Pediatric Intern Clinical Exposure During the COVID-19 Pandemic

We performed a retrospective cohort study at a freestanding children’s hospital of patients cared for by pediatric interns from a single large pediatric residency program. The study hospital’s institutional review board approved the study protocol. At the study hospital, interns rotate through the pediatric hospital medicine (PHM) service, an ICU step-down service, and emergency department (ED).⁸  These rotations were selected because they represent common settings through which pediatric residents across the country typically rotate during the intern year. At the onset of the pandemic, in response to perceived reductions in patient volumes and in an effort to minimize infectious risks, our residency program reduced intern clinical schedules. Shift length was not adjusted during the study period. Patient encounters from other affiliating hospitals where interns also rotate were excluded from the analysis, given their storage in different data warehouses that were not available for data extraction.

We queried the enterprise data warehouse at the study institution and identified patients and the pediatric interns who cared for them during the initial peak of the COVID-19 pandemic (March through June 2020) at the study location, as compared with March through June 2019. We included patient encounters in the hospital’s ED and inpatient setting, including the PHM and ICU step-down services. We included patient encounters in which an intern either wrote a note in the ED or wrote a note or placed an order in the inpatient setting. Patients for whom interns wrote orders during daily rounds were counted toward patient exposures, with the rationale that interns had the opportunity to learn about these patients. For the inpatient setting, a patient encounter may span multiple days, so documentation of a note or order on any day was counted as a single patient encounter exposure.

We evaluated the number of patient encounters per pediatric intern per 2-week block and per shift and number of shifts per intern per 2-week block. Shifts worked were determined by using the residency program’s online scheduling platform. International Classification of Diseases, 10th Revision, Clinical Modification, codes were collected for all patient encounters. We converted these International Classification of Diseases, 10th Revision, Clinical Modification, codes into a smaller group of clinically meaningful categories using the Clinical Classifications Software Refined (CCSR) database, developed by the Agency for Healthcare Research and Quality.⁹  We then evaluated the number of patient encounters with a given CCSR code seen per pediatric intern per 2-week block in the inpatient and ED settings.

Categorical descriptive statistics were used to summarize patient and encounter characteristics. Continuous variables were summarized by using median and interquartile range (IQR). Wilcoxon rank tests (for continuous data) and 2-sample Poisson tests (for incidence data, such as encounters per intern block) were performed to compare the differences in primary outcomes between 2019 and 2020.

The median patient encounters per intern per two-week block declined by 28.0% on the 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) during the pandemic, as compared with the year previous (Fig 1A). The median patient encounters per intern per 2-week block were not significantly different before versus during 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 patient encounters per intern per shift declined in the 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 not significantly different for interns on the PHM service 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 worked per intern per 2-week block was significantly less during the pandemic on the PHM service, whereas there was no significant difference observed in the ED and the ICU step-down service (Fig 1C).

The mean number of patient encounters per pediatric intern with a given diagnosis is compared before versus during the pandemic in Fig 2. In the inpatient and ED settings, there was an increase in mean encounters per intern per 2-week block for the CCSR code, “exposure, encounters, screening or contact with infectious disease.” On the PHM service, the average intern saw 80% fewer patients with acute bronchitis during the pandemic (Fig 2B), and reductions in encounters for respiratory illnesses were observed across all 3 settings. In the ED, there was also a 55% decrease in mean encounters per intern for abdominal pain (Fig 2A).

During the COVID-19 pandemic, pediatric interns at a large pediatric residency program were exposed to fewer patients and worked fewer shifts in the inpatient and ED settings. Our findings are supported by several recent studies revealing reduced pediatric patient volumes across settings nationwide.^4,5,10–15  We observed declines in encounters for respiratory illnesses in support of other recent studies documenting similar trends.^10,11  Although there have been few published studies in which researchers document the impact of COVID-19 on resident patient exposure, 1 study of an emergency medicine residency in Taiwan revealed that ED residents saw less than one-half the typical patient volume.¹⁶  Although our study is reflective of a single residency program’s experience early on in the pandemic, declines in pediatric patient census have been documented nationwide. Similarly, residency programs in other specialties have reported on reduced clinical schedules.^7,17  Therefore, it is likely that pediatric interns across the country saw significantly fewer pediatric patients and worked reduced shifts on pediatric clinical services during the early COVID-19 pandemic.

These changes have heightened concerns among residency program leadership and trainees about whether reduced patient exposure may impact clinical competency.^7,18  In a study of radiology residents in which researchers assessed the impact of exposure on performance, residents who interpreted more radiographic films had improved performance, as measured by accuracy of their diagnostic reads.¹⁹  In 2 other studies in which researchers evaluated family medicine and internal medicine residents, residents who saw more patients scored higher on in-training examinations.^20,21–23  Given this association between exposure and competency, it is, therefore, important for residency programs to consider tracking resident-level patient exposures during the pandemic. It is also important to recognize that concerns about competency may impact intern confidence in medical decision-making, particularly as they gain additional autonomy at the end of intern year. Acknowledging these concerns and addressing gaps in the clinical experience may alleviate this anxiety and provide interns with the tools to feel more confident and comfortable in their decision-making.

Throughout the pandemic, residency programs in specialties across the country have developed innovative strategies to augment resident clinic experience. Radiology and surgical programs have developed simulations to mimic regular workdays for residents.^6,24  In our program, we developed a virtual work from home option for residents with heightened individual or family health risks.²⁵  Although these strategies do not replace in-person clinical interactions, virtual learning and patient care play fundamental roles in advancing resident training while also minimizing infectious risks.

Our study has several important limitations. Our findings represent a single residency program’s experience during a 3-month period at the onset of the pandemic and amid a surge of cases within the community and, therefore, may not be generalizable to all institutions. However, given documentation of widespread reductions in pediatric patient volumes during the pandemic, pediatric residency programs across the country likely experienced similar trends. We were also unable to assess intern patient exposure during rotations outside the main study hospital that provided important additional training opportunities that were not quantified in this study. The next steps include evaluating intern’s clinical exposure through the 2020–2021 academic year as the pandemic has progressed and, also, assessing national trends outside of our single institution.

In a large pediatric residency program, the onset of the COVID-19 pandemic was associated with reductions in overall clinical exposure to patients and the breadth of pediatric disease. We identified a disproportionate decrease in patient exposures for respiratory and abdominal symptoms, common complaints that are key complaints for pediatrics residents to gain experience diagnosing and managing. If the COVID-19 pandemic or future pandemics continue to negatively impact pediatric patient volumes, it will be important for residency programs to track intern patient exposures and assess whether reduced volumes impact competency and the attainment of professional milestones during training. In addition, identifying reductions in patient exposures by specific setting or disease processes, as we have done in this study, would allow programs to develop targeted interventions through simulation or virtual teaching curricula to supplement the clinical experience.