Pulmonologists’ work and clinical life during the COVID-19 pandemic: a society-led survey

Discussion

We aimed to conduct and complete the first survey on pulmonologists’ and pulmonology residents’ clinical life, education, and training during the COVID-19 pandemic. We found that the COVID-19 pandemic has had a significant and higher impact on the participation in educational courses and meetings and workload than on access to supervision and discussions with colleagues. Most of the pulmonologists and residents in pulmonology responded that they received sufficient education for handling the pandemic situation, however, due to the pandemic situation more than one-third had performed technical procedures they did not feel competent in.

“Lesser opportunity to train hands-on procedures locally and internationally, however, many opportunities for webinar and online learning”

Respondent's comment

Pulmonologists and pulmonology residents are required to perform a variety of technical, hands-on procedures in a competent way. Several respondents, most often residents, described less opportunity to develop, train and maintain competences in technical hands-on procedures. On an international level, the ERS has presented structured, evidence-based educational programmes including simulation-based training and assessment in, for example, bronchoscopy, endobronchial ultrasound and thoracic ultrasound [3–5]. Thereby, there is an opportunity to train technical procedures, for example, via simulation without exposure to virus and regardless of the number of patients.

The COVID-19 pandemic has increased the need for the pulmonologists and residents to perform additional procedures like tracheal intubation, airway suction, mechanical ventilation, placement of central venous catheter and performing throat swabs [6]. Procedures which most likely are to be performed on COVID-19 units by physicians independent of original specialty. As mentioned in the respondent's comment above, the pandemic has made it more challenging to learn these practical procedures for several reasons. For example, the increased risk of infection during aerosol-generating procedures like bronchoscopy. The airborne spread of the disease has been debated years before the COVID-19 pandemic in relation to other respiratory diseases, like the Middle East respiratory syndrome and conventional flu, but is today more relevant than ever [7].

“Performance of airborne related procedures are highly affected”, wrote a pulmonology resident as a comment for the survey. There is abundant evidence that proximity is the key to risk of transmission and performing aerosol-generating procedures on COVID-19 positive patients is classified as high risk [8]. As a result, especially at the beginning of the pandemic when the disease was not yet fully explored, much clinical training was reduced. Many elective routine procedures, which are often used in clinical training and education because of the calm environment and possibility for supervision, were postponed and practical courses cancelled. It is estimated that the ERS has cancelled approximately 20 hands-on courses in technical procedures like endobronchial ultrasound and bronchoscopy, and the annual Congress that usual includes approximately 30 hands-on training sessions, ranging from spirometry to cardiopulmonary exercise testing, was held online.

The reduced clinical training and decreased access to supervised technical procedures could, along with the abovementioned issues, be a key factor in the worrying main finding; that more than one-third of the respondents have performed technical procedures that they did not feel competent in due to the pandemic.

“In my opinion during the pandemic the training programme should be postponed and not continuing with evaluations and examinations while working much more hours and not attending the compulsory internships”.

Pulmonologist's comment

As mentioned above, pulmonologists have seen residents struggle to meet the criteria of the training programmes. Much has changed and much has been learned since the beginning of the pandemic in Spring 2020. Hopefully, we are now facing a post-pandemic era where training programmes again are running with high quality, but residents could potentially lack competences that have not been learned in the past 2 years because their focus has been on the COVID-19 pandemic and COVID-19 patients.

Even though online, virtual, and augmented reality to some extents have replaced some parts of the medical training programmes, it is not possible to train practical skills via e-learning, virtual reality or webinars alone [9]. A solution to this can be increased use of simulation-based training that allows practical training of technical procedures [10]. Simulation-based training has several well-known advantages including gaining competences in a structured and calm environment, the possibility to train in high-risk procedures without exposing the patient to risk and an increased level of competency when performing the first patient procedure [11, 12]. The COVID-19 pandemic has introduced another significant important argument; that simulation-based training does not include the risk of disease transmission for healthcare professions.

Thereby, simulation-based education and training can replace some part of the practical training at the beginning of the learning curve, however, apprenticeship, clinical training and supervision are of great importance and unreplaceable.

“We now have easier/wider access to online education forms like webinars”

Respondent's comment

Societies and databases made articles and evidence on COVID-19 open access to share information across institutions and borders regardless of economic status. Additionally, free online meetings, educational sessions and presentations covering different aspects of the COVID-19 pandemic have been arranged. This was commented on several times in the survey, especially by respondents from low-income countries. Gordon et al. [13] and Nayahangan et al. [14] describe unanimously in their systematic reviews of education during the pandemic that the evidence of medical education and educational effects during a pandemic is sparse. It is necessary to discuss if the rapidly increased demand for knowledge-sharing and proposed educational approaches could have entailed a compromised workflow. Medical education and information sharing are not regulated with peer-review like research data and manuscripts. The fast shift towards digital educational material was in the reviews seen as a response because it did not require face-to-face meetings and the asynchronous material made learning accessible in time and place. Independent of platforms, we must continue to strive for structured and evidence-based education on technical procedures [15].

On a positive note, as congresses and international meetings during the pandemic have been primarily online, physicians have been able to join without taking more days off work to travel to the events. A qualitative assessment of the voluntary comments connected to each survey response revealed that there are positive things to highlight and that solutions have been made and evolved during the outbreak. However, concerns are that we have not yet seen the consequences of cancelled congresses and educational activities.

“We have got sufficient training now; this was not the case in the spring 2020”

Pulmonology resident's comment

Overall, our findings indicate that pulmonologists at an international level have been heavily affected by the pandemic. Interpretation of our results also reveal that the highest impact is seen as change in work schedule and workload. COVID-19 departments and units have been organised and structured in almost every country during the first and second lockdown [16], however, there is a continued need for handling non-COVID-19 patients, for example, for cancer screening and investigation. Thereby, the increased workload and work schedule is not surprising.

A general needs assessment on educational needs of doctors and nurses working with COVID-19 patients performed in the early phases of the pandemic in Wuhan, China, found that focus on coping strategies for mental strain was necessary [6]. Several studies have been published with the aim of exploring psychological impact, mental health and burnout following the pandemic [17]. A systematic review of psychological impact of COVID-19 in Western frontline healthcare professionals reports and concludes that pulmonologists among intensive care unit personnel, emergency department personnel and geriatrics are the most affected [18]. Especially during the first months after the outbreak when the disease was not fully elucidated, the anxiety and stress was high and studies highlight that long working hours and the long-term, permanent vigilance required when working in intensive care units, emergency departments and pulmonology departments during a respiratory pandemic worsened the psychological state of the healthcare professionals [19]. Furthermore, the risk of disease transmission to family and relatives kept physicians at a distance to their beloved ones.

Our study was an international, cross-sectional survey on the well-being of pulmonologists and pulmonology residents during the COVID-19 pandemic. Surveys always reflect a snapshot of reality that potentially quickly change in both worse or better directions.

During the pandemic, we have seen varying degrees of impact from country to country but also from region to region and city to city [20]. Changes in restrictions and requirements happen quickly which could affect the responses over time. We are also aware that some areas and countries have been and are more affected than others, and our survey did not differ between high-income countries and developing countries, or between countries that were highly affected by the COVID-19 pandemic and those that were less affected.

In conclusion, we must strive for investment in research on medical education and potentially simulation-based training of technical procedures to ensure competence and decrease the insecurity about new procedures, especially in the setting of worldwide pandemics or acute critical situations.