key: cord-0881046-w95qr2vr
authors: Rodriguez Santos, Fanny; González Salazar, Esteban; Dietrich, Agustin; Cano Busnelli, Virginia; Roni, Carolina; Facioni, Clara; Mutchinick, Agustina; Palavecino, Martin; Beskow, Axel; Figari, Marcelo; Pekolj, Juan; de Santibañes, Martín
title: Teaching Strategies and Outcomes in 3 Different Times of the COVID-19 Pandemic Through a Dynamic Assessment of Medical Skills and Wellness of Surgical Trainees
date: 2021-08-24
journal: Surgery
DOI: 10.1016/j.surg.2021.08.018
sha: bd20241337549ac59b27e11fd0bec479da743c98
doc_id: 881046
cord_uid: w95qr2vr

BACKGROUND: COVID-19 pandemic had a substantial impact on surgical training programs.. This study describes the teaching strategies and outcomes in 3 different times of the COVID-19 pandemic through a dynamic assessment of medical skills and well-being of trainees. METHODS: Three surveys were administered during 2020 to General Surgery residents and fellows in a University Hospital in Argentina. Perceptions on the impact of COVID-19 were described. The stress rate and risk factors were analyzed. RESULTS: The study included 124 answers; 59% were men. 82% of trainees reported concerns about the loss of surgical skills in early phase 1. Time spent with academic activities increased in 94.5% of the cases. Due to the prompt implementation of changes, by the end of 2020, 73% participated in a greater number of procedures (p=0.003); Personal Protective Equipment (PPE) use related problems dropped from 40 to 14% (p=0.031) and the lack of adequate spaces where trainees could express reduced from 28% to zero. Half of the trainees felt stressed and 18% required psychological assistance; reporting problems with PPE use was identified as a risk factor (p=0.012). CONCLUSIONS: Assessing trainees’ perceptions at 3 different times of the COVID-19 pandemic enabled the implementation of dynamic changes. The negative impact on surgical training was partially offset by the optimal use of virtual learning. Half of them felt stressed, identifying problems in the use of PPE as a predisposing factor.

Nowadays, COVID-19 has infected more than 100 million people worldwide and has caused more than 2 million deaths. 1, 2 The pandemic has broken health-care systems, prompting world leaders to take extraordinary social, political, and economic measures with an uncertain outcome. Moreover, thousands of health professionals around the world contracted the SARS COV-2 infection, suffering severe clinical illness in a considerable percentage and even death.

In addition to the risk of being infected with COVID-19, overwork has caused physical, mental and emotional problems in health professionals. [3] [4] [5] [6] Consequently, healthcare centers were forced to make profound changes in their activities with the main objective of ensuring patient care while preserving the safety and health of their professionals. In this context, university hospitals had the additional challenge of guaranteeing and supervising the fulfillment of the academic and teaching activities of their physicians-in-training. While many strategies were suggested to solve educational demands of general surgery training programs in the midst of this sanitary emergency [7] [8] [9] [10] [11] , the first step to achieve their effective adaptation and face the subsequent phases of the pandemic was to know the opinions and concerns of residents and fellows.

Thus, the aim of this study is to describe the teaching strategies and outcomes in 3 different phases of the COVID-19 pandemic through a dynamic assessment of medical skills and well-being of surgical trainees at a University Hospital in Argentina. Surgeons (with high interest in Medical Education [3] ) and the Chiefs of Residents (3). In order to have a more comprehensive perspective, three representatives from different educational areas of the University also joined: education (1), psychopedagogy (1) and sociology (1) .

Starting from the hypothesis that acquiring ongoing knowledge of the impact of the pandemic in the residency would allow for the implementation of measures to tackle its detrimental aspects, therefore enabling a better adaptation to an unprecedented context, the Task Force carried out the design, implementation and analysis of three surveys in different times of the pandemic.

Anonymous online surveys were created and administered using Google TM forms tool during the months of May, July and November 2020. The surveys (annexed 1) included a mean of 47 questions concerning seven main fields related to the impact of COVID-19 in surgical education: (1) profile of participants; (2) surgical training; (3) academic performance; (4) supervision and evaluation; (5) habits and relationships; (6) mental health and emotional state and (7) future perspectives. All surgeons in training from the HIBA GSS were invited to J o u r n a l P r e -p r o o f participate voluntarily by email and were included in the study analyses. A deadline of 15 days was considered for participants to complete the survey, and a reminder was sent subsequently.

This study was approved by the ethics committee of the IUHIBA (IRB Approval No 0026-20).

The same cohort of residents and fellows responded to all three surveys. A new curricular year began on October 1, 2020 and incoming residents were not included in the third survey.

A preliminary analysis was carried out after each survey to detect red flags and act accordingly as part of the dynamic work carried out by the Task Force. This final report shows the results of the 3 measurements. Station, TX, USA). All tests were 2-tailed, with significance established at p < 0.05.

The study included 124 answers analyzed from 3 surveys with a response rate between 65% and 92% (Table 1) .Fifty nine percent of the responders were men, with a mean age of 29 years.

The HIBA bed occupancy by COVID-19 patients at the time of the 3 surveys were administered is shown in Figure 1 , as well as the number of COVID-19 cases and deaths in the region and the country.

In phase 1 surgical activity was restricted to urgent cases in a situation that was progressively recovered throughout the year. Eighty two percent of trainees (45/55) reported concerns about the loss of surgical skills in the first survey. A contingency surgical simulation program was established and trainees were allowed to operate on PCR negative patients according to a safety algorithm. 7 In addition, the curricular year was postponed for 4 months and fewer physicians were admitted into Residency and Fellowships programs. 12 By November 2020, 73% (16/22) of residents and fellows reported having participated in a greater number of surgeries than at the beginning of the pandemic (p = 0.003). In addition, 45% stated to regain their usual work rhythm, and while 32% noted to be working less, 23% perceived that they increased their activity compared to the pre-pandemic period. In accordance with the reduction in the number of surgeries performed in 2020 by the HIBA GSS due to the pandemic, residents (Table 2 )

At the beginning of the pandemic, 95% (52/55) of trainees had increased the time spent with academic activities and 82% (46/55)) reported spending more than 3 hours per day, a percentage that dropped to 27% (6/22)later in the pandemic (p<0.01). In the first survey, 71%

(39/55) declared to be involved in two or more research studies and 6 months later, 82% (18/22) finished or published at least 1 of them. New virtual interactive lectures and courses schedule were carried out with 75% (41/55) of acceptance. (Table 2 )

Only 60% (33/55) felt adequately supervised during the first months of the pandemic and 58% (32/55) did not perceive evaluations in their performance by that time. Although highlighting larger academic supervision, trainees mentioned remarkable differences in the ED work, which motivated the implementation of a formal evaluation instance after the on-call

week shift and a global evaluation through a semi-structured individual interview. Towards the end of the year, for 45% (10/22) the degree of evaluation had remained the same and for 36% (8/22) it had increased; while 59% (13/22) considered having been supervised in a similar way, 32%(7/22) perceived an increase in supervision.

Fifty nine percent (20/35)were forced to abandon a sport and 18%(6/35) a medical training course. Instead, they incorporated new habits such as physical activity at home (34), cooking (39) or starting a virtual medical course (18) , foreign language classes by Zoom ® (13), yoga or meditation (13) and stated that several of these new activities will continue in the long J o u r n a l P r e -p r o o f term. While 44% (24/55)of trainees spent the quarantine with their partners, 29%(16/55) stayed alone. On the one hand, 65 to 80% manifested losing contact with colleagues or loved ones, but on the other, 40 to 46% felt their ties to others close to them, strengthened. As a consequence of the pandemic, 74% (34/55) had to stay away from their family and almost a year later only 50% (11/22) were able to meet them again.

Communication was rated as sufficient in more than 90% of the cases. However, in the first survey 27% (15/55) ) of the residents and fellows reported not having opportunities to share their concerns; a percentage that dropped to 0 in the last survey. They identified the use of WhatsApp ® groups and attendance at virtual meetings with the Chiefs of Residents, Supervisors and the Chairman as the spaces where they could express themselves.

In early phases of the pandemic, when residents and fellows were asked about how they felt as healthcare professionals, 53%(29/55) admitted to be frustrated and 38% (21/55) safe. However, they also highlighted positive aspects such as developing introspective learning, imagination, perspective and resilience, appreciating time at home, caring for family members and incorporating healthier habits.

Seventy seven percent of the trainees considered their feedback was taken into account to implement changes in the contingency and 82% (18/22) 

The surveys allowed the Task Force to detect red flags and implement measures as well as to assess their impact. Table 3 summarizes the most important changes implemented according to the trainees' feedback.

We have presented the results of 3 surveys for a dynamic evaluation of the educational situation of surgical trainees and their perceptions at different times of COVID-19 pandemic during 2020. We selected 3 main findings from the analysis with respect to surgical training, academic performance and personal experiences.

As previously described, the pandemic has had a negative impact on the surgical training of residents and fellows. [13] [14] [15] [16] [17] Our trainees reported being aware of the loss of surgical tasks kills in 81.8% of the cases. Although there is no substitute for hands-on learning through operative experience, surgical simulation strategies have been implemented to prevent decay of surgical skills. [18] [19] [20] [21] [22] A contingency simulation program was established with a schedule considering the shift weeks and quarantine. Despite the postponement of the curricular year and the reduction of admission to residency and fellowships programs, the number of surgical procedures performed was reduced compared with previous years.

In many institutions, residents were reassigned to other departments to support COVID-19 efforts. [23] [24] [25] Although elective rotations outside the hospital were cut, our trainees did not perform duties different from their usual clinical activities. The only new task added was to perform the COVID-19 swab test on surgical patients admitted to the ED.

On the other hand, the effect on academic performance was the opposite. The mandatory quarantine allowed the rise of virtual education as an opportunity to compensate for J o u r n a l P r e -p r o o f the loss of real-time surgical learning. 15, 20, 26, 27 In our Institution a new schedule of virtual interactive lectures was conducted with an acceptance of more than three quarters of the residents. They considered it very positive to have the protective time to carry out and publish research projects in which they were involved. As in other surveys, participants mentioned their interest in continuing the recently adopted virtual activities after the pandemic. 26, 28 Not only with regard to surgical training, residents and fellows also reported negative effects of the COVID-19 pandemic on personal experiences and mental health. [29] [30] [31] [32] [33] A national survey from the USA mentioned that three-quarters of surgeons who began their professional careers mentioned inadequate access to PPE and also a large number of them reported an increase in symptoms of depression and burnout, pointing as risk factors being a woman, caring for known positive patients for COVID-19 or having inadequate access to PPE. 34 In our surveys, more than half of residents and fellows reported feeling stressed in the first two surveys and 18% admitted to needing psychological assistance due to the pandemic. While our trainees mentioned sufficient availability of PPE in more than 90% of the cases, problems related to indication of PPE level or dressing instructions were reported. These PPE-related problems were the only risk factor associated with stress, highlighting the importance of providing adequate training and protocols for use of PPE. 

The authors have no related conflicts of interest to declare.

None of the authors of this manuscript has any direct or indirect commercial financial incentive associated with the publication of this paper. The funding involved in this work has been provided by our institution. footnote: Q= question; S1= Survey 1; S2= Survey 2; S3= Survey 3 ** Due to a pandemic, the number of vacancies for residents and fellows was reduced 

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