key: cord-1017281-ki6ty1q7 authors: Giordano, Lorenzo; Cipollaro, Lucio; Migliorini, Filippo; Maffulli, Nicola title: Impact of Covid-19 on Undergraduate and Residency Training date: 2020-11-12 journal: Surgeon DOI: 10.1016/j.surge.2020.09.014 sha: 2b7d9a8604fa641bac2b0ab3c860ada4cd309973 doc_id: 1017281 cord_uid: ki6ty1q7 Background The covid-19 pandemic has dramatically changed lives of residents and medical students. In particular, the learning process has undergone widely changes, especially due to the rules of social distancing which have forced universities and various institutes to modify lessons, work shifts and internships. Purpose The purpose of our review is to evaluate how the various institutes have faced the covid-19 emergency and guaranteed the perpetuation of the learning process of resident and students. Methods A comprehensive search of the medical literature in PubMed and Google Scholar was performed including all the works explaining how the institutes have reorganized teaching for resident and undergraduate students. Main findings The use of internet for the dissemination of teaching material and educational meetings has built bridges, albeit virtual, between resident and teachers. New techniques for teaching and conducting exams have been introduced. The rotating team system allowed the continuation of the teaching activity in safety. Conclusion Thanks to remodulation of the teach modalities, the massive use of internet platforms, a wise distribution of work shifts, and others, universities and hospitals have not only reduced the impact on the learning process of resident and students but also turn this pandemic into a moment of personal and professional growth for the new generation of healthcare professionals. The novel Covid-19 pandemic marked our lives in an indelible way, changing the reality we were used to. It affected negatively the educational training for all students worldwide; Given the social distancing recommendations, the Coronavirus emergency has led to significant modification within hospitals, such as limiting the presence of residents who are on duty, cancelling elective procedures, decreasing the volume of acute care surgery following surgical professional societies guidelines, and cancelling lectures and educational conferences to adhere to social distancing recommendations. [1] [2] [3] [4] [5] Regarding teaching, in-person academic activities, including face-to-face teaching, and simulation laboratories have been interrupted, along with an interruption of the clinical rotation within the different areas of the same institution. The current pandemic emergency has imposed significant loads on universities and hospitals to promote continued safety, education, and quality patient care. 1, 5, 6 The present article evaluated the methods used by the various institutions to overcome the difficulties that have arisen to allow continuation of training courses medical students and post-graduate medical trainees and identify possible differences between the various institutes. performed. The following Keywords were used in combination: "Covid-19/coronavirus, SARS/CoV-2, pandemic, virtual, rotation, telemedicine, skills, learning, distance, training, students, resident/trainee, webinar, undergraduate students". We considered for inclusion only studies that clearly stated the methods and techniques used by institutes to ensure the safety and continuous education of its own students. Reviews, letters, expert opinion and commentaries were not eligible for inclusion. The Prisma guidelines were followed ( Figure 1 ). The results of the literature search are shown in Table.1 J o u r n a l P r e -p r o o f After removal of duplicate records, 411 articles were assessed. Then, following inspection of the title and the abstracts, 366 articles were excluded because although considering hospital reorganization during covid-19 they do not focus on resident or undergraduate. A further screening excluded another 31 articles because they do not specifically consider how the teaching of trainee or undergraduate students has changed. A total of 14 articles were included. J o u r n a l P r e -p r o o f Given the quick spreading of the SARS-CoV-2 around the world, and the introduction of social distancing measures, many educational systems faced a mandatory closure of in-person activities. All universities suspended their frontal teaching, providing online lecture to guarantee students' teaching and their right to study. 7 The internet has represented the keystone to produce the necessary connections between students and teachers. We assisted to a transitional paradigm from an in-person training to an onlinetraining. The pivot of this system was on-line meetings, which became the only moment of discussion and debate. Numerous platforms have been used for this purpose, including ZOOM™, GOTOMEETING™ , MICROSOFT TEAM™ and many others. During the lockdown period, there was constant improvement of these programmes, improving their versatility and accessibility to students and teachers. These meetings gave the opportunity to learn and discuss topics between students, trainee, residents and clinical and academic staff, or webinars from third party organisations. [8] [9] [10] [11] In this scenario, an innovative teaching method arose: the flipped classroom strategy. Using this innovative teaching method, learners were provided with didactic material, in the form of a pre-recorded video lecture, which they could watch prior to the online meeting. Students expressed high levels of satisfaction with pre-class video lectures because the videos can be accessed at any time and as often as they desire. Students also highly regarded the use of small group discussion-based activities in flipped classroom face-to-face sessions because these sessions increase their motivation to learn, and enhanced their level of engagement and interest in the subject matter. 12, 13 Especially for surgical trainee interactive platforms provide surgical anatomy reviews, surgical procedure walkthroughs, practice test questions, and intricate patient cases. [12] [13] [14] However, their effectiveness in improving surgical performance remains limited. [15] [16] [17] [18] J o u r n a l P r e -p r o o f The most popular video search engine for surgical trainees is YouTube™, whereas specialists tend to rely on videos from specialist surgical societies. 16, 19 Caution should be exerted when choosing videos, because there is no current peer-review process for publishing medical videos online, with many top-ranked videos showing suboptimal technique. 20 Though virtual learning is able to support certain aspects of surgical education, it cannot obviously bridge certain gaps. 12, [21] [22] [23] It is difficult for the current virtual platforms to address the lack of intra-operative experiences. Models and instruments, such as suturing kits with felt or silicone "tissue" or FLS (Fundamentals of Laparoscopic Surgery) box trainers, can be borrowed for technical practice. Written or verbal feedback can be provided remotely, either through faculty review of uploaded recordings or hosted virtual sessions in which residents focus their camera on their technical performance for faculty feedback in real-time. 20,24-28 Some obstacles related to the digital revolution in medical learning have been evidenced, including some teachers and educators struggling with new technologies, participants with poor bandwidth connections, and difficulties in viewing images. However, these limitations can be overcome with an investment of time and effort by staff suppliers who are familiar with these techniques. 29 At the basis of surgical and medical education there is the theory of self-directed learning. In this transition period, trainees can use this time to reflect on their personal learning methodologies, establish a goal, such as improved in-service exam performance, or developing a deeper understanding of a certain topic using review materials textbooks, online review articles, and previously described virtual educational modules. In addition, students can use the time available for setting up or completing academic work and research projects. 8, 9, [12] [13] [14] [22] [23] [24] [25] [26] 28 With regard to the evaluation methods, the most used are the multiple-choice questions concerning the topics covered during the lecture of the day or of the previous days J o u r n a l P r e -p r o o f accompanied by the discussion among the residents. This represents a fundamental moment in the path the learning of these students during the lockdown period, as it keeps attention alive and allows the comparison between resident with different attitudes and interests and at the same time helps to develop the critical sense necessary to face the more and more challenges. 11, 22, 23, 30 Impact Covid-19 on surgical assistance In accordance with international guidelines, elective surgery was suspended, and only emergent and urgent cases could be operated. Consultations were accomplished mostly though a telemedicine platform. Exception was made for those patients with suspected of acute wound healing problems. Participation in these consultations provides continuity of clinical education without additional risk. 31, 32 The other operative cases were staffed by no more than a single faculty and a single resident to limit exposure. Consequently, the number of residents physically present in hospitals decreased significantly, helping to prevent the spread of Covid-19. Residents were divided into two or more groups: the home group focused on virtual teaching, the in-service group and sometimes a reserve group (composed of two or three resident who stayed at home and were ready to replace a colleague on duty in the event of illness). Trainees rotated from one group to the other every two or more weeks. The duties of in-service resident varied from assisting in ward rounds, helping to implement ventilator protocols, providing general intensive care unit care, responding to ancillary staff queries, providing updates to the family of the Covid-19 patient, and monitoring overall patient status. To protect residents, full personal protective gear respirator masks, eyewear / face-shields, and full head / body gowns was provided to each resident and faculty, along with infrared laser thermometers to record temperatures at the beginning and end of shifts. 16, 24, 25, 27, 28, 30, 35, 36 J o u r n a l P r e -p r o o f During the Covid-19 lockdown, the life of an undergraduate medical student also underwent considerable upheaval. Those students away from their families and hometowns found themselves alone in full lockdown. Their education was interrupted, experiencing intense fear caused by uncertainty. More than half of medical students felt mentally unwell, as the corona virus outbreak determined high levels of anxiety. 34 The Covid-19 pandemic introduced of new methods to provide education to medical students as well. Formal lectures were quickly converted into webinars available online, to be reached via the platforms mentioned in the previous section, in real time or recorded for later use by students wherever they were. 35 Current online webinars include key clinical conditions, case studies, didactic lectures and examination questions. The transition to online medical education also promoted changes in examination methods. Following the recent success of Imperial College London's first ever online exam for final year students, other medical schools adopted a similar approach to ensure students remain engaged with their studies, with many universities adopting an open-book examination (OBE) approach. This approach allows students to use all their material (books, notes etc.) during the test, and represent an alternative from previous exam-hall settings (closed book). OBEs have been reported to reduce student anxiety 36 , although it is not possible to generalize as some students often overestimate the help they can receive from the open book with a detrimental effect on the retention of notions and performance on exams. In addition, anxiety levels do not always have a negative effect on the student's performance, sometimes helping them to try their best and develop a stronger and more confident personality. However, with a global level of heightened fear and apprehension during the current COVID-19 pandemic, an approach to examining students that can minimise the symptoms of stress is welcomed. 38 During the lockdown period, some universities recruited students for hospital-based roles as either students or early graduated frontline workers, while others prohibited any patient interaction. 37, 38 Although medical students are a commendable source of help, their involvement J o u r n a l P r e -p r o o f must be carefully evaluated and their introduction to actual hospital clinical must be strictly controlled. Through their clinical attachments, they operate passively, shading teams, taking stories and observing procedures. Therefore, a well-structured program producing a stable learning environment does not guarantee that students will acquire the confidence and skills necessary to function properly during a pandemic; the lack of required knowledge and capability placed students, and patients, at risk during disaster situations. 39 virtual, between resident and teachers. The rotating team system has made it possible to achieve a balance between the safe and isolation of the resident and a certain amount of in-service hours. This unprecedented circumstance will change the way in which we deliver medical teaching and represents an opportunity for residents not only to focus on the theoretical aspects of their discipline but also a invaluable education in crisis management on a large scale and an opportunity to grow a common sense of belonging to face such adversities. However, maintaining the effective organization described will require continuous innovation and cooperation on the part of educational program directors, and leadership on the part of our professional societies to maintain rigorous standards of education and training for resident and medical student. Learning Journal club -One junior-level resident is designated as the "on call" resident for the 2 adult hospitals -Only emergent consults should be seen by the junior-level resident in order to limit patient interaction and the potential spread of COVID-19 -One senior resident is designated as the "backup" point of contact and is in the hospital during the day to help with major cases -One senior resident is to cover the children's hospital via home call After each meeting, a summary email is sent by program director or chief residents to all members of the residency program, serving both as a debriefing as well as a tracking system of our academic progress during this challenging time. Students work with the resident and faculty of their assigned service to see and present virtual clinic patients during the second week of the clerkship. How Are Orthopaedic Surgery Residencies Responding to the COVID-19 Pandemic? 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