key: cord-0933351-1gjeor3e
authors: Zhang, Andrew S.; Myers, Mitchell; Kee, Clarence J.; McClary, Kaylan N.; Barton, R. Shane; Massey, Patrick A.
title: Adapting Orthopaedic Surgery Training Programs During the COVID-19 Pandemic and Future Directions
date: 2020-06-25
journal: Arthrosc Sports Med Rehabil
DOI: 10.1016/j.asmr.2020.06.008
sha: 97fce40dec9ff2dfc3dbfdfb7bfd92ba2099476e
doc_id: 933351
cord_uid: 1gjeor3e

Abstract The COVID-19 pandemic swept across the world, altering the structure and existence of graduate medical education programs across all disciplines. Orthopaedic residency programs can adapt during these unprecedented times to continue providing meaningful education to trainees, and to continue providing high-quality patient care, all while keeping both residents and patients safe from disease. The purpose of this review is to evaluate the literature and describe evidence-based changes that can be taken to an orthopaedic residency program to ensure patient and resident safety, sustaining the principles of graduate medical education, during the COVID-19 pandemic. We describe measures which can be enacted now or with future pandemics, including workforce and occupational modifications, personal protective equipment, telemedicine, online didactic education, resident wellness, return to elective surgery and factors affecting medical students and fellows. After a review of these strategies, programs can make changes for sustainable improvements and adapt to be ready for second wave events or future pandemics.

education because of social distancing guidelines. However, residencies are still expected to 27 function and be effective in delivering high quality care despite these conditions and the constant 28 threat of nosocomial transmission. 29

During this pandemic, the American College of Graduate Medical Education (ACGME) 30 has released guidelines for residency programs. They describe three stages: "Stage 1 -business 31 as usual, Stage 2 -increased but manageable clinical demand, Stage 3 -crossing a threshold 32 beyond which the increase in volume and/ or severity of illness creates an extraordinary 33 circumstance where routine care education and delivery must be reconfigured to focus only on 34 patient care." 1 During Stage 2, ACGME recommends didactics be done via remote conferencing 35 or web based and residents can be re-assigned. Stage 3 occurs when the designated institutional 36 official (DIO) declares Pandemic Emergency Status. This provides a 30 day period where most 37 common program requirements are suspended. 38

The purpose of this review is to evaluate the literature and describe evidence-based 39 changes that can be enacted within an orthopaedic residency program to ensure patient and 40 resident safety, sustaining the principles of graduate medical education during the COVID- 19 41 pandemic and establish training protocols to withstand a future second wave. We describe 42 workforce and occupational modifications, personal protective equipment (PPE), telemedicine, 43 online didactic education, resident wellness, return to elective surgery and factors affecting 44 medical students and fellows. 45

Background and Epidemiology 46 47

The coronavirus was first described in humans in 1965 by Tyrrell and Bynoe while 48 studying the secretions of an adult with common cold symptoms. 2 Electron microscopy was 49 performed by Almeida and Tyrrell on isolates from fluids obtained from organ cultures, and they 50 described the "halo-like" appearance of the surface protein projections on the viral particles. 3 51 This lead to the coronavirus designation, derived from the Latin corona for "crown" or "halo". 52

Other members of the coronavirus family have since been identified to cause serious respiratory 53 system infections in humans. These include both the SARS-CoV (severe acute respiratory 54 syndrome coronavirus) in 2003, and the MERS-CoV (middle eastern respiratory syndrome 55 coronavirus) in 2012. 4, 5 Epidemiologic studies after the SARS outbreak identified bats and palm 56 civets as hosts of the virus in nature. 6 57 58

On March 11 th , 2020, the World Health Organization (WHO) declared COVID-19 a 59 pandemic. 7 By April 9 th , 2020, there were 1.5 million cases worldwide, with 89,000 deaths 60 reported. 8 At a time when the coronavirus appears to be spreading at a seemingly exponential rate, 67 governments heavily advocated for social distancing and even enacted stay-at-home orders. This 68 entailed limiting interpersonal interaction to greater than six feet, elimination of group outings 69 and gatherings, cancellation of classes and school and imposing travel restrictions. 9, 10 Because 70 of the gravity of the social distancing, residencies can take several measures in order to comply 71 with these recommendations and to maintain the overall health of the residents. 72

At the onset of the COVID-19 outbreak, individuals who were exposed or suspected of 74 being exposed to infected patients were asked to quarantine for two weeks per CDC 75 recommendations. 9, 11 Many programs instituted weekly or bi-monthly rotating schedules to 76 mitigate risk to the orthopaedic team. Some programs utilized one team for inpatient care and 77 one team for telemedicine, with rotations occurring every two weeks. 12 Other trauma institutions 78 have segmented into a three-team system with a trauma team rotation for one week followed by 79 two weeks away from the hospital. 13 Whether orthopaedic programs instituted a two-team or 80 three-team approach, most rotation schedules centered around the idea of decreasing inpatient 81 exposure risk and 14 days of minimal contact after an inpatient rotation. Our institution heeded 82 to these advisories and restructured our resident complement to incorporate this. With a total of 83 15 residents, three teams of five were established ( Figure 1 ). The establishment of three 84 individualized teams physically isolates residents from each other, thereby limiting any possible 85 spread of the virus amongst co-residents and decreases the likelihood of an entire residency from 86 being infected simultaneously. These groups of residents rotated weekly in an inpatient, 87 The inpatient setting was expected to contain a higher concentration of COVID-19 119 patients, and therefore placed the residents at most risk of being exposed to the virus. In Wuhan, 120

China, 79.2% of orthopaedic surgeons who contracted COVID-19 believed it was from the 121 inpatient wards. 15 This inpatient group of our residents was the main team tending to all 122 operative activities during this time when surgical volumes have dampened and all elective cases 123 remained postponed. This team rounded and rendered care for the orthopaedic inpatients, as well 124 as fielding consults within the hospital and through the emergency room (ER). All other 125 residents were asked to stay away from the inpatient premises while they were off this rotation. 126

This, in essence, theoretically spared the remaining residents from being exposed to a high-viral 127 burden and from the heightened risk of nosocomial transmission. The inpatient team would then 128 rotate out of the hospital for the next two weeks. The rotating nature of this team-based 129 approach inherently provided a built-in self-quarantine time of two weeks, until they were 130 needed back in the inpatient setting. With fewer demands in the outpatient and elective settings, 131 there was adequate substitution among members of the team should any individual fall ill and 132 need to be replaced interchangeably. 133

In the outpatient setting, clinical encounters were pared to only essential visits. This 135 entailed postponing new non-urgent consults and rescheduling follow-ups for chronic ailments. 136

Residents still engage in seeing these outpatient encounters, either by telemedicine or in-person 137 with ample PPE. Notably, the duties of this group of residents were limited to the outpatient 138 setting and do not overlap with the residents at the other sites. 139

Elective/Off Site Rotations 140 141

The elective/off site rotations were clustered in one group as they had become less 142 demanding while state governments maintained their elective restrictions. Residents utilized this 143

week to rest and recuperate if they became ill. If they were absolved of clinical responsibilities, 144 residents were encouraged to make progress on research and scholarly activity and participate in 145 educational activities such as reading and doing questions. Senior residents used this dedicated 146

week to perform intensive studying in preparation for board examinations, as they would 147 otherwise be sent to Board Review Courses during this time. 148

Monitoring exposure risk and return to normal operations 149 150

While each residency is innately different in its number of constituents and in the nuances 151 of rotations and sites, programs can draw from these principles and restructure their teams 152 accordingly. Based on the risk of inpatient exposure, we recommend any rotations schedule 153 involve weekly changes with a dedicated inpatient team that rotates out. Most programs that 154 have adjusted, have incorporated some variation of this principle. 16, 17 All residents receive 155 SARS-CoV-2 reverse transcription polymerase chain reaction (RT-PCR) testing every 2 weeks. 156

When residents tested positive, they would self-quarantine for 2 weeks and provide telemedicine 157 services from home with no known spread to any other residents or faculty. As the state 158 legislature has lifted the stay-at-home order, we have returned to a traditional rotation schedule. 159

The benefit of the three team model, is it provides comprehensive coverage of all services and 160 can be quickly implemented. In the event that there is a second wave phenomenon, programs 161

can easily convert to the three team rotation to mitigate inpatient risk to residents. Aside from isolating residents into separate groups, another measure for those residents 172 working together in the same team is establishing individual workstations. Coronavirus has been 173 found to persist on inanimate objects ranging from several hours to several days. 18 Communal 174 tools such as computers, keyboards and office supplies can act as niduses for infection if not 175 properly cleansed, and consequently used by another resident. At our institution, individualized 176 workstations for each resident were created, separating desks and computers for residents to use 177 at least six feet apart from each other and with physical barriers between each other ( Figure 2 The Centers for Medicare and Medicaid (CMS) has stated that telehealth, telemedicine, 230 and related terms generally refer to the exchange of medical information from one site to another 231 through electronic communication to improve a patient's health. This exchange of medical 232 information spans from the basic telephone services to laptops and tablets. Electronic health 233 records (HER) have been integrating and streamlining telemedicine capabilities into their 234 technologies, while stand-alone videoconferencing apps such as Zoom, have transitioned into 235 healthcare with Zoom for Healthcare. Some applications such as Amwell are also seamlessly 236 integrated with popular EHRs such as EPIC and Cerner, which are already adopted by many 237 major hospital systems. 238

The CDC and the WHO urged hospitals to expand their telemedicine services by late 240 February 2020. The expansion of Telehealth 1135 waiver then went into effect on March 6th, 241 2020. According to CMS, this new waiver allows "Medicare to pay for office, hospital, and other 242 visits furnished via telehealth across the country and including in patient's places of residence". 20 243 Before this waiver, payment for telehealth was on a "limited basis" by Medicare. The waiver 244 also allowed patients without an established relationship with the practitioners to be seen without 245 audit during this public health emergency. 20 Additionally, the U.S. Department of Health and 246

Human Services Office of Civil Rights have relaxed HIPAA-compliance regulations, giving rise 247 to use of popular platforms such as FaceTime, Facebook Messenger and Skype for telemedicine 248 visits without fear of compliance penalties (see table 1 ). 249

Implementation of telemedicine 250 251

In our experience, converting many non-urgent appointments to a telemedicine visit was 252 accomplished with relative ease. Previously, the Epic software was updated to allow the 253 telemedicine feature on Haiku and Canto found on portable devices. A patient must be signed up 254

for MyChart and download the MyChart app onto their iOS or Android device. The time for 255

MyChart enrollment and troubleshooting technical difficulties is the rate limiting step for 256 implementation of this technology. Once the enrollment is completed, changing patients to a 257

MyChart Video Visit through Epic and completing the visit is straightforward. Incorporating a 258 group of clinical assistants and technical support to screen the patients before the visit allows for 259 a more efficient workflow and pleasant experience for the patient. 260

Once an acceptable system has been established to convert non-urgent visits to 262 telemedicine visits, attention can then be directed towards the user interface and improving 263 efficiency. The Canto iPad app is a more robust tool for telemedicine which adds features such 264 as notifications of patient status, an improved microphone system, and a larger screen for 265 viewing. Requesting hospital administration to purchase or applying for governmental assistance 266 for improved technology to deliver quality care is a helpful step in the success of telemedicine. 267 AAOS has provided a resource guide that aids in billing, HIPAA compliance, and links to 268 resources. https://www.aaos.org/globalassets/about/COVID-19/aaos-telemedicine-resource-269 guide.pdf. 21 Please review these guidelines before engaging in any telemedicine visits to ensure 270 correct billing and coverage of services offered. 271

As we have return to seeing patients in person at our clinics, we limited patient visits to 273 space out visits 15 minutes to respect physical distancing. As less patients could be physically 274 seen, we incorporated telemedicine concurrently during these clinics. Based off our overwhelmingly successful experience with telemedicine during the height 281 of COVID-19, the future of its continued use is significant in our department. We have found 282 this approach especially helpful for underserved patients that have difficulty traveling several 283 hours to see us, without compromising a high quality of care. Online visits will be incorporated 284 more routinely, especially for patients who are in nursing homes or live far away. Additionally, 285 now that the telemedicine system is integrated into all of our clinics, we are ready to transition 286 back to all telemedicine clinic encounters if a second wave resurgence of COVID-19 occurs. 287 In the wake of the global spread of COVID-19, sweeping measures were taken by 292 institutions of higher learning throughout the country to curtail large cohorts for educational 293 purposes. These efforts were made to promote physical distancing and prevent further spread of 294 the virus. Similarly, didactics are fundamental to an orthopaedic resident's graduate medical 295 education. While these were traditionally live lectures, residencies have also turned to other 296 online mediums in order to respect distancing guidelines. 12, 17, 22 In our experience, an important 297 feature for education is the ability to screen share, so that an individual can share prepared 298 presentations to everyone logged into the meeting. Table 2 outlines several popular alternative 299 platforms that other institutions have already adopted. (The authors disclose no proprietary or 300 monetary investment in these listed products.) 301 Instead of physically gathering residents, these conferences can be streamed during 305 mutually amenable times and dates. Orthopaedic residencies can hold these didactics at their 306 regularly scheduled times before the pandemic, or establish other times. In promoting these 307 activities, residents were provided some semblance of normalcy as they are still able to virtually 308 interact with one another and still maintain the structure of orthopaedic education with the 309 backdrop of an unpredictable health crisis. Future directions include having the ability for staff 310 to be present for resident lectures remotely. Additionally, guest speakers were easily able to 311 present presentations to our residents from remote locations. If there is a resurgence of COVID-312 19 cases, the ease of use of these applications allows them to rapidly be used to convert 313 conferences to remote versus in person. 314 315

As resources are depleted in the hotspots of active coronavirus, the pool of healthcare 317 personnel who would otherwise be at the frontlines of care, such as in the ICU and ER, are also 318 being exhausted as they, too, are falling ill to the virus. As such, orthopaedic residents and 319 faculty were asked to be redeployed to staff these settings. 23 In many instances, providers such 320 as orthopaedic surgeons may not have any formal or significant experience with critical care 321 during their training and must be re-acquainted with, or in some instances learn, a dedicated skill 322 set previously foreign to them. Certain programs are having their residency programs attend an 323 intensive training camp to prepare them for ICU-level duties. 24, 25 In these situations, residency 324 programs coordinated with intensive care nurses to host day-long workshops to expedite the 325 training needed for these redeployed providers. Fortunately, there are also several supplements 326 that can be accessed online to help in familiarizing with these new skills. There are various online 327 resources for the non-ICU clinician. The Society of Critical Care Medicine (SCCM) has created an 328 online platform for training the non-ICU clinician for critical care, airway management and prone 329 ventilation at https://covid19.sccm.org/nonicu.htm. The American College of Physicians (ACP) also has 330 a helpful website with multiple videos for critical care education at https://www.acponline.org/featured-331 products/critical-care-video-shorts/view-critical-care-video-shorts .

As evidenced by increased regulations on duty hours and vigilance for resident burnout, 335 graduate medical education has taken a particular focus on overall resident well-being in the past 336 decade. 26 Early reports from the current pandemic have already highlighted the importance of 337 maintaining the clinician's wellness in order to provide continued effective care. 27 There are 338 multiple factors that account for a resident's overall wellness. One factor which has been studied 339 extensively in recent years is sleep deprivation. One study showed that physicians in their 340 surgical residency were 20% more likely to make errors during the day after they had been 341 awake overnight, compared to those that had rested. 28 Additionally, less than seven hours of 342 sleep per night has been shown to lead to adults reporting higher rates of depression, asthma and 343 heart attacks. 29 A report from Wuhan, China showed that fatigue was a significant risk factor for 344 COVID-19 infection in orthopaedic surgeons. 15 If well-rested residents are less likely to make 345 medical errors and have lower rates of certain medical problems, it stands to reason that allotting 346 more time for physicians-in-training to rest and sleep is better for both patients and trainees. By 347 shifting the resident rotations into teams that rotate out of the inpatient setting for two weeks and 348 incorporating night float, residents can maintain a healthy amount of sleep and rest. 349

Additionally, conference times can be shifted from early in the morning to the afternoon, to 350 allow residents who are not rounding on the inpatient service, additional rest. 351

Another factor that is vital for resident wellness is healthy eating habits. Diets high in 353 antioxidants and Omega-3 fatty acids have been shown to increase hippocampal synaptic 354 plasticity and enhance cognitive function, while a diet low in Omega-3's has been associated 355 with mental health disorders, such as depression, bipolar disorder and attention deficit disorder. 30 356

Exercise also has the ability to combat depressive properties while enhancing learning and 357 memory. 30, 31 Residency programs and hospitals can support the mental and physical health of 358 their residents by providing high quality, healthy meal options, a fitness facility with wellness 359 instructors, and an allotted time to use these benefits. 360

Finally, many residents neglect their own health problems in order to care for others. 362

Several ways of improving healthcare access for time-pressed residents have been proposed. 363

These include primary care video visits for trainees, as well as concierge scheduling services. 364

Concierge scheduling includes rapid response telephone services with flexible scheduling for 365 visits. These methods have been shown to decrease perceived barriers and delays to healthcare 366 among residents. 32 367

Per the Green Cross Academy of Traumatologists (GCAT) there are standards of self-368 care based on two rules: "First, do no harm to yourself in the line of duty when helping/treating 369 others. Second, attend to your physical, social, emotional, and spiritual needs as a way of 370 ensuring high quality services to those who look to you for support as a human being." 33 371

Achieving true wellness involves a multi-faceted approach, and it is the responsibility of both the 372 resident and their program to keep trainees healthy and functioning at a high level . This serves 373 to benefit residents, their program and their patients. During this tumultuous time, focusing on 374 resident wellness may be beneficial in preventing COVID-19 infection and symptoms in 375 trainees. Table 3 includes facets of wellness incorporating those listed in the GCAT guidelines 376 with barriers and some strategies to consider for how to address these issues. 33 377 

Medical schools across the country have been increasingly changing their curriculum to be 385 online and allow students to learn wherever and whenever they want over the past several years. 386

The COVID-19 pandemic has caused many more medical schools to rapidly transition to a 387 similar style of teaching in order to keep their students safe. 35 Our institution has implemented 388 many changes like these in order to keep students physically distanced and to avoid the spread of 389 At our institution, pre-clinical medical students switched entirely to online lectures during 391 the COVID-19 pandemic. This allowed them to continue their medical education and move 392 toward their clinical years, while maintaining physical distance from their classmates and others. 393

Students were able to learn from the safety of their own homes, yet not fall behind during this 394 critical time in their education. Clinical students were able to complete online modules to 395 simulate their rotations. While this is not the same as caring for actual patients in the hospital, it 396 did allow the students to continue to learn how to care for patients while avoiding unnecessary 397 exposure and avoid depleting the hospital's PPE. Additionally, fourth year medical students were 398 graduated early to allow them to start as early interns at their respective residency programs if 399 needed in areas that were under-staffed during the pandemic. 400

Going forward, several changes will be instituted to avoid further spread of with regards to medical students, as well as to protect them from exposure. First, as 402 recommended by The Coalition for Physician Accountability's Work Group, all interviews for 403 medical school will be virtual. 36 This will prevent students from all over the country from 404 gathering together in large groups in small interview rooms, thus risking spread of COVID-19 405 across states lines as they return home. Second, away rotations for medical student are strongly 406 discouraged, unless the student's home program does not have the specialty they are looking to 407 go in to, or it is required for their graduation. 36 At our institution, we will be expanding the 408 amount of time that medical students can spend on sub-specialty rotations within orthopedics, as 409 they will not be completing away rotations. This will include rotations such as sports medicine, 410 hand, orthopedic research, etc. for up to four week blocks. Finally, as most orthopaedic 411 programs will not be performing in person interviews, we have increased our social media and 412 created videos of our institution for interviewees. As interviewees will not get to visit any 413 potential orthopaedic programs in person, it is important that all programs provide a robust 414 amount of media so they can get to know the program virtually. 415

The strategies outlined in this article have proven to be successful at our institution during the 417 COVID crisis. Other residencies have documented their experiences, though limited follow up 418 has been described. 14, 17, 22, 23 In the event of a second wave, many of these same approaches 419 will be implemented again through a coordinated effort by the faculty and residents to ensure the 420 safety of all members of the orthopaedic department while continuing to deliver excellent patient 421 care and maintaining proper orthopaedic education. 422

After the publications of these seminal articles, a few other considerations have 423 manifested as residencies approached the end of the academic year. Fifth year residents typically 424 dedicate the latter half of the year to prepare for board examinations. This would usually entail 425 attending board review courses. A schedule was also created for all the national orthopaedic 426 meetings available to residents. Additional measures such as protecting time for these senior 427 residents to focus on studying or to attend virtual courses should be considered. Applying for the 428 board examination should also be planned as soon as possible, since special accommodations 429 may need to be arranged due to social distancing limitations at testing centers. 37 430

It should be noted, that in addition to the clinical need of patients, the Orthopaedic 432

Residents in training are required to have a certain number of surgical cases in different areas to 433 graduate. Among the core case requirements, there are case minimums required for knee 434 arthroscopy, shoulder arthroscopy, ACL reconstruction, total hip arthroplasty (THA), total knee 435 arthroplasty (THA), Spine decompression/ posterior spine fusion, foot and ankle fusion, carpal 436 tunnel release, and oncologic procedures. Many of these cases were not performed during the 437 pandemic so this may affect the numbers of cases that graduating residents who were training 438 during the pandemic will have. 439

It is our experience that with extensive planning, and stockpiling of cases, residents will 440 be able to graduate with adequate surgical training. As some programs have ramped up elective 441 surgery, they have added surgical days on the weekend to catch up. When surgical volumes are 442 down some programs have supplemented surgical training with simulation based training or 443 virtual training. 38 Due to the nature of surgical rotations, it is likely that each resident will be 444 deficient in a single area (arthroplasty). This needs to be taken into account when planning 445 future rotations (there may be a resident who missed out on joint arthroplasty and will need a 446 future arthroplasty rotation to compensate). In our program, residents that missed sports 447 medicine cases and arthroplasty cases, were given compensatory rotations the following year. 448

Finally, when orthopaedic programs complete their annual ACGME report, they should clearly 449 communicate resident case deficiencies as they relate to the pandemic. the ideal number of spine cases to be performed during this year is 250, and luckily this metric 459 was met prior to mid-March of 2020. 39 However, this may not be true across all fellowships. In 460 light of these conditions, the ACGME has released statements recognizing these shortcomings 461 and recommend ultimately placing the onus on the program director to determine whether a 462 fellow is ready to graduate. 40 463

An additional facet that must be considered is the role of international candidates who fill 464 these fellowship positions in the United States. Not only will they be subject to the limitations of 465 our country and the quarantine times that must be imposed upon arrival to the states, but they 466 may also be confronted by visa issues as well as the travel restrictions of their own countries. 467

This could in some cases, prevent them from completing the year altogether. At our institution, a 468 visiting international fellow arrived just prior to the declaration of COVID-19 as a pandemic. 469

The fellow was quarantined for two weeks and then returned home shortly thereafter. It is 470 unclear how the role of the international fellow will change this year, but will almost certainly be 471 subject to many restrictions. 472

The fellow in training will also be met with challenges with employment. Traditional in-473 person interviews with practices may be substituted with virtual meetings in light of travel 474 restrictions and coronavirus precautions. Employers may also be in hiring freezes due to the 475 allocation of resources to other priorities such as maintaining ICUs and PPE, making job 476 vacancies that much harder to find. Indeed, this is a time of uncertainty, with a unique set of 477 obstacles yet unseen by fellows before. 478

During the early phase of the COVID-19 Pandemic, the Surgeon General recommended 480 to discontinue "elective surgeries". 41 This had many sequelae including an exponentially 481 decreased surgical volume in orthopaedic surgery programs, and economic impacts to surgery 482 centers and hospital systems. As clinical volume decreased significantly, a compensatory 483 decrease in personnel hours occurred for many groups. 42 During the height of the pandemic, 484 many orthopaedic programs decided to only do emergent, urgent or expedited surgery (surgery 485 which should be done within 2 weeks). At our institution, these decisions on which surgeries 486 should be done when resources were scarce were made at the local level, by a committee of 487 surgeons and anesthesiologists, based on what resources were available. 488

When orthopaedic programs are mostly seeing patients via telemedicine, surgeries can 489 still be scheduled. It is important that surgeons have clear communication with patients that the 490 surgery will not be performed until state and local leaders have recommended a return to elective 491 surgery. During this low surgical volume time, cases can be stockpiled and categorized by their 492 priority based on various recommendations. 14, 43, 44 By continuing to evaluate patients for 493 surgery, maintaining an organized list of surgical patients, and communicating clearly with 494 patients, surgeons will be able to rapidly increase their surgical volume. 495

As COVID-19 hospitalizations decreased and hospital resources became stable, 497 orthopaedic training programs should strategically plan which non-emergent cases to prioritize. 498

In the event that there is a second wave phenomena as occurred with SARS in Canada, it is 499 prudent to prioritize short-term delayed surgeries first. 45 A stratified urgency of orthopaedic 500 surgeries has been described based on how long it is safe to delay different types of orthopaedic 501 surgeries. 14 As we ramped up non-emergency surgeries again, we prioritized the surgeries that 502

should not be delayed more than 3 months such as acute rotator cuff repairs in younger patients, 503 anterior cruciate ligament reconstruction, and multi-ligamentous knee reconstructions. Once the 504 back log of these short-term delayed surgeries was surgically treated, then all surgical priority 505 surgeries were resumed. 506

Additionally, as many hospitals decreased their staffing for financial efficiency, a 508 rebound in staffing should occur. Prior to ramping elective surgeries back up, our department 509 met with hospital leadership, nursing leadership, and anesthesia leadership to ensure that proper 510 personnel resources would be available for the resurgence of elective cases. Resuming Total 511

Joint Arthroplasty (TJA) should be done when there is resource availability with respect to 512 hospital beds, intensive care unit (ICU) beds and blood transfusion products. 46 When these 513 resources are appropriate and a committee involving anesthesia, ICU management, hospital bed 514 management and surgeons determines it is appropriate, return to TJA can resume. 515

As orthopaedic surgeries ramp back up, it is important to maintain a safe environment for 517 residents and patients. Recommendations have been made by numerous authors and 518 organizations on how to safely resume surgery. 14, 43 Some key points are that all patients 519 receiving non-urgent orthopaedic surgery must have a SARS-CoV-2 reverse transcription 520 polymerase chain reaction (RT-PCR) test performed prior to surgery. 43 When a patient is 521 positive for COVID-19, their non-emergent orthopaedic surgery should be delayed. Also, when 522 an emergent or urgent surgery on a COVID-19 patients are performed at our institution, only one 523 resident is allowed in the surgery with no medical students allowed. 524 525

The COVID-19 pandemic has presented a multitude of challenges to healthcare professionals, 527 not only in handling the care of patients, but also to maintaining traditional graduate medical 528 education. Indeed, these are unprecedented times, however, we present adaptations to resident 529 complement structure, changes to resident work environments, and modifications to education to 530 enable residency programs to function during this crisis. Residents should follow and understand 531 guidelines for PPE, have team structures that employ physical distancing, maintain clinical care 532 via telemedicine, maintain education via teleconferencing, and focus on well-being for the 533 continued success and functionality of the residency. With flexibility and strategic planning, 534 training programs can adapt to be ready for second wave events or future pandemics. 535 536

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