The SARS-CoV-2 pandemic has brought radical changes to the regular practice of gastroenterology.
The transmission routes of the new coronavirus (droplets, aerosol and probably fecal-oral)
put all gastroenterological activities at high risk of contamination, especially in
the endoscopy digestive practice .
The exponential increase in COVID-19 cases in Europe led to the issuing of numerous
recommendations by different national and international entities, which called for
a profound reorganization of the gastroenterology departments [2, 3, 4]. The main
focus was on clinical service prioritization, restrictive procedure triage and constrained
settings of human and equipment resources. Consequently, training programs and trainees
were faced with unexpected challenges.
The specific training programs have undergone a remarkable evolution in an attempt
to follow that of the specialties themselves, but none of them were prepared for a
Obviously, the impact on training programs is different according to the specialties
and may even constitute a unique opportunity for some of them. In specialties such
as public health, internal medicine, intensive care medicine or infectious diseases,
trainees are being empowered with exceptional and incomparable knowledge, performance
levels and skills.
Also for specialties not directly involved in the COVID-19 response, the reallocation
of human resources constitutes an unquestionable training advantage, providing for
the acquisition or consolidation of competences, impossible to program outside of
an exceptional pandemic setting.
Even though health care personnel working in gastroenterology departments are not
in the frontline, the impact on gastroenterology activity is still remarkable.
Online care and telephone consultations have been strongly suggested and should be
provided, in order to minimize the presential clinical evaluations. The inpatient
care approach is also changing. The entire hospital dynamic is undergoing a profound
transformation, and even patients suffering from chronic illnesses with alarm symptoms/relapse
resist seeking medical care. It was strongly suggested that gastrointestinal endoscopy
units temporarily postponed elective, nonurgent activity and accurately identified
time-sensitive procedures. Only essential and experienced endoscopy personnel should
be present in the selected endoscopy cases (trainees are not allowed), and appropriate
personal protective equipment (PPE) and infrastructures should be available.
All these aspects significantly weaken the structural pillars of gastroenterology
training and bring trainees increased pressure due to the difficulty in achieving
their training plan on time. Furthermore, dealing with psychological distress and
infectious risks endangers the trainees' physical and mental health.
Additionally, the increasing pressure on health services has imposed the relocation
of some gastroenterology interns to COVID-19 patient care, keeping them away from
specialized clinical practice. Participation in postgraduate events and public scientific
presentations, as required for the core curriculum, are also suspended for the time
In spite of the significant limitations such as diminished gastroenterology practice
activity, the current situation might enhance scientific opportunities, allow for
the acquisition of a wide range of theoretical knowledge and reinforce competences
in the ability to adapt to a dynamic hospital reorganization, procedure eligibility
and judicious use of PPE.
Trainees are health care professionals with inestimable value who ensure the continuity
of medical care in the future and therefore must be protected. Their knowledge and
abilities should also be taken into account, in order to improve the current situation.
The uncertainty about the future raises many doubts, and several issues deserve deep
reflection and imminent decisions.
To minimize the negative impact of the pandemic, and in order to ensure that the training
program remains feasible, even in necessarily atypical circumstances, there must be
a connection between the different authorities in this matter.
In order to restrict presential events and to keep the focus on fighting the pandemic,
the Portuguese authorities have postponed all final board exams and issued some guidelines
for the reorganization of local training programs. The continuity of internships is
guaranteed, provided that sufficient conditions for their completion are ensured.
While the continuity of internships connected with COVID-19 is easily approved, the
access to more advanced or differentiated practices is mostly suspended due to circulation
restrictions and other measures imposed to control the pandemic.
The different agents involved in this process (trainees, trainers, training leaders
and institutions) should take concerted efforts to reach an inclusive, individualized
and timely planned decision.
The main goal must be to defend the intern's interests and to provide optimal conditions
for the development of essential skills required for independent gastroenterology
In the Portuguese gastroenterology training, the first year is dedicated to internal
medicine and intensive care and therefore should not be affected by the current pandemic.
In the second and third years, basic clinical and endoscopic gastroenterology skills
should be achieved but eventual gaps can be filled in the remaining training time.
The biggest challenge will be for the fourth- and fifth-year internships. Opportunities
for optional training modules can be lost and not easily replaced. These unexpected
circumstances must be overcome, and comprehensive measures should be considered.
A dynamic and timely supervision by the trainer is essential in order to promptly
identify and overcome gaps in the individual training plan. A tremendous impact on
training plans is already a reality but is also expected in the postpandemic gastroenterology
activity, resulting from the increased pressure on clinical services to respond to
the postponed and time-sensitive medical procedures. Efforts to reorganize training
programs should not be limited to the outbreak period but include the postpandemic
phase as well. The workload is inevitable, and it is essential that the trainees'
activity remains focused on fulfilling their training requirements.
It is mandatory that trainees have the same opportunities regardless of local or regional
circumstances. Furthermore, the gastroenterology training phases dictate a necessarily
individual approach based on the year and specific stage.
The failure to achieve basic skills within the time schedule has to be addressed and
may imply an extension of training time. Extraordinary assessment and recognition
of competencies must be prepared to respond to this exceptional situation. The impossibility
of completing advanced optional internships should be taken into account at the final
exam evaluation, according to well-defined guidelines and protecting the intern. These
optional internships are often the most desirable aims of trainees for which they
have fought throughout their training route. This experience must be encouraged and
promoted, even after the end of internship, to overcome frustrations and encourage
personal and professional development.
The COVID-19 public health emergency continuously imposes changes on the gastroenterology
exercise paradigm. Patients' and health care professionals' safety prioritization
is consensual but is causing collateral damage. The gastroenterology training program
is not an exception. Coherent, fair, context-adapted and feasible measures should
be continuously implemented to minimize the most immediate impact and to prepare the
reaction to future challenges that will not vanish and remain demanding.
The authors have no conflicts of interest to declare.
Both authors contributed equally to the editorial.