key: cord-318370-l2fdd4zt
authors: Wittayanakorn, Nunthasiri; Weng Nga, Vincent Diong; Sobana, Mirna; Ahmad Bahuri, Nor Faizal; Baticulon, Ronnie E.
title: COVID-19’s Impact on Neurosurgical Training in Southeast Asia
date: 2020-08-15
journal: World Neurosurgery
DOI: 10.1016/j.wneu.2020.08.073
sha: 
doc_id: 318370
cord_uid: l2fdd4zt

ABSTRACT Objective Neurosurgery departments worldwide have been forced to restructure their training programs due to the coronavirus disease 2019 (COVID-19) pandemic. In this study, we describe the impact of COVID-19 on neurosurgical training in Southeast Asia. Methods We conducted an online survey among neurosurgery residents in Indonesia, Malaysia, Philippines, Singapore, and Thailand from 22 to 31 May 2020 using Google Forms. The 33-item questionnaire collected data on elective and emergency neurosurgical operations, ongoing learning activities, and health worker safety. Results A total of 298 out of 470 neurosurgery residents completed the survey, equivalent to a 63% response rate. The decrease in elective neurosurgical operations in Indonesia and in the Philippines (median=100% for both) was significantly greater compared with other countries (p <.001). For emergency operations, trainees in Indonesia and Malaysia had a significantly greater reduction in their caseload (median=80% and 70%, respectively) compared with trainees in Singapore and Thailand (median=20% and 50%, respectively, p <.001). Neurosurgery residents were most concerned about the decrease in their hands-on surgical experience, uncertainty in their career advancement, and occupational safety in the workplace. Most of the residents (221, 74%) believed that the COVID-19 crisis will have a negative impact on their neurosurgical training overall. Conclusions An effective national strategy to control COVID-19 is crucial to sustain neurosurgical training and to provide essential neurosurgical services. Training programs in Southeast Asia should consider developing online learning modules and setting up simulation laboratories, to allow trainees to systematically acquire knowledge and develop practical skills during these challenging times.

for COVID-19 patients. [1] [2] [3] [4] [5] [6] Several letters to the editor and research articles have previously enumerated changes in neurosurgical education in North America, Europe, and Africa. [7] [8] [9] [10] [11] [12] [13] [14] [15] [16] These data are lacking for Southeast Asian countries.

In this study, we aimed to describe the COVID-19 pandemic's impact on neurosurgical training in Indonesia, Malaysia, Philippines, Singapore, and Thailand. Although there is no unified neurosurgical training program in the region, the five countries share similar program structures, strengths and weaknesses, and cultural norms in neurosurgical education. 17 Geographic proximity and existing socioeconomic ties also make collaborative effort during the recovery period feasible. The results of the current study are vital to address present and future challenges to neurosurgical education arising from this global health crisis. The last author (RB) drafted the survey questionnaire based on previously published studies on COVID-19 and neurosurgical practice. 7, 15, 16, 18, 19 The co-authors, who are consultant neurosurgeons involved in neurosurgical training in their respective countries, vetted the questions and revised items as necessary. The final survey instrument consisted of 33 questions (See Appendix A) and would take 5 minutes to complete.

The following data were collected: country of origin, residency training information (name of institution and year level), changes in neurosurgical department activities due to (emergency and elective surgeries, outpatient clinics, conferences, research activities), ongoing educational activities and availability of resources to support online learning, as well as information relevant to health worker safety (availability of personal protective equipment

[PPE] and COVID-19 testing). Two open-ended question at the end of the survey probed for the greatest concerns of the trainees and their planned strategies to bridge gaps in skills and knowledge during the pandemic period.

We distributed the survey link (http://tinyurl.com/covidsea) to the different training programs of the five Southeast Asian countries using personal communications and online methods (e.g., email, Twitter, and messaging applications such as WhatsApp, Telegram, Line, and Viber). Only neurosurgery residents in the region were included in the survey. Post-residency fellows and international trainees doing clinical rotations were excluded. 

We received a total of 324 responses. We removed 21 that were duplicates based on provided email addresses and 5 that were invalid. Thus, 298 responses were included in the data analysis. This represented 63% of the estimated 470 neurosurgical trainees in the region (See Table 1 and Figure 1 ). All 33 training programs had at least two respondents in the survey.

There were 63 chief residents (21%), defined as residents in their final year of training. The majority of the respondents (260, 87%) worked in a hospital that treated both COVID and non-COVID patients (i.e., hybrid hospital). Table 2 ). Statistical analyses showed that there was a significantly greater reduction in elective cases in Indonesia and the Philippines (i.e., less surgeries performed) compared with any of the other countries (p <.001). For emergency J o u r n a l P r e -p r o o f cases, median reduction in neurosurgical operations ranged from 20% in Singapore to 80% in Indonesia. Trainees in Indonesia and Malaysia performed significantly fewer emergency procedures compared with trainees in Singapore or Thailand (p <.001).

We investigated if year level in training influenced the decrease in surgical exposure (See Table 3 ). The reduction of elective neurosurgical procedures was similar for chief residents and the rest of the trainees (median at 96% and 98%, respectively, p = 0.621). Likewise, no significant difference was observed for the reduction in emergency neurosurgical procedures (median at 50% and 70%, respectively, p = 0.237).

The respondents were asked to select elective neurosurgical procedures that they were allowed to perform in their hospitals during the study period. The results for six neurosurgical conditions (benign brain tumor, malignant brain tumor, spinal cord tumor, degenerative disease of the spine, congenital hydrocephalus, and unruptured aneurysm) are presented in 

Most neurosurgical departments had modified morbidity and mortality conferences and grand rounds from face-to-face to virtual meetings. The trainees reported adequate access to technological resources. The majority owned a smartphone (287, 96%) or a laptop computer (267, 90%), and they connected to the internet primarily using mobile data (274, 92%).

However, many (139, 47%) did not use an online learning platform (e.g., Google Classroom, Canvas, Moodle). In Indonesia, Malaysia, and the Philippines, it was mentors who initiated learning activities. The opposite was true for Singapore and Thailand, where learning activities were more likely to be trainee-initiated. International webinars were most popular among the Indonesian residents, 91% of whom reported watching the online lectures twice a week or more. Among the Thai trainees, 68% said that they attended webinars only once a month or less. Only 6% of the trainees reported having access to a neurosurgical simulation laboratory.

At some point, 107 (36%) of the respondents had been deployed to COVID-19 units of their hospitals such as wards, intensive care units (ICUs), and acute respiratory infection clinics.

While all Singaporean trainees indicated that they were provided adequate and appropriate PPE in the workplace, 43% and 41% of respondents from Indonesia and the Philippines, respectively, said that the PPE in their hospital was either inappropriate or inadequate in J o u r n a l P r e -p r o o f supply. Testing for COVID-19 was widely available among all training institutions but not routine. The majority (231, 78%) said that their hospitals only tested heath workers with symptoms or exposure to COVID-19.

Most of the trainees (221, 74%) believed that the COVID-19 crisis will have a negative impact on their overall neurosurgical training (See Figure 5 ). There was no significant difference in the opinions of the chief residents compared with the rest of the trainees (67% vs. 76%, p = 0.299, Table 3 ). Analysis of the free-text responses showed that the residents were most concerned about the following: (1) 

Our findings confirm that COVID-19 has affected all aspects of neurosurgical training in Southeast Asia. The extent of the impact varied among the five countries included in this study. Significantly higher reductions in neurosurgical operations were observed in Indonesia and the Philippines. These effects were less evident in Singapore and Thailand, where a higher percentage of trainees continued to perform key neurosurgical procedures. Malaysian J o u r n a l P r e -p r o o f trainees also had a marked decrease in emergency operations, but their capacity to perform elective procedures was higher compared with colleagues in Indonesia and the Philippines.

The majority of the trainees worked in hybrid hospitals that managed both COVID and non-COVID patients. Thus, it was usually not necessary to transfer confirmed or suspected COVID-19 patients when they required neurosurgical care. This was particularly true in Singapore and Thailand. On the other hand, in Indonesia and the Philippines, when the aforementioned patients were initially admitted in non-COVID hospitals, they were immediately transferred to COVID centers. At their discretion, neurosurgeons in the Philippines could opt to perform emergency procedures in non-COVID hospitals, but full PPE was required for staff. The approach was slightly different in Malaysia. Dedicated COVID centers cancelled all elective and emergency surgeries at the height of the pandemic.

Neurosurgical patients were then diverted to non-COVID hospitals. Emergency procedures were allowed in hybrid hospitals, but COVID-19 testing was mandatory for all patients and full precautions were undertaken during the surgery.

It is worthwhile to examine these differences in the context of the countries' existing health care systems and national strategies to control COVID-19 transmission. [20] [21] [22] Indonesia and the Philippines are lower-middle income countries with the lowest neurosurgeon : population ratios. At the other end of the spectrum, Singapore is a high-income country, with the highest density of neurosurgeons. Thailand and Malaysia are upper-middle income countries, with neurosurgeon : population ratios closer to the benchmark commonly set at 1 in 100,000. 23 These five countries were at different stages of the pandemic at the time of the survey (See Table 4 ). 22 Several reasons may account for the marked decrease in emergency and elective consults.

Because of fear of contracting COVID-19 in health care facilities, people may delay seeking consult, even for urgent neurosurgical conditions. 3, 29 Strict lockdown policies and lack of public transportation have also restricted movement of people across regions; this is important to consider, especially since most neurosurgical centers are located in urban areas and city centers.

It may take some time before outpatient clinics resume normal services, especially if a hospital's infrastructure does not provide adequate ventilation or allow social distancing among patients and staff. Many neurosurgical departments have shifted to telemedicine and virtual clinics. 30, 31 Doctors must keep in mind that patients, especially from low-and middleincome countries, may not necessarily have the gadgets or internet connection to avail of these services, leading to further delays in the provision of care.

When a patient inevitably needs neurosurgery, training officers are often confronted with the question, "Who should do the case?" 8, 9, 12, 32 Should it be the senior or chief resident, who is expected to take up less time in the operating theater, require no assist and therefore less PPE, and have a lower risk of complications, potentially avoiding a prolonged hospital stay? But what about the junior residents, who also need to learn neurosurgery from hands-on experience, not just from online videos? In Singapore, operations were generally consultantled, to minimize surgical time and patient exposure.

At the start of the pandemic, when testing capacity was low and results took several days to be released, neurosurgical centers in Indonesia, Malaysia, and the Philippines treated all patients as if they had COVID-19, following all safety protocols and personnel restrictions as described above. These concerns were hardly encountered in Thailand and Singapore, where the capacity to test patients was rapidly increased early on, making it possible to immediately identify non-COVID patients who only required the standard of care. As testing capacity increased and turnaround times for results shortened in the other countries, we observed a corresponding increase in cases where we could safely allow trainees to scrub in. Once again, this highlights that an effective response against COVID-19 has a direct positive impact on neurosurgical care.

Neurosurgical trainees in Southeast Asia were most worried about the dramatic decrease in their neurosurgical operations, potentially leading to loss of skills and lack of opportunities to acquire new ones. Many were concerned about their future, and rightly so. They were uncertain if they would be allowed to graduate from training or take the national board exam, considering the strict competency assessment in neurosurgery. No one knows for sure how long the pandemic will last and when neurosurgical services around the world will return to "normal." While a vaccine against the virus is not yet available and herd immunity is questionable, a second or third wave of infections may easily force hospitals to shut down their operating rooms again.

The trainees' fears could only be allayed by clear guidelines and expectations from the neurosurgical societies of the different countries. Training programs should also address concerns regarding health worker safety, especially the lack of PPE. 33, 34 The constant fear of bringing home the virus to one's family only adds to the trainees' physical exhaustion and psychological stress during this time. 7, 35 Amidst the COVID-19 pandemic, it is imperative that neurosurgical education continue in this part of the world, where there remains a large deficit in the neurosurgical workforce. 36 To increase surgical volumes, one strategy has been to improve the neurosurgical capacity of 

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

This is a survey on the impact of COVID-19 on neurosurgical training and education in Southeast Asia. The survey is open to all neurosurgical residents in Indonesia, Malaysia, Philippines, Thailand, and Singapore. The entire survey will only take 5 minutes to complete. If you are NOT from any of these countries, there is no need to answer the survey.

Participation in this survey is voluntary. By answering the survey, you consent to providing your personal information to the study investigators. The researchers will maintain the confidentiality of data and all data will be de-identified prior to analysis. Training hospitals will de-identified as well in the final paper. J o u r n a l P r e -p r o o f May 2020 compared with 3 months before the pandemic). This graph shows the frequency of responses in each Southeast Asian country, stratified from 100% reduction (i.e., no elective cases were allowed) to 0% reduction (i.e., no change in the number of elective cases). Red and orange bars represent a greater reduction in the number of cases. J o u r n a l P r e -p r o o f Figure 3 : In the survey questionnaire, we asked the respondents, "How many percent of emergency neurosurgical operations are you doing now?" (i.e., 22 to 31 May 2020 compared with 3 months before the pandemic). This graph shows the frequency of responses in each Southeast Asian country, stratified from 100% reduction (i.e., no emergency cases were allowed) to 0% reduction (i.e., no change in the number of emergency cases). Red and orange bars represent a greater reduction in the number of cases. J o u r n a l P r e -p r o o f Figure 4 : We asked the respondents to select neurosurgical procedures that they were allowed to perform in their training centers at the time of the survey (24 to 31 May 2020). This graph shows the percentage of respondents in each country for six neurosurgical conditions. During the pandemic, a higher percentage of neurosurgery residents from Thailand, Malaysia, and Singapore continued to perform surgeries for brain tumors, spinal cord tumors, and degenerative diseases of the spine. 

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☒ The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.☐The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:J o u r n a l P r e -p r o o f