The objective of EM residency training is to enhance residents’ knowledge and breadth of clinical experience. Specifically, the primary goal of EM residency training programs is to ensure that residents gain the required clinical experience to master the knowledge and clinical skills necessary to practice EM.(12) Case exposure based on seeing a variety of patients with varying acuity levels, chief complaints, and diagnoses is crucial for the development of comprehensive experience.(13–15) Our study demonstrated that the decrease in ED volume caused by the COVID-19 pandemic significantly affected the case exposure of EM residents. Inadequate clinical exposure may hinder residents in attaining clinical competency and experiencing core EM diagnoses.(16) The adequate patient volume recommended for EM residency training is unknown; nevertheless, previous studies have reported that 15,000 annual ED visits to a training hospital and 1.1–1.4 PPH on average for trainees are reasonable.(14, 17, 18) The PPH for residents in the AED decreased significantly during the pandemic period relative to that during the prepandemic period. However, if the pandemic persists, the long-term effect of the change in patient volume on resident training is unknown. Although the ED volume was lower during the pandemic period, the severity of illness in patients visiting the ED did not increase significantly as expected. Training in the management of critically ill patients is essential for emergency physicians, and the training would be affected by the number of patients seen during the pandemic period.(19) Accordingly, a monitoring system for assessing residents’ case exposure regularly is necessary during the COVID-19 pandemic.(13)
Our study revealed that the pediatric patient volume was most affected during the pandemic period. The volume of patients seen by residents during the pandemic period was less than half of that observed during the prepandemic period. The acuity level of patients remained unchanged during the pandemic period. Fear of having COVID-19 or getting infected by the virus in the hospital could be a reason for parents not bringing their children to the hospitals. The importance of pediatric training in EM residency programs has been mentioned in previous reports, but the sufficiency level of training is inconclusive.(16, 20, 21) Previous surveys have revealed that EM faculties perceived that they were less prepared to manage pediatric patients than they were for managing adult patients.(22) Decreased pediatric case exposure in EM training during the pandemic period could exacerbate the issue of insufficient pediatric training of EM residents. Revising the EM training course to increase pediatric training time should be considered if the reduction in pediatric patient volume persists; however, such an adjustment may affect other portions of EM residency training programs. Ancillary methods, such as web-based learning and high-fidelity simulation, may help toward pediatric EM training during the pandemic period.(23–26)
The volume of trauma patients also dropped during the pandemic period in our study. Possible reasons for this drop are people’s reduced frequency of leaving the house because of fear of COVID-19 and quarantining of high-risk groups. A decrease in trauma patient volume reduces the number of emergency surgical procedures performed by residents and reduces residents’ experience in managing trauma patients, which can lead to poor educational outcomes of traumatology training.(27) Although the magnitude of decrease in trauma patient volume was not as high as that observed for the volume of pediatric patients, close observation and evaluation by senior doctors are necessary to ensure that traumatology training is sufficient for EM residents.
At the time of writing, the COVID-19 pandemic continues to be a global health crisis. Reduced ED volumes are continuing to be noted in hospitals worldwide. Our study may serve to remind EM educators to evaluate their resident training programs during the pandemic. Along with addressing the pandemic and handling the surge of respiratory tract infection cases, regular EM residency training with other EM core diagnoses should be considered. Adjusting training programs and adding ancillary training methods may be necessary to ensure adequate training for EM residents.
Limitations
This study has several limitations. First, because our study was retrospective, some bias may have existed. Second, our study was limited to three hospitals in a single country; hence, it may not be representative to situations in other hospitals worldwide. The effect of the COVID-19 pandemic may vary in different countries; additional data from other countries are thus required to further evaluate EM education during the COVID-19 pandemic in other countries. Third, our study mainly focused on the role of clinical exposure in EM residency training. Although case exposure cannot be replaced by other ancillary methods, it is not the only measure of EM residency training. Our study did not assess educational outcomes between the prepandemic and pandemic periods and did not investigate the effect of the reduced level of case exposure during the pandemic on residents’ learning. Further research is necessary to compare the two periods with respect to other indicators to derive a complete assessment of residents’ clinical training and performance.