Introduction

The COVID-19 pandemic had a major impact on the general population’s health, but also on the health of healthcare workers. Thousands of healthcare workers worldwide were infected with SARS-CoV-2 and suffered a considerable percentage of severe clinical conditions and even died¹. As a result, healthcare centers were compelled to make profound changes in their functioning to prioritize the safety and health of their professionals without neglecting patient care. In this context, university-based hospitals addressed the additional challenge of preserving medical education for trainees.

Understanding the views and concerns of residents and fellows is critical to effectively adapt surgical training programs and address the subsequent phases of the pandemic. The aim of this study is to describe and interpret the perceptions of physicians in training in a department of general surgery during the initial phase of the COVID-19 pandemic.

Material and methods

We conducted a cross-sectional study with the answers from a survey responded by physicians in training from a department of general surgery in a university-based hospital in the City of Buenos Aires. The department has a 4-year residency program in general surgery, recognized by Asociación Argentina de Cirugía, and fellowships for advanced training in 8 surgical subspecialties: hepato-pancreato-biliary surgery and liver transplant surgery, gastroesophageal surgery, colon and rectal surgery, phlebology and lymphology, abdominal wall surgery, head and neck surgery, minimally invasive surgery and kidney-pancreas transplant, and thoracic surgery.

All the residents and fellows were invited to participate on a voluntary basis, ensuring the confidentiality of the information. The only exclusion criterion was refusal to answer the survey. The survey consisted of 51 questions grouped in 5 domains: institutional, healthcare, academic, domestic and emotional (Appendix 1).

The questions were developed by physicians from the Department of General Surgery together with the Department of Education of Instituto Universitario del Hospital Italiano de Buenos Aires and administered through Google forms on May 14, 2020, in reference to the changes implemented in the initial contingency due to the COVID-19 pandemic (Table 1)^2-4. This survey was the first of three planned during the different phases of the pandemic.

Table 1 

These are the preliminary results of the initial phase. Data were exported and analyzed using STATA^® software package. Categorical variables are presented as percentages. Continuous variables were grouped and independently coded and expressed as percentages.

The study protocol was approved by the institutional review board for university research protocols of Hospital Italiano de Buenos Aires (Project N° 0026-20).

Results

The survey was completed by 55 physicians (91.7%): 35 residents and 20 fellows. Mean age was 29.4 years (SD +/- 2.86) and 56.4% were men.

Emotional domain

52.9% of respondents reported that they felt frustrated, and 38.2% felt confident (Fig. 1). 54.5% expressed fear of becoming infected and/or infecting their partner or family. Four physicians (7.3%) suffered an act of violence as healthcare workers outside the hospital setting.

Figure 1 Question: In the context of the pandemic, as a healthcare worker you feel... 

65.5% reported feeling stressed and attributed these feelings to the uncertainty about future employment (86.1%-31/36); they used recreational activities such as meditation and art as a means to relieve stress in 58% of the cases.

Regarding the way in which the COVID-19 pandemic affects their training as surgeons, 81.81% stated that they lose surgical technical skills, although 43.6% (24/55) highlighted that the pandemic has taught them lessons as healthcare workers.

Although 82.7% agreed with the measure ordered by the National Ministry of Health to postpone the end of year curriculum, 65.3% recognized that this measure affects them directly, interfering either with a work project (17) or training abroad (8).

34.54% of the respondents plan to move to another country within the next few years, which corresponds to 39.28% (11/28) of last year residents, chief residents and fellows. While 68.4% (13/19) of them made the decision some time ago, 31.57% (6/19) are considering it in the context of the pandemic. Among the reasons, they mentioned the search for better income (17), professional development (16) and lifestyle (15). Four respondents (7.3%) are considering changing their medical specialty; two of them are thinking so for the first time in the current context, attributing this decision to the pursuit of better lifestyle (3) and income (2).

Table 2 summarizes the changes implemented in the training program based on the results of the survey.

Discussion

Because of the COVID-19 pandemic, training programs must address the challenge of ensuring continuity of learning and the well-being of residents and fellows. As part of restructuring activities, roles and strategies, understanding their perceptions and concerns allows for the identification of opportunities for improvement and better adaptation to the dynamic context imposed by the pandemic.

Effective communication is essential in times of change. Almost all the physicians surveyed rated communication between working groups and at the institutional level as effective and/or sufficient.

The lack of personal protective equipment (PPE) seems to be a recurrent phenomenon in several countries worldwide; however, in our department, most of the respondents reported adequate availability of PPE^5,6. However, in spite of previous instructions, 38% of those surveyed expressed inconveniences when using them, which led to further practice in simulated scenarios⁷.

In addition to the risk of becoming infected with COVID-19, overwork has caused physical, mental and emotional problems in healthcare workers due to their daily practice during the pandemic⁸. The on-call system implemented by the residency of general surgery was designed to reduce exposure to the virus and prevent burnout. The residents agreed with this schedule and are aware of the changes that the pandemic has caused in their healthcare practice; they also expressed concern for losing manual dexterity. Since preoperative swab testings have been indicated to all the patients, physicians in training are authorized to perform procedures under supervision in patients with negative tests; nevertheless, the volume of scheduled surgeries and the exposure to them will remain low for the following months, as it was reported in other countries^9,10. In response to this concern, team-based supervised simulation practices were coordinated.

In addition to the intensive activity schedule and subsequent quarantine, the social, preventive and mandatory isolation decreed by the national government produced radical changes in routine: many surveyed physicians gave up a sport or training courses, incorporated new activities such as cooking or exercise, and considerably increased the hours dedicated to academic activities. Although virtual platforms for conferences and classes such as Zoom^®, Meet^® or Skype^® already existed, it was not until the COVID-19 pandemic that virtual classes and online conferences became the preferred means for clinical education, demonstrating their scope and limitations¹¹. The residents also highlighted greater supervision of their academic performance.

58.15% of the respondents perceived that their performance was not being evaluated, which led to some immediate decisions, such as scheduling feedback meetings using semi-structured questionnaires with the on-call attending physicians by the end of the on-call rotation week and conducting periodic virtual evaluations with those responsible of the residency.

Although 72.7% of the trainees stated that they had spaces where they could express their concerns or worries, weekly meetings were set up with those in charge of the residency via a virtual platform in response to the 27.3% who did not consider this was sufficient. In addition, a “ mentorship” program previously launched was reinforced, and became more significant in this context.

54.5% expressed fear of becoming infected and/or infecting their partner or family, a finding similar to that reported in a survey among general surgery residents in the United States¹².

Although physicians in training considered it appropriate to postpone the year curriculum, 65.3% recognized that it interferes with a work project or training abroad, which in turn affects their perception of uncertainty and anguish, together with the global economic crisis. 52.9% of respondents feel frustrated and 65.5% feel stressed, attributing this feeling to the uncertainty about future employment.

The institutions should count with psychological support systems; the Education Department of Hospital Italiano has set up a specific path, guided by the department of Psychopedagogy, Psychology and Psychiatry, to provide emotional support to hospital residents.

Finally, 34.54% of the respondents plan to move to another country within the next few years and 7% to change their medical specialty. The pandemic context has led many of them to do so, in search of better remuneration, professional development and lifestyle. Although it may seem alarming, this figure is lower than that reported by Mahoney et al., where 26% of surgeons stated that they would give up surgical practice, citing lifestyle as the main reason¹³.

To date, there is little evidence in the literature on which strategies should be implemented to meet the educational demands of training programs in surgery during an unprecedented health emergency. We believe that the arguments mentioned here could be useful for other institutions. Although this survey included physicians in training from a single department of general surgery, its results led to reformulate strategies for the next phases of the pandemic.

Surveys are a valuable tool for evaluation and decision-making. As we have previously mentioned, this survey is the first of three planned to be conducted in different phases.

Conclusion

New educational strategies had to be implemented in an unprecedented contingency scenario caused by the COVID-19 pandemic. In this context, understanding and analyzing the perceptions of surgeons in training in the initial phase made it possible to detect opportunities for improvement and incorporate modifications to address the following phases, ensuring learning and prioritizing their physical and psychosocial well-being.