key: cord-252661-wa0hdg1u authors: Pennington, Zach; Lubelski, Daniel; Khalafallah, Adham; Ehresman, Jeff; Sciubba, Daniel M.; Witham, Timothy F.; Huang, Judy title: Letter: Changes to neurosurgery resident education following onset of the COVID-19 pandemic date: 2020-05-22 journal: World Neurosurg DOI: 10.1016/j.wneu.2020.05.139 sha: doc_id: 252661 cord_uid: wa0hdg1u Abstract Background The COVID-19 pandemic has led to the postponement of a large proportion of neurosurgical cases with an accordant radical change in resident experiences. As residents rely upon operative exposure and in-person didactic lectures for education, the disruptions caused by the pandemic have forced programs to revise how they educate residents. Here we surveyed program directors (PDs) to ascertain how they have altered the education and clinical care responsibilities of residents in response to the COVID-19 pandemic. Methods Surveys were sent to the PDs of all ACGME-accredited neurosurgery programs. Survey questions targeted changes in resident staffing and coverage, changes in didactic material delivery, and changes in resident wellness initiatives. PD concerns were also elicited. Results Of the 116 program PDs invited, 57 responded (49.1%). We found that most programs have reduced resident work weeks (65%) and in-hospital resident shift census (95%). Few have redeployed residents and most are increasingly relying on teleconferencing solutions for meetings and resident education. Most commonly programs are using faculty- (91%) or resident-led (65%) lectures, though nearly 75% are supplementing resident education with materials from the Congress of Neurological Surgeons (CNS). Continuing education in spite of decreased case volume and maintaining resident morale are cited as the most common concerns of PDs. Conclusion Here we find that there is great homogeneity in the responses of neurosurgical residency programs to the COVID-19 pandemic. Programs are increasingly incorporating teleconferencing platforms and third-party education materials, most commonly materials from the CNS. Additionally, most respondents indicated that their program has not redeployed residents in the care of COVID-19 positive patients. The results of the present study may assist program directors in developing a uniform resident curriculum and consider wellness initiatives during this time of crisis. The COVID-19 pandemic has led to the postponement of a large proportion of neurosurgical 3 cases with an accordant radical change in resident experiences. As residents rely upon operative 4 exposure and in-person didactic lectures for education, the disruptions caused by the pandemic 5 have forced programs to revise how they educate residents. Here we surveyed program directors 6 (PDs) to ascertain how they have altered the education and clinical care responsibilities of 7 residents in response to the COVID-19 pandemic. 8 9 Methods 10 Surveys were sent to the PDs of all ACGME-accredited neurosurgery programs. Survey 11 questions targeted changes in resident staffing and coverage, changes in didactic material 12 delivery, and changes in resident wellness initiatives. PD concerns were also elicited. 13 14 Results Of the 116 program PDs invited, 57 responded (49.1%). We found that most programs have 16 reduced resident work weeks (65%) and in-hospital resident shift census (95%). Few have 17 redeployed residents and most are increasingly relying on teleconferencing solutions for 18 meetings and resident education. Most commonly programs are using faculty-(91%) or resident-19 led (65%) lectures, though nearly 75% are supplementing resident education with materials from 20 the Congress of Neurological Surgeons (CNS). Continuing education in spite of decreased case 21 volume and maintaining resident morale are cited as the most common concerns of PDs. 22 23 Conclusion 24 Here we find that there is great homogeneity in the responses of neurosurgical residency 25 programs to the COVID-19 pandemic. Programs are increasingly incorporating teleconferencing 26 platforms and third-party education materials, most commonly materials from the CNS. 27 Additionally, most respondents indicated that their program has not redeployed residents in the 28 care of COVID-19 positive patients. The results of the present study may assist program 29 directors in developing a uniform resident curriculum and consider wellness initiatives during 30 this time of crisis. 31 With the onset of the COVID-19 pandemic and the resultant cancellation of elective surgical 1 cases nationwide, 1 there have been significant changes to how neurosurgery is taught and 2 practiced. The dramatic decrease in operative cases has significantly impacted the training of 3 neurosurgical residents, who depend on elective surgical volume to hone their clinical and 4 operative skills. 2 As residents must meet minimum case volumes to demonstrate proficiency 5 upon program completion, 3 there is concern among both residents and program directors 6 regarding the severity of the impact of COVID-19 on neurosurgical resident education. 4 7 8 Recently, several centers have reported the significant changes that their departments have 9 undergone as a result of the COVID-19 pandemic. [5] [6] [7] [8] Included in these changes are alterations to 10 the methods for educating residents 9 and the clinical care duties of residents. For example, 11 Weber et al 2 at the Medical University of South Carolina and Burke et al 7 at the University of 12 California San Francisco described reorganizing their services to reduce the number of residents 13 in the hospital at any one time. Face-to-face patient handoffs have also been minimized and usual 14 didactic programs have been shifted to videoconferencing platforms to reduce resident-to-15 resident contact. 2 In spite of these single institution experiences, there has yet to be a description 16 of how residency programs on the whole are dealing with the pressures exerted by the COVID- 17 19 pandemic. Here we sought to address this outstanding need by polling program directors with 18 the goal of using the information to help inform residency directors about how programs across 19 the country are addressing resident education during the COVID-19 pandemic. 20 21 Methods Survey of program directors 23 After obtaining IRB approval, a survey was developed using REDCap software (Supplementary 24 Figure 1 ). Domains addressed by the survey included: program details (residency size, location, 25 hospital size), COVID-19 burden in the catchment area of the associated hospital/health system, 26 changes in case volume and resident duties (e.g. shift changes, responsibility for care of COVID-27 positive patients), and changes in resident wellness/support. We also included items about the 28 exact interventions being employed to continue resident education during the COVID- 19 29 pandemic, including changes to regular meetings (e.g. grand rounds, morbidity and mortality 30 (M&M) conferences), changes to didactic lectures, utilization of outside materials (e.g. materials 31 published by the American Association of Neurological Surgeons (AANS) or Congress of 32 Neurological Surgeons (CNS), and usage of tools to track resident participation/progress within 33 the updated curriculum. 34 35 The survey was sent to program directors of all 116 ACGME-accredited neurosurgery programs 36 using REDCap electronic data capture tools hosted at our institution. 10 The survey elicited responses from 57 (49.1%) programs ( Table 1) . The median program size 50 was 2 residents per class, and the majority of programs were located in the Midwest (35.0%), 51 Northeast (23.3%), or Southeast (16.7%). For responding programs, the median health system 52 size was 890 beds (interquartile range 600-1200 beds). The inpatient burden of COVID-positive 53 patients at the time of response was that most programs had <50 COVID-positive patients 54 (47.5%), or 51-100 COVID-positive patients (15.3%); few programs had >200 COVID-positive 55 patients. Current case volume for most programs was <20% of pre-COVID volume (54.4%); 56 only a small minority of programs had >50% of their baseline case volume (11.9%). While 57 programs with higher COVID burdens tended to have greater reductions in their surgical volume, 58 this difference was not statistically significant (χ²=18.75; p=0.09). There was no significant 59 interaction between case volume and either geographic region or residency program size. 60 61 Changes in resident workload 62 The majority of programs have reduced resident COVID exposure risk by reducing the number 63 of residents in the hospital at one time (94.7%) and by reducing the number of days per week 64 that each resident works (35.1%) ( Changes in resident support 79 More than a third of programs (37%) reported that they have provided additional benefits to their 80 residents since the onset of the COVID pandemic. The most common newly added benefits were 81 providing counseling or wellness smartphone application resources (37%), hotel vouchers (32%), 82 and child care vouchers (19%). There was no significant association between COVID patient 83 burden and the odds of a program offering any of these additional benefits. Of note, a significant 84 proportion of programs were already offering counseling or wellness smartphone applications to 85 their residents prior to the onset of the COVID pandemic. 86 87 Changes in resident education 88 Nearly all programs were conducting grand rounds (100%) and M&M conferences (88%) using 89 teleconferencing software ( Table 3) . The remaining programs either completely cancelled (12%) 90 or had some small in-person meetings (4%). PDs reported that didactic lectures were primarily 91 live-streamed lectures led by faculty (91%) or residents (65%). A substantial percentage 92 endorsed also sourcing lectures (47%) or grand rounds from outside institutions (39%), or 93 previously recorded sessions (33%). In general, lecture materials were being selected by the 94 program director (65%) or by the residents (61%), rather than by the speaker or a previously 95 formalized curriculum. Across all respondents there was a relatively equal distribution regarding 96 the change in the quantity of lectures delivered (39% increased the number of lectures, 30% 97 decreased), with the majority (56%) of programs delivering 3-6 hours of didactic material per 98 week. There was no association between COVID-positive patient burden and either the absolute 99 number of hours of didactic material delivered per week or the reported change in the quantity of 100 didactic material delivered from pre-COVID onset to post-COVID onset. Resident participation 101 was predominantly assessed via direct engagement of resident attendees by the lecturer (58%). 102 Some institutions also indicated that they were using mock oral boards (25%) and virtual polling 103 (21%) features to further ensure resident engagement. The majority of programs were 104 incorporating outside resources to supplement the education of their residents, most commonly 105 in the form of the freely available Complimentary Online Education offered by the CNS (74%). 106 Program size was not significantly associated with odds of using any of the outside resources 107 listed (all p>0.05). Roughly half of programs were including advanced practice providers (58%) 108 and medical students (51%) in their resident didactic sessions. 109 110 Program director concerns 111 Program directors overwhelmingly reported that increased utilization of teleconferencing 112 solutions is the biggest change to the methods employed to educate residents. The majority state 113 their biggest concerns regarding the current crisis are: maintaining resident education in the face 114 of decreased case volume, attempting to maintain resident morale, and reducing resident risk of 115 developing the COVID-19 infection. PDs note one positive effect of the COVID pandemic is 116 increased utilization of teleconferencing solutions, which many report has increased attendance 117 by both residents and faculty. Consequently, some see these teleconferencing sessions as team-118 building exercises and a majority (76%) indicate that moving forward they will likely increase 119 their use of teleconferencing systems to either improve attendance or increase the number of 120 potential lecturers. Additionally, while the COVID pandemic has decreased operative volumes, 121 several PDs find that the increased off-service time has led to increased resident productivity in 122 terms of clinical research activities. 123 124 Discussion 125 Here we present the results of a survey of PDs for ACGME-accredited neurosurgery residency 126 programs regarding their responses to the COVID-19 pandemic. In general, we found that most 127 programs made similar changes to resident duties in response to the COVID pandemic; most 128 reduced the number of days per week worked by each resident and the number of residents in the 129 hospital at any one time. Additionally, redeployment of neurosurgery residents to care for either 130 COVID-positive or non-COVID patients did occur. A percentage of programs newly introduced 131 access to wellness/counseling apps in response to the COVID pandemic, though most (72%) had 132 already offered these benefits prior to the COVID pandemic. At present, PDs are optimistic that 133 the COVID pandemic will not prevent either current or incoming chief residents from reaching 134 ACGME case minimums. However, they also reported that residents would be transitioned from an in-person didactic 190 program to a videoconferencing-based system with a minimum of 90-minutes of lecture led by 191 senior residents using material assembled by staff neurosurgeons or sourced from online 192 material. Carter and Chiocca described the implementation of similar curriculum changes at the 193 Harvard-affiliated programs. 8 They described the implementation of daily "lunchtime lectures" 194 using videoconferencing software. During these lectures, department staff and medical students 195 are instructed using a combination of operative video, journal club, and didactics. In a separate 196 publication, the authors additionally reported the continuation of normal resident lectures and 197 M&M sessions using videoconferencing software. 5 Though less specific, similar changes were 198 endorsed by Eichberg and colleagues at the University of Miami. 6 Lastly, Bray and colleagues 4 199 described the impact of COVID-19 on resident education at Emory. As with the above centers, 200 they reported transition of grand rounds and didactic lectures to videoconferencing software. 201 They additionally reported using this platform to stream daily case conferences for residents, 202 fellows, and medical students, and for streaming third-party materials provided by the CNS. In 203 sum, the interventions reported by these programs appear to be similar to those reported by the 204 majority of the survey respondents in the present study and demonstrate a strategy that could 205 likely be implemented in all neurosurgical residencies. 206 207 There has been a reported uptick in the number of electronic resources made available to 208 neurosurgical residents. 9 These include resources offered by professional societies, for example 209 the Grand Round webinars and Virtual Visiting Professor series offered by the CNS 14 and the 210 free resident courses offered through the Neurosurgery Research & Education Foundation of the 211 AANS. 15 Additionally, there has been increased use of third-party resources, including The 212 Neurosurgical Atlas, which has reported more than a 20% increase in users/viewers since the 213 onset of the pandemic. 9 Here we found that a majority of programs are embracing lecture 214 delivery via teleconferencing materials. Additionally, nearly three-quarters of programs are 215 incorporating the CNS Complimentary Online Education into their educational programs. This 216 finding that programs are increasingly relying on video and other online materials is expected 217 and reassuring given the limitations imposed by the COVID crisis. While such education will 218 never replace operative experience, video instruction has substantial precedent in both US 219 academic centers as well as in limited resource settings. 16 The authors reviewed the most popular applications and found them to be high-quality 230 overall, with few instances of incompleteness and no instances of false statements. However, 231 they did caution that care must be taken with widespread usage of the mobile applications, as 232 they are not subject to the same rigorous peer review used for the primary literature. In the 233 present survey we found that mobile applications appear to be only minimally utilized, with only 234 7% of programs reporting using them as part of their didactic curriculum. While it is possible 235 that individuals are using them on their own, formalizing and raising awareness about such 236 applications may represent an additional means of educating residents at a distance. 237 238 An additional strategy that was not considered by the survey involves using mobile devices to 239 aid residents in practicing operative skills. Huotarinen et al 23 described using a smartphone's 240 camera in conjunction with suture and several household supplies to allow residents to 241 individually improve their microsurgical skills. The authors found this training method to 242 significantly improve resident skill using the conventional microscope. Though the tested sample 243 was extremely small, this represents a potential option for residents and programs that have been 244 forced to reduce resident participation in surgical cases due to the COVID-19 pandemic. 245 246 Resident wellness 247 One aspect of the COVID crisis that has been largely overlooked in the neurosurgery literature is 248 work to maintain resident wellness. In this time of crisis, it is widely acknowledged that extreme 249 physical and emotional stresses are being placed upon medical trainees at all levels. Trainees 250 report stress regarding the physical risks posed by having to care for COVID-positive 251 patients 24, 25 as well as the potential impact that COVID restrictions may have on future career 252 prospects. 26 Neurosurgical residency is demanding, 27, 28 and while overall attrition rates are below 253 average (11% between 2005 and 2010 versus 18% for general surgery residents), 29, 30 it has been 254 noted that low operative volume and outside social stressors are associated with higher rates of 255 burnout. 31 This raises concern for increased resident burnout rates during the COVID crisis. To 256 address resident burnout, multiple programs have previously implemented resident wellness 257 initiatives (Table 4) . 27, 28, 32, 33 In the setting of this COVID pandemic, it would seem that these 258 wellness initiatives would be increasingly important. Previous initiatives outside the COVID 259 pandemic have include implementation of gym memberships, group exercise sessions, regular 260 lectures on wellness 28 ( al. 27 In subsequent publications, this group reported that such interventions were seen by 266 residents as "very important," with the vast majority reporting the interventions to have positive 267 impacts on their physical and mental health. 34 They also reported team-building efforts to 268 increase team-cohesiveness, and to improve scores on previously validated measures of anxiety 269 and sleepiness. 33 In response to this, Louisiana State University implemented a similar exercise 270 program for residents at their New Orleans campus; two-thirds of the residents reported the 271 intervention to significantly improve their job satisfaction. 28 Implementation of a mindfulness-272 based initiative at the University of Florida was similarly reported to improve resident 273 motivation and conflict-handling abilities. 28 Along these same lines, since the pandemic began, 274 our institution began offering all students and trainees free mental telehealth counseling to deal 275 with some of the new challenges and stressors. 276 277 In the setting of the current COVID pandemic, many of these initiatives may not be possible. 278 However, similar interventions using videoconferencing software (e.g. group online fitness 279 classes, etc.) can help foster the same level of camaraderie that has been found to boost resident 280 performance and quality-of-life. Additionally, PDs responding to our survey noted that virtual 281 social gatherings, happy-hours, and similar such events via videoconferencing software can help 282 bolster resident morale and sense of community. Ammar et al noted similar effects in their report 283 on efforts to maintain wellness amongst neurosurgical residents at a New York City program. 35 They endorsed the increased use of check-ins between faculty and residents and between 285 residents as a means of maintaining contact during these times of social distancing. The authors 286 also reported offering child care resources and flexible work scheduling to help reduce resident 287 anxiety about non-clinical concerns. In the present survey, we found only a minority of programs 288 are currently providing these. 289 290 Limitations 291 The present study has several limitations inherent to all survey-based research. First, we had only 292 a 50% response rate to our survey. While this is relatively high for such survey studies, it is 293 possible that novel educational interventions being employed at centers are not captured here. 294 Additionally, many questions were set up as multiple-choice questions to simplify responding. 295 As this can miss some of the nuances of open-ended answers, 36 we intentionally included some 296 areas for free text response to capture additional details of the response. As a result, there may be 297 interventions being employed at some programs that were missed. 298 299 Conclusion 300 The COVID-19 pandemic has led to drastic changes in neurosurgical training and overall 301 resident experience. Here we provide the results of a survey of program directors describing both 302 the interventions being pursued to continue resident education and the changes in resident 303 involvement. We find that most programs have experienced large drops in their case volume and 304 are attempting to compensate by moving didactic lectures to teleconferencing software and 305 increasingly incorporating educational resources from outside sources. Additionally, most 306 programs are reducing resident in-hospital time and reducing the number of residents in-house at 307 any one time to reduce risk of COVID exposure. We hope that these results can help create 308 transparency and consistency across neurosurgery residency programs for the benefit of all 309 current trainees, as well as generate consideration of how the common adaptations adopted 310 rapidly by programs will impact how neurosurgical education occurs in the future. 311 312 Acknowledgement 313 We would like to thank all program directors who responded to the survey. We appreciate their 314 participation and hope that additional collaborations of this nature will help to foster a unified 315 response to the COVID pandemic. 316 317 Tables 1 Table 1 : Profile of Responding Programs 2 Table 2 : Changes in resident roles and deployment in response to COVID pandemic 3 Table 3 : Changes in resident educational sessions in response to COVID pandemic 4 Table 4 : Previously described resident wellness initiatives 5 6 7 Non-Emergent, Elective Medical Services, and Treatment Recommendations Letter: For Whom the Bell Tolls: Overcoming the Challenges of the COVID Pandemic as a Residency Program Trends in United States neurosurgery residency education and training over the last decade Letter: Maintaining Neurosurgical Resident Education and Safety During the COVID-19 Pandemic Letter: Adaptation Under Fire: Two Harvard Neurosurgical Services During the COVID-19 Pandemic Academic Neurosurgery Department Response to COVID-19 Pandemic: The University of Miami/Jackson Memorial Hospital Model Letter: The Coronavirus Disease 2019 Global Pandemic: A Neurosurgical Treatment Algorithm COVID-19 and academic neurosurgery Innovations in neurosurgical education during the COVID-19 pandemic: is it time to reexamine our neurosurgical training models? Research electronic data capture (REDCap)-A metadata-driven methodology and workflow process for providing translational research informatics support The REDCap consortium: Building an international community of software platform partners Proclamation on Declaring a National Emergency Concerning the Novel Coronavirus Disease (COVID-19) Outbreak. White House Proclamations Declaration of State of Emergency and Existence of Catastrophic Health Emergency -COVID-19 Complimentary Online Education American Association of Neurological Surgeons Toward the development of 3-dimensional virtual reality video tutorials in the French neurosurgical residency program. Example of the combined petrosal approach in the French College of Neurosurgery Neurosurgery videos on online video sharing sites: The next best teacher? Free-access open-source e-learning in comprehensive neurosurgery skills training Virtual Reality-Based Simulation Training for Ventriculostomy Structured Online Neurosurgical Education as a Novel Method of Education Delivery in the Developing World The use of simulation in neurosurgical education and training Mobile Applications in Neurosurgery: A Systematic Review, Quality Audit, and Survey of Canadian Neurosurgery Residents Efficient, and Mobile Way to Train Microsurgical Skills During Busy Life of Neurosurgical Residency in Resource-Challenged Environment We Signed Up for This!" -Student and Trainee Responses to the Covid-19 Pandemic A neurosurgery resident's response to COVID-19: anything but routine Impact of COVID-19 on neurosurgery resident research training Incorporation of a Physical Education and Nutrition Program Into Neurosurgery A Comparison of the Existing Wellness Programs in Neurosurgery and Institution Champion's Perspectives Analysis of national trends in neurosurgical resident attrition Prevalence and Causes of Attrition Among Surgical Residents Factors associated with burnout among US neurosurgery residents: a nationwide survey Pursuit of Balance: The UPMC Neurosurgery Wellness Initiative Impact of a Residency-Integrated Wellness Program on Resident Mental Health, Sleepiness, and Quality of Life Perspectives from a Residency Training Program Following the Implementation of a Wellness Initiative Managing a Specialty Service During the COVID-19 Crisis How Question Types Reveal Student Thinking: An Experimental Comparison of Multiple-True-False and Free-Response Formats • Gym memberships • Mind-body wellness sessions • Team workout sessions Medical University of South Carolina • Exercise lectures • Mind-body wellness sessions • Primary care appointments and bloodwork • Spouse support programs • Team workout sessions • Teambuilding exercises Tufts Medical Center • Financial wellness lecture series • Holiday parties and social events • Team bonding experiences University of Florida • Exercise lectures • Mind-body wellness sessions University of Minnesota • Conflict resolution skill sessions • Exercise lectures • Personal development and career planning sessions • Teambuilding exercises University of Pittsburgh • Faculty mentorship program • Gym memberships • Team workout sessions • Wellness and mindfulness lectures Vanderbilt • Exercise lectures • Gym memberships • Leadership lectures • Teambuilding exercises and trips Wake Forest • Exercise lectures • Gym memberships • Mind-body wellness sessions • Quarterly resident/faculty events • Team workout sessions • Teambuilding exercises Sources 1 Supplementary Figure 1 . Survey utilized for gathering program director input on changes to 2 resident education following onset of the COVID-19 pandemic. 3 4 7 (11.9) Key: IQR -interquartile range †Health system defines as all hospitals in institutions health system that are staffed by the program's neurosurgery residents prior to onset of the COVID-19 pandemic ‡Case volume defined as proportion of pre-COVID case volume