Diagnostic and Interventional Radiology Case Volume and Education in the Age of Pandemics: Impact Analysis and Potential Future Directions

A Review of COVID-19's Impact on Radiology Residents' Academics and Wellness in North America

BACKGROUND

The COVID-19 pandemic caused major disruptions in radiology departments throughout North America. Radiology residency programs were forced to make dramatic changes to their training programs, which had major impacts on resident academics and wellness. The goal of this review is to evaluate the impact of COVID-19 on radiology residents' academics and wellness in North America, while also identifying effective measures taken by programs to mitigate the effects of the pandemic.

METHODS

The search strategy involved database search via PubMed, Embase, and Web of Science with specific key words related to COVID-19, radiology residents, education, wellness, and virtual learning. Studies discussing the education and wellness of radiology residents in North America published after 2020 were included. The data were analyzed using a narrative synthesis approach.

RESULTS

The three main domains affected by the pandemic include the residency curriculum, research, and resident wellness. The decline in case volume and diversity of cases had negative overall impact on education of radiology residents, but simulated cases and virtual learning proved its value during the pandemic and may have lasting implications for the postpandemic world. Research initiatives transitioned to a remote format with greater emphasis on quality improvement and COVID-19-related studies. Reduced face-to-face interaction opportunities made it difficult to establish strong and meaningful interpersonal connections and had a negative impact on resident wellness, mentorship, and professional development. Implementing mentorship programs and virtual "town hall meetings" were effective measures to maintain connections during times of social distancing. Finally, the COVID-19 pandemic introduced unprecedented stressors and challenges for radiology residents that negatively impacted their mental health and wellness. Incorporating wellness initiatives such as wellness hours and team-building activities and using social media were helpful in promoting wellness and mental health for radiology residents.

CONCLUSION

The COVID-19 pandemic has had a significant impact on the academics and wellness of radiology residents across North America but has taught us many lessons that can help us navigate the ongoing challenges of the pandemic, the postpandemic world, and future pandemics.

Advancing IR in Underserved Regions: Interventional Radiology Simulation Near and Far

Simulation facilitates learning by imitating real-world systems or processes utilizing educational tools and models. Various fields, including business, aviation, and education use simulation for training. In healthcare, simulation provides trainees opportunities to develop procedural skills in a safe environment, building their understanding through hands-on interactions and experiences rather than passive didactics. Simulation is classified into low, medium, and high fidelity, based on how closely it mimics real-life experience. Its use in education is a valuable adjunct to instructional support and training with multiple potential benefits. Interventional radiology (IR) trainees can build technical and clinical proficiency prior to working directly on a patient. Simulation promotes experiential learning, constructivist learning, and student centeredness, thus giving students control over their learning and knowledge acquisition. More recently, the creative use of remote simulation has augmented traditional virtual didactic lectures, thereby further engaging international learners and enhancing remote collaboration. Despite the challenges to implementation, the addition of simulation in IR education is proving invaluable to supporting trainees and physicians in underserved regions.

Results of the 2021-2022 Survey of the American Alliance of Academic Chief Residents in Radiology

RATIONALE AND OBJECTIVES

An annual survey of chief residents in accredited North American radiology programs is conducted by the American Alliance of Academic Chief Residents in Radiology (A3CR2). Special topics surveyed for the 2021-2022 academic year were procedural competency and virtual radiology education in the COVID-19 pandemic. The purpose of this study is to summarize the 2021-2022 A3CR2 chief resident survey.

MATERIALS AND METHODS

An online survey was distributed to chief residents from 197 Accreditation Council on Graduate Medical Education-accredited radiology residency programs. Chief residents responded to questions regarding their individual procedural readiness and attitudes on virtual radiology education. A single chief resident from each residency answered programmatic questions including the use of virtual education, faculty coverage, and fellowship choices among their graduating classes.

RESULTS

We received 110 individual responses from 61 programs, yielding a 31% program response rate. Although the majority (80%) of programs maintained purely in-person attending readout throughout the COVID 19 pandemic, only 13% of programs reported purely in-person didactics and 26% converted to all virtual didactics. The majority (53%-74%) of chief residents perceived virtual learning (in read-out, case conference, and didactic formats) to be less effective than in-person learning. One third of chief residents reported decreased procedural exposure during the pandemic, and 7%-9% of chief residents felt uncomfortable with basic procedures (basic fluoroscopy examinations, basic aspiration/drainage procedures, and superficial biopsy procedures). The number of programs with 24/7 attending coverage increased from 35% in 2019 to 49% in 2022. Body, neuroradiology, and interventional radiology were the most popular advanced training options among graduating radiology residents.

CONCLUSION

The COVID-19 pandemic had a profound impact on radiology training, particularly in terms of virtual learning. These survey results suggest that although digital learning offers increased flexibility, most residents still prefer in-person readout and didactics. Despite this, virtual learning will likely remain a viable option as programs continue to evolve following the pandemic.

COVID-lateral Damage: Impact of the Post-COVID-19 Era on Procedural Training in Emergency Medicine Residency

Introduction: Hospitalizations during the coronavirus 2019 (COVID-19) pandemic peaked in New York in March-April 2020. In the months following, emergency department (ED) volumes declined. Our objective in this study was to examine the effect of this decline on the procedural experience of emergency medicine (EM) residents compared to the pre-pandemic period. Methods: We conducted this multicenter, retrospective cohort study of patients seen and key procedures performed by EM residents at hospitals spanning three Accreditation Committee for Graduate Medical Education-approved EM residencies in New York City and Nassau County, NY. We obtained numbers of procedures performed during May-July 2020 and compared them to the same time period for 2019 and 2018. We a priori classified critical care procedures-cardioversion, central lines, chest tubes, procedural sedation, and endotracheal intubation. We also studied "fast-track" procedures-fracture/joint reduction, incision and drainage (I&D), laceration repairs, and splints. Results: Total number of critical care procedures in the months following the COVID-19 peak decreased from 694 to 606 (-12.7%, 95% confidence interval [CI] 10.3-15.4%), compared to an increase from 642 to 694 (+8.1%, 95% CI 6.1-10.5%) the previous year (difference -9.3%). Total number of fast-track procedures decreased from 5,253 to 3,369 (-35.9%, 95% CI 34.6-37.2%), compared to a decrease from 5,333 to 5,253 (-1.5%, 95% CI 1.2-1.9%) the year before (difference -36.3%). Specific critical care procedures performed in 2020 compared to the mean of 2019 and 2018 as follows: cardioversion -33.3%; central lines +19.0%; chest tubes -27.9%; procedural sedation -30.8%; endotracheal intubation -13.8%. Specific fast-track procedures: reductions +33.3%; I&D -48.6%; laceration repair -17.3%; and splint application -49.8%. Conclusion: Emergency medicine residents' critical and fast-track procedural experience at five hospitals was reduced during the months following the COVID-19 peak in comparison to a similar period in the two years prior. Training programs may consider increasing simulation-lab and cadaver-lab experiences, as well as ED and critical care rotations for their residents to offset this trend.

Evidence for an adverse impact of remote readouts on radiology resident productivity: Implications for training and clinical practice

After their rapid adoption at the onset of the coronavirus pandemic, remote case reviews (remote readouts) between diagnostic radiology residents and their attendings have persisted in an increasingly remote workforce, despite relaxing social distancing guidelines. Our objective was to evaluate the impact of the transition to remote readouts on resident case volumes after the recovery of institutional volumes. We tabulated radiology reports co-authored by first-to-third-year radiology residents (R1-R3) between July 1 and December 31 of the first pandemic year, 2020, and compared to the prior two pre-pandemic years. Half-years were analyzed because institutional volumes recovered by July 2020. Resident volumes were normalized to rotations, which were in divisions categorized by the location of the supervising faculty during the pandemic period; in 'remote' divisions, all faculty worked off-site, whereas 'hybrid' divisions had a mix of attendings working on-site and remotely. All residents worked on-site. Data analysis was performed with Student's t test and multivariate linear regression. The largest drops in total case volume occurred in the two remote divisions (38% [6,086 to 3,788], and 26% [11,046 to 8,149]). None of the hybrid divisions with both in-person and remote supervision decreased by more than 5%. With multivariate regression, a resident assigned to a standardized remote rotation in 2020 would complete 32% (253 to 172) fewer studies than in identical pre-pandemic rotations (coefficent of -81.6, p = .005) but would be similar for hybrid rotations. R1 residents would be expected to interpret 40% fewer (180 to 108) cases on remote rotations during the pandemic (coefficient of -72.3, p = .007). No significant effect was seen for R2 or R3 residents (p = .099 and p = .29, respectively). Radiology residents interpreted fewer studies during remote rotations than on hybrid rotations that included in-person readouts. As resident case volume is correlated with clinical performance and board pass rate, monitoring the readout model for downstream educational effects is essential. Until evidence shows that educational outcomes remain unchanged, radiology residencies may wish to preserve in-person resident readouts, particularly for junior residents.

Teaching with Technology-Matching Pedagogy with Purpose in Radiology Education

The response to pandemic-related teaching disruption has revealed dynamic levels of learning and teaching flexibility and rapid technology adoption of radiology educators and trainees. Shutdowns and distancing requirements accelerated the adoption of technology as an educational tool, in some instances supplanting in-person education entirely. Despite the limitations of remote interaction, many educational advantages were recognized that can be leveraged in developing distance learning paradigms. The specific strategies employed should match modern learning science, enabling both students and educators to mutually grow as lifelong learners. As panel members of the "COVID: Faculty perspective" Task Force of the Association of University Radiologists Radiology Research Alliance, we present a review of key learning principles which educators can use to identify techniques that enhance resident learning and present an organized framework for applying technology-aided techniques aligned with modern learning principles. Our aim is to facilitate the purposeful integration of learning tools into the training environment by matching these tools to established educational frameworks. With these frameworks in mind, radiology educators have the opportunity to re-think the balance between traditional curricular design and modern digital teaching tools and models.

[Status and recommendations for interventional radiological procedures in COVID-19 patients]

BACKGROUND

Particularly at the beginning, the COVID-19 (coronavirus disease 2019) pandemic caused a reduction in the number of interventions in interventional radiology. At the same time, interventional training became more challenging. Infectious patients and disease transmission within interventional radiology departments continue to pose significant challenges.

OBJECTIVES

This article describes the status and recommendations for interventional radiological procedures in COVID-19 patients.

MATERIALS AND METHODS

Guidelines and recommendations from international and national societies as well as original works and reviews were evaluated.

RESULTS

Interventional radiological care of COVID-19 patients with complicated courses of infection has become established during the course of the pandemic. To protect patients and staff, interventions in COVID-19 patients should be prioritized, performed in separate procedure rooms if possible, and patients should be tested before interventions. Logistics, staff planning, and hygiene measures should be continuously optimized.

CONCLUSIONS

Structured workflows within interventional radiology in dealing with COVID-19 patients appear necessary to minimize infection risks and to guarantee the staff's work capability and health. In order to develop concepts for the handling of COVID-19 patients and to be prepared for potential upcoming waves of infections, recommendations of the Robert Koch Institute (RKI) and (inter-)national professional societies are helpful.

The Impact of the COVID-19 Pandemic on Radiology Resident Education: Where Do We Go From Here?

The Coronavirus Disease of 2019 (COVID-19) pandemic caused a dramatic shift in radiology resident education. Primarily, physical distancing prompted a general transition to virtual learning. Common changes made by radiology residency programs included virtual rounds and readouts, the use of simulation technology, and case-based learning which utilized pedagogical approaches such as the flipped classroom for teaching residents. Virtual learning appears to be a suitable alternative to traditional, in-person learning, and may have a place post-pandemic as part of a blended curriculum with in-person and virtual components. The extent of disruption to radiology resident education varied based on the local impact of COVID-19 and the prevalence of redeployment, as did residents’ mental health and wellbeing. Accessibility of mental health resources for residents was highlighted as an issue that programs need to address during these difficult times. Moreover, the pandemic resulted in unavoidable reductions in procedural exposure which programs mitigated through the use of simulation technologies and virtual learning resources. Professional development activities such as mentorship and career planning were also dramatically impacted by the pandemic and remains a challenge that programs need to consider moving forward post-pandemic. The purpose of this review is to outline the changes made to radiology resident education as a result of the COVID-19 pandemic and suggest what changes may be worthwhile to continue.

Review of Learning Tools for Effective Radiology Education During the COVID-19 Era

Coronavirus disease 2019 (COVID-19) has significantly disrupted medical education around the world and created the risk of students missing vital education and experience previously held within actively engaging in-person activities by switching to online leaning and teaching activities. To retain educational yield, active learning strategies, such as microlearning and visual learning tools are increasingly utilized in the new digital format. This article will introduce the challenges of a digital learning environment, review the efficacy of applying microlearning and visual learning strategies, and demonstrate tools that can reinforce radiology education in this constantly evolving digital era such as innovative tablet apps and tools. This will be key in preserving and augmenting essential medical teaching in the currently trying socially and physically distant times of COVID-19 as well as in similar future scenarios.

What is the impact of the COVID-19 pandemic on residency training: a systematic review and analysis

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has greatly affected medical education in addition to clinical systems. Residency training has probably been the most affected aspect of medical education during the pandemic, and research on this topic is crucial for educators and clinical teachers. The aim of this study was to understand the effect of the COVID-19 pandemic comprehensively through a systematic review and analysis of related published articles.

METHODS

A systematic review was conducted based on a predesigned protocol. We searched MEDLINE and EMBASE databases until November 30, 2020, for eligible articles. Two independent reviewers extracted data by using a customized form to record crucial information, and any conflicts between the two reviewers were resolved through discussion with another independent reviewer. The aggregated data were summarized and analyzed.

RESULTS

In total, 53 original articles that investigated the effect of the COVID-19 pandemic on residency training were included. Studies from various regions were included in the research, with the largest percentage from the United States (n = 25, 47.2%). Most of these original articles were questionnaire-based studies (n = 44, 83%), and the research target groups included residents (79.55%), program directors (13.64%), or both (6.82%). The majority of the articles (n = 37, 84.0%) were published in countries severely affected by the pandemic. Surgery (n = 36, 67.92%) was the most commonly studied field.

CONCLUSIONS

The COVID-19 pandemic has greatly affected residency training globally, particularly surgical and interventional medical fields. Decreased clinical experience, reduced case volume, and disrupted education activities are major concerns. Further studies should be conducted with a focus on the learning outcomes of residency training during the pandemic and the effectiveness of assisted teaching methods.

Physician Burnout in Radiology: Perspectives From the Field

Physician burnout is increasingly recognized as a public health crisis given the impact of burnout on physicians, their families, patients, communities, and population health. The COVID-19 pandemic has superimposed a new set of challenges for physicians to navigate, including unique challenges presented to radiologists. Radiologists from a diversity of backgrounds, practice settings, and career stages were asked for their perspectives on burnout.

Evolution of the Interventional Radiology (IR) Pathway-Various Changes and Interrelation to Diagnostic Radiology (DR)

Interventional radiology continues to evolve into a more robust and clinically dynamic specialty underpinned by significant advancements in training, education, and practice. This article, prepared by members of the 2020-2021 Association of University Radiologists' task force of the Radiology Research Alliance, will review these developments, highlighting the evolution of interventional radiology pathways with attention to growing educational differences, interrelation to diagnostic radiology training, post-training practice patterns, distribution of procedures and future trends, amongst other key features important to those pursuing a career in interventional radiology as well as those in practice.

Interventional Radiology in the Coronavirus Disease 2019 Pandemic: Impact on Practices and Wellbeing

PURPOSE

To report the impact of the coronavirus disease 2019 (COVID-19) pandemic on interventional radiology (IR).

MATERIALS AND METHODS

A 78-question survey was distributed to practicing interventional radiologists and IR trainees. The survey consisted of demographic and practice environment queries. Anxiety symptoms were evaluated using the Generalized Anxiety Disorder-7 (GAD-7) screener, and coping strategies were assessed using the Brief-Coping Orientation to Problems Experienced (Brief-COPE) questionnaire.

RESULTS

There were 422 respondents including 333 (78.9%) attending interventional radiologists and 89 (21.1%) interventional radiologists-in-training from 15 counties. Most respondents were from academic medical centers (n = 218; 51.7%). A large majority (n = 391; 92.7%) performed a procedure on a patient with confirmed COVID-19 infection. An N95 mask was the most common (n = 366; 93.6%) safety measure employed. Cancellation or limitation of elective procedures were reported by 276 (65.4%) respondents. Many respondents (n = 177; 41.9%) had self-reported anxiety (GAD-7 score >5) with an overall mean GAD-7 score of 4.64 ± 4.63 (range: 0-21). Factors associated with reporting anxiety included female gender (p = 0.045), increased call coverage (p = 0.048), lack of adequate departmental adjustments (p <0.0001), and lack of adjustments in a timely manner (p <0.0001). The most utilized coping strategy was acceptance (mean of 5.49 ± 1.88), while the most employed dysfunctional coping strategy was self-distraction (mean of 4.16 ± 1.67). The odds of reporting anxiety increased by >125% with adoption of dysfunctional strategies.

CONCLUSION

The COVID-19 pandemic induced practice alterations and high rates of self-reported anxiety in IR. Female gender, increased call coverage, and lack of adequate or timely departmental adjustments were associated with increased anxiety levels.

The impact of the COVID-19 pandemic on family medicine residency training

BACKGROUND

Family physicians have played a unique clinical role during the COVID-19 pandemic. We hypothesized that the pandemic would be associated with significant deleterious effects on clinical activity, educational training, personal safety and well-being.

OBJECTIVE

We conducted a national survey to obtain preliminary data that would assist in future targeted data collection and subsequent evaluation of the impact of the pandemic on family medicine residents and teaching faculty.

METHODS

An anonymous online survey of residents and faculty was distributed via the Association of Family Medicine Residency Directors list serve between 5/21/2020 and 6/18/2020. Survey questions focused on clinical and educational activities, safety and well-being.

RESULTS

One hundred and fifty-three residents and 151 teaching faculty participated in the survey. Decreased clinical activity was noted by 81.5% of residents and 80.9% of faculty and the majority began conducting telehealth visits (97.9% of residents, 91.0% of faculty). Distance learning platforms were used by all residents (100%) and 39.6% noted an overall positive impact on their education. Higher levels of burnout did not significantly correlate with reassignment of clinical duties (residents P = 0.164; faculty P = 0.064). Residents who showed significantly higher burnout scores (P = 0.035) and a decline in levels of well-being (P = 0.031) were more likely to participate in institutional well-being support activities.

CONCLUSIONS

Our preliminary data indicate that family medicine residents and teaching faculty were profoundly affected by the COVID-19 pandemic. Future studies can be directed by current findings with focus on mitigation factors in addressing globally disruptive events such as COVID-19.

Impact of the COVID-19 pandemic on interventional radiology services across the world

AIM

To review data on the impact of the COVID-19 pandemic on interventional radiology (IR) services.

MATERIALS AND METHODS

A systematic review of the available studies was performed according to the PRISMA guidelines.

RESULTS

A total of 14 studies met the inclusion criteria. IR caseload reduced between 16.8-80%, with elective activity affected more than emergency work. Trainees also experienced a 11-51.9% reduction in case volumes and many were redeployed to critical care. IR departments re-organised operations and personnel, and many continued to offer 24/7 services and support critical care areas through redeployment of staff. The majority of studies report no significant issues with the availability of personal protective equipment and that local or national governing body or radiology society guidelines were followed.

CONCLUSION

The COVID-19 pandemic reduced case volumes and training opportunities. IR departments showed flexibility in service delivery. The lessons learned offer novel insights into how services and training can be reorganised to ensure that IR continues to thrive.

Sources of Revenue Loss and Recovery in Radiology Practices During the Coronavirus Disease 2019 (COVID-19) Pandemic

Rationale and Objectives

This study seeks to quantify the financial impact of COVID-19 on radiology departments, and to describe the structure of both volume and revenue recovery.

Materials and Methods

Radiology studies from a large academic health system were retrospectively studied from the first 33 weeks of 2020. Volume and work relative value unit (wRVU) data were aggregated on a weekly basis for three periods: Presurge (weeks 1–9), surge (10–19), and recovery (20–33), and analyzed compared to the pre-COVID baseline stratified by modality, specialty, patient service location, and facility type. Mean and median wRVU per study were used as a surrogate for case complexity.

Results

During the pandemic surge, case volumes fell 57%, while wRVUs fell by 69% relative to the pre-COVID-19 baseline. Mean wRVU per study was 1.13 in the presurge period, 1.03 during the surge, and 1.19 in the recovery. Categories with the greatest mean complexity declines were radiography (−14.7%), cardiothoracic imaging (−16.2%), and community hospitals overall (−15.9%). Breast imaging (+6.5%), interventional (+5.5%), and outpatient (+12.1%) complexity increased. During the recovery, significant increases in complexity were seen in cardiothoracic (0.46 to 0.49), abdominal (1.80 to 1.91), and neuroradiology (2.46 to 2.56) at stand-alone outpatient centers with similar changes at community hospitals. At academic hospitals, only breast imaging complexity remained elevated (1.32 from 1.17) during the recovery.

Conclusion

Reliance on volume alone underestimates the financial impact of the COVID-19 pandemic as there was a disproportionate loss in high-RVU studies. However, increased complexity of outpatient cases has stabilized overall losses during the recovery.

COVID-19 and Radiology Resident Imaging Volumes-Differential Impact by Resident Training Year and Imaging Modality

Rationale and Objectives

The COVID-19 pandemic has greatly impacted radiology departments across the country. The pandemic has also disrupted resident education, both due to departmental social distancing efforts and reduced imaging volumes. The purpose of this study was to assess the differential impact the pandemic had on radiology resident imaging volumes by training year and imaging modality.

Materials and Methods

All signed radiology resident reports were curated during defined prepandemic and intrapandemic time periods. Imaging case volumes were analyzed on a mean per resident basis to quantify absolute and percent change by training level. Change in total volume by imaging modality was also assessed. The number of resident workdays assigned outside the normal reading room was also calculated.

Results

Overall percent decline in resident imaging interpretation volume from the prepandemic to intrapandemic time period was 62.8%. R1s and R2s had the greatest decline at 87.3% and 64.3%, respectively. Mammography, MRI and nuclear medicine had the greatest decline in resident interpretation volume at 92.0%, 73.2%, and 73.0%, respectively. During the intrapandemic time period, a total of 478 resident days (mean of 14.5 days per resident) were reassigned outside of the radiology reading room.

Conclusion

The COVID-19 pandemic caused a marked decrease in radiology resident imaging interpretation volume and has had a tremendous impact on resident education. The decrease in case interpretation, as well as in-person teaching has profound implications for resident education. Knowledge of this differential decrease by training level will help residency programs plan for the future.