To the Editor:
Singapore was one of the earliest countries outside of China to be affected by the COVID-19 pandemic.1 Singapore’s response has been lauded by the World Health Organization2 and led to low acquisition rates of the virus by health care workers. Cardiology staff, including trainees, face a significant risk of exposure given that the virus can cause cardiac arrhythmias and acute myocardial injury.3 We are taking the following steps to balance potential exposure and reduced training for postgraduate cardiology trainees during COVID-19.
Trainees are split into 2 independent teams covering different functions. These teams exchange roles every 2 weeks to ensure equal learning opportunities and duty hours. They are separated by location and time; trainees are not allowed to interact with members of the other team, reducing the risk of cross-contamination and need for quarantine.
Trainees undergo annual hand hygiene assessment and are instructed on the use of personal protective equipment (PPE), including gloves, gowns, respiratory protection, and eye protection.4 In situations with potentially aerosolized secretions, such as transesophageal echocardiography and the review of patients on high-flow nasal oxygen or positive airway ventilation, the use of powered air-purifying respirators has been instructed.
Staffing requirements have necessitated the suspension of all leave. Trainees are observed for signs of overwork, and there are open lines of escalation and disclosure.
Trainees are required to fulfill subspecialty postings to achieve basic competency. Learning materials are accessed via an e-learning portal, which allows for progress tracking.
We use a commercial videoconferencing software for the live broadcast of continuing medical education. Trainees gain access through personal digital devices and interact with the presenter and faculty via voice and video-chat. We have successfully employed this model for subspecialty teaching, journal clubs, and department meetings.
We recognize that separating trainees into teams and suspending leave could have significant impact on morale and wellness. Additionally, sustained PPE usage is physically strenuous and adds to potential exhaustion. The long-term effects of these changes on mental and physical health are not known. The use of virtual learning technologies in this setting, especially over a sustained period, is similarly unproven; the effectiveness of training should be further studied.
COVID-19 presents a great challenge to faculty and trainees. We hope that other institutions may reference our measures and adopt appropriate stances to help trainees in cardiology navigate these difficult times.
The authors thank all faculty members, trainees who have been contributing tirelessly and without complaint in this time of need, and the program coordinator Lin Sihan for her forbearance. They also thank Poh Kiang Keong, Director of Postgraduate Medical Education, and Yeo Tiong Cheng, Deputy Director, National University Heart Centre, Singapore, for their contributions during this period.
1. Wong JEL, Leo YS, Tan CC. COVID-19 in Singapore—Current experience: Critical global issues that require attention and action [published online ahead of print February 20, 2020]. JAMA. doi:10.1001/jama.2020.2467
2. Coronavirus: Singapore’s response to outbreak praised by experts and observers. The Strait Times. https://www.straitstimes.com/asia/se-asia/singapores-response-to-coronavirus-outbreak-praised-by-experts-and-observers
. Published February 19, 2020 Accessed June 29, 2020
3. American College of Cardiology. COVID-19 clinical guidance for the cardiovascular team. https://www.acc.org//~/media/Non-Clinical/Files-PDFs-Excel-MS-Word-etc/2020/02/S20028-ACC-Clinical-Bulletin-Coronavirus.pdf
. Reviewed and Approved March 6, 2020 Accessed June 29, 2020
4. Centers for Disease Control and Prevention. Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html
. Updated May 22, 2020 Accessed June 29, 2020