key: cord-0761181-c6podxzl authors: Aulakh, Gurnam; Wanis, Christine; Wilson, Gavin; Moore, Richard title: The Impact of COVID‐19 on Oral Surgery Training date: 2021-02-27 journal: Oral Surg DOI: 10.1111/ors.12612 sha: 1c9bae2fd88310c15f59f0d13df9ddbbfc654a43 doc_id: 761181 cord_uid: c6podxzl AIM: Coronavirus disease, caused by severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), originated in December 2019 from Wuhan, China. This virus has spread worldwide, with over 16 million cases and over 650,000 deaths. The novel coronavirus disease (COVID‐19) has resulted in significant impact on the livelihoods of the British public and has had implications for healthcare delivery. The cancellation of elective procedures is likely to affect Oral Surgery specialty training. This paper aims to ascertain the extent of any impact of COVID‐19 on Oral Surgery specialty training. MATERIAL AND METHODS: A survey was created for Oral Surgery specialty trainees in the UK. A variety of questions were used, including multiple choice, yes/no, Likert scales and free text answers. All questions were related to the impact of COVID‐19 on training. RESULTS: A total of 34 full responses were recorded. Results showed that COVID‐19 has had an immense impact on Oral Surgery training, with most trainees recording high anxiety levels regarding the future of their training. The overall experience of most trainees involved a reduction in logbook procedures, cancelled study days, courses or conferences. CONCLUSION: Though oral surgery training has been deficient during this period, some trainees reported positive experiences while redeployed in other fields or specialties. In addition, we highlight the significant effect on trainees’ mental health. Most trainees suggested a training period extension to remedy deficiencies. From this paper, we identify the wide‐ranging effects of the pandemic, and Oral Surgery trainees now await decisions on the future of specialty training. Coronavirus disease, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) originated in December 2019 from the Wuhan province of China. 1 This virus has since spread worldwide, with the total number of confirmed cases exceeding 16 million and over 650,000 deaths at the time of writing. 2 The novel coronavirus disease (COVID-19) has resulted in significant impact on the livelihoods of the British public and has had implications for delivery of healthcare. The UK Government declared a nationwide lockdown on 23 rd March 2020, advising members of the public to stay home in order to limit spread of the virus. 3 On 17 th March 2020, a letter from the NHS Chief Executive and Chief Operating Officer was sent out to all NHS trusts, ordering postponement of all nonurgent elective operations from April 15th, in order to increase capacity within hospitals in preparation for the surge in COVID-19 cases. 4 At the time of writing, most elective operations remain postponed, though NHS England have now advised trusts to "Where additional capacity is available, restart routine electives, prioritising long waiters first". 5 There are 49 Oral Surgery (OS) Specialty Trainees in the UK. Trainees must undertake regular clinical assessments along with a number of other requirements in order to pass their Annual Review of Competency Progression (ARCP), and progress towards finally completing the MOralSurg exit qualification. It is therefore logical to hypothesise that trainee experience will suffer as a direct consequence of a reduction in elective procedures. This article is protected by copyright. All rights reserved We carried out a survey to determine the impact of COVID-19 on oral surgery training from the trainees' perspective and explored potential solutions to the outcomes reported. A survey was created by the authors for all OS specialty trainees in the UK using SurveyHero, an online survey platform (www.surveyhero.com). The survey was disseminated by the trainee representative, ensuring that General Data Protection Regulation (GDPR) was maintained and owners of the survey were not given direct names and contact details of trainees. The survey was distributed electronically on Tuesday 14th April 2020 with a deadline of 8th May 2020, consisting of 38 questions (Appendix 1) assessing the following themes: Likert scales (0-10 scales) and free text answers. Analysis was carried out using the survey platform's report function. Data was handled anonymously, and no individual responses were recorded in the results. 46 responses were received out of a total of 49 trainees, however only 34 responses were complete therefore 12 responses were excluded resulting in a response rate of 69%. This article is protected by copyright. All rights reserved Respondents were fairly evenly distributed across 1 st (38%), 2 nd (29%) and 3 rd (27%) training years, and over half of the responding trainees were from London and Yorkshire. 3 trainees (7%) were Out of Programme (OOP). Trainees' views on the impact of COVID-19 on training When asked how concerned they are that training could be affected in the future by COVID-19 (Figure 1 ), 24% of trainees gave a response of 10, indicating extreme concern, and 50% of trainees gave a response of 8 or higher. When asked the same question on how training has already been affected so far, 35% of trainees gave a response of 10. 56% of trainees gave a response of 8 or higher. With regard to the various ways in which training was affected (Figure 2 ), the most common response was cancellation or postponement of study days (94%), while 85% of trainees reported a reduction in logbook procedures. Of the trainees who had study days or courses cancelled, a quarter were rearranged to take place virtually. 43% of responding trainees stated that they had a planned examination or assessment cancelled or postponed. 59% of trainees had already been or were due to be redeployed. The most common destination for redeployed trainees was their local Oral and Maxillofacial Surgery (OMFS) team (41%) though a number were sent to Urgent Dental Care centres (29%) and critical care (18%). Of those redeployed, 47% felt that tasks undertaken during redeployment met competencies in the specialty curriculum. This article is protected by copyright. All rights reserved with drill was an AGP, but 38% felt that a simple forceps extraction was also an AGP. Trainees overall felt that they had good access to PPE in redeployment (96%) and normal training activity (83%), however a fifth of trainees had postponed treatment due to lack of PPE. Health and wellbeing of trainees 38% of OS trainees had self-isolated at the time of survey. Reasons included shielding (38%), occupational health recommendation (6%), personal symptoms (38%) or symptoms of a household member (19%). 9% of trainees had been tested at the time of survey. Trainees indicated high levels of anxiety ( Figure 5 ) with regards to contracting COVID-19 (62% of trainees gave a score of 7 or higher); treating COVID-19 patients (half of the trainees gave a score of 7 or higher) and spreading COVID-19 to their families (79% gave a score of 7 or higher). 48% of trainees felt that anxiety had affected their training capability and 62% felt overwhelmed with information and guidance. This article is protected by copyright. All rights reserved Postponing elective dental care for all patients was essential in reducing transmission of disease, and dentists played a significant role in disrupting the transmission rate of COVID-19. 6 Throughout this national survey, it is clear that the impact of COVID-19 on OS training is significant. By virtue of the nature of a 'surgical' specialty the rate of AGPs is likely to be high, although there remains a debate as to the use of a surgical handpiece, high-speed turbine and piezo-surgical handpiece, and the difference between the aerosol or droplet generation. The authors wish to highlight the continued need for oral surgery and the high demand on oral surgical procedures throughout the pandemic period resulting from the increased number of patients presenting in acute settings with dental abscesses requiring surgical input. This comparatively higher demand for oral surgery highlights the importance of the specialty. As national lockdown measures are gradually lifted, it is currently unclear how long the effects of this crisis will last and when normal service will resume. With the return of routine dentistry, we may see an uptick in the number of unrestorable teeth requiring extraction as a result of delayed presentation. This, in turn, is likely to add to the volume of work required of oral surgeons both in primary and secondary care. With further local lockdowns emerging as a possibility, we explore some of the key areas in which COVID-19 has affected OS trainees. There were high levels of concern among trainees that training would be affected by the pandemic, and these results were comparable to opinions on how severely training had already been affected, indicating that at the time of the survey a significant number of trainees had already experienced or were expecting to experience impact on their training. The specific changes brought about by the impact on training were explored (Figure 2) , highlighting particular components of the training curriculum such as work based assessment completion, logbook procedures and study days/courses. We found that the majority of trainees had been affected in at least one of these ways, which would have a detrimental impact on the trainee's progression. The Joint Committee on Surgical Training (JCST) has now taken this into consideration for all trainees and updated requirements for progression alongside the Statutory Education Bodies (SEB) accordingly and added outcome 10 as a potential outcome of ARCP. 7, 8 Additionally, it must be noted that Oral Surgery training has a normal duration of 3 years. Therefore, any This article is protected by copyright. All rights reserved duration of altered or hindered training will have a substantial impact on overall training time, especially when compared to other specialties with longer training periods. All trainees who were due to undertake their exit examination (MOralSurg) in June 2020 have had this postponed as per the joint JCST and Royal College of Surgeons England (RCSEng) statement. 9 Our results found that this, in addition to postponement of ARCPs, has affected 42% of respondents ( Figure 2 ). Out-of-placement (OOP) trainees also had disruption to their training in this period, and some trainees have had to return to oral surgery training on a less than full time (LTFT) basis in order to complete work left unfinished from their OOP year. Given the issues of disruption to training during this period, we asked participants for suggestions on how the aforementioned training deficiencies could be remedied. Suggestions included an extended training period (76% selected), additional funded study (59% selected) and additional timetabled clinical sessions (50% selected). The practicalities of these suggestions may throw up their own challenges, such as funding or provision of childcare. The authors are also aware that these options mainly focus on deficiencies in clinical activity, but this is a reflection on the practical nature of the specialty. The new outcome 10 accommodates for these deficiencies, however it is yet to be seen how training deficiencies will be remedied on a practical basis. 7 At the time of survey dissemination, 59% of respondents had been redeployed or were due to be redeployed in the future. Redeployment for OS trainees appears to be varied, with the most common settings being an OMFS team (21%), Urgent Dental Care centres (15%) and Critical Care (6%). Though there are national redeployment guidelines available for medical and dental staff, 10, 11 there are no specific guidelines for OS trainees, and any changes to job plans have tended to be on a trust-by-trust basis. Of the trainees who had been redeployed, the tasks given to them in new roles varied extensively. Less than half of the redeployed trainees felt that these tasks met competencies in the specialty curriculum, but with the understanding that this is an unprecedented event requiring flexibility of all involved, it is commendable that trainees are searching for avenues in which to further their training. This article is protected by copyright. All rights reserved Treating patients OS trainees showed awareness of current guidelines at the time of survey distribution, with 91% of trainees having knowledge of the BAOS and BAOMS position paper guidelines. There was, however, variance in the guidance followed by individual trainees. The guidelines most commonly adhered to were the BAOS/BAOMS position paper and local trust guidelines (62% each). This suggests that trainees are aware and influenced by specialty bodies such as BAOS and BAOMS. At the time of survey dissemination, there was a disparity between the BAOS/BAOMS and PHE guidance regarding AGPs, with the BAOS/BAOMS paper advising that any intraoral examination or treatment should be considered an AGP. This advice was derived from findings that OMFS and ENT surgeons were some of the highest risk groups among all medical specialties. [12] [13] [14] Since this survey was carried out, guidance has been rapidly evolving due to emergence of new data and evidence. From the findings in this survey, it would appear that OS trainees will be able to respond to this dynamic flow of new information well, though it should be noted that many trainees (61%) have felt that there is an overwhelming amount of information and guidance. The AGP has become somewhat of a buzzword during the COVID-19 pandemic. AGPs have been identified as more likely to cause spread of coronavirus than non-AGPs, due to bio-aerosol production. Some sources have found that dental procedures have the ability to deposit aerosol up to 4 metres away from the source, with high contamination detectable up to 1.5 metres away 15 94% of trainees felt that surgical removal of a root using a surgical handpiece is an AGP. However, for some other procedures, there is evidently some confusion as to what constitutes an AGP (Figure 4) . 38% of trainees felt that a simple extraction is an AGP. 47% of trainees stated that the definition of an AGP is not clear, and this is likely due to conflicting messages from PHE and BAOS/BAOMS. 16, 17 In addition, classifying the risk as to whether or not a procedure is an AGP will determine the type of PPE required. This is another source of confusion for trainees with over a quarter of trainees feeling that guidelines on PPE were unclear. 17, 18 The lack of clarity surrounding AGPs highlights the need for further research in order to characterise their risk within dentistry. Health and wellbeing At the time of survey dissemination, 38% of trainees had been required to self-isolate, although only 9% of trainees had tested positive at the time. 24% of trainees had reported COVID-19 symptoms but had not been tested. Though these findings are concerning, the authors are aware that data was collected around the same time that the government was attempting to ramp up testing of symptomatic individuals, 19 which would explain the lack of testing at the time. Currently, antibody testing has been rolled out to NHS staff 20 although there is some variability between Trusts, with PCR testing more readily available for new suspected cases. This has undoubtedly reassured many trainees, though doubts are still raised over the specificity and sensitivity of the testing methods. OS trainees reported high levels of anxiety with regards to COVID-19 ( Figure 5 ). Results indicate that trainees have more anxiety that they may pass the virus onto their families rather than treating patients with, and contracting COVID-19. Almost half of the trainees felt that increased anxiety had affected their training capability. There should be a distinction made between this and clinical or logistical reasons for training deficiency; trainees feel that training is hampered by anxiety surrounding treatment of patients and the potential consequences of this. The free text responses to "What, in your opinion, would help reduce these anxieties?" were telling. Many trainees commented on inadequate PPE as a source of anxiety, along with lack of widespread testing. The psychological burden on healthcare workers during the pandemic is of paramount importance. 21 Some trainees have commented that they have taken the decision to isolate themselves from their families, knowing that they are at high risk for contracting the virus. This prolonged isolation along with other sources of anxiety mentioned will likely have an effect on the mental health of trainees, and the authors advise that from a government to a local trust level, adequate measures should be undertaken to safeguard the psychological wellbeing of OS trainees along with the wider healthcare community. OS training has felt the full impact of COVID-19. Trainees have suffered a significant reduction in clinical activity which has hindered progression, and many will, understandably, be left wondering how this deficiency may be resolved. Through this study, the authors have identified some options in this regard, but it will be up to the deaneries and other stakeholders to decide on the way forward. This article is protected by copyright. All rights reserved This difficult period has created a variety of opportunities within redeployment for some and many will have acquired additional skills and knowledge which will be transferable to their chosen careers. In addition, the reduction in face-to-face contact may fuel a movement to bring clinical practice and training into the 21 st century with more emphasis on using technology such as video consultations and use of virtual media to deliver education. A recent example of this is the annual BAOS trainee study day held virtually for the first time. One aspect that was not addressed in this survey was the disparate impact of coronavirus on Black, Asian and Minority Ethnic (BAME) individuals. At the time of survey dissemination this data was not collected, however it has come to light that the BAME community are at a higher risk of morbidity and mortality from COVID-19 infection. 22 The effect on OS trainees is unknown at this point, but the authors hypothesise that BAME trainees may feel higher levels of anxiety with regards to coronavirus which may affect their training to a greater degree than non-BAME trainees. In addition, a letter to all Trusts from the Chief Executive and Chief Operating Officer of the NHS 5 has prompted some Trusts to pull at-risk BAME staff from the frontlines, which would again disadvantage BAME trainees by reducing clinical activity. In summary, the findings of this survey outline the trainees' experiences and how they feel their training should adapt to replace the deficits experienced during the COVID-19 pandemic. With most trainees suggesting an extension of training period, there may be potential impact on both ends of the specialty training pathway, including a potential reduction in numbers of new training positions available for the upcoming year, as well as high competition for post-CCST employment opportunities. This survey was conducted at a relatively early stage of the pandemic, and there is likely to be much uncertainty in the months ahead as it progresses. For this reason, another survey in the near future could offer an insight into whether the perspectives and opinions of Oral Surgery trainees have remained the same or changed significantly. In the meantime, the authors alongside OS trainees await decisions on specialty training in the midst of the COVID-19 pandemic. 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