BRIEF REPORT Pediatric Intern Clinical Exposure During the ...

BRIEF REPORT

Pediatric Intern Clinical Exposure During theCOVID-19 PandemicAlexandra T. Geanacopoulos, MD,a Kathryn M. Sundheim, MD,a Kimberly F. Greco, MPH,b Kenneth A. Michelson, MD, MPH,a,c Chase R. Parsons, DO, MBI,d

Jonathan D. Hron, MD,d Ariel S. Winn, MDd

BACKGROUND AND OBJECTIVES: Pediatric health care encounters declined during thecoronavirus disease 2019 (COVID-19) pandemic, and pediatric residency programs have adaptedtrainee schedules to meet the needs of this changing clinical environment. We sought to evaluate theimpact of the pandemic on pediatric interns’ clinical exposure.

METHODS: In this retrospective cohort study, we quantified patient exposure among pediatricinterns from a single large pediatric residency program at a freestanding children’s hospital. Patientencounters and shifts per pediatric intern in the inpatient and emergency department settings wereevaluated during the COVID-19 pandemic, fromMarch to June 2020, as compared with these 3months in 2019. Patient encounters by diagnosis were also evaluated.

RESULTS: The median number of patient encounters per intern per 2-week block declined on thepediatric hospital medicine service (37.5 vs 27.0; P< .001) and intensive care step-down unit (29.0 vs18.8; P = .004) during the pandemic. No significant difference in emergency department encounters wasobserved (63.0 vs 40.5; P = .06). The median number of shifts worked per intern per 2-week block alsodecreased on the pediatric hospital medicine service (10.5 vs 9.5, P< .001). Across all settings, there weremore encounters for screening for infectious disease and fewer encounters for respiratory illnesses.

CONCLUSIONS: Pediatric interns at the onset of the COVID-19 pandemic were exposed to fewerpatients and had reduced clinical schedules. Careful consideration is needed to track and supplementmissed clinical experiences during the pandemic.

www.hospitalpediatrics.orgDOI:https://doi.org/10.1542/hpeds.2021-005899Copyright © 2021 by the American Academy of Pediatrics

Address correspondence to Alexandra T. Geanacopoulos, Department of Pediatrics, Boston Children’s Hospital, 300 Longwood Ave, Boston,MA 02115. E-mail: [email protected]

HOSPITAL PEDIATRICS (ISSN Numbers: Print, 2154-1663; Online, 2154-1671).

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

FUNDING: Dr Michelson received funding through award 1K08HS026503 from the Agency for Healthcare Research and Quality. Thefunder/sponsor did not participate in the work. Funded by the National Institutes of Health (NIH).

POTENTIAL CONFLICT OF INTEREST: The authors have no conflicts of interest relevant to this article to disclose.

Drs Geanacopoulos and Winn conceptualized and designed the study, collected data, conducted the data analyses, drafted the initialmanuscript, reviewed and revised the manuscript, and had full access to all the data in the study and take responsibility for theintegrity of the data and the accuracy of the data analysis; Dr Sundheim contributed to the design of the study, drafted the initialmanuscript, and reviewed and revised the manuscript; Ms Greco contributed to the design of the study, conducted the data analyses,and reviewed and revised the manuscript; Dr Michelson contributed to the design of the study, contributed to the data analysis, andreviewed and revised the manuscript; Dr Parsons contributed to the design of the study and reviewed and revised the manuscript; DrHron contributed to the design of the study, collected data, conducted the data analyses, and reviewed and revised the manuscript;and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

COMPANION PAPER: A companion to this article can be found online at www.hosppeds.org/cgi/doi/10.1542/hpeds.2021-005970.

A B S T R A C T

dDivision of GeneralPediatrics, aDepartment

of Pediatrics andbInstitutional Centers forClinical and TranslationalResearch andcDivision of

Emergency Medicine,Boston Children’sHospital, Boston,Massachusetts

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In the setting of social distancingmeasures during the coronavirus disease2019 (COVID-19) pandemic, pediatrichospitals have reported lower pediatricpatient volumes across hospitalsettings.1–5 In response to these changesand in an effort to minimize residentexposure, residency programs havealtered resident schedules.6,7 We sought toevaluate the impact of the COVID-19pandemic on pediatric interns’ exposureto different types and care settings ofpediatric diseases, at the onset of thepandemic and amid the initial surge. Wehypothesized that pediatric internsevaluated fewer patients and thesepatients had a different spectrum ofdisease during the COVID-19 pandemic.

METHODSStudy Design and Setting

We performed a retrospective cohort study ata freestanding children’s hospital of patientscared for by pediatric interns from a singlelarge pediatric residency program. The studyhospital’s institutional review board approvedthe study protocol. At the study hospital,interns rotate through the pediatric hospitalmedicine (PHM) service, an ICU step-downservice, and emergency department (ED).8

These rotations were selected because theyrepresent common settings through whichpediatric residents across the countrytypically rotate during the intern year. At theonset of the pandemic, in response toperceived reductions in patient volumes andin an effort to minimize infectious risks, ourresidency program reduced intern clinicalschedules. Shift length was not adjustedduring the study period. Patient encountersfrom other affiliating hospitals where internsalso rotate were excluded from the analysis,given their storage in different datawarehouses that were not available for dataextraction.

Patient Population

We queried the enterprise data warehouse atthe study institution and identified patientsand the pediatric interns who cared for themduring the initial peak of the COVID-19pandemic (March through June 2020) at thestudy location, as compared with Marchthrough June 2019. We included patient

encounters in the hospital’s ED and inpatientsetting, including the PHM and ICU step-downservices. We included patient encounters inwhich an intern either wrote a note in the EDor wrote a note or placed an order in theinpatient setting. Patients for whom internswrote orders during daily rounds werecounted toward patient exposures, with therationale that interns had the opportunity tolearn about these patients. For the inpatientsetting, a patient encounter may span multipledays, so documentation of a note or order onany day was counted as a single patientencounter exposure.

Study Outcomes

We evaluated the number of patientencounters per pediatric intern per 2-weekblock and per shift and number of shifts perintern per 2-week block. Shifts worked weredetermined by using the residency program’sonline scheduling platform. InternationalClassification of Diseases, 10th Revision,Clinical Modification, codes were collected forall patient encounters. We converted theseInternational Classification of Diseases, 10thRevision, Clinical Modification, codes into asmaller group of clinically meaningfulcategories using the Clinical ClassificationsSoftware Refined (CCSR) database, developedby the Agency for Healthcare Research andQuality.9 We then evaluated the number ofpatient encounters with a given CCSR codeseen per pediatric intern per 2-week block inthe inpatient and ED settings.

Data Analyses

Categorical descriptive statistics wereused to summarize patient and encountercharacteristics. Continuous variables weresummarized by using median andinterquartile range (IQR). Wilcoxon ranktests (for continuous data) and 2-samplePoisson tests (for incidence data, such asencounters per intern block) wereperformed to compare the differences inprimary outcomes between 2019 and 2020.

RESULTS

The median patient encounters per internper two-week block declined by 28.0% onthe PHM service (37.5 [IQR: 36.0–43.0] vs 27.0[IQR: 22.0–36.0]; P < .001) and 35.5% on the

ICU step-down service (29.0 [IQR: 21.5–35.0]vs 18.75 [IQR: 14.0–22.0]; P = .004) duringthe pandemic, as compared with the yearprevious ( F1Fig 1A). The median patientencounters per intern per 2-week blockwere not significantly different before versusduring the pandemic in the ED (63.0 [IQR:57.0–71.0] vs 40.5 [IQR: 32.0–57.0]; P = .06;Fig 1A). The median number of patientencounters per intern per shift declined inthe ED (6.7 [IQR: 6.3–7.1] vs 4.5 [IQR: 3.2–5.7];P = .04) and ICU step-down service (2.7 [IQR:2.0-3.5] vs 1.8 [IQR: 1.6–2.2]; P = .03),whereas encounters per shift were notsignificantly different for interns on the PHMservice during the pandemic (3.5 [IQR:3.3–4.2] vs 3.3 [IQR: 2.7–3.9]; P = .13; Fig 1B).Importantly, the number of shifts workedper intern per 2-week block was significantlyless during the pandemic on the PHMservice, whereas there was no significantdifference observed in the ED and the ICUstep-down service (Fig 1C).

The mean number of patient encounters perpediatric intern with a given diagnosis iscompared before versus during the pandemicin F2Fig 2. In the inpatient and ED settings, therewas an increase in mean encounters perintern per 2-week block for the CCSR code,“exposure, encounters, screening or contactwith infectious disease.” On the PHM service,the average intern saw 80% fewer patientswith acute bronchitis during the pandemic(Fig 2B), and reductions in encounters forrespiratory illnesses were observed across all3 settings. In the ED, there was also a 55%decrease in mean encounters per intern forabdominal pain (Fig 2A).

DISCUSSION

During the COVID-19 pandemic, pediatricinterns at a large pediatric residencyprogram were exposed to fewer patientsand worked fewer shifts in the inpatient andED settings. Our findings are supported byseveral recent studies revealing reducedpediatric patient volumes across settingsnationwide.4,5,10–15 We observed declines inencounters for respiratory illnesses insupport of other recent studies documentingsimilar trends.10,11 Although there have beenfew published studies in which researchersdocument the impact of COVID-19 onresident patient exposure, 1 study of an

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emergency medicine residency in Taiwanrevealed that ED residents saw less thanone-half the typical patient volume.16

Although our study is reflective of a singleresidency program’s experience early on inthe pandemic, declines in pediatric patient

census have been documented nationwide.Similarly, residency programs in otherspecialties have reported on reduced clinicalschedules.7,17 Therefore, it is likely thatpediatric interns across the country sawsignificantly fewer pediatric patients andworked reduced shifts on pediatric clinicalservices during the early COVID-19 pandemic.

These changes have heightened concernsamong residency program leadership andtrainees about whether reduced patientexposure may impact clinical competency.7,18

In a study of radiology residents in whichresearchers assessed the impact of exposureon performance, residents who interpretedmore radiographic films had improvedperformance, as measured by accuracy oftheir diagnostic reads.19 In 2 other studies inwhich researchers evaluated family medicineand internal medicine residents, residents whosaw more patients scored higher on in-training examinations.20,21–23 Given thisassociation between exposure andcompetency, it is, therefore, important forresidency programs to consider trackingresident-level patient exposures during thepandemic. It is also important to recognizethat concerns about competency may impactintern confidence in medical decision-making,particularly as they gain additional autonomyat the end of intern year. Acknowledging theseconcerns and addressing gaps in the clinicalexperience may alleviate this anxiety andprovide interns with the tools to feel moreconfident and comfortable in their decision-making.

Throughout the pandemic, residencyprograms in specialties across thecountry have developed innovativestrategies to augment resident clinicexperience. Radiology and surgicalprograms have developed simulations tomimic regular workdays for residents.6,24

In our program, we developed a virtualwork from home option for residents withheightened individual or family healthrisks.25 Although these strategies do notreplace in-person clinical interactions,virtual learning and patient care playfundamental roles in advancing residenttraining while also minimizing infectiousrisks.

FIGURE 1 Box and whisker plot of patient encounters per intern per 2-week block (A), patient en-counters per intern per shift (B), and shifts worked per intern per 2-week block (C) in theED, PHM, and ICU step-down settings before versus during the COVID-19 pandemic.

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Our study has several important limitations.Our findings represent a single residencyprogram’s experience during a 3-month periodat the onset of the pandemic and amid asurge of cases within the community and,therefore, may not be generalizable to allinstitutions. However, given documentation ofwidespread reductions in pediatric patient

volumes during the pandemic, pediatricresidency programs across the country likelyexperienced similar trends. We were alsounable to assess intern patient exposureduring rotations outside the main studyhospital that provided important additionaltraining opportunities that were not quantifiedin this study. The next steps include evaluating

intern’s clinical exposure through the2020–2021 academic year as the pandemichas progressed and, also, assessing nationaltrends outside of our single institution.

In a large pediatric residency program, theonset of the COVID-19 pandemic wasassociated with reductions in overall clinicalexposure to patients and the breadth of

FIGURE 2 Encounters associated with common CCSR codes before versus during the COVID-19 pandemic for the ED (A), PHM (B), and ICU step-down(C) settings. Values are reported as mean encounters by CCSR code per intern per 2-week block. Common CCSR codes were identified by us-ing the top 10 CCSR codes by setting for both the prepandemic and pandemic cohorts. *P< .05, the statistically significant difference be-tween the prepandemic and pandemic cohorts.

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pediatric disease. We identified adisproportionate decrease in patientexposures for respiratory and abdominalsymptoms, common complaints that are keycomplaints for pediatrics residents to gainexperience diagnosing and managing. If theCOVID-19 pandemic or future pandemicscontinue to negatively impact pediatricpatient volumes, it will be important forresidency programs to track intern patientexposures and assess whether reducedvolumes impact competency and theattainment of professional milestones duringtraining. In addition, identifying reductions inpatient exposures by specific setting ordisease processes, as we have done in thisstudy, would allow programs to developtargeted interventions through simulation orvirtual teaching curricula to supplement theclinical experience.

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DOI: 10.1542/hpeds.2021-005899 originally published online April 16, 2021; 2021;11;e106Hospital Pediatrics 

Michelson, Chase R. Parsons, Jonathan D. Hron and Ariel S. WinnAlexandra T. Geanacopoulos, Kathryn M. Sundheim, Kimberly F. Greco, Kenneth A.

Pediatric Intern Clinical Exposure During the COVID-19 Pandemic

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Michelson, Chase R. Parsons, Jonathan D. Hron and Ariel S. WinnAlexandra T. Geanacopoulos, Kathryn M. Sundheim, Kimberly F. Greco, Kenneth A.

Pediatric Intern Clinical Exposure During the COVID-19 Pandemic

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