key: cord-0891023-v2rbrhb6
authors: De la Cerda-Vargas, María F.; Stienen, Martin N.; Soriano-Sánchez, José A.; Campero, Álvaro; Borba, Luis A.B.; Nettel-Rueda, Barbara; Castillo-Rangel, Carlos; Ley-Urzaiz, Luiz; Ramírez-Silva, Luis H.; Sandoval-Bonilla, B. A.
title: Impact of the COVID pandemic on working and training conditions of neurosurgery residents in Latin America and Spain.
date: 2021-03-06
journal: World Neurosurg
DOI: 10.1016/j.wneu.2021.02.137
sha: e25dd3b8f6174c38abab57b53f7061fcc87739a2
doc_id: 891023
cord_uid: v2rbrhb6

Background The COVID-19 pandemic has exerted a significant impact on health-care workers. Recent publications have reported the detrimental effects of the pandemic on neurosurgery residents in North America, Asia and Italy. However, the impact of the pandemic on neurosurgical training in Latin America and Spain has not been yet reported. In the present report we describe effects of COVID-19 on training and working conditions of neurosurgery residents in these countries. Methods An electronic survey with 33 questions was sent to neurosurgery residents between September 7, 2020 to October 7, 2020. Statistical analysis was made in IBM SPSS Statistics 25. Results 293 neurosurgery residents responded. Median age was 29.47 ± 2.6 years, 79% (n = 231) were male. 36.5% (n = 107) were of residents training from Mexico. 42% surveyed reported COVID-symptoms and two (0.7%) received ICU care. 61.4% of residents had been tested for COVID and 21.5% had a positive result. 84% of the respondents mentioned persisted with same workload (≥70 hours per week) during the pandemic. Most of residents from Mexico were assigned to management of COVID patients compared to the rest of the countries (88% vs 68.3%, p <0.001); mainly in the areas of medical care (65.4% vs 40.9%, <0.001), mechanical ventilators (16.8% vs 5.9%, p=0.003) and neurological surgeries (94% vs 83%, p=0.006). Conclusion Our results offer a first glimpse of the changes imposed by the COVID-19 pandemic to neurosurgical work and training in Latin America and Spain, where health systems rely strongly on resident workforce.

The recent coronavirus disease is an infection of the respiratory tract, caused by the SARS-COV-2 virus 1, 2 . It is a potentially fatal disease with a reported mortality of 3-4% by the WHO 3 . COVID-19 disease represents a challenge for health-care personnel, including neurosurgeons and neurosurgery residents.

The quality of resident training has been negatively affected as a result of the COVID-19 pandemic [4] [5] [6] [7] . Neurosurgery residents face a great challenge, especially those who work in hospitals caring for a high number of COVID-19 patients. Strategies to increase the capacities of intensive care units (ICUs) include a reduction of all -especially elective -surgical activities 6 . Many neurosurgical centers have postponed their elective surgeries, which lowers the exposure of residents with typical neurosurgical diseases and their treatment 4, 5, 8, 9 . Several programs have reduced the number of residents for neurosurgical activities, ordering the remaining trainees to stay at home 7 . Nearly all neurosurgical programs around the world have switched their academic face-to-face meetings to online communication in an attempt to reduce physical contact.

Few authors have yet evaluated the impact of COVID-19 on neurosurgical residents (see Annex 1). ence, it was our objective to survey the impact of this pandemic on theoretical education and training strategies, practical exposure to neurosurgical procedures and management of neurosurgical and COVID-19 patients, as well as on health of neurosurgery residents in Latin America and Spain.

The survey was created using Google Forms Survey. It was based on previous studies on COVID-19 and its impact on neurosurgical practice and residents (see Annex 1) . But adapted in terms of content and response options to our particular interests. The final survey consisted of 33 questions organized in 4 sections (Supplemental Appendix 1).

The questions referred to demographic data of residents, postgraduate year (PGY), countries of origin and of neurosurgical training, academic strategies and resident workload, the guidelines in neurosurgical and non-surgical management of COVID-positive patients, the effect on emergency and/or neurosurgical procedures, the use of personal protective equipment (PPE), the supervision that residents received for the management of COVID patients and the areas where residents were assigned for nonneurosurgical management of COVID patients. Besides the impact of the pandemic on neurosurgery residency, we also assessed its impact on both physical and mental health of residents.

Survey links to versions in Spanish and Portuguese language were distributed via email to different training programs to the aforementioned countries between September 7, 2020 and October 7, 2020. Project collaborators included neurosurgeons involved in the development of academic programs in their respective countries and contributors to both EANS (European Association of Neurosurgical Societies) and FLANC (Latin American Neurosurgical Societies), which helped with the distribution of the survey among certified neurosurgical programs. All results were collected in a Google forms database.

Approximately 90% of surveyed residents reported that outpatient clinical activities, academic meetings and conferences were canceled (Table 2) . 43.7% (n = 128) reported an increase in academic activity while 32% (n = 94) mentioned that it decreased, and 17% (n = 50) answered that it remained unchanged. Teleconferences were the most frequent strategy described among respondents (87.1%, n = 256) ( Table 2) . Of the residents who responded spending more than 10 academic hours per week (AHW) prior to COVID (n = 44), 52.3% of those surveyed persisted with the same academic time during the pandemic (p <0.001) (Figure 4 ).

Mexico reported a greater number of AHW (>10 hours) prior to COVID compared to other countries (57% vs 43%, p=0.002). However, during COVID-19, the other countries reported a greater AHW than Mexico, but without being statistically significant (52% vs 47%, p=0.051). According to the type of hospital, prior to COVID-19, the medical specialty hospitals presented a greater AHW compared to the other types of hospitals (43%, p=0.003), but during the pandemic the general hospitals spent more AHW (47.5%, p=0.004), this is probably because residents of medical specialty hospitals presented a higher percentage of positive COVID test compared to other hospitals (57.1%, p <0.001) which did that sick residents require disability due to the disease. Regardless of the type of hospital, the majority were transformed into COVID hybrid hospitals (61% of the Exclusive Hospitals for neurological diseases, 95% of the medical specialty hospitals and 90% of the General Hospitals, p <0.001), in addition 83% of respondents belonging to hybrid COVID hospitals mentioned spending more than 10 AHW compared to other hospitals (p <0.001) ( Table 4) .

Three quarters (76%; n = 222) of participants reported that neurosurgery residents take part in the management of COVID-19 patients at their hospital. In 84.7% (n = 256) of the cases, they are assigned to neurological surgeries, 49.8% (n = 146) assigned to medical care, 32% (n = 93) to the emergency area and 28% (n = 83) to the ICU and 10 % (n = 29) helped in the management of mechanical ventilators. Only 57% (n = 167) of residents were supervised in the management of COVID patients in both surgical and medical procedures. 51.5% (n = 151) answered that appropriate PPE was provided at their center, while 46.4% (n = 136) reported insufficient equipment. 78.2% (n = 229) of the residents considered that provided training for the use of PPE was adequate. A 45.4% of residents reported being uncomfortable while handling COVID-19 patients and 55% responded that they did not feel competent in the management of these patients (table 2) .

Although 87.4% (n = 256) of those surveyed answered that their hospitals performed surgeries on patients with COVID, approximately 92.4% (n = 276) residents reported that elective surgeries were postponed at their hospital. Two responders (0.7%) answered that emergency surgeries were canceled (Table 2, Figure 2 .) 98% of the respondents answered that surgeries decreased greater than or equal to 50% and despite having a sufficient EEP, elective surgeries decreased in more than 50% of those surveyed (51.2%, p=0.044). The workload during COVID was inversely related to the number of elective surgeries, since 84.3% (n = 242) of J o u r n a l P r e -p r o o f the residents who persisted with a workload of ≥70 hours per week reported a reduction in surgeries However, the decrease in scheduled neurosurgery did not prevent residents from getting sick: 1.4% (n = 4) of the residents had respiratory disease that warranted hospitalization (p=0.006) and one resident (0.3%) required management in ICU (p<0.001) (see table 5 ).

Four out of ten (42%; n = 123) residents reported presenting symptoms compatible with COVID-19 infection.

The main symptoms were headache (30%), muscle and body pain (27%), and cough (24%) (Appendix 3).

Fever was only reported in 20% of the cases. Hospitalization and intensive care were required in 5 (1.7%) and 2 (0.7%) cases, respectively. At the moment of the survey, 180 residents (61%) have been tested for COVID-19 and 21.5% (n = 63) have obtained a positive result ( Table 2 ).

In the statistical analysis, it was observed that a positive PCR test for COVID-19 was presented more frequently in Hospitals of medical specialties (57.1%, p <0.001), and 8% (n = 5) of these patients presented a severe respiratory disease that warranted hospitalization (p <0.001). Having sufficient PPE or receiving adequate training in the use of PPE was not enough to protect residents from the disease (46% of residents with sufficient PPE, p <0.001, and 81% of those who received PPE presented a positive PCR for COVID-19, p=0.010). 94% of the patients with symptoms had a positive PCR (Table 6 ). In addition, female residents had a higher percentage of positive PCR than men (27.4% vs 20%, p=0.467) and a higher percentage of respiratory disease that warranted hospitalization (3.2% vs 1.3%, p=0.298), on the other hand, Male residents presented a severe respiratory disease that warranted management in the ICU (0.9% vs 0%, p=0.462) ( Table   7) .

Two thirds (66%, n = 194) of participants think that COVID-19 negatively impacted their neurosurgical training. More than half of surveyed residents (54.9%, n = 161) reported that the COVID pandemic affected either their mental or physical health ( Table 2) . Male residents reported a greater negative impact of COVID-19 on their neurosurgical training compared to female residents (75% vs. 25%, p=0.036). Despite the fact that the most used strategy to reduce the exposure of residents to COVID-19 was the reduction of work days (work by guards), 55% of the residents who underwent this type of strategy mentioned a negative impact of COVID-19 in their neurosurgical training (p=0.04), the management of COVID patients was also a variable that negatively influenced neurosurgical training according to the results obtained by the surveyed residents (81% vs 64%, p=0.002). Table 8) .

Junior residents were more frequently assigned to the management of COVID patients compared to Senior residents (82% vs 66.4%, p=0.002). Mainly in the areas of medical care (57.5% vs 38.7%, p=0.002) and emergency units (36.8 vs 24.4, p=0.025), while Senior residents were assigned mainly to the ventilator management (14.3 vs 6.9, p=0.038) and neurological surgeries (73.1 vs 59.8%, p=0.019), this could be seen reflected because two (1.7%) of the Senior residents presented severe respiratory disease that merited ICU management while no Junior resident deserved this type of care (Table 9 ).

The COVID-19 pandemic affected the neurosurgical training of residents in Latin America and Spain in multiple ways. Several publications have evaluated the impact of COVID and hospital strategies to reduce residents' exposure to the infection. The reduction of neurosurgical procedures and hours of work conditioned an increase in the development of theoretical knowledge; however, a negative impact was observed in the practical and surgical training of neurosurgery residents worldwide. [10] [11] [12] [13] [14] .

Our results show that the most popular strategy was reducing the number of working days per week in Latin America and Spain (51%). In other countries it was decided to initially restrict resident access to the hospitals 10, 11 . In North America and the Middle East, a reduction in the number of resident working days per week intended to decrease their exposure. 12 In Italy, no neurosurgery residency program stopped working, however the length of stay in the service was shorter 15 .

In the literature, a reduction of neurological surgeries from 67.5% to 99.5% was reported, mainly elective surgeries and older residents were affected 10, 11, 13, 14, 16, 17 . In some centers, emergency surgeries were also suspended 13 . Approximately 88% of our respondents responded to perform neurological surgeries on COVID-19 patients, while 92% mentioned that elective surgeries were suspended and less than 1% mentioned that emergency surgeries were canceled. However, the decrease in scheduled neurosurgery did not prevent the residents from getting sick, it was reported that 1.4% (n = 4) of the residents had respiratory disease that required hospitalization (p=0.006) and one resident (0.3%) required intensive care (p<0.001).

Shorter workday hours reduced residents' exposure to the disease. Other authors have reported a 44.8% to 74.8% reduction in weekly working hours 11, 14, 18 . During the pandemic we found in our study that 83.6% of the residents persisted with a workload ≥70 hours per week; however, no association was found with the presence of severe respiratory disease that required intensive care (p<0.001) despite the high hour per workweek exposure.

The reduction in working hours and the number of neurosurgical procedures favored an increase in academic hours and clinical research studies 14 12 10, 18 . In line with previous reports in other regions 14 19 12 16-18, 20 , teleconferences became the most common format for seminars and classes in Latin America and Spain.

Mexico reported a greater number of hours to academics per week (>10 hours) before COVID compared to other countries (57% vs 43%, p=0.002). However, during COVID-19, the other countries reported a higher number of academic hours than Mexico, but without being statistically significant (52% vs 47%, p=0.051).

Depending on the type of hospital, before COVID-19, medical specialty hospitals had a greater number of weekly academic hours compared to other types of hospitals (43%, p=0.003), but during the pandemic general hospitals spent a higher number of academic hours per week (47.5%, p=0.004) this is probably due to the fact that residents of medical specialty hospitals presented a higher percentage of positive COVID test compared to other hospitals (57.1%, p <0.001) that caused ill residents to require disability due to illness.

Wittayanakorn et al. 13 , and DAHS reported that 87-88% of their respondents work in a hybrid hospital, while 90% of our respondents work in a hospital with the same characteristics. Italy reported that 70.4% of their residents do not participated in the treatment of patients with COVID 14 . Canada, USA, India, and other countries in the Middle East reported that 35.1% to 91.1% of residents provided non-neurosurgical care to COVID patients 10, 11, 17, 18 . In our study, approximately 75.8% of residents were assigned to manage COVID patients, although only 57% mentioned working under supervision, and PPE was sufficient in only 51.5% of responses.

The assignment of residents to medical care services for COVID patients, especially in intensive care units, was a matter of concern for residents resulting in discomfort due to the lack of skills for this work [11] [12] [13] , in addition to a higher probability of getting sick from COVID-19 16 .

The minority of our survey was assigned to COVID ICU (28%) and management of mechanical ventilators (10%). Residents mentioned feeling uncomfortable (45.4%) and incompetent (55.1%) in the management of these patients. Furthermore, 87.4% of the residents at the time of the survey mentioned they were participating in neurosurgical procedures performed on patients with COVID-19 and 79.5% mentioned that J o u r n a l P r e -p r o o f these surgeries were performed only if adequate PPE was available, while 20 % reported that they were made even without PPE. Residents of Mexico were more exposed to COVID patients than the rest of the surveyed countries (88% vs 68.3%, p<0.001) in the same way as Junior residents (82% vs 66.4%, p=0.002). Junior residents were assigned mainly in the areas of medical care (57.5% vs 38.7%, p=0.002) and coverage of emergency units (36.8 vs 24.4, p=0.025), while Senior residents were assigned mainly to ventilator management (14.3 vs 6.9, p=0.038) and neurological surgeries (73.1 vs 59.8%, p=0.019), this could be reflected because two (1,7%) of the Senior residents presented severe respiratory disease that warranted management in the ICU area, while no junior residents required intensive care.

Despite the availability of the test in many participating countries, it was not performed routinely and most of the tests were performed in residents with symptoms and exposure to COVID-positive patients 13 . In the published studies more than 60% of residents were no tested for COVID-19 which could condition many asymptomatic carriers 14 . At the time of our survey, 180 residents (61%) were tested for COVID-19 and 21.5% (n = 63) had obtained a positive result. A positive PCR test for COVID-19 was presented more frequently in the Hospitals of medical specialties (57.1%, p<0.001), and 8% (n = 5) of these patients presented a serious respiratory disease that required hospitalization (p<0.001). Women had a higher percentage of positive PCR than men (27.4% vs 20%, p=0.467) and a higher percentage of respiratory disease that warranted hospitalization (3.2% vs 1.3%, p=0.298), but not female residents warranted management in the ICU in contrast to male (0% vs 0.9%, p=0.462) Another issue that concerns residents is not reaching a minimum number of cases to be accredited by their training program 12, 17, 18 . Despite the fact that this variable was not included in our study, we consider it to be an important problem in all grades of neurosurgery residency since it represents a potential deficit, both academic and skills, the loss of which will hardly be compensated, especially in senior residents. This is particularly important as the pandemic seems to continue with different waves and yet there is no end in sight.

Pelargos et al. 11 , reported a negative pandemic impact in a third of their respondents, while Wittayanakorn et al. 13 , mentioned 74% deficit in training. In our study two-thirds (66%, n = 194) of the participants reported This survey is the first carried out on neurosurgery trainees in Latin America and Spain. It is shocking how 21% of those surveyed refer a positive PCR test for COVID. According to our results, it is unquestionable that residents, despite hospital strategies to reduce the risk of infection, were exposed to COVID-19 in areas where patients are carriers of a higher viral load, such as intensive care areas, or the operating room. We did not evaluate hospital policies for conducting the pre-surgical COVID-19 test within the surveyed countries, which could increase exposure in the centers where surgical procedures continued to be performed, in the same way we did not evaluate the impact on admissions that occurred during the pandemic and quarantine periods applied to residents infected or not, as did other authors 16, 17 . We also did not evaluate the impact of Burnout and professional satisfaction that our residents experienced during this pandemic and how it could negatively influence their personal satisfaction 18 . The specific type of surgical procedures was not evaluated, even when 88% of our residents referred, they performed neurological procedures in patients with COVID in their hospitals. Despite their persisting neurosurgical practice, we are unaware of the complexity of the procedures performed, which undoubtedly may skew the real impact on their neurosurgical training, biased by a greater number of emergency surgeries, such as placement ventriculostomy, valves or trephine drainage which are surgeries that require less complexity.

Reduction of neurological surgeries and workdays, as well as teleconferences have been the most popular strategies during this pandemic to reduce resident's exposure to COVID-19. However, the negative impact on practical training and health of the neurosurgery residents reported by the surveyed is an evident problem. Our study represents the first approximation to know the impact that the COVID-19 pandemic had on the neurosurgery training in Latin America and Spain. New strategies to improve neurosurgical procedures on the operating room must be found to continue with an integrate formation of our residents in this pandemic's times.

There are no conflicts of interest. J o u r n a l P r e -p r o o f The quality of resident training has been negatively affected as a result of the recent COVID-19 pandemic. As the number of infected cases increases significantly, neurosurgeons in different countries are significantly affected in multiple ways. Neurosurgery residents face a great challenge, especially those who work in hospitals with a high number of COVID-19 patients. Also, some residents are fully responsible for patients with this infection. The reduction of elective and urgent neurosurgical procedures, online classes, the reduction of shifts in the hospital, have been used as a strategy to increase the number of residents in areas of care for COVID-19 patients, which has led to up a 50% reduction in residents in person at the hospital.

The objectives of this survey are:

1) Collect the number or percentage of elective or emergency neurosurgical procedures, hours of work, as well as strategies used in each hospital to propose adjustments in the training and education of neurosurgery residents in the Era of Covid-19.

2) Analyze hospital strategies in the face of the pandemic and how they impact the training of neurosurgery residents in Latin America.

What we offer you:

Any participant who contributes to the collection of information will have a mention in an appendix at the end of the article as a reward, and their full name will appear indexed in Pubmed, unless the participant prefers to remain anonymous.

Please note that all data will be collected and analyzed anonymously. Other than indexing purposes, the participant's name will not be displayed and in particular individual data will not be displayed. 

10. Which of the following strategies has your department adopted to reduce residents' exposure to COVID-19? Please check the one that best applies to your hospital. * • You go fewer hours but every day. • I work for guards.

There have been no changes.

World Health Organization Coronavirus disease (COVID-2019) Situation Report-57

The outbreak of COVID-19: An overview

World Health Organization Coronavirus disease (COVID-2019) Situation Report-46

Academic Neurosurgery Department Response to COVID-19 Pandemic: The University of Miami/Jackson Memorial Hospital Model

Neurosurgical priority setting during a pandemic: COVID-19

Neurosurgery in the storm of COVID-19: suggestions from the Lombardy region, Italy (ex malo bonum)

Impact of COVID-19 on neurosurgery resident training and education

Response to COVID-19 in Chinese neurosurgery and beyond

COVID-19 and academic neurosurgery

Neurosurgery Residents' Perspective on COVID-19: Knowledge, Readiness, and Impact of this Pandemic

An Evaluation of Neurosurgical Practices During the Coronavirus Disease

Letter to the Editor "Changes to Neurosurgery Resident Education Since Onset of the COVID-19 Pandemic

Impact of COVID-19 on

COVID-19 and neurosurgical training and education: an Italian perspective

Neurosurgery during the COVID-19 pandemic: update from Lombardy, northern Italy

A Continental Survey on the Impact of COVID-19 on Neurosurgical Training in Africa

Neurosurgery training in India during the COVID-19 pandemic: straight from the horse's mouth

A national survey on the impact of the COVID-19 pandemic upon burnout and career satisfaction among neurosurgery residents

An Evaluation of Neurosurgical Resident Education and Sentiment During the Coronavirus Disease

COVID-19's Impact on

How many hours per week, on average, did you work in your residency program prior to the COVID-19 pandemic? * • 70 or more

How many hours per week, on average

COVID hybrid hospital (Admits positive and negative COVID patients) • No, the hospital does not receive COVID patients • I'm not sure 14. Does your hospital perform neurosurgical procedures on patients with probable or confirmed COVID-19? * • Yes • No • I'm not sure 15. Which of the following services were canceled at your hospital?

What percentage of EMERGENCY neurosurgical procedures are currently being performed compared to the prepandemic period (6 months)? *EMERGENCY neurosurgical surgeries are defined as surgeries that can result in death or significant morbidity if not performed within 24 hours

What percentage of ELECTIVES neurosurgical procedures are currently performed compared to the pre-pandemic period (6 months)? * • Decrease less than 50% • Decreased more than 50%

what is common practice in your department? * • Surgery is done, even if there is no proper personal protective equipment • Surgery is done, only if there is adequate personal protective equipment • The department refuses to perform the surgery, even if there is adequate personal protective equipment • Neurosurgery Online Learning 19. The theoretical (conferences, seminars, magazine clubs

Has your hospital of residence modified the academic sessions, and if so, how? Check the ones that are necessary * • Teleconferences (eg Zoom, GoToMeeting, ...) • Face-to-face

How many hours per week does your program currently dedicate to didactic learning in the COVID-19 pandemic? * • More than 10

Has your hospital asked you to provide medical services to treat COVID-positive patients? * • Yes • No If your answer is yes, please specify which of the following: * • ICU with positive COVID patients • Health care area • Fan handling • Coverage of emergency areas • Neurological surgeries in COVID-positive patients

How comfortable are you providing non-neurosurgical medical care to COVID-positive patients (ICU, ventilator management, triage in the emergency room, etc.) if requested by your hospital? * COVID patients? * • Yes • No 27. How would you describe the supply of personal protective equipment (PPE) in your hospital? * • Enough • Insufficient • The hospital does not provide PPE

Did you receive any formal training on how to use and remove personal protective equipment (PPE) during this pandemic? * PCR test for COVID-19? * • Yes, and the test came back positive • Yes, and the test came back negative

Do you think the COVID-19 pandemic will have a significant NEGATIVE impact on your neurosurgery training? * • Yes • No 33. Do you think your health could be affected during this pandemic? • Yes, mainly my physical health • Yes, mainly my mental health • Yes, my physical and mental health

Conception and design of the work, data collection, data analysis and interpretation, critical revision of the article and final approval of the version to be published

Stienen: Design of the work, data analysis and interpretation and critical revision of the article

Critical revision of the article and final approval of the version to be published

Campero: Design of the work and data collection

Soriano: Data collection

Borba: Data collection

Nettel: Data collection

Data collection

Design of the work and data collection

Design of the work, data collection, data analysis and interpretation, critical revision of the article and final approval of the version to be published

We would thank all residents, professors, institutions, and members of the FLANC that contribute to this project. 

Andres Francisco Rojas Gallegos