Introduction

Few phenomena throughout human history have been capable of shaping societies and cultures as much as outbreaks of infectious diseases, wiping out large numbers of the world population and changing the course of wars and other historical social events. But they have also been a source of significant progress in technology, medical sciences and public health¹. Undoubtedly, the pandemic we have been walking through since December 2019 has not only posed a challenge in the medical performance of all hospitals worldwide, but also in the way medicine is taught in universities and residency programs².

For years training of new residents in the surgical specialties has been based on their active participation in the procedures as the mainstay to achieve hands-on and theoretical capabilities to reproduce the entire surgical technique, and to ensure that the professional can manage the possible intraoperative and postoperative complications in a rapid, pragmatic and effective manner. In Argentina, most hospitals had to cancel scheduled surgeries and only performed emergency surgeries and surgical oncology procedures. The beds in the surgery wards were assigned to hospitalization of COVID-19 patients. Work groups were organized with different modalities of rotating shifts and the participation of residents in the surgical activity was minimized to reduce the risk of becoming infected. In addition, the medical staff was reassigned to other non-surgical tasks to support health care services for patients with COVID-19^3-5.

This makes us wonder if the training of residents in surgery is really effective, if our residents achieve the basic targets required by their corresponding residency program to be certified as specialists, if their mere participation in operating rooms and seminars is sufficient, and if we have solid and effective surgical simulation programs as a learning tool for residents. We are also concerned about how to deal with all these questions in times of a pandemic that threatens not only the health of patients, but also the training of our residents.

Material and methods

We conducted a cross-sectional and observational study using an anonymous survey consisting of 20 multiple-choice questions via the Google Forms on-line platform (Table 1). The questions inquired about the type of institution and province where they attended their residency program, postgraduate year level, number of residents per year, presence and details of surgical simulation programs, number of surgeries per week in which they participated, structural and training changes during the COVID-19 pandemic, impact on surgical skills, and gaps in academic training. All the residents in general surgery in Argentina were invited to participate. The link to the survey was sent via SMS, social networks of residents in Argentina (Instagram and WhatsApp) and e-mail. Asociación Argentina de Médicos Residentes de Cirugía General (AAMRCG) was asked for help for spreading the survey. Data was collected between September 14 and 24, 2020.

Table 1 Survey with results grouped by private or public hospital 

A database was created for statistical analysis using the Python^® programming language. An explanatory analysis of the categorical and continuous variables was performed. Categorical variables were expressed as absolute frequencies and percentages and were compared using the chi-square test. Continuous variables with normal distribution were expressed as mefan ± standard deviation and compared with the Shapiro-Wilk test. Variables with asymmetric distribution were expressed as median, lower quartile (Q1), upper quartile (Q3) minimum value (Min) and maximum value (Max). The Kruskal-Wallis test was used to compare the independent groups.

A p value <0.05 was considered statistically significant.

Results

The survey was responded by 100 residents in general surgery from Argentina. Of these, 60% of respondents were trained in a public institution and most of them were PGY-1 residents (31%) and PGY-3 residents (30%). Forty-nine percent responded that 2 residents per year were admitted to their program. It is worth mentioning that, when the respondents were analyzed according to the type of hospital they belonged (public or private), 68% of the residents from public hospitals reported a quota of 2 residents per postgraduate year level, and 55% of those from private hospitals reported a quota of 3 or more residents per postgraduate year level (p < 0.01). The responses came from residents in the city of Buenos Aires, province of Buenos Aires, Mendoza, San Juan, Córdoba, Tucumán and Chubut.

Before the pandemic, the residents participated in 8.9 (+/- 5.5) surgeries per week which decreased to 3.3 (+/- 2.6) surgeries per week during the pandemic. Interestingly, there was a difference in the number of surgeries per week before the pandemic between residents from public institutions and those from private institutions: 7.7 (+/- 4.5) versus 10.7 (+/- 6.2), respectively (p <0.01). Sixty-nine percent of the respondents reported a negative impact on the academic training sessions; up to 77% used virtual platforms as a way to continue with the different training stages, such as ward rounds, seminars or case conferences. Fifty-seven percent of residents reported that their hospital had a surgical simulation program, and half of them used to train a maximum of 2 hours per week before the pandemic (Q1 = 1 h; Q3 = 4 h) but did not use it during the pandemic (Q1= 0 h; Q3 = 2 h) (p < 0.05).

There was a significant difference in the time spent on simulation training during the pandemic between public and private hospitals (Fig. 1). It should be noted that, of the participants in a residency program with a surgical simulation module, 54.4% reported that they had not met the basic general targets required for their postgraduate year level according to the requirements determined by their department or teaching committee, and this figure reached 74.4% in those without a surgical simulation module as a learning tool incorporated into their residency program (p = 0.05).

Figure 1 Comparison of hours spent by residents in surgical simulation during and before the pandemic, differentiated by public hospital and private hospital 

Only 19% of the participants considered that the pandemic had not affected their training as residents in general surgery, and of these, 78.9% had a mandatory surgical simulation program in their department (Fig. 2).

Figure 2 Percent of residents who consider there were gaps in training during the pandemic versus those who consider training was normal during the pandemic, divided by residency programs with or without surgical simulation 

Seventy-four percent of residents were reassigned or had to work in non-surgical areas during the pandemic, attending hospital for 14 days or 7 days (26% and 24%, respectively) followed by a 14-day break period. Of the total participants, 81% felt that the sharp decline in surgical practice during this period severely affected their practical skills. Fifty percent of these residents participated in at least 8 surgeries per week before the pandemic (Q1= 5; Q3 = 12), and in only 2 surgeries during the pandemic period (Q1= 1; Q3 = 4) (p <0.05).

Discussion

These final results are worrisome and are not just isolated situations in Argentina: several recent publications from Colombia, Mexico, the United States and Southeast Asia have revealed a similar picture for residents of other parts of the world with the same problems^6-10. This shows that the “master-apprentice” teaching model implemented by William Halsted in 1889 in the United States and disseminated to hospitals worldwide should continue to evolve using current tools to enable knowledge transmission between the teaching surgeon and his/her residents¹¹. This model based on mentoring and hierarchy is being challenged by the current world situation, forcing surgical training institutions to adapt to technological progress to ensure that their residents are learning and are encouraged to continue innovating. A meta-analysis from the University of Texas on factors influencing skill decay and retention concludes that the loss of fully learned skills after effective training is particularly sensitive, estimating that procedural memory is impaired after more than 365 days of nonuse or nonpractice producing a performance decline to less than 92% of performance level before the nonpractice interval¹². The health emergency period seems to be nearing one year since the beginning of the pandemic. If this is extrapolated to a surgeon or to a resident performing a surgical procedure again, the probability of malpractice or of an undesired surgical gesture leading to complications will be much higher than if, during that period, handson surgical training had not been interrupted. In this regard, the data from the residents surveyed is a matter of concern, demonstrating a marked decrease in their surgical activity during the pandemic compared with previous periods.

A systematic review conducted by an Australian group provides evidence to support the routine use of simulation as a learning tool in different surgical procedures, stating that the skills learned during the use of surgical simulators are transferable to the operating room and reproducible in the live patient setting¹³. There is abundant literature supporting and suggesting that residency programs should count with an effective surgical simulation program because it is not only beneficial for trainees but also for patients and for the hospital. A better trained professional carrying out a surgical procedure can help reduce the operative time and the rate of complications of the department. In this way, postoperative recovery of patients can be shortened by reducing the length of hospital stay and the number of supplies used. The type of simulator with the greatest proven benefits is the one capable of simulating real surgical interventions and its use should be supervised by trained surgeons requiring the resident to comply with different goals and objectives while timing each exercise. However, it should be noted that there are also models for laparoscopic, thoracoscopic, endoscopic and open surgery simulation, as well as gadgets to practice how to tie knots and suture. To address current limitations on how to train without patients and how to do this at a distance, faculty and students from the Department of Otolaryngology and Head and Neck Surgery at the University of Stanford designed a simulation kit that they distributed to their junior residents so that they could take them home. These models were 3D printed in silicon, and were aimed to represent either usual surgical situations, as soft tissue handling, local flaps, intubation and tracheotomy, or commonly seen otolaryngology consultations as facial lacerations or auricular hematoma. Each resident had to solve these situations together with a corresponding clinical case on a virtual platform and were supervised online by a senior resident and otolaryngology attending¹⁴. In his thesis, Dr. Ebbe Thinggaard performed an exhaustive analysis of five studies on take-home simulation-based training. He not only demonstrated the importance of simulation as a learning tool, but also that the opportunity to do it outside the workplace through guided self-regulated learning and with clear targets, is highly effective and achieves statistically significant better adherence to the program and better results in less time¹⁵.

After analyzing our data series, we cannot help recognizing that surgical simulation programs were one of the fundamental tools that partially counteracted the negative effect of the COVID-19 pandemic on the training of residents in surgery in Argentina.

Academic training through virtual platforms or E-learning is a teaching and learning tool that has been gaining increasing relevance since 2009, not only in the field of medicine, but in all sciences¹⁶. This has provided the largest scientific societies of different medical specialties with the possibility to continue spreading the latest research and publications by broadcasting the different congresses and scientific meetings that were regularly held, through a new online modality called webinars. Webinars have not only allowed the perpetuation of these academic spaces but have also achieved higher levels of audience thanks to the globalization of the Internet and the interaction of specialist professionals from different places, allowing attendance of physicians and residents worldwide who otherwise would have no access to these spaces where specialists meet. This E-learning tool has also helped residency programs with training, giving the opportunity to hold clinical case conferences, morbidity and mortality meetings, journal club sessions and online ward rounds with the participation of the entire medical staff, thanks to the different virtual platforms^17-19. Argentina has not been the exception in this regard, or at least in the field of general surgery, since Asociación Argentina de Cirugía has facilitated the attendance to several online courses and webinars, and the results of this study show that at least 77% of the residents used these tools in their departments during the pandemic.

Although the results obtained from the present study are of concern, it should be noted that as the sample is small and its distribution is not uniform among all residents in general surgery in Argentina, the conclusions derived from its analysis may not be representative of the reality of all the residency programs. This work should be the trigger for future studies with similar objectives, avoiding the selfselection bias of an online survey, as in this case. Recall bias should also be avoided by accessing the databases of the different departments of surgery. The information provided by respondents is subjective and not entirely reliable and may be underestimated or overestimated due to recall errors and the different ways in which the pandemic affected them, as in this study.

This phase will be over, and the population will have to restructure to return to “new normal” and prepare for the economic consequences of the pandemic that will inevitably affect hospitals and public health response capacity. Surgical education programs will have to adapt to hospital restructuring and to the high demand for elective surgeries that will arise because of cancellations during the pandemic. The residents will have the inevitable task of solving these issues together with their mentors, and those who had access to simulation and virtual platforms will have to implement the knowledge learned. In addition, they will have to suggest innovative methods to solve the situations encountered during surgery and for the system of teaching, since, as history shows, we do not know when another microorganism with the capability to revolutionize mankind will emerge.

Conclusions

The current SARS-CoV-2 pandemic has produced a negative impact on surgical training systems. Therefore, we suggest that a solid, supervised and timed surgical simulation program aimed at achieving goals consistent with the level of complexity corresponding to each year of training would be optimal to effectively train residents in surgery nowadays. Organizing activities through virtual platforms such as seminars, case conferences, morbidity and mortality meetings and theoretical classes would seem an advisable complementary measure. Implementing these suggestions would not only provide a complete surgical education for residents but would also solve the learning gaps in situations similar to those the world is going through today, although more studies would be needed to demonstrate so.