Introduction

An ongoing outbreak of respiratory disease was first identified in Wuhan, China, in December 2019. A novel coronavirus was identified as the cause of the outbreak and was named SARS-CoV-2. In February 2020, the World Health Organization (WHO) officially named the disease COVID-19. The outbreak quickly spread throughout Asia and the rest of the world, and was declared a pandemic on March 11, 2020¹. In Argentina, the first case was confirmed on March 3, 2020³, while in Santa Fe the first case was reported on March 15⁴.

As part of the measures aimed to prevent the spread of the pandemic in our country, the executive decree 297/2020 was issued, declaring mandatory social isolation; borders were closed and mass gathering events and trips were canceled². In the new setting, the Ministry of Health of the Province of Santa Fe declared Hospital Eva Perón (HEEP) in the city of Granadero Baigorria as COVID-19 designated hospital, defining it as a high-complexity facility that would provide care for adult patients with COVID-19⁴. This measure implied changes and adjustments in all the activities carried out in the hospital, including administrative activities, outpatient care, emergency department visits, hospital admissions, surgeries, and the incorporation of the Modular Hospital with 76 beds for the exclusive care of COVID-19 patients.

The postgraduate program in General Surgery of Facultad de Ciencias Médicas at Universidad Nacional de Rosario lasts 4 years. HEEP is one of the training centers that integrates this postgraduate program, which admits two trainees per year and one chief resident. As part of the postgraduate program in general surgery, the HEEP offers trainees healthcare activities (scheduled and emergency surgeries, outpatient clinic, care of hospitalized patients), academic activities (seminars conducted by residents) and research activities supervised by staff surgeons. The aim of the postgraduate program is the comprehensive training of a general surgeon in the care of the surgical patient; he/she should be able to perform emergency surgeries and intermediate and minor scheduled surgeries with independence and autonomy⁵. The designation of HEEP as hospital dedicated to the care of COVID-19 patients also had an impact on the daily activities of trainees in general surgery. The aim of this study is to describe the changes made and the performance of the postgraduate program in general surgery at HEEP during the COVID-19 pandemic, and its impact on trainees’ education.

Material and methods

We conducted a retrospective and comparative study. The education of trainees of the postgraduate program in general surgery at HEEP was evaluated between March 20, 2020 (date when surgeries and appointments were suspended) and September 30, 2020 (date when PGY-4 residents completed the program and new residents were admitted), and these data was compared with the same period in 2019 (28 weeks).

The evaluation considered healthcare, academic and research activities. The variables analyzed included number of surgeries (scheduled and emergency procedures), hours spent in hospital, number of in-house call shifts, activities in the outpatient clinic and evaluation of patients hospitalized in the department, theoretical seminars, attendance to classes of the postgraduate program and research work. Quantitative variables are expressed as mean and standard deviation. Statistical analysis was performed using the paired Student’s t test.

Results

During the period analyzed in 2019, 625 surgeries were performed, with a mean of 22.93 per week (standard deviation ± 7.76) versus 157 surgeries in 2020, with a mean of 5.81 per week (standard deviation ± 4.10). This represents 468 fewer surgeries in 2020 compared with the same period in 2019 (-74.88%) (p < 0.005) (Table 1).

Table 1 Number of surgeries performed in both periods and difference between them 

During the period analyzed in 2020, a total of 51 scheduled surgeries were performed, with a mean of 1.89 surgeries per week (standard deviation ± 2.64). Over the same period in 2019, 354 scheduled surgeries had been performed, with a mean of 12.89 surgeries per week (standard deviation ± 5.54). This represents 202 fewer surgeries in 2020 compared with the same period in 2019 (-85.59%) (p < 0.05) (Table 1). During the period analyzed in 2020, a total of 99 emergency surgeries were performed, with a mean of 3.67 surgeries per week (standard deviation ± 2.35). Over the same period in 2019, 269 emergency surgeries had been performed, with a mean of 9.74 surgeries per week (standard deviation ± 4.46). This represents 170 fewer emergency surgeries in 2020 compared with the same period in 2019 (-63.19%) (p < 0.05) (Table 1). The reduction in the total number of surgeries directly implied that the residents participated in fewer surgeries as surgeons and assistants (Table 2).

Table 2 Number of surgeries in which each trainee participated as surgeon and assistant in both periods evaluated and their variation, expressed in absolute numbers and percentage. 

The number of in-house call shifts and hours spent in hospital by the trainees were also affected (Table 3).

Table 3 In-house call shifts and hours spent in hospital per resident during both periods studied; the variation is expressed in absolute numbers and percentage. 

A total of 188 patients were admitted during the study period in 2020, with a mean of 6.89 patients per week (standard deviation ± 4.03). Over the same period in 2019, 725 patients were admitted, with a mean of 25.89 admissions per week (standard deviation ± 6.98). This represents 537 fewer patients admitted (-74.06%) (p < 0.05). Before the pandemic outbreak, all 1st, 2nd and 3rd-year trainees were responsible for the care of patients in the outpatient clinic. Their tasks included wound care, preoperative visits and general surgery clinic. Preoperative visits and the general surgery clinic were suspended. Only the wound care clinic remained active, but it was mostly dedicated to patients with complex wounds, and the interval between appointments was lengthened as much as possible (Table 4).

Table 4 Comparison of outpatient clinic activities between both periods 

Before the pandemic, the trainees were in charge of the weekly academic activities in addition to theoretical seminars and oncology seminars with the participation of staff surgeons and oncologists, internists and specialists in diagnostic imaging, depending on the activity. As part of the postgraduate program in general surgery, all the trainees attended classes at the school of medical sciences. During the time interval analyzed, face-toface academic activities and oncology seminars were canceled. The academic activities were organized using the Zoom platform. Bibliographic reviews, updates, readings and discussion of scientific papers were done through this platform. They also had active participation in the activities organized by other institutions (case conferences with other hospitals via Zoom or webinars, among others). Face-to-face classes of the postgraduate program in general surgery were suspended but were carried out through virtual platforms (Zoom, Google Meet^®). During 2019, research activities were irregular and scientific papers were often postponed, prioritizing healthcare activities. During the period analyzed in 2020, the reduction in healthcare activities resulted in more time available to organize the theoretical framework of scientific papers previously initiated, and to develop other research works to be continued during the post-pandemic period.

Discussion

The reduction in the number of scheduled and emergency surgeries directly implied that all the residents participated in fewer surgeries as surgeons and assistants. This difference was greater for 1st and 2ndyear trainees and was also evident for 3rd-year trainees. There were no differences in the number of surgeries performed by 4th-year trainees compared with 2019.

The number of patients admitted was highly affected by the pandemic. The cancellation of scheduled surgeries and the lower number of patients visiting the emergency department led to a reduction in the number of hospitalizations. In addition, the fact that the physical attendance of trainees to hospital and daily ward rounds were suspended, resulted in fewer opportunities for trainees to evaluate patients. Something similar occurred with the patients evaluated in the outpatient clinic. Although there are no exact data available on the number of patients seen, outpatient care was significantly affected.

As the time dedicated to patient care decreased, more time was dedicated to academic activities. Despite the impossibility of holding face-toface meetings, the use of technology made it possible to organize virtual meetings between trainees and instructors. Prior to the pandemic, academic activity was face-to-face, but irregular. During the pandemic, it was possible to organize a better agenda, with topics assigned to the different trainees. Meetings held twice a week were conducted by trainees under the supervision of staff surgeons. On some occasions, physicians from other departments of the hospital and even surgeons from other cities participated.

Attendance to face-to-face classes of the postgraduate program, as during 2019, was also affected. Once again, technology made it possible to continue with classes through virtual meetings. Technology also allowed trainees to actively participate in activities organized by other institutions, as Asociación Argentina de Cirugía and Asociación de Cirugía de Rosario, among others. Overall, the number academic activities developed by the trainees during the pandemic was higher than during 2019. Another option proposed was the use of laparoscopic surgery simulators. Simulation has been used for several years under different names (experimental surgery, hands-on courses, etc.). There has been an exponential increase in the development of simulation courses. However, simulation demands high costs for implementation and maintenance, thus hindering its access in a public hospital as HEEP^7-10. The School of Medical Sciences counts with a simulation center, but its access was also restricted.

Once the pandemic is over, the challenge will undoubtedly be to recover the number of surgeries that were performed previously, integrating them with the new academic activities that arose during the pandemic. Access to courses, conferences, congresses and simulation programs should be encouraged by the authorities.

A reduction in the number of procedures was also reported in publications from other departments, such as the Department of Cardiovascular Surgery of Hospital Garrahan and the Pancreatic Surgery team of Hospital Argerich^11,12. Other departments have also described different organization of the residency program. The negative effect of the pandemic on postgraduate training is not limited to general surgery or to Argentina. Negative effects have been described worldwide, mainly in South America, Europe and Africa, and have been reported in other surgical or interventional specialties such as gynecology, orthopedics, urology, endoscopy and diagnostic imaging^13-20.

Among the limitations of this study, we can mention the lack of precise data on the number of patients evaluated in the outpatient clinic, and the number of academic and research activities carried out in both periods. By limiting the study period to the date of graduation of 4th-year trainees (September 30, 2020), we have excluded from the study the 2021 period in which there was a new increase in COVID-19 cases, with new limitations to surgical activities. The analysis of such period may result in a new study. Whether the lower number of surgeries had an impact on the development of practical skills among trainees is something to be evaluated in the future, a matter we believe will be difficult to assess.

Conclusion

The COVID-19 pandemic significantly affected trainees’ education in the postgraduate program in general surgery at HEEP. The reduction of time spent in hospital, the lower number of in-house call shifts, of patients hospitalized and the reduced volume of surgeries interrupted surgical training of residents. In view of these conditions, non-traditional teaching methods were used to continue training.