key: cord-0758478-0p192lmv
authors: Pelargos, Panayiotis E.; Chakraborty, Arpan; Zhao, Yan D.; Smith, Zachary A.; Dunn, Ian F.; Bauer, Andrew M.
title: An Evaluation of Neurosurgical Resident Education and Sentiment During the COVID-19 Pandemic: A North American Survey
date: 2020-06-05
journal: World Neurosurg
DOI: 10.1016/j.wneu.2020.05.263
sha: 093c68f374089a3d3b4d10615a04885ba759b1ad
doc_id: 758478
cord_uid: 0p192lmv

ABSTRACT Background The COVID-19 pandemic has had a tremendous impact on the healthcare system. Due to restrictions in elective surgery and social distancing guidelines, the training curriculum for neurosurgical trainees is rapidly evolving. This evolution may have significant long-term effects on the training of neurosurgery residents. Objective To assess the impact of COVID-19 on neurosurgical training programs and residents. Methods A survey consisting of thirty-one questions assessing changes to resident clinical and educational workload and their sentiment on how these changes may affect their careers was distributed electronically to neurosurgery residents in the United States and Canada. Results The survey respondents were spread over 29 states and Canada and were relatively evenly spread across all levels of residency. Nearly 82% reported that the inpatient and outpatient volumes were either greatly (44.0%) or moderately (37.8%) reduced. Greater than 91% reported that their work responsibilities or access to the hospital had been reduced with a significant reduction in work hours and a significant increase in resident didactics (p <.001). Senior residents expressed concern about their educational experience as well as their future career prospects as a result of the pandemic. Conclusion Universally, residents have experienced reduced work hours and reduction in their operative case volumes. Programs have adapted by increasing didactic time and using electronic platforms. It is quite possible that this remarkable time period will prompt a critical re-appraisal of the pre-COVID-19 adequacy of educational content in our training programs, and that enhanced educational efforts driven by this pandemic may be lasting.

platforms. It is quite possible that this remarkable time period will prompt a critical re-appraisal 24 of the pre-COVID-19 adequacy of educational content in our training programs, and that 25 enhanced educational efforts driven by this pandemic may be lasting. 26

In late December 2019, severe acute respiratory syndrome coronavirus 2 was initially 28 detected in Wuhan, China in a cluster of patients suffering from pneumonia of unknown source. 1 

The virus subsequently spread rapidly, putting a significant strain on the healthcare system 30 globally with ripple effects that have reached nearly all aspects of life. 2 The first case of 31 coronavirus disease 2019 in the United States was confirmed on January 20, 2020, 32 and on March 13, 2020, the American College of Surgeons recommended the cessation of 33 elective surgeries and triaging of the remaining cases based on level of acuity. [3] [4] [5] To help reduce 34 the burden on the healthcare system during this pandemic, neurosurgery departments throughout 35 the United States and Canada have reduced elective surgeries, made changes to faculty and 36 resident schedules, changed the structure of their inpatient and outpatient services, and reduced 37 larger group meetings. 6-10 While necessary, these changes may have significant effects on the 38 training of neurosurgery residents. 39

To better assess the impact of COVID-19 on neurosurgical training programs, we 40 conducted a survey of all neurosurgical residents to determine how elements of their professional 41 and personal lives have been affected during this pandemic. In this report, we seek to 42 demonstrate how the current phase of the COVID-19 pandemic has altered neurosurgical 43 training. 44 (ACGME)-and The Royal College of Physicians and Surgeons of Canada (RCPSC)-accredited 50 neurosurgery residency programs across the United States and Canada, respectively. The survey 51 consisted of 31 questions which were designed and vetted by the authors. Due to the rapid 52 progression of the pandemic, the survey was not validated prior to distribution. The questions 53 pertained to resident demographics, year of training, location of training program, clinical 54 volume and didactic changes during the pandemic, and sentiment towards the changes 55 implemented and how they affect resident training and future career plans. The questions were 56 designed to obtain the respondents' general experience and reaction toward the pandemic. 57

Responses were collected anonymously via the Qualtrics interface. One hundred ninety-seven 58 resident responses (of an estimated 1300 active residents) 11 were collected between April 17, 59 2020 and April 30, 2020, for a response rate of 15%. 60 of the pandemic as well as the number of hours per week didactic lectures were offered at 73 programs before and after the pandemic. For all tests, significance was set at a p-value less than 74 .05. 75

Work hours and Case Volume 78

The survey respondents were spread over 29 states and Canada and were evenly spread across all 79 residency levels (p =.619) ( Figure 1 ). Ninety-nine percent of residents reported institutional 80 limits on elective cases with 99.5% reporting that the volume of operations performed at their 81 institution has decreased. Nearly 82% reported that the inpatient and outpatient volumes were 82 either greatly (44.0%) or moderately (37.8%) reduced. Greater than 91% reported that their 83 work responsibilities or access to the hospital had been reduced. Prior to the COVID-19 84 pandemic, 97.9% of residents reported working at the hospital >60 hours per week, while during 85 the pandemic only 34% reported working more than 60 hours per week and 44.8% reported 86 working fewer than 50 hours per week. The decline in work hours was found to be statistically 87 significant (p <.0001) ( Figure 2 Approximately three-fourths of residents reported being engaged by their program in formulating 112 COVID-19 response plans, but just over one-third of respondents (35.1%) were asked to provide 113 non-neurosurgical care to COVID-19 patients. Residents in highly impacted states were more 114 likely than residents from less impacted states to be asked to assist in the medical care of 115 COVID-19 patients (40.2% vs. 20.3%, respectively; p =.008). Overall, the majority of residents 116 (nearly 70%) said they would be comfortable providing critical care or medical services for 117 of respondents felt that their program had been negatively affected by needing to self-quarantine 119 -or by a co-resident needing to do so -after being exposed to or contracting COVID-19. 120

Overall Effect on Resident Sentiment ( Table 1 ) 122

The majority of respondents (68.2%) said that working as a physician during the pandemic had 123 not had a negative impact on their home or family lives, while 31.6% did feel that it negatively 124 affected their interpersonal relationships. Although 55.4% of trainees had to alter vacation or 125 elective schedules due to the COVID outbreak, 88.7% responded that they did not feel unfairly 126 burdened by alterations to their work schedule or responsibilities. Roughly a third (33.7%) of 127 respondents were concerned that this epidemic would negatively affect their overall residency 128 education while another third (32.7%) were convinced that the course of their education would 129 be unaltered. The remaining third (33.7%) were unsure of the long-term impact this epidemic 130 would have on their education. However, when categorized by junior and senior residents, 131 senior residents were more likely to feel that their cumulative residency experience has been 132 negatively influenced by the pandemic (43.8% vs. 26.7%; p = .028). Only 8.2% of residents 133 were concerned that this would limit their overall case numbers required by the ACGME. 134

However, 26.5% were concerned that this would limit their ability to get the job or fellowship of 135 their choice. Senior residents felt that the pandemic might (22.5%) or definitely will (18.8%) 136 affect their chances of obtaining a fellowship or job of their choice; among junior residents, 137 15.5% felt it might and 0.9% felt it definitely would affect their future opportunities. This 138 difference was statistically significant (p <.001). Overall, 74% of residents were unchanged in 139 their perception of neurosurgery as a career, while 13.8% felt more favorable about their career, residents from highly impacted states having a more favorable perception of a career in medicine 142 compared to those from less impacted states (18.1% vs. 5.1%, respectively; p =.058) 143 144

The COVID-19 pandemic has resulted in many challenges unparalleled in modern to the pandemic. 16,17 These accounts largely detailed the negative impact that the pandemic has 157 on resident education and home life, suggesting that trainees are unjustly required to bear much 158 of the risk in caring for COVID patients, with little reward. Our survey sought to elucidate the 159 true impact of this pandemic on neurosurgical residency education and residents themselves. We 160 found that the effect was felt universally by nearly all neurosurgical trainees. Despite significant 161 reduction in operative cases and work hours, residency programs swiftly and nearly universally 162 transitioned educational activities into electronic platforms which have been favorably adopted been a momentous effort by many programs and national organizations and is consistent with 165

reports from individual programs about the changes made to didactics during the pandemic 166 period. 9,10,13,14 This likely will supplement resident training and fill some of the loss that would opportunities that otherwise would not have been available to trainees and has enriched the 179 learning environments for neurosurgical education as a whole. In our experience, this has also 180 fostered collaboration between programs that are geographically separated and allowed our 181 residents to broaden their horizons with experts in the field without ever having to leave their 182 home. This may provide a model for the future of neurosurgical education and will definitely 183 serve as a model for similar crises in the future. 184

The sentiment of those residents that responded to the survey towards the pandemic 185 appears to be one of an eagerness and willingness to help. Our survey found that about 75% of 186 trainees had been involved in helping formulate a plan for their involvement in the care of COVID-19 patients and nearly 60% received extra training should the need arise. Though they 188 were prepared, most neurosurgery residents (64.9%) were not approached about providing non-189 neurosurgical care for COVID patients. Training programs did an excellent job of preparing 190 their residents for these circumstances. Several of the other published accounts of resident 191 reaction to COVID suggested some frustration that residents were bearing the burden of care and 192

were forced to compromise their education. 16, 17 However, in our survey, 88.7% of residents did 193 not feel that the changes to their work or academic schedule or changes to their work 194 responsibilities were unfair. Indeed, 87.6% of respondents said that their perception of their 195 career in medicine was either unchanged or actually improved after the COVID pandemic. 196

Senior residents were 15 times more likely to express concern about their educational experience 197 as well as their future career prospects as a result of the pandemic (Table 1 ). This finding 198 suggests that senior residents may feel the effects of decreased operating time and reduced ability 199 for in-person interviews more than their junior counterparts. This may require more acute 200 attention from the faculty with respect to preparing our senior residents for moving on to their 201 fellowship or ultimate job. 202

While our results represent the views of a cohort of US neurosurgical residents that are 203 broadly representative of both geographic location and level of experience, a number of 204 limitations still exist. As with any survey, there is the opportunity for response bias. Our 205 selected population was not random, and it is quite possible that residents most affected by the 206 pandemic were non-responders due to their increased responsibilities working on the front lines 207 caring for COVID patients. The overall sample size is relatively small given that there are an 208 estimated 1300 neurosurgical residents currently in training in the US and Canada. 11 We 209 acknowledge this as a shortcoming of this work. Given the demands of this event and additional burden of coordination efforts, we do acknowledge that survey participation was likely one of 211 many priorities on the list of a program director or resident. This likely contributed to the low 212 response rate of 15% and limits the generalizability of the results. Also, with the rapid 213 progression of the pandemic, we did not have the opportunity to validate this survey as a 214 psychometric analysis tool. Therefore, the results should be interpreted more in a descriptive 215

We are pleased to see that our own department's experience was similar to that of other 217

North American programs. This has by and large been a positive adaptation. Although 218 emergent and urgent cases continued, elective cases were halted at our institution in early April. 219

We pivoted within days of this case hold to a daily virtual two-hour didactic schedule that 220 included a departmental journal club, webinars from the CNS, attending and resident 221 subspecialty didactics, facilitated use of surgical videos, attending-driven mock oral board cases, 222 ad hoc national virtual conferences (e.g. multi-institutional "Virtual Global Spine Conference"), 223 and kept our standard weekly Grand Rounds and monthly Morbidity and Mortality conference. 224

Further, many faculty met with virtually with residents and fellows to discuss ongoing and newly 225 developed research projects and initiatives. In our discussions with residents, regardless of level, 226 the additional didactics have been received only positively, and we plan to layer in several 227 elements of this curriculum to our weekly schedule even as elective cases resume. Further, our 228 residents have not openly expressed concern for their clinical training or future careers during 229 this time. We hope this is a reflection of enhanced clinical didactic and academic training 230 introduced to offset some the inevitable loss of training time in the operating room. It is likely 231 that a number of novel educational changes will result from this pandemic. Electronic learning, 232 which was not broadly deployed in neurosurgical education, expands the reach of our educational efforts in both space and time. 18 Residents who are on other services outside the 234 hospital or on vacation are still able to participate in educational activities or even re-watch these 235 on their own time via recordings. This unique situation has led many programs to explore the 236 greater use of video and virtual reality in resident training which will be yet another opportunity 237 for learning outside of the operating room. The effort to train neurosurgical residents in critical 238 care remains strong and is evidenced by the fact that the majority of our respondents felt 239 comfortable providing critical care and medical services to COVID-19 patients if required. 240

The educational effects of COVID have been nearly universally experienced across 243 neurosurgical residency programs. Nearly all residents have experienced reduced work hours 244 and reduction in their operative case volumes. Programs have been effective, however, in 245 increasing didactic time through use of electronic platforms that have been favorably received by 246 residents. Ultimately, the respondents to our survey did not feel they were unfairly bearing the 247 burden of care for COVID patients or neurosurgical patients on their services. Most were not 248 concerned that this would have long-term negative effects on their overall education or future 249 career prospects. Undoubtedly, some of the changes that programs have made due to COVID-19 250 will be useful adjuncts that will continue into the future. While we do not know how long the 251 changes brought about by COVID-19 will last, it is encouraging that neurosurgery has been able 252 to quickly adapt educational programs to fit the needs of our resident trainees. Future efforts will 253 undoubtedly work to quantify both the educational impact of the virus and the success our 254 interventions have had in mitigating this impact. 255

The authors acknowledge Camille K. Milton, BS, for her assistance during this study. 

A Novel Coronavirus from Patients with Pneumonia in 265

Clinical Characteristics of Coronavirus Disease

American College of Surgeons. COVID-19: Guidance for Triage of Non-Emergent Surgical 271

Using Technology to Maintain the Education

Residents During the COVID-19 Pandemic

Resident Workforce and Education During the COVID-19 Pandemic: Evolving Strategies and 315

A Neurosurgeon Takes New Role to Care for Coronavirus Patients and Families

Doctors In Training Are Dying, And We Are Letting Them Down

Young Doctors Struggle to Treat 323

We Are Horrified and Scared

Supplement 1. 31-question survey distributed electronically to all U.S. and Canada neurosurgery 352 residents

AANS American Association of Neurologic Surgeons ACGME Accreditation Council for Graduate Medical Education CNS Congress of Neurological Surgeons COVID-19 Coronavirus disease 2019 PGY Post-graduate year (PGY RCPSC The Royal College of Physicians and Surgeons of Canada Declarations of interest: none CRediT

S. -investigation, data curation, writing (original draft and revisions), visualization

BS -writing (original draft and revisions)

Zhao Ph.D. -validation and formal analysis, visualization

Smith M.D. -writing (original draft and revisions), writing (review

MBA -conceptualization, methodology, investigation, data curation, writing (original draft and revisions), wrigint (review and editing), project administration and supervision