key: cord-1010887-dwpcwxzt
authors: Burks, Joshua D.; Luther, Evan M.; Govindarajan, Vaidya; Shah, Ashish H.; Levi, Allan D.; Komotar, Ricardo J.
title: Early changes to neurosurgery resident training during the Covid-19 pandemic at a large United States academic medical center
date: 2020-09-28
journal: World Neurosurg
DOI: 10.1016/j.wneu.2020.09.125
sha: a40fd0f82efa5ecede8df56cfc84e79373e3dc8d
doc_id: 1010887
cord_uid: dwpcwxzt

Introduction The 2019 coronavirus disease (Covid-19) pandemic has led to sweeping changes in residency programs across the world, including cancellation of elective cases. The impact of safety measures on neurosurgical training remains unclear. To understand how neurosurgical residents have been affected, the authors analyze operative experience in months leading up to and during the pandemic. Materials and Methods Resident and institutional case totals were tallied for a single residency program in Miami-Dade County, USA from January 01, 2019 to June 30, 2020. Matched cohort analysis was performed before and during the pandemic to assess effect on resident surgical training. Results Case totals for all levels of training were lower when restrictions were placed on elective surgeries. An average of 11 cases were logged in April 2020, down from 26 in April 2019 (mean 8.7 – 22, 95% CI; p <0.01), and an average of 20 cases was logged in May 2020, down from 25 in May 2019 (mean 1.2 – 8.8, 95% CI; p = 0.01). In April 2020 there were 299 (66%) fewer cases performed at our institution compared to the year prior, and in May 2020 there were 148 (50%) fewer cases. Conclusions Operative experience was reduced for residents during months when elective cases were restricted. Our data suggests experience in some areas of neurosurgery are more impacted than others, and residents at different levels of training are affected differently. However, the extent of the Covid-19 Pandemic on neurosurgical training is unlikely to be understood in the short-term

The 2019 coronavirus disease pandemic has had a major impact on every 33 aspect of the United States healthcare system. The disease outbreak has led academic medical 34 centers across the nation to restructure residency programs to limit exposure of residents-who 35 serve a critical function of the workforce-while continuing to provide patient care. 1, 2 The 36 spread of infection within neurosurgery training programs, which tend to be smaller compared to 37 other specialties, would be catastrophic as any infected individual would be required to leave the 38 workforce for a minimum of 10-14 days. Efforts to mitigate this risk have broadly focused on 39 reducing bedside consultations to when absolutely necessary, non-voluntary time off, minimizing 40 in-person handoffs, and cancelling cases. In recent domestic and international surveys of 41 neurosurgery residents, the vast majority reported their surgical training had been affected. 3-5 42 Within the department of neurological surgery at our institution, there was a clear benefit 43 from early strategies to reduce exposure and limit disease transmission among residents. To date, 44 there have only been 2 documented cases of Covid-19 among trainees in our program. However, 45 the impact of safety measures on surgical training remains unclear. For our institution these 46 measures included cancellation of non-urgent cases for approximately 3-4 weeks beginning in 47 late March 2020. 48

Four months after restructuring resident duties to meet the needs of our community, the 49 authors compare institutional operative experience in months leading up to, and since, the 50 pandemic began to better understand which areas of surgical training have been impacted most. 51

Miami-Dade County was at the epicenter of a second spike in Covid-19 cases, which in turn led 52 to another moratorium on elective surgeries as of late July 2020. This latest reduction in surgical 53 volume underscores a need to better understand how resident training is being impacted, so that 54 training programs can move to soften its impact on training from one year to the next. This 55 analysis should serve to inform other surgical subspecialty training programs of anticipated 56 differences in operative experience as a result of Covid-19. 57

Program restructuring during the 2019 Coronavirus pandemic 60

Our service covers 5 hospitals, with the bulk of resident training taking place at the 61 university and county hospitals. The main county hospital is divided into three subservices which 62 are cranial surgery, spine surgery, and trauma neurosurgery. The university hospital is a 63 combination of all subspecialties covered by a separate team. Teams change rotations every four 64 months. In March 2020, these services were consolidated to minimize the number of residents in 65 the hospital at any given time. The three subservices at the main hospital were merged into one 66 covering service, with residents rounding on their individual services only as needed. Likewise, 67 the daily rounding/covering team at the university hospital was reduced by half. The Covid-19 68 coverage team responsibilities were as follows: the in-house/on call junior makes rounds with the 69 covering PGY-6 or PGY-7 at their respective hospitals. Then junior and senior residents proceed 70 to the operating room for the day's cases, with the junior resident breaking as necessary to see 71 consults and respond to calls from the ICU and floors. Standard ICU responsibilities for junior 72 residents additionally include minor procedures such as central line or intracranial pressure 73 monitor placement and tracheostomy. 74

For larger censuses or busier operative days, additional junior and senior residents are 75 called in. Residents off-service or on elective rotations were to act as "reserves" if needed. 76

Adhering to this schedule, one of three residents per class was exempt from clinical duty each 77

week. Figure 1 illustrates resident coverage during the pandemic. Additionally, all handoffs, 78 conferences, and didactics were performed by telephone or video conference. 79

Standard precautions were taken within the hospital as have been described elsewhere, 80

including minimizing face-to-face patient interactions to when it was absolutely necessary for the 81 sake of obtaining a clinical exam. 6 Residents were supplied with recommended personal 82 protective equipment (PPE), and N95 facemask and eye protection were mandatory at all times 83 for residents while in the hospital. Cases performed after March 18, 2020 and before April 27, 84 2020 were done only on an emergency or urgent basis. Urgency was assessed by a dedicated OR 85 departmental committee, described in Eichberg et al. 7 Cases deemed urgent were so judged on 86 the basis of progressive disability or unacceptable risk to the patient. 87 88

Within the neurosurgery residency program, case numbers are prospectively recorded 90 using the Accreditation Council for Graduate Medical Education (ACGME) Case Log System. 91

All procedures are logged at the discretion of the resident both for purposes of accreditation and 92 personal records. We obtained resident case logs for our institution from January 01, 2019 to 93 J o u r n a l P r e -p r o o f Given substantial growth of the department with the addition of new faculty over the past 2 95 years, only case data from the year prior to the pandemic was used for matched comparison. 96

Institutional approval was obtained prior to collection of data for this study (IRB #20200632). 97

Resident case totals were then matched for comparison by PGY-level, month, and 98 rotation to account for differences in divisions of in-house call and floor-related work among 99 junior-and senior-level residents, and for seasonal fluctuations in hospital admissions and 100 caseload. Case numbers for residents on dedicated elective time and for residents rotating off-101 service were not included in the analysis. 102

Institutional case totals were obtained from prospectively collected departmental records. 103

Recorded data included surgery date, procedure name, CPT (Current Procedural Code) 104 terminology, and resident/fellow/attending surgeons present during the case. Case classifications 105 were broadly adapted from the ACGME Case Log System minimum requirement categories. As 106 with resident case totals, institutional case totals were matched by month and year for 107 comparison. 108 109

Continuous variables are reported as means with 95% confidence intervals unless 111 otherwise specified. Categorical variables are reported by frequency. Between group analyses 112 were conducted using paired difference testing, and bivariate correlation was assessed. 113

Independent samples t-test was used for mean comparison in unpaired samples. A p value ≤ 0.05 114 was considered statistically significant. All statistical analysis was performed using SPSS 115 (version 24, IBM). 116

A total of 24 resident case logs were reviewed for the study period. There was no lapse in 119 resident coverage for the months reviewed. During the study period, highest case totals were 120 noted for PGY-6 and PGY-7 residents. Lower case totals for all levels of training were noted on 121 all rotations in April 2020. With the exception of spine service PGY-7, all residents recorded 122 fewer cases for May 2020 as well. Resident case totals are shown in Figure 2 . 123

In matched analysis, an average of 15 (58%) fewer cases was logged in April 2020 (8.7 -124 22, 95% CI; p <0.01). An average of 5 (20%) fewer cases was logged in May 2020 (1.2 -8.8, 125 95% CI; p = 0.01). There was no significant difference in cases logged during the other months 126 studied. This is shown in Table 1 . 127

Comparison of institutional case numbers showed a significant reduction in overall case 128 numbers during the months of April 2020 and May 2020 compared to the year prior (mean 129 difference -21, 95% CI -36 --5.5 p = 0.01; mean difference -10, 95% CI -20 --1.0 p = 0.03, 130 respectively). 102 thoracic/lumbar laminectomy with or without instrumentation cases were 131 performed in April 2019 (23% of all monthly cases), and 22 were performed in April 2020 (14% 132 of all monthly cases, 78% reduction). 19 functional/epilepsy cases were performed in April 2019 133 (4% of all monthly cases), and 2 were performed in April 2020 (1% of all monthly cases, 89% 134 reduction). 118 neuro-endovascular cases were performed in April 2019 (26% of all monthly 135 cases) and 33 were performed in April 2020 (21% of all monthly cases, 72% reduction). 136

Institutional case numbers by month are shown in Table 2 . 137

Mean number of residents participating per case is given in The full extent of the impact of the pandemic on U.S. training programs will not be 152 known for some time. After initial quarantine restrictions were lifted in the state of Florida in late 153

April 2020, Miami-Dade county has seen a remarkable second spike in Covid-19 cases, with 154 J o u r n a l P r e -p r o o f more than 1 in 4 individuals tested having a positive result as of July 15, 2020. 13 Notably, 12 of 155 30 (40%) players on the Miami Marlins professional baseball team tested positive at the end of 156

July, while Major League Baseball had previously reported a 0.05% positive rate across the rest 157 of the league. 14 This unfortunate resurgence of cases across the region again led to cancellations 158 of most elective cases at our institution. 159

It is unclear what the long-term effects of the pandemic will be on residency training, and 160 particularly on surgical training which relies heavily on operative experience. Earlier authors 161 have proposed thoughtful suggestions for supplementing resident training, 15 however, our 162 experience in Miami presently offers a unique opportunity for interim assessment. By analyzing 163 resident case logs and institutional case numbers at our high-volume centers before and during 164 the pandemic, the present study offers an early look at how neurosurgery resident operative 165 experience has been affected. 166

Across the program, we found a reduction in case numbers during months under 167 moratorium on elective cases. Residents on operative rotations performed an average of 58% 168 fewer cases in April 2020 than the year before, and an average of 20% fewer cases in May 2020 169

than the year before. In June 2020, residents actually performed, on average, slightly more cases 170 than their counterparts on the same rotation the year before. 171

This reduction in resident cases logged corresponded to an overall reduction in case 172 volume across the institution. In April 2020 there were 299 (66%) fewer cases compared to the 173

year prior, and in May 2020 there were 148 (50%) fewer cases. As resident case logs increased 174 in June 2020 compared to the month prior, so too did total institutional cases during that month 175 by 51 cases (113%). During the moratorium, the most impacted case types were those involving 176 thoracic or lumbar laminectomy and instrumentation, epilepsy surgery, deep brain stimulation, 177 and endovascular surgery. Other authors have similarly noted a disproportionate cancellation of 178 complex spine cases, 16 and a major impact on neuro-interventional cases. 17 Brain tumor cases 179 constituted a higher proportion of the cases performed during those months, although also 180 reduced in number compared to the year prior. Other authors have provided details regarding 181 case numbers at the height of the pandemic, 17, 18 but this is the first report on relative changes in 182 surgical case numbers during the pandemic by case type. 183

In response to a decrease in the number of operative cases that began in late March 2020, 184 new measures were adopted to increase resident operative experience. In the early days of the 185 J o u r n a l P r e -p r o o f pandemic, our institution limited resident coverage of cases to avoid unnecessary exposure to the 186 virus. However, the availability and turnaround time of Covid-19 PCR testing rapidly improved 187 in subsequent months, allowing more residents to scrub into cases once a negative Covid-19 test 188 result had been obtained. This is apparent from the increase in mean residents per case during the 189 month of May 2020 from 1.5 to 1.8, meaning more cases had 2 or more residents in each case 190 than in months prior. Interestingly, there was a similar increase in residents per case in June 2020 191 despite an overall increase in the number of cases that month compared to the year prior. institution, a positive test result requires a 2-week quarantine, followed by repeat testing before a 199 resident is allowed to return to work. As only 2 residents tested positive during the pandemic to 200 date, residents in our program were only off-service on their scheduled "off-weeks," which in 201 total resulted in no more than 2-3 weeks out of the operating room for any given resident. 202

as this is the greatest source of between-resident variability in case numbers. For instance, junior 204 residents tend to carry most of the in-house call in U.S programs, 19 and consequently will 205 perform fewer operations than their senior counterparts who are unburdened by post-call days 206 off. Additionally, senior-level residents are typically involved in more complex cases that would 207 be done on an elective basis. Hence, the impact of a pandemic would be expected to have a lesser 208 impact on the operative experience of a PGY-1 than a We emphasize that the effect on operative experience seen in this study is the result of 210 several weeks of elective case cancellations, and that resident training would be impacted at a 211 much higher magnitude if cancellations were to last through the fall. For this reason, we began to 212 allowed double-scrubbing of urgent cases (resident-resident or resident-fellow). Other 213 institutions have conversely reported the loss of resident participation in operations during the 214 pandemic. 20 There are advantages and disadvantages to higher numbers of residents participating 215 in each case. There can be more opportunities for fellow-resident and resident-resident teaching, 216 J o u r n a l P r e -p r o o f sometimes counteracted by less hands-on time during the case. Under these circumstances an 217 operating room culture that supports education and teamwork is critical. 218

Training adjuncts have long been understood to have an important role in the 219 development of technical skill among neurosurgery residents. 21 We found cases involving 220 thoracic and lumbar spinal instrumentation, open vascular microsurgery, endovascular 221 neurosurgery, and functional and epilepsy surgery to be the most impacted during by restrictions. This would suggest these should be areas of focus for learning within the lab setting. The study's principle limitations result from a number of inherent differences between 239 the residents included. Characteristics such as motivation, skill level, and attending preference 240 are difficult to quantify, yet could contribute to a resident completing more or fewer cases. 241

Even in the absence of a global pandemic, neurosurgical training requires constant 242 evaluation to ensure the highest quality education for trainees. 27 Ultimately, multi-institutional 243 analysis following the pandemic will highlight the operative/training disparities during the 244 pandemic, and long-term follow up of trainees' experiences will be warranted in the future as 245 other authors have noted. 28 Such analysis will prove valuable in reassessing requirements for 246 accreditation. 29 And yet, as Kemp and colleagues recently suggested, greater collaboration 247 J o u r n a l P r e -p r o o f among departments nationally and internationally may be an unexpected "silver lining" of the 248 pandemic. 30 Other innovations such as improved laboratory and virtual models could be a 249 valuable addition to resident surgical training even after the pandemic subsides. 250

Our findings affirm that the pandemic's impact on training is intimately connected to 251 resumption of surgical activity in each hospital, which is dependent on national, local, and 252 institutional protocols. Our institution's experience will vary by comparison with other residency 253 programs in other cities or countries, 31 but it may serve as an example for others who wish to 254 push the envelope to ensure the highest possible level of training for neurosurgery residents 255 during the pandemic. At the time of this writing, several states including Wisconsin, Utah, and 256

Oklahoma are still seeing a rise in new case numbers 32 with no clear end in sight. 257

In our study of a single academic training center, operative experience was reduced for 260 neurosurgery residents when elective cases were restricted. Our analysis suggests experience in 261 some areas of neurosurgery are more impacted than others. However, the effect of the Covid-19 262

Pandemic on neurosurgical training is unlikely to be understood in full until a long-term, multi-263 center study becomes feasible. With the exception of spine service PGY-7, all residents recorded fewer cases for May 2020 as 384 well. 385 

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