GI fellowship in the time of COVID-19: Moving forward

The COVID-19 pandemic has affected essentially all aspects of our lives. Doctors in training are especially vulnerable from it as we are one of the many frontliners in this time. We will always be remembered as the COVID-19 pandemic batch. We were caught off guard with the coming of the pandemic early this year, and it came like a deluge that swept everything it reached, including our personal and professional lives. Definitely, one will not consider this as the perfect time to undergo fellowship training. However, given this unique setting, we face it positively with various opportunities to move forward. It is not a matter of being left with no choice but, rather, choosing what is the best for everyone. Herein, we share some thoughts and perspectives regarding the impact of the pandemic on our training as gastroenterologists, and how we cope and adapt with it. As gastrointestinal (GI) practice is shifting gears and adopting new strategies to overcome the challenges, we provide an outline of the different measures we GI fellows can observe as we continue in our training (Table 1).

Table 1.

Challenges in GI fellowship training during the COVID-19 pandemic.

Training activity	Challenges	Strategies and solutions
Inpatient rounds	- Protocols mandating limited patient contact and exposure- Safety of both patient and physician from potential viral transmission- Limited PPE resources- Decrease in patient census	- Focused and quick patient rounds- Group practice scheme with the consultants divided into teams (e.g. 1 fellow, 2 consultants per day doing rounds) to limit exposure and preserve PPE resources- Virtual discussion of fellows (e.g. admitting conference) regarding difficult inpatient cases
Outpatient consults	- Cancelled outpatient clinics- Some patients need ‘face-to-face’ consults and physical examination	- Telemedicine consults for non-urgent cases- Traditional ‘face-to-face’ consults with appropriate PPE if necessary- Outpatients needing urgent endoscopic procedure should undergo appropriate screening and clearance prior to procedure
Endoscopic procedures	- Limited involvement of fellows during procedures- Limited PPE resources- Postponement of nonurgent procedures (e.g. screening endoscopies)- Unable to reach required census of endoscopic procedures	- Didactics on endoscopic procedures using virtual format (e.g. videos, images)- Live streaming or recording of endoscopic procedures for viewing of fellows- Virtual endoscopy conferences facilitated by different local and international GI societies- Regular sessions using endoscopic simulators and models- COVID screening done on patients could also serve as triage if fellows can assist in the procedure (e.g. if with negative result)
Didactics and conferences	- Cancellation of department conferences and didactics	- Continue department conferences virtually- Make a monthly schedule and attend GI webinars facilitated by different local and international GI societies- Maximize social media resources
Research	- Clinical trials requiring patients put on hold temporarily- Limited access to research facilities	- Conduct other types of research which can be done at home (e.g. meta-analysis, reviews)- Remote access to database and charts- Submit completed researches for publication- Encourage to do COVID-related researches

In our country, the Philippines, GI inpatient, outpatient and endoscopy cases were immediately on a downward trend at the beginning of the outbreak. We felt the impact starting to trickle early this year. As time went by, the trickles turned into waves, and so are the patients who came in positive for the coronavirus infection. As many healthcare workers become infected as well, hospital manpower became marginal. Within the next few days, our responsibilities broadened. We assumed internist duties, such as manning the frontline, and took our gastroenterology posts on a skeletal force. We put down our endoscopes and we relearned to operate our mechanical ventilators and interpret arterial blood gases. As the pandemic hit the world with great magnitude, this scenario became a common picture among healthcare workers and different medical specialties.¹ With the growing pressure, we moved forward, adopting best practices, adhering to the ever-changing guidelines, and devising ways to limit exposure while maximizing the use of our depleting resources.

From the perspective of gastroenterology, the pandemic had specific impacts regarding staff and patient safety resulting in postponement of non-urgent clinical and endoscopic services.² As GI endoscopy is considered to be a risk for viral transmission, elective endoscopic procedures were postponed.³ A higher threshold for performing endoscopic procedures was adopted.⁴ Furthermore, endoscopy performed by GI fellows was suspended in most institutions.⁵ Trainees were discouraged from performing or assisting in endoscopic procedures in order to shorten procedure time, limit exposure, and preserve personal protective equipment (PPE) resources. This declining number of endoscopic procedures performed by fellows had a great impact on our training. In our country, the overall reduction in endoscopic procedures has been the primary concern of all 59 fellows. Supplementary programs, such as simulation-based learning and virtual endoscopy mentoring, could be arranged so that fellows could achieve sufficient competency. A study in Australia showed that 45% of GI trainees were in favour of additional ‘catch-up’ endoscopy training, while 36% favoured an extended training duration due to the limited access to endoscopy.⁶

Given the disruption of the usual learning activities of GI fellows, an issue that could emerge with this kind of set-up is burnout.⁷ Compounding concerns on high job demands, protection from the virus and self-isolation periods from families have led to occupational stress and burnout. These should not be ignored as it could possibly lead to inferior patient outcomes.⁸ A recent study of 770 trainees from 63 countries has also shown that 52% were anxious over prolongation of training and lack of availability of institutional support for emotional health, while 19% felt burnt out.⁵ Aside from educational support, emotional support strategies should also be provided.

During the times we are off duty, our opportunity to learn continues. From our books and scopes, we shifted to virtual learning. Multidisciplinary conferences, scientific lectures and journal clubs were hosted on different digital platforms.⁹ Social media has served as a unique avenue on intellectual discourses.⁴ Our local GI societies and institutes have primarily served at the forefront providing impactful educational opportunities. Major and highly anticipated international conferences were shifted to virtual formats and became more reachable to us. We were able to join the larger GI community by participating in different sponsored webinars as far afield as Europe and the Americas, where world-class endoscopy experts led trainee education. Indeed, the internet has made distance learning possible and we found ourselves meeting foreign GI fellows in different online courses. We embraced a technology-driven future and it has been an enriching experience.

Opportunities to do research had also widened. While non-COVID-related clinical trials had been put aside and access to research facilities had been limited, we were able to allocate more time towards other types of research such as doing systematic analysis or reviews on COVID-related topics. Research repositories and registries that link COVID-19 and digestive diseases became widely available for our use.¹⁰ Survey studies, database research and chart reviews can also be done remotely.⁹ In addition, fellows can engage in different online courses offered in evidence-based medicine and statistical methodology to acquire new research skills. As data changes every day, so does the chance to share knowledge and best practices to other parts of the world.

As we move forward into uncharted territories, may we be reminded to always choose to adapt and evolve. As GI fellows, we may have been deluged and it may be seen as a loss, but these unprecedented challenges can actually bring out the best in us. It is up to us to respond by constantly striving to progress and think out of the box. While we are not able to do the traditional routines during our training, we can still grow uniquely as we take hold of the fact that, 10–20 years from now, we will always be remembered as the GI fellows of the pandemic generation – the creative, innovative and resilient gastroenterologists.

Authorship

All authors reviewed the literature, provided the analysis, and drafted the manuscript. All authors read and approved the final manuscript.

Conflict of Interest

None declared.

ORCID iD

Enrik John T. Aguila https://orcid.org/0000-0003-3440-2406