On January 30, 2020, the World Health Organization announced the 2019-nCoV epidemic a health international emergency, naming the disease Coronavirus disease 2019 (COVID-19). Increasing number of COVID-19 cases quickly overloaded hospitals. Several rehabilitation wards admitted COVID-19 patients, leading to major changes in daily activities.1 With the aim of assessing pandemic impact during the first two critical months (March and April 2020) on work experience and training activities of residents of physical medicine and rehabilitation (PM&R), a nationwide online survey was sent to each Italian PM&R residency school. We stratified population according to geographical areas: zone 1 regions with >20,000 COVID-19 positive cases, zone 2 between 5000 and 20,000 cases and zone 3 <5000 cases (updated April 30, 2020). We asked subjects to evaluate differences between the period before COVID-19 pandemic (pre-COVID, until the end of February 2020) and during the pandemic (during-COVID, March and April 2020).
A total of 291 subjects (51.7%) of 563 Italian PM&R residents completed the survey, distributed as follows: 124 subjects in zone 1 (women 79, 63.7%); 114 in zone 2 (women 74, 64.9%); 53 in zone 3 (women 30, 56.6%). At the time of pandemic onset, most of residents (217, 74.6%) were working in public hospitals.
In the pre-COVID, residents worked mainly in orthopedics and neurology in the three zones (Q1) (Table I). Service type, during pre-COVID included outpatient activity for 197 subjects, in patients’ activities for 167 and in patients’ consultations for 113 residents (Q2) (Figure 1A).
Table I. —Clinical data.
| Variables | Overall | Zone 1 | Zone 2 | Zone 3 | |
|---|---|---|---|---|---|
| Q1‡ Pre-COVID internship | Muscular-skeletal | 133 (45.7) | 43 (34.7) | 56 (49.1) | 34 (64.2) |
| Neurologic | 108 (37.1) | 48 (38.7) | 45 (39.5) | 15 (28.3) | |
| Cardiac-respiratory | 4 (1.4) | 1 (0.8) | 2 (1.8) | 1 (1.9) | |
| Geriatric | 4 (1.4) | 3 (2.4) | 1 (0.9) | 0 (0) | |
| Oncologic | 1 (0.3) | 0 (0) | 0 (0) | 1 (1.9) | |
| Pediatrics | 9 (3.1) | 4 (3.2) | 5 (4.4) | 0 (0) | |
| Other | 32 (11) | 25 (20.2) | 5 (4.4) | 2 (3.8) | |
| Q2* Pre-COVID service | Out-patient activity | 253 (86.9) | 101 (39.9) | 90 (35.6) | 62 (24.5) |
| In-patients’ consultations | 113 (38.8) | 50 (44.2) | 37 (32.7) | 26 (23) | |
| In-patients | 167 (57.4) | 86 (51.5) | 58 (34.7) | 23 (13.8) | |
| Q3* During COVID service | Out-patient activity | 69 (23.7) | 22 (31.9) | 32 (46.4) | 15 (21.7) |
| In-patients’ consultations | 110 (37.8) | 44 (40) | 38 (34.5) | 28 (25.5) | |
| In-patients | 173 (59.9) | 84 (48.6) | 68 (39.3) | 21 (12.1) | |
| Q4‡ Increase in working hours | No | 235 (80.8) | 80 (64.5) | 103 (90.4) | 52 (98.1) |
| Yes | 56 (19.2) | 44 (35.5) | 11 (9.6) | 1 (1.9) | |
| Q5‡ Changes in work settings | No | 162 (55.7) | 58 (46.8) | 73 (64) | 31 (58.5) |
| Yes | 129 (44.3) | 66 (53.2) | 41 (36) | 22 (41.5) | |
| Q6‡ Changes in patients’ type | No | 74 (25.4) | 17 (13.7) | 29 (25.4) | 28 (52.8) |
| Yes | 217 (74.6) | 107 (86.3) | 85 (74.6) | 25 (47.2) | |
| Q7* Patients’ type | Postacute neurologic | 145 (49.8) | 76 (52.4) | 44 (30.3) | 25 (17.2) |
| Chronic neurologic | 59 (20.3) | 22 (37.3) | 23 (39) | 14 (23.7) | |
| Post traumatic orthopedic | 96 (33) | 38 (39.6) | 40 (41.7) | 18 (18.8) | |
| Elective orthopedic | 72 (24.7) | 22 (30.6) | 30 (41.7) | 20 (27.8) | |
| Cardiological | 45 (15.5) | 28 (62.2) | 12 (26.7) | 5 (11.1) | |
| Pneumological | 126 (43.3) | 79 (62.7) | 37 (29.4) | 10 (7.9) | |
| Q8* Type of service | Kept home | 71 (24.4) | 15 (21.1) | 45 (63.4) | 11 (15.5) |
| Rehabilitation COVID+ | 21 (7.2) | 13 (61.9) | 8 (38.1) | 0 (0.0) | |
| Rehabilitation COVID- | 35 (12.0) | 18 (51.4) | 13 (37.1) | 4 (11.4) | |
| Rehabilitation post COVID | 31 (10.7) | 17 (54.8) | 14 (45.2) | 0 (0.0) | |
| Acute COVID+ | 25 (8.6) | 14 (56.0) | 8 (32.0) | 0 (0.0) | |
| Non- rehabilitative pathologies | 25 (8.6) | 14 (56.0) | 10 (40.0) | 1 (4.0) | |
| External support COVID+ | 28 (9.6) | 18 (64.3) | 7 (25.0) | 3 (10.7) | |
| Q9‡ Post COVID-19 neuro-motor | No | 196 (67.4) | 65 (52.4) | 80 (70.2) | 51 (96.2) |
| Yes | 95 (32.6) | 59 (47.6) | 34 (29.8) | 2 (3.8) | |
Data are shown as total number of cases and percentage in brackets. ‡In case of single choice question percentages are reported in columns; *in case of multiple choices question, percentages are reported in rows.
Figure 1.
—A) Region distribution of type of service carried out before and during COVID; B) region distribution of type of patients mostly treated during the emergency. Graphics represent data that are normalized to the total number of single zone residents who participated in the survey.
Instead, during-COVID, we observed a significant decrease in outpatient activities in all three zones (P<0.005 in zone 1 and 2 and P<0.05 in zone 3) (Q3) while no significant differences were found for what concerns in-patients’ activities. Regarding weekly working hours during-COVID, most of PM&R residents did not report any increase (Q4). Instead, 56 subjects did report an increase and the majority of these were from zone 1, significantly more compared to zone 2 (P<0.0001) and zone 3 (P<0.005).
Following emergency onset, 162 subjects changed work settings (Q5), with significantly higher changes in zone 1 compared only to zone 2 (P<0.01). The majority of residents (74.6%) reported changes in patients’ type treated during-COVID (Q6), with a statistically significant increase for residents working in zone 1 with respect to zone 2 (P<0.05) and zone 3 (P<0.0001). There was a higher prevalence of subacute diseases, both neurological and orthopedic (Q7) (Figure 1B) and subjects treated also many patients with pneumological complications. Some residents changed also the type of service during the pandemic (Q8) and were reassigned to COVID-19-free rehabilitation departments, post-COVID-19 rehabilitation wards, external support of COVID Sub-Intensive Care Units (SICUs), COVID SICUs and COVID-positive rehabilitation departments. Interestingly, 71 residents were kept home during the pandemic period, mostly from zone 2.
Even more, around 32.6% of residents treated patients with neuro-motor complications (Q9) occurred after COVID-19, significantly more in zone 1 compared to zone 2 (P<0.005) and zone 3 (P<0.0001). Common complications included dysphagia, equilibrium and cognitive deficits, peripheral neuropathy, muscle hypotrophy and bed rest syndrome.
We investigated whether the program of professional activities for PM&R residents was affected by pandemic (Table II).
Table II. —Education data.
| Variables | Overall | Zone 1 | Zone 2 | Zone 3 | |
|---|---|---|---|---|---|
| Q1‡ Functional diagnostic | Not reduced | 4 (1.4) | 2 (1.6) | 1 (0.9) | 1 (1.9) |
| Not performed | 80 (27.5) | 38 (30.6) | 37 (32.5) | 5 (9.4) | |
| Partially reduced | 64 (22) | 24 (19.4) | 30 (26.3) | 10 (18.9) | |
| Completely reduced | 143 (49.1) | 60 (48.4) | 46 (40.4) | 37 (69.8) | |
| Q2‡ Psychometric measures | Not reduced | 51 (17.5) | 22 (17.7) | 21 (18.4) | 8 (15.1) |
| Not performed | 51 (17.5) | 30 (24.2) | 20 (17.5) | 1 (1.9) | |
| Partially reduced | 101 (34.7) | 43 (34.7) | 39 (34.2) | 19 (35.8) | |
| Completely reduced | 88 (30.2) | 29 (23.4) | 34 (29.8) | 25 (47.2) | |
| Q3‡ Biomedical diagnostic | Not reduced | 13 (4.5) | 6 (4.8) | 6 (5.3) | 1 (1.9) |
| Not performed | 57 (19.6) | 28 (22.6) | 25 (21.9) | 4 (7.5) | |
| Partially reduced | 110 (37.8) | 47 (37.9) | 44 (38.6) | 19 (35.8) | |
| Completely reduced | 111 (38.1) | 43 (34.7) | 39 (34.2) | 29 (54.7) | |
| Q4‡ Prostheses and daily living aids | Not reduced | 32 (11) | 13 (10.5) | 16 (14) | 3 (5.7) |
| Not performed | 50 (17.2) | 29 (23.4) | 20 (17.5) | 1 (1.9) | |
| Partially reduced | 141 (48.5) | 62 (50) | 50 (43.9) | 29 (54.7) | |
| Completely reduced | 68 (23.4) | 20 (16.1) | 28 (24.6) | 20 (37.7) | |
| Q5‡ Mini-invasive interventions | Not reduced | 8 (2.7) | 2 (1.6) | 5 (4.4) | 1 (1.9) |
| Not performed | 79 (27.1) | 40 (32.3) | 28 (24.6) | 11 (20.8) | |
| Partially reduced | 84 (28.9) | 35 (28.2) | 30 (26.3) | 19 (35.8) | |
| Completely reduced | 120 (41.2) | 47 (37.9) | 51 (44.7) | 22 (41.5) | |
| Q6* Didactic pre COVID | Frontal lessons | 253 (86.9) | 115 (45.5) | 96 (37.9) | 42 (16.6) |
| Journal club | 87 (29.9) | 44 (50.6) | 20 (23) | 23 (26.4) | |
| Online didactic material | 70 (24.1) | 24 (34.3) | 26 (37.1) | 20 (28.6) | |
| Suggested article/texts | 116 (39.9) | 35 (30.2) | 53 (45.7) | 28 (24.1) | |
| Webinar online | 22 (7.6) | 6 (27.3) | 3 (13.6) | 13 (59.1) | |
| Q7* Didactic during COVID | Frontal lessons | 15 (5.2) | 2 (13.3) | 4 (26.7) | 9 (60) |
| Journal club | 7 (2.4) | 0 (0) | 3 (42.9) | 4 (57.1) | |
| Online didactic material | 138 (47.4) | 52 (37.7) | 59 (42.8) | 27 (19.6) | |
| Suggested article/texts | 112 (38.5) | 24 (21.4) | 59 (52.7) | 29 (25.9) | |
| Webinar online | 224 (77) | 92 (41.1) | 94 (42) | 38 (17) | |
| Q8‡ Formative period | No | 83 (28.5) | 33 (26.6) | 28 (24.6) | 22 (41.5) |
| Yes | 208 (71.5) | 91 (73.4) | 86 (75.4) | 31 (58.5) | |
| Q9‡ Changes in PM&R activities | No | 49 (16.8) | 15 (12.1) | 22 (19.3) | 12 (22.6) |
| Yes | 242 (83.2) | 109 (87.9) | 92 (80.7) | 41 (77.4) | |
| Q10‡ New professionalizing activities | No | 28 (9.6) | 12 (9.7) | 12 (10.5) | 4 (7.5) |
| Not performed | 118 (40.5) | 43 (34.7) | 51 (44.7) | 24 (45.3) | |
| Yes, partially | 51 (17.5) | 22 (17.7) | 20 (17.5) | 9 (17) | |
| Yes, completely | 94 (32.3) | 47 (37.9) | 31 (27.2) | 16 (30.2) | |
| Q11‡ New skills | No | 24 (8.2) | 12 (9.7) | 6 (5.3) | 6 (11.3) |
| Yes | 267 (91.8) | 112 (90.3) | 108 (94.7) | 47 (88.7) | |
| Q12* New teachings | Online lessons | 226 (77.7) | 88 (38.9) | 95 (42) | 43 (19) |
| Tele-medicine | 160 (55) | 69 (43.1) | 63 (39.4) | 28 (17.5) | |
| Scientific collaborations | 118 (40.5) | 49 (41.5) | 48 (40.7) | 21 (17.8) | |
| Practical webinar | 198 (68) | 79 (39.9) | 84 (42.4) | 35 (17.7) | |
| No change | 24 (8.2) | 12 (50) | 6 (25) | 6 (25) | |
Data are shown as total number of cases and percentage in brackets. ‡In case of single choice question percentages are reported in columns; *in case of multiple choices question, percentages are reported in rows.
Important changes in residents’ activities were found with a decrease in functional diagnostic procedures such as gait analysis (Q1), in psychometric measures such as muscle and articular tests (Q2), in the execution of biomedical diagnostic procedures (Q3), in the prescription and testing of prostheses and daily living aids (Q4) and in mini-invasive interventions (Q5).
Regarding the educational activities and we evaluated specific changes pre-COVID and during COVID (Q6 and Q7), we observed a severe reduction in lectures and Journal Club (JC) meetings during the pandemic, the reading of texts and articles did not change pre- and during COVID while an important increase in online didactic material and webinars was observed.
Considering all changes occurred in education during-COVID (Q8), a high percentage of residents felt they received a different, but still valid, education, although Zone 3 residents felt they received a less valid education, significantly different compared to zone 1 (P<0.05). In terms of PM&R residency specific activities, the majority of residents reported important changes (Q9) during COVID. In fact, we observed the learning of new scheduled and non-scheduled activities and in some case the interruption of scheduled activities (either partial or complete).
During-COVID, residents learned also professionalizing activities not related to the PM&R program; half of them even felt these new capacities will be useful for their future job (Q10). Interestingly, almost all residents (Q11) agreed with the fact that during-COVID new ideas and teaching methodologies were born. Specifically, residents felt that telemedicine, online lessons and practical webinars were very useful, also in the future (Q12). Even more, almost half of residents agreed that during-COVID period new scientific collaborations aroused.
The COVID-19 pandemic has changed the Italian National Health Service, with a great impact on PM&R education. Indeed, data from our study demonstrate that zone 1 residents experienced an increase in working hours compared to those of zone 2 and zone 3, confirming that, in zone 1, hospitals required an increased support also from PM&R residents due to the high number of COVID-19 patients. We observed that about half residents changed activities during-COVID period, with a decrease in outpatient activities. Another interesting difference was noted in the change of patients’ type treated during-COVID. The percent increase of neurological and orthopedic subacute cases could be due to the fact that the Italian government stopped hospital admissions for chronic patients, in order to favor subacute cases. Another explanation of this phenomenon could be related to the fact that COVID-19 led to neurological complications,2 increasing intensive rehabilitation needs. Additionally, residents in zone 1 and zone 2 treated also patients with respiratory complications who needed rehabilitation, as described in literature.2-4 As expected, all professionalizing activities decreased in all zones during-COVID.
Regarding teaching, major changes were observed in all zones, since lectures were suspended and the majority of residents attended online classes, as reported by Escalon et al.5 in the USA; in Italy, this phenomenon occurred mostly in zone 1 and 2. Through these changes, all residents acquired new knowledge and expressed their wish to continue these teaching modalities also in future. Finally, a high percentage of residents (71.5%) reported acquisition of knowledge during-COVID not strictly related to the rehabilitation program, but useful for their future job. Taken together, our findings showed the profound impact of COVID-19 pandemic on Italian PM&R Resident Program.
References
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