key: cord-0840421-c1yyax0w authors: Paskal, Adriana M.; Jaremków, Paweł; Małyszczak, Paulina; Paskal, Wiktor; Wójcik, Korneliusz; Opyrchał, Jakub; Paul, Marek A. title: Impact of COVID-19 pandemic on plastic surgery training in Europe date: 2021-12-01 journal: J Plast Reconstr Aesthet Surg DOI: 10.1016/j.bjps.2021.11.090 sha: 8306bb7b5fead9a27349d05160bdc7e45af614ac doc_id: 840421 cord_uid: c1yyax0w BACKGROUND: The COVID-19 pandemic has disrupted the functioning of global society and healthcare systems, including surgical departments. We aimed to assess alterations in plastic surgery training in Europe during the COVID-19 pandemic. METHODS: A 34-question survey was emailed in January and February 2021 to 54 National Associations of Plastic, Reconstructive and Aesthetic Surgeons throughout European countries. The questions concerned the general profile of plastic surgery trainees, plastic surgery department, and training organization during the COVID-19 pandemic and its influence on respondents’ health. Acquisition of responses was finalized at the end of February 2021. RESULTS: All 71 of the respondents reported alterations in planned courses/workshops/conferences. Organizational changes included team rotation 62%, followed by redeployment to another department 45.1%. Reduction in admissions to the plastic surgery departments was more significant during the 1(st) wave, than the 2(nd) wave of COVID-19 pandemics. During the interim period, admission restrictions were proportional to the infection number. The most frequently reported surgical procedures performed were skin cancer surgeries, trauma, and burns (79%, 77%, and 77%). The majority, 62% of the respondents, noticed the negative impact of pandemics on training; 53.5% think their manual skills and clinical knowledge may deteriorate because of the pandemic. Respondents noticed that their mental (50.7%) and physical (32%) health worsened, along with feeling more stressed in general (57%). CONCLUSION: The COVID-19 pandemic limited plastic surgery departments’ activities and implementation of the plastic surgery training program in all European countries involved in our study. The Covid-19 pandemic has disrupted the functioning of global society and healthcare systems. The continuing dilemmas have changed the surgical activities in many countries, including reshaping the work organization in surgical departments, redeployment, change in number and types of procedures performed, restricted access to operating theaters, and changes in treatment protocols. [1] [2] [3] [4] [5] The ongoing Covid-19 related epidemiological situation has affected the organization and implementation of plastic surgery training worldwide. [6] [7] [8] [9] [10] [11] The residents had to postpone exams and fellowships, partial transfer of education to online platforms, a noticeable loss of time of training, and expected prolongation of overall training. [6] [7] [8] [9] [10] Besides, this complicated situation also affects their mental health and personal life. Increased anxiety levels seem to 3 result from the risk of infection, concerns regarding the loss of operational experience, and uncertainty about the future of their residency. 12 To the date many studies have been published on plastic surgery residents' training during the COVID-19 pandemic. [6] [7] [8] [9] [10] [12] [13] [14] They all show a wide variety of problems within an examined country, but none of them is related to the situation in Europe as a whole. As epidemiological situation varies between the countries it is essential to understand the concerns of training systems in the European continent's conditions. Therefore, we decided to survey plastic surgery training and the wellbeing of plastic surgery residents during the pandemic. This article aims to identify issues, check whether they are consistent with the literature, and propose solutions, to improve the training of plastic surgery residents and the plastic surgery departments' organization. 2 15, 16 Visualization was prepared in GraphPad PRISM 9.1, (CA, USA) and Datawrapper (Berlin, Germany). Data on COVID-19 cases number were acquired/retrieved from https://ourworldindata.org/coronavirus. 16 Fisher's exact test, and R-spearman correlation were used to analyze the data (GraphPad PRISM 9.1, CA, USA). The General profile of respondents 52,1% of respondents (57/71) were in the 25-30yo range during the survey, followed by 38% (27/71 ) in the 30-35yo range. Respectively 5,6% (4/71) and 4.2% (3/71) declared 35-40yo, 40-45yo range. 49,3% of respondents were within the 1st-3rd year of residency (25,4%, 15,5%, and 8,5% respectively), followed by 15,5% of participants in the 4th and 5th year. Finally, 19,7% of participants were finishing their training (14/71) ( Fig. 1) The survey has been completed by representatives of 13 European countries, for details see Total COVID-19 cases/million were correlated with reported reduction of admission in respondents' countries in each of three phases of COVID-19 pandemic (first wave, the interim period and second wave). Admissions' limitation in both waves revealed insignificant correlation with total cases/million citizens (r=0,053, p=0,66 and r=0,159 p=0,19). However, during the interim period the admissions' rates limitation correlated positively with total cases/million (r=0,318, p=0,007). The three most frequently reported surgical procedures performed during first and second wave were skin cancer surgeries, trauma, and burns (79%, 77% and 77%) ( Appendix Table A2 . Both first and second wave of the pandemic significantly affected admissions to plastic surgery departments in all countries involved in the study. During the first wave, every department limited the admissions, while during the second wave no restrictions were needed in some departments (7.04% respondents). It may suggest better preparation for the secondwave and using protocols developed during first one. The level of restrictions was proportional to the extent of SARS-CoV-2 infection number only during the interim period. During the COVID-19 pandemic, previously established work organization in plastic surgery departments was disturbed, and work focused on emergency cases, postponing elective reconstructions and aesthetic procedures 7,10,13,17 . Our survey showed that the treatment during the pandemic concentrated on trauma, burns, and skin cancers. 73.2% of our respondents reported shortening of patients' stay or changing the type of anesthesia from general to local (40.8%) in the departments, which may be dictated by minimizing the risk of contamination. 4 Testing patients before the admission protects the healthcare workers from COVID-19 exposure and decreases the risk of interpatient transmission. The majority of our respondents indicated that either a PCR test or an antigen test was required before admission (80.3%). In order to avoid situations when the whole staff must be quarantined, it is essential to change the work organization. The most common change/difference mentioned by Armstrong et al. is team rotation, which was confirmed in our survey (62% of respondents). 3 It was reported that plastic surgeons had to treat the SARS-CoV-2+ patients. 45.1% of our respondents were transferred to another department, and 35.2% had a separate section for patients with COVID-19, created within the Plastic Surgery Departments. Nevertheless, in this unpredictable situation, innovative management can allow suitable department reorganization. 18 Although 74.6% of our respondents had to treat the SARS-CoV-2+ patients, most of them (57.7%) weren't offered any training dedicated to managing such patients. Lack of mandatory training in treating SARS-CoV-2+ patients before redeployment to ICU departments may increase anxiety levels among residents. While access to PPE is fundamental, 36,6% of respondents indicated that the access, the amount, or protection level of it was insufficient. 19 One of the utmost issues was the difficulty in completing the residency training, mentioned by Armstrong et al. and Cho et al. 3, 19 The decreased number of operations due to COVID-19 is among the greatest concerns of surgical residents. 20 As they felt the lack of proper training (Zingaretti et al.) . 6 It is substantial to provide residents with substitutive activities in the department. Even though 46% of our respondents spent more time on self-study during the pandemic than before, 40.8% of them were left without any additional educational support in their departments. 62% of respondents mainly noticed the pandemic's negative impact on their training, and 53.5% thought that their manual skills and knowledge could be less adequate in the future. Hamidian et al. mentioned many potential methods to fill the lack of training: relevant reading materials, videos recorded during operations, training on mannequins, animals, and others. 7 Other studies show the benefits of online education. 6, 9, 21 The most frequent additional educational activity reported by the respondents was to attend on-line webinars (39.4%). Even though telemedicine may benefit plastic surgery departments' work, more than 50% of our respondents did not use it at all. Only 1,37% of them trained with cadaver dissection and only 2,74% watched intraoperative videos. It is worth mentioning that no spe-cialized devices are needed to record operating procedures, as GoPro cameras are used with great results. 22 COVID-19 pandemic has also affected other aspects of residents' lives and their stress levels increased. 12 The majority of the respondents felt more stressed in general (57.7%). 50,7% reported worsening of their mental and 32,4% physical health. Despite that, only 9,59% of them tried mental health support, and only 4,1%/three benefited from it. Regular online meetings addressing residents' wellbeing can be organized to improve their general mental health. 23 A pandemic provides extra time-off work due to isolation, quarantine, lockdown, team rotation, or limited hospital admissions, when one can focus on other activities. According to the survey, our respondents used it well, spending it mostly on household duties, hobbies, passions, spending quality time with family, learning new skills, or doing physical activities. Leisure time activities are necessary as they decrease the risk of burnout, especially when treating COVID-19+ patients what is more stressful, work-demanding, and poorly related to plastic surgery. 24, 25 Despite high variance of responses within countries and low response rate, our results reflect plastic surgery residents' situation in individual countries mentioned previously in the literature. Undoubtedly, the COVID-19 pandemic limited plastic surgery departments' activities, residents' work, and implementation of plastic surgery residency training programs in all European countries involved in our study. The limitations slightly varied between the countries, as the epidemiological situation differed. The modifications in the organization of work forced the residents to use other, additional forms of training. Webinars and self-education have become an indispensable part of education. The responses/answers from 13 countries reflect the situation of plastic surgery residents in Europe, described in previously conducted research regarding the situation in individual countries. None. Anonymous survey study does not bear the characteristics of a medical experiment and does not require an opinion Bioethics Committee in Poland. None. Covid-19: Initial experience of an international group of hand surgeons A plastic surgery service response to covid-19 in one of the largest teaching hospitals in europe Restarting plastic surgery: Drawing on the experience of the initial covid-19 pandemic to inform the safe resumption of services Surgical training during the covid-19 pandemic: Challenges and opportunities for junior trainees The impact of covid-19 on plastic surgery residency training Impact of the covid-19 pandemic on the education of plastic surgery trainees in the united states The impact of covid-19 and lockdown on plastic surgery training and practice in india Plastic surgery training during covid-19: Challenges and novel learning opportunities The impact of covid-19 on the plastic surgery activity in a high-complexity university hospital in brazil: The importance of reconstructive plastic surgery during the pandemic Covid-19. The implications for surgical trainees in the delivery of care and training Exploring the Impact of COVID-19 on Progress Towards Achieving Global Surgery Goals Covid-19: Initial experience of an international group of hand surgeons A plastic surgery service response to covid-19 in one of the largest teaching hospitals in europe Restarting plastic surgery: Drawing on the experience of the initial covid-19 pandemic to inform the safe resumption of services Surgical training during the covid-19 pandemic: Challenges and opportunities for junior trainees The impact of covid-19 on plastic surgery residency training Impact of the covid-19 pandemic on the education of plastic surgery trainees in the united states The impact of covid-19 and lockdown on plastic surgery training and practice in india Plastic surgery training during covid-19: Challenges and novel learning opportunities The impact of covid-19 on the plastic surgery activity in a high-complexity university hospital in brazil: The importance of reconstructive plastic surgery during the pandemic Covid-19. The implications for surgical trainees in the delivery of care and training Stress and the surgical resident in the covid-19 pandemic The impact of coronavirus disease 2019 on plastic surgery training: The resident perspective Adapting plastic surgery residency training during covid-19: The experience of a chilean university hospital The europe second wave of covid-19 infection and the italy "strange" situation Coronavirus pandemic (covid-19) Impact of covid-19 outbreak on plastic surgery: Taken precautions, distribution of surgical procedures and changes in admissions to outpatient clinic From chaos to a new norm: The birmingham experience of restructuring the largest plastics department in the uk in response to the covid-19 pandemic The early effects of covid-19 on plastic surgery residency training: The university of washington experience Stress and the Surgical Resident in the COVID-19 Pandemic Emerging role of online virtual teaching resources for medical student education in plastic surgery: Covid-19 pandemic and beyond Optimizing intraoral surgery video recording for residents' training during the COVID-19 pandemic: Comparison of 3 point of views using a GoPro Impact of COVID-19 on a plastic surgery residency education program: Outcomes of a survey Burnout phenomenon in U.S. plastic surgeons: risk factors and impact on quality of life Factors Associated With Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease Admission rates were exhibited as % of average admission before the COVID-19 pandemic A) COVID-19 infections in 1st wave, interim period and 2nd wave in surveyed countries expressed as total cases/million citizens [data source B) Median admissions' rates in surveyed countries in first wave, interim period, and second wave of COVID-19 pandemic (median ± range) We gratefully acknowledge the contribution of all survey respondents, who took valuable time apart from their daily activities to participate in this work. We are also grateful to all mentors who contribute to the international online education of plastic surgery residents during the COVID-19 pandemic.