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 Table of Contents  
RAPID COMMUNICATION
Year : 2020  |  Volume : 3  |  Issue : 4  |  Page : 131-136

Impact of the COVID-19 pandemic on European residency training programs in Physical and Rehabilitation Medicine: The point of -view of the International Society Of Physical and Rehabilitation Medicine World Youth Forum task force


1 Deputy Coordinator of the International Society of Physical and Rehabilitation Medicine World Youth Forum Task Force; Chief Coordination of the Italian Society of Physical and Rehabilitative Medicine (SIMFER) Residents Section; Department of Health Sciences, University of Eastern Piedmont “A. Avogadro”; Rehabilitation Unit, “Mons. L. Novarese” Hospital, Moncrivello, Vercelli, Italy, Rehabilitation Unit, “Mons. L. Novarese” Hospital, Moncrivello, Vercelli, Italy
2 Chief Coordinator of the International Society of Physical and Rehabilitation Medicine World Youth Forum Task Force; Department of Physical Medicine and Rehabilitation, University of Miami, Miami, FL, USA
3 Department of Anatomy, Histology, Forensic Medicine and Orthopedics, Sapienza University, Rome, Italy
4 Department of Physical Medicine and Rehabilitation, Hospital Garcia de Orta, Almada, Portugal
5 Department of Rehabilitation Medicine, Coordination Centre for Rehabilitation Research, Hannover Medical School, DE-30625 Hannover, Germany
6 Department of Neurorehabilitation, Lille University Hospital, F-59037 Lille, France
7 Department of Rehabilitation and Sports Medicine, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
8 Immediate Past-President of the International Society of Physical and Rehabilitation Medicine; Department of Physical Medicine, Rehabilitation, and Sports Medicine, University of Puerto Rico School of Medicine, San Juan, Puerto Rico
9 President-Elect of the International Society of Physical and Rehabilitation Medicine; Department of Mental and Physical Health and Preventive Medicine, University of Campania “Luigi Vanvitelli,” Napoli, Italy

Date of Submission22-May-2020
Date of Decision03-Jul-2020
Date of Acceptance08-Jul-2020
Date of Web Publication09-Oct-2020

Correspondence Address:
Dr. Alessandro de Sire
Physical and Rehabilitative Medicine, Department of Health Sciences, University of Eastern Piedmont, Novara, Italy. Viale Piazza D'Armi 1, 28100, Novara
Italy
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jisprm.jisprm_22_20

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  Abstract 


Coronavirus disease 2019 (COVID-19) has been declared a global public health emergency. The demand for services has altered the organization of medical services resulting in significant changes that have altered dramatically the education of residents in various medical specialties including physical and rehabilitation medicine. In this rapid communication, we summarize the impact of COVID-19 on residency training programs in five European countries. Open interviews were conducted with Country Ambassadors of the International Society of Physical and Rehabilitation Medicine World Youth Forum. The most common changes were closing of rehabilitation units and outpatient clinics, redeployment of residents to acute care services, and the increase use of technology for patient care and educational purposes.

Keywords: COVID-19, International Society of Physical and Rehabilitation Medicine World Youth Forum, physical and rehabilitation medicine resident education


How to cite this article:
Sire Ad, Poudel MK, Agostini F, Freitas MM, Ranker A, Rosselin C, Sobotová K, Frontera WR, Gimigliano F. Impact of the COVID-19 pandemic on European residency training programs in Physical and Rehabilitation Medicine: The point of -view of the International Society Of Physical and Rehabilitation Medicine World Youth Forum task force. J Int Soc Phys Rehabil Med 2020;3:131-6

How to cite this URL:
Sire Ad, Poudel MK, Agostini F, Freitas MM, Ranker A, Rosselin C, Sobotová K, Frontera WR, Gimigliano F. Impact of the COVID-19 pandemic on European residency training programs in Physical and Rehabilitation Medicine: The point of -view of the International Society Of Physical and Rehabilitation Medicine World Youth Forum task force. J Int Soc Phys Rehabil Med [serial online] 2020 [cited 2020 Dec 3];3:131-6. Available from: https://www.jisprm.org/text.asp?2020/3/4/131/297640




  Introduction Top


The large number of patients with coronavirus disease 2019 (COVID-19) in many countries has resulted in a significant demand for health services for this population. In the early stages of the pandemic, this has been particularly true for the intensive and hospital-based level of care.[1],[2] Further, the government-mandated lockdown in many countries has reduced the access of patients to rehabilitation units and outpatient clinics.[3] As a result, the educational and training experiences in many residency training programs, including physical and rehabilitation medicine (PRM), have changed.

Due to of the above fact, the International Society of Physical and Rehabilitation Medicine (ISPRM) World Youth Forum Task Force (ISPRM-WYF) asked several country ambassadors in Europe to report on their individual national situations and on the effects of the pandemic on their PRM training programs including the educational activities and clinical rehabilitation services that are part of the training programs.

In this rapid communication, we intend to briefly summarize the experiences in five European countries during the pandemic and suggest ways to deal with the COVID-19 pandemic and/or other future crises.


  International Society of Physical and Rehabilitation Medicine World Youth Forum Task Force Top


The ISPRM has recently acknowledged the role of youth in PRM (early-career physiatrists, residents, and aspirant medical students), the future of PRM worldwide, with the creation of a youth task force. On May 12, 2019, three young PRM physicians founded the ISPRM-WYF under the supervision of Walter R. Frontera (ISPRM President at the time) and Francesca Gimigliano (ISPRM Vice-President at the time) who supported and encouraged the young members of the society to promote the ISPRM's mission and objectives. During the ISPRM 2019 World Congress held in Kobe, Japan, the ISPRM-WYF was officially introduced to the participants from all over the world by Manoj K. Poudel and Alessandro de Sire who were elected as Chief and Deputy Coordinator of the ISPRM-WYF, respectively. The first action of the ISPRM-WYF was to enroll one representative (Country Ambassador) from each nation member of ISPRM for all the geographical areas in ISPRM (Americas; Europe, Eastern Mediterranean, and Africa; Asia-Oceania). An important objective of the ISPRM-WYF is to foster the participation in ISPRM of those who are still in training and to help strengthen educational experiences for this group of future leaders. Due to the above fact, it is important to understand the impact of COVID-19 on this younger generation of PRM physicians.


  Impact of Covid-19 on Health Care in Europe Top


The disease

On January 30, 2020, the World Health Organization (WHO) declared the new COVID-19, a novel infectious disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a public health emergency of international concern. On March 13, 2020, the WHO considered Europe as the active center of the 2019–2020 coronavirus pandemic. On March 17, 2020, all countries within Europe had at least one confirmed case of COVID-19, with Montenegro being the last European country to report their first case. The number of cases by country across Europe has doubled over periods of approximately 3–4 days, with some countries (mostly those at earlier stages of detection) showing a doubling of cases every 2 days.[4] At the moment of this writing (July 2, 2020), the total number of diagnosed cases in the world exceeds 10 million including more than 500,000 deaths; in Europe, a total of 2,442,760 cases have been reported, including 192,993 deaths.[5]

The most common symptoms of COVID-19 are fever, fatigue, and dry cough, followed by headache, nasal congestion, sore throat, myalgia, and arthralgia.[6] In 10%–20% of cases, the respiratory injury evolves into an acute respiratory distress syndrome, which can lead to respiratory failure, and is associated with prolonged hospital stay, high morbidity, and mortality.[7]

SARS-CoV-2 infection not only involves the lungs but also involves the cardiovascular system (severe primary cardiovascular lesions, vasculitis, microthrombi), hematopoietic system (reduced spleen, with bleeding and focal necrosis), liver (degenerated hepatocytes), and kidneys (degeneration of epithelial tubules).[8],[9] Central and peripheral nervous system involvement has also been reported, with neuronal degeneration (hyperemia and edema) of the cerebral parenchyma, altered consciousness or neuropsychological manifestations, dysgeusia, hyposmia, and possibly, the appearance of postinfectious myopathies and neuropathies, such as Guillain–Barré syndrome.[10],[11]

To date, two distinct phases of SARS-CoV-2 syndrome have been identified: The first acute phase is characterized by a prevalent respiratory syndrome, while in the second one, together with the progressive recovery of the respiratory disease, prolonged bed rest syndrome and invasive mechanical ventilation sequelae have been reported.[12],[13],[14]

It is clear from this brief clinical description that many individuals with COVID-19 have significant impairments and a large number may result in chronic issues requiring extensive post-acute care and rehabilitation.

Health systems during the pandemic

The COVID-19 pandemic has dramatically transformed the organization and functioning of public and private health systems in all European countries. The rapid spread of the virus has significantly impacted all hospital organizations, including rehabilitation units. Indeed, in many countries, the number of patients in the intensive care units (ICUs) alone has surpassed the actual capacity of the National Health Systems. This situation has forced hospitals to increase the number of intensive care beds and to convert some inpatients beds, including beds assigned to rehabilitation and other specialties, into COVID-19 wards. Therefore, PRM specialists had to quickly respond to the need to admit post-acute patients from acute care units by discharging all those who were not in urgent need for rehabilitation.[15]

The need for rehabilitation

It follows from the above that the proportion of patients with COVID-19-related disability is predicted to rapidly grow. Thus, a larger response from PRM specialists is crucial to attend to the needs of patients from the acute to the chronic phase of this condition. An active and well-organized rehabilitation strategy will allow the acute hospitals to take care of more patients in acute stages of the disease and to formulate adequate guidelines for outpatient and home-based rehabilitation.[1],[2]

There is a need all over the world to provide health professionals with timely information on the rehabilitation of individuals with disabilities secondary to COVID-19 infection. Thus, a series of systematic living rapid reviews of the rehabilitation needs that are associated with COVID-19 is now being published.[16],[17],[18] The following important steps have also been taken: (1) publication of the first epidemiological data on the incidence of neurological sequelae in patients hospitalized with COVID-19; (2) development of rapid guidelines on the management of chronically disabled patients during COVID-19 pandemic; (3) dissemination of notes to provide early respiratory rehabilitation and telerehabilitation for COVID-19 patients in the acute and postacute phase, respectively; and (4) development of adequate careful neurological monitoring protocols that take into account the risk of a long-lasting disability.


  Country-Specific Effects of Covid-19 on Physical and Rehabilitation Medicine Residency Training Programs Top


In the context of the current situation in Europe described above, the education programs for PRM residents underwent significant changes and adaptations.[19] To understand the consequences of the pandemic on the training of residents in various health systems, we asked the five European Country Ambassadors representing Italy, Portugal, Germany, France, and the Czech Republic to briefly report by e-mail on the situation in their countries from the point of view of residents and to describe how the COVID-19 pandemic altered their educational activities and clinical duties.

To provide some context, we have described in [Table 1] the number of PRM training programs, PRM residents, and duration of the training in these five countries. We have also briefly summarized in [Table 2] the main characteristics of the organization of rehabilitation services and the role of PRM residents in the five European countries mentioned above during the pandemic. The following is a descriptive narrative provided by the resident ambassadors.
Table 1: Estimated number of Physical and Rehabilitation Medicine residents and residency training programs in the five European countries surveyed in the present study

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Table 2: Main characteristics of the organization of rehabilitation services and the role of Physical and Rehabilitation Medicine residents in the five European countries in the study during the Coronavirus Disease 2019 pandemic

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In Italy, the training of PRM residents is performed not only in the University Hospitals but also in rehabilitation units (there is variability among universities) located throughout the national territory. Each PRM school (residency training program) can count on a regional network of rehabilitation units. In addition, residents have the chance to spend part of their training outside of this network in another Italian region or abroad. Due to the pandemic, clinical rotations in some of these units were no longer possible and the collaboration agreements between some rehabilitation units and universities were put on hold. This interruption resulted from the suspension of some of the rehabilitation activities, the national lockdown, and the need to reduce the number of people in direct contact with patients. Due to this, many residents were sent back to their university, and as a consequence, the workload for each resident was reduced. In some cases, PRM residents in their last year of residency were re-assigned to special COVID-19 units for patients affected by the pandemic. It is important to note that educational activities of the PRM residents continued with professors using online interactive technologies (i.e., Skype, Microsoft Teams, or Google classrooms).

In Portugal, one of the challenges was the heterogeneity of decisions made by individual hospitals. Some PRM residents continued their regular and standard training, while others had their scheduled rotations canceled. All hospitals had to face the reorganization of their teams and create a contingency plan to be able to safely treat both COVID-19 and non-COVID-19 patients. Some departments faced a lack of human resources because of the demands to take care of COVID-19 patients. More specifically, some residents were reassigned to emergency departments and COVID-19 test centers. In some hospitals, PRM residents received specific education and training in ICU rehabilitation and respiratory rehabilitation. In other hospitals, the residents continued their clinical practice in rehabilitation centers and hospitals without COVD-19 cases. All the outpatient rehabilitation services were suspended and replaced with telemedicine. However, participation in educational activities was highly encouraged, and webinars and national guidelines were available for all residents. Finally, the PRM national congress was postponed for October 2020.

In Germany, due to the federal system with 16 states, the organization and characteristics of the residency training programs vary among different states and institutions. In other words, under normal circumstances, there is no standard and official rotation plan for PRM residents for the 5 years of training. The residents can themselves organize clinical rotations to learn surgical skills (one year) and medical knowledge in internal medicine, neurology, or anesthesiology (one year). During the pandemic, PRM residents were assigned to work as assistants to other specialists in various departments (particularly, internal medicine, orthopedics, and neurological rehabilitation units). Furthermore, educational opportunities were limited, all national congresses scheduled for 2020 were canceled including the national congress of the German PRM National Society, and the spring school for residents organized by the German Youth Forum for PRM was postponed for 2021. Other educational activities such as webinars were used to replace this type of educational meeting or activity.

In France, the first three cases of COVID-19 were reported on January 24 and the lockdown was implemented by the government on March 17. Patients in rehabilitation units were discharged if they were in stable conditions to admit COVID-19 patients. Moreover, some outpatient treatments, such as botulinum toxin injections for adult and pediatric populations, were reorganized and only urgent patients were scheduled for injections. Some coma units were assigned to admit postacute COVID-19 patients with neurological conditions. PRM residents were asked to work in COVID-19 units to make their contribution together with residents in other specialties. All resident rotations were canceled during the period of March to the end of May and restarted on June 1, 2020. International training opportunities which are a regular part of residency training in France were canceled. Finally, all educational lectures were also canceled and all research projects were suspended.

In the Czech Republic, individual hospitals made different decisions regarding residency training and there was no national standard plan used by all residency training programs to cancel rescheduled or reorganized educational activities. Some clinical rotations ran on a normal and regular schedule. Lectures and examinationss were delayed for 1 month during the pandemic. Considering the heterogeneity in the National Health System and the fact that decisions regarding residency rotations depended on individual hospitals, it may be too early to understand the real impact of the pandemic and actions taken by the health system on the education of PRM residents. Corrective actions may be implemented if needed.


  Conclusions Top


This brief report summarized the point of view of European ISPRM-WYF Country Ambassadors, describing the impact of COVID-19 pandemic on residency training programs in their countries. These observations demonstrate the heterogeneity of the impact and responses to the pandemic and may also reflect the differences among countries in health systems and educational approaches.

In this context, we believe that the ISPRM-WYF should focus on the following key actions:

  1. Recommend corrective actions to make up for the cancellations of PRM-specific clinical rotations
  2. Distribute educational material via the ISPRM website and Journal on the core PRM topics to maintain and increase the level of training during the COVID-19 era or any other similar situation
  3. Organize webinars with experts to compensate for the cancellation of some educational activities (Note: The first ISPRM webinar was held on May 8, 2020, and addressed the different needs of PRM residents in three countries, Italy, Brazil, and the United States during the pandemic, 452 persons from 78 different countries attended)
  4. Encourage research studies, including international collaborations, on related topics and particularly focusing on respiratory rehabilitation in individuals with COVID-19 at different stages of the disease and in different health-care settings (inpatient, outpatient, and home based).


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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