key: cord-0977184-c9axfg9l
authors: Alexandru, Mihaela; Favier, Valentin; Coste, André; Carsuzaa, Florent; Fieux, Maxime; Fath, Léa; Bartier, Sophie
title: Deterioration experienced by French otolaryngology residents in their training during the Covid-19 pandemic; a STROBE analysis
date: 2022-05-03
journal: Eur Ann Otorhinolaryngol Head Neck Dis
DOI: 10.1016/j.anorl.2022.04.006
sha: 073a97afcb9062c52c26717566b610aecd11fe93
doc_id: 977184
cord_uid: c9axfg9l

Objective: To evaluate the impact of the first three waves of Covid-19 on the academic and surgical training of ENT and Head and Neck Surgery residents in France. Material and methods: Observational, retrospective study. A 55-item survey of academic education and surgical training was sent to ENT residents in five major French regions (Ile-de-France, Rhône-Alpes Auvergne, Occitanie, Grand Est, Grand Ouest) from August to October 2021. Results: 89 out of 135 residents (66%) responded. Two-thirds considered that surgical training was more affected than academic education, with reductions evaluated of 50-75%, 25-50% and 0-25% for the first three waves, respectively. Residents in Ile-de-France, Rhône-Alpes Auvergne and Grand Est were the most affected by the first wave (75-100% reduction in surgical activity, in parallel to increased admissions). Otology, rhinology and functional exploration were the most affected, whereas pediatrics and oncology were spared. 71 of the 89 residents (79.7%) felt that the first wave impacted their career, while this proportion decreased to 39.3% and 44.9% for the second and third waves, respectively. Conclusion: The first wave of Covid-19, compared to the following two waves, severely impacted the surgical training of French ENT residents, especially in regions severely impacted by the pandemic, while academic education was relatively safeguarded by the implementation of e-learning alternatives.

Since March 2020, the worldwide Covid-19 (Coronavirus disease 2019) pandemic has put our health system under constant strain. Successive waves required day-to-day adaptation of admission capacities; dedicated Covid units needed premises, equipment, staff redeployment and cancellation or rescheduling of non-urgent admissions and operations [1] [2] [3] . This drastic reduction in medical and surgical activity affected all specialties, but ENT and head and neck surgery (ENT-H&N) was in double jeopardy, H&N surgeons being especially exposed to SARS-CoV-2 as they operate on a daily basis on the upper airways, with high risk of aerosolization [4, 5] .

Consequently, student training in ENT-H&N has had to adapt over these last 2 years, both in medical and surgical practice and in academic education, with many classes, exams and seminars cancelled or postponed. E-learning was rapidly developed, worldwide, with on-line teaching and lectures, to be able to pursue training while adhering to shielding measures and distancing [6] . The pandemic is still ongoing, with the emergence of new variants, and ENT-H&N residents' practical and academic training is likely to continue to be impacted.

The main aim of the present study was to analyze French ENT-H&N residents' assessment of their practical and academic training during the Covid-19 pandemic. Secondary objectives comprised: analysis of the impact on practical and academic training according to subspecialty compared to the pre-Covid baseline; analysis of chronological impact over the first 3 waves and geographic impact according to region and to regional health situations; and analysis of the alternative educational solutions and redeployment of residents.

This was a retrospective observational study, using the STROBE methodology (https://www.equator-network.org/) [7] . To obtain an overview of the impact of Covid-19 on The questionnaire comprised 55 items assessing the quality of practical and academic training during the Covid-19 pandemic (see Appendix).

Th inclusion criterion was being an ENT-H&N resident in France between November 2019 and May 2021 (i.e., the 3 residency semesters corresponding to the first 3 Covid-19 waves).

Response rate was calculated from the annual number of residents per subdivision. Nonspecialty training periods, inter-hospital residencies and internships in functional exploration and Transverse Specialized Training were included in calculating the response rate.

Demographic data comprised: age at questionnaire delivery, gender, and residency subdivision. For the 3 study semesters (November 2019-May 2020, May 2020-November 2020, November 2020-May 2021), data were collected for: residency structure (university hospital, other public-sector hospital, private-sector hospital), seniority (residency semester), and specialty (general medicine, oncology, rhinology, pediatrics, otology) of the residency department (as reported by the respondent).

To meet the first objective, respondents assessed the pre-Covid quality of academic education (number of hours of lectures and classes, both for the "DES" national degree course and for "DU" university diploma courses) and practical training (percentage weekly time spent in theater, in consultation and the emergency department and on ward and department management) and then assessed the respective percentage reductions during the pandemic.

For the secondary endpoints of impact according to subspecialty and chronological impact per wave, respondents assessed the reduction in medical and surgical practice in oncology, Diseases [8, 9] , the significance threshold was set at p<0.005. Table 1 shows the characteristics of the 89 residents from the 9 subdivisions of the 5 Regions (Ile-de-France, Rhône-Alpes Auvergne, Occitanie, Grand Est, Grand Ouest) who answered the online questionnaire between August and October 2021. The response rate was 66% (89/135), and was lowest in the Ile-de-France Region (28/74, 38%). Respondents were mainly in the first 4 years of residency in the first wave (Table 1 ). There were no significant interregion differences in age, gender or seniority (Supplementary Table 1 Region. There were no significant inter-regional differences in activity distribution between theater, department and consultation/emergency (respectively, p=0. 14 Independently of wave, two-thirds of respondents reported surgical training to be far more strongly impacted than academic education (respectively 55/89 (61.8%), 53/89 (59.6%) and 57/89 (64%) for the 3 waves). Figure 3 shows that surgical training was reduced by 50-75% for 37/89 respondents (42%) in the 1 st wave, whereas 40/89 (45%) estimated the reduction at 25-50% in the 2 nd wave, and 34/89 (38%) estimated it at 0-25% in the 3 rd wave. Table S5 (Supplemental Material) shows that Ile-de-France, Rhône-Alpes Auvergne and Grand Est were the most strongly affected Regions in the 1 st wave (majority of estimates at 75-100% reduction in surgical practice), while Occitanie was the most strongly affected in the 2 nd wave (majority of estimates at 50-75% reduction in surgical practice), and Ile-de-France, Rhône-Alpes Auvergne and Occitanie were moderately affected in the 3 rd wave (majority of estimates at 25-50% reduction in surgical practice). In the 3 waves, the reduction in academic education for the DES national degree course was most often estimated at 0-25%: respectively 31/89 (34.8%), 41/89 (46.1%) and 34/89 (38.2%) per wave (Figure 3 ). 

The questionnaire revealed a reduction in training time for ENT-H&N residents in 5 large Regions of France that were variously affected by the first 3 Covid-19 waves. According to two-thirds of respondents, surgical training suffered more than academic education, functional surgery being the most severely affected. It was notable, however, that, while 79% (71/89) considered that the 1 st wave had a negative impact on their training, only 39% (35/89) and 44.9% (40/89) had the same feeling regarding the 2 nd and 3 rd waves respectively, whether due to resumption of activity and/or to adaptation of the hospital and university system.

Reductions in surgical activity varied between Regions, and paralleled the local health situation (Figure 2 ). This feeling of deterioration in training under the pandemic was reported in many studies worldwide, in both medical and surgical residents [10] [11] [12] . The American study by Aziz et al., in 1,102 general surgery residents, found a significant reduction of more than 50% in the number of weekly cases operated on by residents compared to the pre-Covid situation [10] . Surgical and interventional specialties were more strongly impacted in terms of training than medical fields or fields such as radiology with less patient contact [13] [14] [15] [16] [17] [19] .

Head and neck surgery is at particular risk of contamination by aerosolization [20] .

This accounts for the large reduction not only in surgery but also in non-urgent and high-risk clinical activity such as nasal endoscopy, audiometry, rhinomanometry and acoustic rhinometry, or olfactometry. The French ENT Society (SFORL) published guidelines to limit unnecessary high-risk interventions (https://www.sforl.org/wpcontent/uploads/2020/03/Alerte-Covid-19-Endoscopies-et-fibroscopies.pdf), and to postpone surgeries that could be deferred [2] . There was consequently an inexorable decrease in both clinical and surgical activity, impacting resident training. This was confirmed in the present study, where the most severely affected subspecialties were otology and rhinology, whereas oncology and pediatrics were little affected, in line with recommendations [21, 22] . Amparore et al. [18] reported that residents in Northern Italy, severely affected by the 1 st wave, were especially affected by the fall in activity; likewise in the present study, Regions in which the health situation was notably critical (Ile-de-France, Rhône-Alpes Auvergne and Grand Est)

were those in which respondents reported the greatest decrease in activity.

86.5% of respondents (77/89) reported alternatives to compensate for the lack of practical and academic training, implemented as of the 1 st wave according to 41% (36/89) and adapted to needs according to 50.6% (45/89). One of the main alternatives reported in the literature is e-learning, which is highly appreciated by residents and by the medical community as a whole, as it saves on travel time and offers easily accessible extra training [23] [24] [25] [26] . Telemedicine likewise partially compensates for decreases in consultation. However, although patients are very well satisfied [27] , it is better appreciated and more adapted for medical than surgical residents, especially in head and neck surgery where direct clinical examination is often indispensable [12] . Bandi et al. reported that dissection is the alternative to actual surgery that is best appreciated by residents (53%), followed by online teaching and webinars (46%) [28] . In the present series, however, very few ENT-H&N residents has dissection sessions or simulations, as anatomy and simulation labs were locked down in France during the 1 st wave. Although generally satisfied with the alternatives provided, two-12 thirds of respondents had needed to look for training aids over and above those provided officially. This argues for increasing e-learning and other alternatives such as simulation, which, if possible, should be directly available in hospital or university departments [26, 29] .

This was the first French study to assess the impact of Covid-19 on training for surgery residents and specifically on the national ENT-H&N surgery degree course. Its main interest compared to other studies in the international literature was to compare reduction in activity over the first 3 waves, whereas other studies were restricted to wave 1 or else did not assess comparisons. This disclosed major impact in the 1 st wave, parallel to local health situations (number of Covid-19 admissions directly related to closure of operating rooms and beds), whereas the subsequent waves had less impact on residents' training, thanks to better preparation and organization.

The study shows the limitations inherent to any survey: response rate varying between Regions, and the retrospective declarative nature of the responses. It would be useful to supplement subjective assessment by objective operative data, which we were unable to do due to inter-regional differences and the risk excessive declaration bias over a period of 18 months. We chose to focus on 5 large Regions, diversely impacted by the pandemic, but a larger nationwide study would be useful. The psychological impact of the crisis on ENT-H&N residents was not studied, although ENT-H&N is a highly exposed specialty and it would be interesting to assess levels of stress and anxiety, which may be high, as reported by Ashoor et al. [30] . However, in the free text part of the questionnaire, respondents rarely reported fear of contamination or severe stress.

Page 13 of 24 J o u r n a l P r e -p r o o f 13 This study highlighted reduced activity, both practical and academic, reported by French ENT-H&N residents, related to the Covid-19 epidemic. The reduction was greater during the 1 st wave than the 2 subsequent waves, and mainly affected residents in Regions in which the epidemic was most severe. The study thus indicates a need for reorganization and nationallevel harmonization of training and educational tools, whether in view of another wave or more generally. Reform of the 3 rd cycle of medical studies has been underway for years in France, seeking to make residents more autonomous, and it would be interesting to assess progress in the light of the present context. Continuous variables reported as mean ± SD (standard deviation). Qualitative variables reported a number and percentage (n (%)). Qualitative variables reported as number and percentage (n (%)). 

Safety recommendations for evaluation and surgery of the head and neck during the COVID-19 pandemic

COVID-19 and ENT Surgery

Role and management of a head and neck department during the COVID-19 outbreak in Lombardy

COVID-19 and the otolaryngologist: preliminary evidence-based review

Tracheostomies after SARS-CoV-2 intubation, performed by academic otorhinolaryngologists in the Paris area of France: preliminary results

Medical education adaptations: really good stuff for educational transition during a pandemic

The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies

Statistics in scientific articles published in the European Annals of Otorhinolaryngology Head & Neck Diseases

Mastering the descriptive statistics used in otorhinolaryngology

Effect of COVID-19 on surgical training across the United States: a national survey of general surgery residents

Effect of the COVID-19 pandemic on medical student career perceptions: a national survey study

Medicine and surgery residents' perspectives on the impact of COVID-19 on graduate medical education

The impact of COVID-19 on plastic surgery residency training

Impact of COVID-19 epidemic on maxillofacial surgery in Italy

The impact of COVID-19 on thoracic surgery residency programs in the US: A program director survey

The impact of COVID-19 related lockdown on ophthalmology training programs in India -Outcomes of a survey

Impact of COVID-19 on IR Fellowship

Impact of the COVID-19 pandemic on urology residency training in Italy

Impact of the COVID-19 pandemic on otolaryngology trainee education

French consensus on management of head and neck cancer surgery during COVID-19 pandemic

Impact of the first month of Covid-19 lockdown on oncologic surgical activity in the Ile de France region university hospital otorhinolaryngology departments

COVID-19 and ENT Pediatric otolaryngology during the COVID-19 pandemic. guidelines of the French association of pediatric otorhinolaryngology (AFOP) and French society of otorhinolaryngology (SFORL)

Impact of the COVID-19 pandemic on otolaryngology residency: a real-life experience

COVID-19 pandemic and head and neck surgery residency program: proposals for the "phase 2

The impact of COVID-19 on medical education

The technological impact of COVID-19 on the future of education and health care delivery

Telemedicine for ENT: effect on quality of care during Covid-19 pandemic

Strategies to overcome limitations in otolaryngology residency training during the COVID-19 pandemic

What is the role of surgical simulation on operative opportunity for the trainee ENT surgeon?

The psychological impact of the COVID-19 pandemic on otolaryngologists: should we be concerned?

Acknowledgments. The authors thank the ENT-H&N students who agreed to fill out the questionnaire.

The authors have no conflicts of interest to disclose.

Age (years) (mean ± SD) 28 ± 2Region, n (%)Ile-de-France (Paris) 28