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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 4  |  Issue : 3  |  Page : 119-124

Impact of COVID-19 pandemic on medical rehabilitation training and education in Asia, eastern mediterranean, and oceania


1 International Society of Physical and Rehabilitation Medicine, World Youth Forum Task Force; Department of Rehabilitation, Royal Melbourne Hospital; Australian Rehabilitation Research Centre, Royal Melbourne Hospital, Parkville, Victoria, Australia
2 International Society of Physical and Rehabilitation Medicine, World Youth Forum Task Force, Parkville, Victoria, Australia; Department of Physical Medicine and Rehabilitation, University of Miami/Jackson Health System, Miami, Florida, USA
3 International Society of Physical and Rehabilitation Medicine, World Youth Forum Task Force, Parkville, Victoria, Australia; Department of Medical and Surgical Sciences, University of Catanzaro “Magna Graecia”, Catanzaro, Italy
4 International Society of Physical and Rehabilitation Medicine, World Youth Forum Task Force, Parkville, Victoria, Australia; Institute of Physical and Rehabilitation Medicine, Dow University of Health Sciences, Karachi, Sindh, Pakistan
5 International Society of Physical and Rehabilitation Medicine, World Youth Forum Task Force, Parkville, Victoria, Australia; Royal Jordanian Rehabilitation Center, Royal Jordanian Medical Service, Amman, Jordan
6 International Society of Physical and Rehabilitation Medicine, World Youth Forum Task Force, Parkville, Victoria, Australia; Department of Physical Medicine and Rehabilitation, St. Luke's Medical Center, Quezon City, Philippines
7 International Society of Physical and Rehabilitation Medicine, World Youth Forum Task Force, Parkville, Victoria, Australia; Rehabilitation Medicine Unit, Department of Orthopaedics and Traumatology, Hospital Canselor Tuanku Muhriz, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
8 International Society of Physical and Rehabilitation Medicine, World Youth Forum Task Force, Parkville, Victoria, Australia; Department of Rehabilitation, Counties Manukau District Health Board, Auckland, New Zealand
9 International Society of Physical and Rehabilitation Medicine, World Youth Forum Task Force, Parkville, Victoria, Australia; Department of Physical Medicine and Rehabilitation, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
10 International Society of Physical and Rehabilitation Medicine, World Youth Forum Task Force, Parkville, Victoria, Australia; Department of Physical Medicine and Rehabilitation, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
11 International Society of Physical and Rehabilitation Medicine, World Youth Forum Task Force, Parkville, Victoria; Department of Rehabilitation, Mackay Hospital and Health Service, Queensland, Australia
12 International Society of Physical and Rehabilitation Medicine, World Youth Forum Task Force, Parkville, Victoria, Australia; Department of Physical Medicine and Rehabilitation, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh; Department of Physical Medicine and Rehabilitation, Spinal Injury Rehabilitation Centre, Sanga, Nepal
13 International Society of Physical and Rehabilitation Medicine, World Youth Forum Task Force, Parkville, Victoria, Australia; Armed Forces Institute of Rehabilitation Medicine, Rawalpindi, Punjab, Pakistan
14 International Society of Physical and Rehabilitation Medicine, World Youth Forum Task Force, Parkville, Victoria, Australia; Department of Rehabilitation, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
15 International Society of Physical and Rehabilitation Medicine, World Youth Forum Task Force, Parkville, Victoria, Australia; Division of Neurology, Department of Medicine, National University Hospital, Singapore
16 Department of Physical Medicine, Rehabilitation, and Sports Medicine, University of Puerto Rico School of Medicine, San Juan, Puerto Rico
17 Division of Rehabilitation, Department of Medicine, Tung Wah Hospital, Hong Kong

Date of Submission07-Oct-2020
Date of Decision02-Dec-2020
Date of Acceptance28-Dec-2020
Date of Web Publication01-Jun-2021

Correspondence Address:
Su Yi Lee
Department of Rehabilitation Medicine, Royal Melbourne Hospital, 34-54 Poplar Road Parkville, Victoria 3052
Australia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JISPRM-000119

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  Abstract 


Background: The Coronavirus Disease 2019 (COVID-19) pandemic has adversely impacted the Physical and Rehabilitation Medicine (PRM) residency training program in many countries. Aims and Objectives: To describe and analyse the issues and challenges faced by PRM trainees in Asia, Eastern Mediterranean and Oceania, and to discuss strategies to encounter the training and educational challenges amidst the pandemic. Materials and Methods: A cross-sectional survey was completed by Country Ambassadors of the International Society of Physical and Rehabilitation Medicine (ISPRM) World Youth Forum Task Force, to assess the COVID-19 impact on PRM trainees across Asia, Eastern Mediterranean, and Oceania. Results: Participants reported issues including training program disruption, limited practical skills training, examination postponement, negative psychological consequences, PRM service delivery restructuring, and deployment to acute services. Conclusion: The COVID-19 pandemic has variably impacted PRM residency training programs in the countries. The role of National Societies, training programs, and ISPRM is crucial to support trainees during the pandemic.

Keywords: Coronavirus disease 2019, education, pandemic, rehabilitation, training


How to cite this article:
Lee SY, Poudel MK, de Sire A, Al Arabia DH, Alomari AM, Mendoza-Genato A, Yuliawiratman BS, Adair DL, Is EE, Khan II, Lewis J, Gurung JB, Noor MB, Farhoud S, Jong SC, Frontera WR, Li LS. Impact of COVID-19 pandemic on medical rehabilitation training and education in Asia, eastern mediterranean, and oceania. J Int Soc Phys Rehabil Med 2021;4:119-24

How to cite this URL:
Lee SY, Poudel MK, de Sire A, Al Arabia DH, Alomari AM, Mendoza-Genato A, Yuliawiratman BS, Adair DL, Is EE, Khan II, Lewis J, Gurung JB, Noor MB, Farhoud S, Jong SC, Frontera WR, Li LS. Impact of COVID-19 pandemic on medical rehabilitation training and education in Asia, eastern mediterranean, and oceania. J Int Soc Phys Rehabil Med [serial online] 2021 [cited 2021 Oct 24];4:119-24. Available from: https://www.jisprm.org/text.asp?2021/4/3/119/317388




  Introduction Top


Since the declaration of the novel coronavirus disease 2019 (COVID-19) global pandemic by the World Health Organization (WHO) on March 12, 2020,[1],[2] the number of infected human cases and death toll as a result of COVID-19 continue to rise worldwide.[3] Clinical manifestations of COVID-19 include acute respiratory symptoms, myalgia, fatigue with characteristic laboratory findings, and lung abnormalities on computed tomography.[4] Some studies have also described neurological manifestations; skeletal, muscle, cardiac, liver, and kidney damage; as well as psychological disorders such as depression, anxiety, hallucinations, and delusions.[1],[4],[5],[6],[7],[8] The spectrum of disease severity is wide, ranging from asymptomatic or mild cases (80%) to critical, requiring life support and ventilation (5%).[1],[4],[5]

As of October 3, 2020, the number of infected cases was more than 34 million in 188 countries and more than one million deaths globally.[3] In Asia, India has the most infected cases, recording a total of 6,473,544 cases and 100,842 deaths. This is followed by Iran (464,596 cases; 26,567 deaths), Indonesia (295,499 cases; 10,972 deaths), Turkey (321,512 cases; 8325 deaths), Pakistan (313,984 cases; 6507 deaths), Philippines (319,330 cases; 5678 deaths), Bangladesh (366,383 cases; 5678 cases), etc.[3] In Australia and New Zealand (NZ), the total number of recorded infected cases was 27,121 and 1849, and the death toll stood at 893 and 25.[3] Since the COVID-19 outbreak, many challenges were faced by global healthcare systems and emergency services, and affected countries were imposed with huge socioeconomic burden, with strict travel and social distancing restrictions in place to prevent worsening spread of the disease.[9]

As a result of the overwhelming amount of infected cases and medical complications resulting from COVID-19, rehabilitation becomes especially important for the management of postintensive care unit deconditioning and critical illness myopathy and cardiac, respiratory, neurological, and/or musculoskeletal impairments.[1],[5],[8] As the need for acute hospital beds rise due to an expected increased infected cases, rehabilitation may become less of a priority to meet the demands of acute management of patients with COVID-19.[1],[7],[8],[10] However, acute rehabilitation is still crucial for patients admitted to hospital to prevent complications from prolonged immobilization and respiratory and neurological sequelae of infection.[5],[11] Regardless, trained medical rehabilitation professionals are necessary in the management of patients who are still recovering or recovered from COVID-19 from a rehabilitation perspective.[1],[8],[12],[13]

It is especially important for physical and rehabilitation medicine (PRM) physicians, especially those who are in their early career or still in training programs to continue developing their clinical and patient management skills amid this pandemic. Training in PRM should still be prioritized, despite the multiple challenges set by the pandemic. In this context, the present study aims to describe and analyze the issues and challenges faced by PRM trainees in Asia, Eastern Mediterranean, and Oceania and to discuss strategies to encounter the training and educational challenges amid the pandemic.


  Methods Top


Study design

This investigation was a cross-sectional, individual perspective study using a survey.

Participants and settings

The study was conducted under the auspices of the International Society of Physical and Rehabilitation Medicine (ISPRM). A survey was designed to investigate the impact of COVID-19 pandemic on PRM education and training programs. The survey was distributed via e-mail by the ISPRM World Youth Forum Task Force (ISPRM-WYF) to Country Ambassadors of Asia, Eastern Mediterranean, and Oceania of the ISPRM-WYF. Demographic information was obtained from the ISPRM databases.

Data collection and analysis

The survey was designed to provide cross-sectional assessment of PRM training and education in various countries across Asia, Eastern Mediterranean, and Oceania. The contents of the survey included 15 questions [Appendix 1] about demographics, history of PRM and formation of National Societies in respective countries, impact of COVID-19 on PRM trainees in regard to in-hospital training, fellowship examinations, mental health, and challenges faced. The submitted surveys were scrutinized and analyzed individually, and the common issues and challenges faced by PRM trainees were identified.


  Results Top


The survey was sent to 12 Country Ambassadors of Asia, Eastern Mediterranean, and Oceania, and 11 responded [Table 1].
Table 1: Impact of Coronavirus Disease 2019 on physical and rehabilitation medicine training and education in various countries

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Country-specific status of physical and rehabilitation medicine trainees during the pandemic

Saudi Arabia

The 4-year PRM residency training program in Saudi Arabia has a total number of training positions between 33 and 35 each year. As of October 3, 2020, the total number of COVID-19 cases was 335,578, and the death toll recorded at 4823.[3] Inpatient rehabilitation wards were partially converted to general medicine ward. Some PRM trainees were deployed to COVID-19 care medical teams, and several trainees who were exposed to high-risk environment were infected with COVID-19. Elective surgeries/procedures were cancelled as well. Telehealth was used for outpatient rehabilitation appointments to ensure social distancing. With the reduction of exposure to onsite rehabilitation patients, procedural practice and clinical exposure were affected as well. Video webinars were held instead of face-to-face tutorials or lectures. Furthermore, all PRM elective specialty rotations were cancelled for the year. PRM licensing examinations will most likely be conducted via virtual means, and the final decisions will be made by the National Board of Examinations. Psychological supports were provided by relevant hospitals and head of services.

Pakistan

PRM was first introduced in Pakistan in 1961 and the National Society of Pakistan (Pakistan Society of Physical Medicine and Rehabilitation) was founded in 2012. To date, there are 70 PRM physicians in Pakistan; 24 trainees are currently enrolled in the PRM postgraduate training program in six accredited training institutes across the country. PRM residency/training first commenced in July 1997. The training program duration is 4 years, with an average of 4–6 new PRM trainees each year. Following the pandemic, rehabilitation management was shifted to outpatient/telehealth services. PRM trainees have only been managing a smaller population of inpatient cases. Multidisciplinary team meetings were discontinued. Some PRM trainees were deployed to the emergency departments to provide medical care to COVID-19 patients. Besides that, interventional pain and spasticity management procedures and electrodiagnostic procedures in the outpatient settings were significantly reduced. Some training institutions were partially repurposed into inpatient COVID-19 services. In addition, lectures are being conducted virtually. On the positive note, the PRM licensing examinations were not affected. However, clinical examinations were replaced with task-oriented assessment of clinical skills and viva voce examinations. Despite the above challenges, with several PRM trainees contracting the virus, trainees have actively participated in the management of patients with COVID-19 and those with rehabilitation needs, as well as continuing their education and training in PRM.

Singapore

There are two residency programs (3-year program) in Singapore with approximately eight training positions each year. As October 3, 2020, the total number of infected cases was 57,798 and a death toll of 27.[3] Following the COVID-19 pandemic, outpatient attendances dropped significantly. However, with the low numbers of new infected cases, rehabilitation clinics were reinstated gradually. Similar to other countries, PRM trainees were deployed to acute COVID-19 wards. Teaching and interhospital rotations were cancelled, and virtual/self-learning became the new normal. Licensing examinations were delayed and examination structures were altered. Despite the challenges above, there were great supports from seniors and supervisors.

Malaysia

PRM was first introduced in Malaysia in 1991, and the residency training program commenced in 1997. The National Society (Malaysian Association of Rehabilitation Physicians) was founded in 2011. Currently, there are approximately 100 PRM physicians in the country. There is only one training program (4 years) with training positions between 8 and 10 per year. As of October 3, 2020, Malaysia recorded 11,771 infected cases and 136 deaths.[3] Due to the pandemic, outpatient rehabilitation clinics were significantly affected, and telehealth was offered to some patients. Most outpatient rehabilitation therapies were suspended as well. In addition, interventional procedures were undertaken with additional precautions (e.g., screening, personal protective equipment [PPE], limited contact time). Several inpatient rehabilitation services were suspended or temporarily relocated to non-COVID hospitals. PRM licensing examinations were deferred for 6 months. Fifty percent of PRM trainees were deployed to acute services. Moreover, tutorials were converted to online-based learning. Some trainees expressed loss of motivation to work due to future uncertainties. Other challenges included inability to complete research projects, limited hands-on skills, and potential impact on training scholarship, which may incur financial burden on trainees if longer training years was required.

Bangladesh

PRM first started in Bangladesh in 1961. There are 155 PRM physicians in the country. The residency training program (5-year program) commenced in 2010. Following the COVID-19 pandemic, the health system was overwhelmed due to increased numbers of infected cases and limited availability of PPE and pathology laboratories for diagnostic purposes. More than 2000 healthcare workers were given new appointments in public hospitals and temporary hospitals were built to accommodate for healthcare demands. PRM services were provided mainly via telehealth. Following easing of restrictions in June 2020, therapeutic interventions/procedures were conducted only for highly selective cases, with additional safety precautions in place. From a PRM training perspective, licensing examinations were deferred to a later stage. Regular training examinations were conducted via an online system. PRM academic activities were also greatly affected, in particular, bedside teachings, interactive didactic lectures, and presentations. Academic activities were conducted in virtual environment as well. The pandemic has impacted the mental health of PRM trainees. Other challenges include limited rehabilitation resources to accommodate for COVID-19 patients who require rehabilitation and the huge burden/extended duty hours of trainees and healthcare workers amid the pandemic.

Turkey

In Turkey, PRM started in 1927 and the National Society of PRM was formed in 1958. To date, there are approximately 3250 PRM physicians. The PRM residency program commenced in 1945. Currently, there are eighty 4-year training programs, with 160 training positions each year. Since the first confirmed COVID-19 case in Turkey on March 11, 2020, university hospitals were converted into pandemic hospitals, and huge number of residents/trainees (91.2%) deployed to COVID-19 services.[14] As of October 3, the recorded number of cases was 321,512; however, this figure may not represent the true number of infected cases in Turkey.[3] Outpatient and inpatient rehabilitation services were significantly affected until the normalization process in June 2020, where clinics and inpatient units were working with less patients according to new enhanced safety restrictions. PRM licensing examinations were postponed to a later stage. Academic lectures and conferences commenced again via an online-based system in May 2020. Out of 91 residents who participated in a national online survey, 75.8% very severely affected in the 1st month of pandemic in terms of the level of training programs which they received.[14] Residents also had to adapt to providing healthcare for COVID-19 patients, which can be physically and emotionally exhausting. In addition, progression of research projects and write-up of thesis were interrupted due to the pandemic.

Jordan

The PRM residency program in Jordan commenced in 1970. The Jordanian Society of PRM was first established in 1984. There are three 4-year PRM residency programs. To date, there are 140 PRM physicians in Jordan. As of October 3, 2020, there were 13,650 recorded infected cases and 79 deaths due to COVID-19. Outpatient and inpatient rehabilitation services were affected due to the surge in COVID-19 cases in September 2020, only urgent and acute rehabilitation cases were admitted to inpatient services. PRM trainees noted a negative impact on training and education with reduced numbers of patients in the rehabilitation service. Licensing examinations were still held with social distancing and use of PPE. Virtual lectures were conducted for continual education. Furthermore, PRM trainees reported some levels of anxiety with the limited COVID-19 testing resources and risk of exposure to the virus.

Nepal

The Nepalese Association of Physical Medicine and Rehabilitation was formed in 2016. However, there are currently no official residency programs due to the limited number of PRM physicians. As of October 3, 2020, there were 82,450 recorded infected cases and 520 deaths as a result of COVID-19.[3] Following the pandemic, the healthcare system was overwhelmed with infected patients admitted to hospitals, leading to longer shifts for healthcare workers. Telerehabilitation was utilized and proven effective for patients with disability to access healthcare services, especially in setting of movement limitations due to the lockdown imposed by the government and the difficult terrains in Nepal. In August 2020, the only dedicated Spinal Cord Injury Rehabilitation Centre in the country had an outbreak of COVID-19 and was converted into an isolation center for 2 weeks. Due to workforce shortages, even COVID-19–positive healthcare workers (including residents) volunteered to work in managing infected patients. Licensing examinations were postponed due to safety concerns. Lectures and presentations were conducted via an online-based system/virtual learning. Furthermore, the mental health of healthcare workers and trainees was impacted due to personal safety concerns, longer working hours, and uncertainties about training and examination processes.

Philippines

PRM in the Philippines and its residency training program were established in the 1971. The Philippine Academy of Rehabilitation Medicine, the PRM national society in the country, was founded in 1974. To date, there are 369 active PRM physicians with 75 residents in training from six accredited institutions (3-year program). The number of training slots each year ranges from 2 to 12. In compliance with the implementation of enhanced community quarantine, outpatient and inpatient services, as well as most of residency-related activities, were halted from March to April 2020. Face-to-face activities in some institutions gradually resumed in May 2020 following strict infection control measures. Many training hospitals resorted to telerehabilitation as early as April 2020. However, most in-patient referrals were still restricted to non-COVID patients. Virtual didactics, videoconferences, and examinations recommenced in June 2020, which were conducted through online platforms, and supplemented by webinar series. Both written and oral examinations were postponed until further notice; however, the PMR residency duration in the Philippines will not be extended.

Australia and New Zealand

In 1976, rehabilitation medicine was first recognized as a specialty. In 1980, the first National Society of Australia and NZ was formed (1980 - Australasian Faculty of Rehabilitation Medicine; 2019 - Rehabilitation Medicine Society of Australia and NZ). To date, there are more than 678 PRM physicians across Australia and NZ. The training program duration varies from 4 to 8 years. There are approximately 210 training positions in Australia and eight training positions in NZ each year. Due to the pandemic, restructuring of many subacute rehabilitation hospitals and cancellation of elective surgeries were performed to accommodate for the increased demands of COVID-19 management. In states with huge spikes of infected cases (Victoria), rehabilitation wards were converted to COVID-19 wards and trainees were deployed to COVID-19 services. Majority of on-site outpatient rehabilitation clinics (including procedural clinics) were converted to telehealth to enforce social distancing. Community-based rehabilitation programs and group therapy had to be rescheduled or postponed. Other potential challenges were conversion of regular PRM tutorials and education to online-based learning, which may limit the trainee's access to practical hands-on skills, and completion of research projects for fulfillment of training requirements. PRM licensing examinations had to be postponed to the following year, which could also mean that final-year trainees were unable to progress through their training and into their careers as physicians. With the above challenges amid the pandemic and the increased workload of rehabilitation physicians and trainees, plus the increased vulnerability of frontline doctors to mental health issues reported, considerations on the mental health and psychological aspects of rehabilitation trainees are crucial at this stage and should be addressed and managed accordingly.


  Discussion Top


This cross-sectional survey demonstrated the negative impact of COVID-19 on the PRM residency training programs in several countries in Asia, Eastern Mediterranean, and Oceania. Overall, the issues and challenges reported by PRM trainees were very similar in all countries listed in this study: disruption of academic activities and training program, limited/lack of hands-on PRM-related practical and procedural skills training, postponement of licensing examinations, and emotional turmoil among trainees regarding future uncertainties of their training program and career. Other challenges included restructuring of PRM service delivery, reduction in numbers of outpatient and inpatient rehabilitation services, utilization of telehealth for medical consultations, and deployment of trainees to acute COVID-19 services. These challenges were very similar to those reported by the PRM residency programs of Europe and the Americas.[15],[16]

Residency training and education is a priority even during these difficult times. The disruption in the PRM training program can have an adverse impact on individual trainees, the PRM specialty, rehabilitation services, and the healthcare system as a whole. Fair treatment should be given to trainees absent from training due to the impact of COVID-19. It should be a priority of those responsible for the programs to ensure adequate supervision and necessary support to maintain a healthy PRM and rehabilitation workforce. National societies or national training programs could provide additional support to trainees by introducing webinars, resources, or workshops, to prepare trainees in the management of patients with COVID-19 in a rehabilitation environment. For example, an e-learning course (https://study.unimelb.edu.au/find/short-courses/neurological-rehabilitation-elearning/) on neurological rehabilitation, introduced by PRM clinicians is currently available on-line via the University of Melbourne, subsidized and catered for developing countries. Most importantly, mental health and well-being support services should be accessible to all trainees if required.

The ISPRM can play a crucial role in providing up-to-date resources on COVID-19 rehabilitation management. In collaboration between the ISPRM-WYF and the ISPRM Education Committee, the ISPRM Webinar Series on the global situation of PRM during the COVID-19 pandemic was held to provide insights into the impacts of COVID-19 on the rehabilitation medicine specialty and to address issues encountered by young PRM physicians and trainees in their training and career.[15],[17] Regional meetings for Country Ambassadors of the ISPRM-WYF were also held to discuss issues and challenges encountered by PRM trainees during the COVID-19 pandemic and encourage knowledge sharing and dissemination among PRM trainees across different countries.

The COVID-19 pandemic has variably impacted PRM residency training programs in the countries included in this study. This survey not only serves as an efficient way of assessing training and education challenges of PRM trainees during a pandemic, but also the outcome of the survey prepares PRM trainees for similar situations in the future. Further, it encourages trainees to consider the various adaptations in care delivery that may be needed during times of crisis, as well as in the learning and teaching activities. Further research should also be conducted to provide up-to-date information and evidence-based medicine in the rehabilitation management of patients recovering/recovered from COVID-19 and formulate guidelines for conducting interventional, diagnostic, and therapeutic rehabilitation procedures safely during the pandemic era, thus minimizing the risk of infective transmission. These resources can be used as future guides for physicians and trainees to ensure that the best treatment is provided to patients with COVID-19 to promote optimal functional outcome and quality of life.

Acknowledgment

This study was supported from internal resources of the ISPRM-WYF. We would like to thank all Country Ambassadors of the World Youth Forum (Asia-Oceania Region) for your contribution in this review.

Financial support and sponsorship

This study was supported from internal resources of the ISPRM-WYF.

Conflicts of interest

There are no conflicts of interest.


  Appendix Top


Appendix 1: Survey Questions: Impact of COVID-19 on Physical and Rehabilitation Medicine training and education

  1. Name of country
  2. Name of Country Ambassador
  3. Date of commencement of Physical and Rehabilitation Medicine (PRM) specialty in your country
  4. Date of formation of National Society of PRM in your country
  5. Total number of PRM physicians in your country
  6. Date of PRM residency commencement in your country
  7. Total number of residency program and available training positions in your country each year
  8. Total number of years to complete PRM training in your country
  9. Total number of COVID cases and deaths (to-date) in your country
  10. How did COVID-19 affect PRM residency in your country? (outpatient rehabilitation service and procedures)
  11. How did COVID-19 affect PRM residency in your country? (inpatient rehabilitation service)
  12. How did COVID-19 affect PRM residency in your country? (lectures and conferences)
  13. How is the overall mental health of PRM trainees during this pandemic?
  14. Will the PRM residency program be prolonged due to the COVID-19 pandemic?
  15. What are the challenges faced by residents in your country during this pandemic?




 
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