curriculum, it could prove useful if further spread of
the contagion will increase hospital staffing needs or in case of new
flares of the epidemic over the next months. Anyhow, more effective
measures to increase the availability and the correct use of PPE are
needed since 60% of residents reported inadequate supplies for
high-risk procedures and a 5% infection rate10.
CONCLUSIONS
The survey demonstrates that the COVID-19 outbreak highly impacted ENT
residents in all Italian regions. The reduction of activities, above all
surgery, had significant impact on residents’ training. It is therefore
essential to rapidly implement effective solutions to maintain a high
training level, especially in light of the uncertain duration of the
pandemic and the possibility of future outbreaks. Furthermore, when
regular Otorhinolaryngological activities will resume, widespread
availability of proper PPE will be essential to prevent contagion among
residents and consultants alike.
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