COVID-19 Restrictions Presented Opportunities and Challenges for Plastic Surgery Residents Translated title: Les restrictions imposées par la COVID-19: des sources de possibilités et de difficultés pour les résidents en chirurgie plastique
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Abstract
Background:
Restrictions placed during the COVID-19 pandemic to prevent viral spread led to substantial
changes in surgical resident education. The aim of this study was to assess the positive
and negative impact of COVID-19 on plastic surgery education and training and provide
recommendations for continued competency.
Methods:
A cross-sectional online survey of plastic surgery residents across Canada was used
to evaluate the impact of COVID-19 on clinical exposure, experience with virtual education,
and long-term impact of COVID-19 on surgical training.
Results:
This study included 61 plastic surgery residents (40% participation rate). Common
educational modalities used during COVID-19 included online seminars (95%) and workshops
(58%). Teaching sessions were effective if structured around patient cases (72%),
recorded (66%), and limited to 1 hour (64%). There were mixed reactions towards online
education sessions; residents reported feeling grateful (54%), motivated (38%), enthusiastic
(28%), overwhelmed (41%), pressured to participate (23%), and anxious (13%). There
were significantly less residents who felt that their clinical exposure was sufficient
during (21%) versus before (72%) pandemic restrictions (
P < .001). Overall, 87% of residents felt that the pandemic had a negative impact on
their training, surgical skill development, fellowship plans, and job prospects.
Conclusions:
During the initial wave of COVID-19, residents faced altered educational opportunities,
which elicited positive and negative emotions with concern regarding surgical skill
development and impact on future career plans. Characterizing early educational impact
on residency training to identify opportunities for change is worthwhile as the overall
effect of the pandemic is ongoing and remains uncertain.
Translated abstract
Historique:
Les restrictions imposées pendant la pandémie de COVID-19 pour en éviter la propagation
virale ont entraîné des changements importants dans la formation des résidents en
chirurgie. La présente étude visait à évaluer les répercussions positives et négatives
de la COVID-19 sur l’enseignement et la formation en chirurgie plastique et à formuler
des recommandations sur le maintien des compétences.
Méthodologie:
Les chercheurs ont utilisé un sondage transversal en ligne auprès des résidents en
chirurgie plastique du Canada pour évaluer les répercussions de la COVID-19 sur l’exposition
clinique, l’expérience de l’enseignement virtuel et les conséquences à long terme
de la COVID-19 pour la formation en chirurgie.
Résultats:
La présente étude incluait 61 résidents en chirurgie plastique (pour un taux de participation
de 40%). Les modes d’enseignement couramment utilisés pendant la COVID-19 incluaient
les séminaires en ligne (95%) et les ateliers (58%). Les séances d’enseignement étaient
efficaces si elles étaient structurées autour de cas de patients (72%), enregistrées
(66%) et se limitaient à une heure (64%). Les réactions étaient mitigées quant aux
séances de formation en ligne. Les résidents ont déclaré se sentir reconnaissants
(54%), motivés (38%), enthousiastes (28%), dépassés (41%), poussés à participer (23%)
et anxieux (13%). Beaucoup moins de résidents avaient l’impression que leur exposition
clinique avait été suffisante pendant les restrictions liées à la pandémie (21%) qu’auparavant
(72%; p<0,001). Dans l’ensemble, 87% des résidents trouvaient que la pandémie avait
un effet négatif sur leur formation, l’acquisition de leurs compétences chirurgicales,
leurs projets de surspécialité et leurs perspectives professionnelles.
Conclusions:
Pendant la première vague de COVID-19, les résidents ont dû composer avec des modifications
à leurs possibilités de formation, qui ont donné lieu à des émotions positives et
négatives et à des inquiétudes quant à l’acquisition de leurs habiletés chirurgicales
et aux répercussions sur leur plan de carrière. Il est intéressant de caractériser
les répercussions précoces sur la formation en résidence pour déterminer les occasions
de changement, car l’effet global de la pandémie se poursuit et demeure incertain.
Background The COVID-19 pandemic presents a unique challenge to surgical residency programs. Due to the restrictions recommended by the Centers for Disease Control and Prevention and other organizations, the educational landscape for surgical residents is rapidly changing. In addition, the time course of these changes is undefined. Methods We attempt to define the scope of the problem of maintaining surgical resident education while maintaining the safety of residents, educators, and patients. Within the basic framework of limiting in-person gatherings, postponing or canceling elective operations in hospitals, and limiting rotations between sites, we propose innovative solutions to maintain rigorous education. Results We propose several innovative solutions including the flipped classroom model, online practice questions, teleconferencing in place of in-person lectures, involving residents in telemedicine clinics, procedural simulation, and the facilitated use of surgical videos. Although there is no substitute for hands-on learning through operative experience and direct patient care, these may be ways to mitigate the loss of learning exposure during this time. Conclusions These innovative solutions utilizing technology may help to bridge the educational gap for surgical residents during this unprecedented circumstance. The support of national organizations may be beneficial in maintaining rigorous surgical education.
‘All of humanity’s problems stem from the man’s inability to sit quietly in a room alone’. We need to revisit this statement by Blaise Pascal time and again to unearth something invaluable, to reinforce something primal, especially in times such as these where the whole world is in a state of lockdown, courtesy the corona virus disease 2019 (COVID-19). This disease caused by SARS-CoV-2, has literally brought the world down to its knees just within last few months. COVID-19 The world is facing a global public health crisis for the last three months, as the coronavirus disease 2019 (COVID-19) emerges as a menacing pandemic. Besides the rising number of cases and fatalities with this pandemic, there has also been significant socio-economic, political and psycho-social impact. Billions of people are quarantined in their own homes as nations have locked down to implement social distancing as a measure to contain the spread of infection. Those affected and suspicious cases are isolated. This social isolation leads to chronic loneliness and boredom, which if long enough can have detrimental effects on physical and mental well-being. The timelines of the growing pandemic being uncertain, the isolation is compounded by mass panic and anxiety. Crisis often affects the human mind in crucial ways, enhancing threat arousal and snowballing the anxiety. Rational and logical decisions are replaced by biased and faulty decisions based on mere ‘faith and belief’. This important social threat of a pandemic is largely neglected. We look at the impact of COVID-19 on loneliness across different social strata, its implications in the modern digitalized age and outline a way forward with possible solutions to the same. There is no doubt that national and global economies are suffering, the health systems are under severe pressure, mass hysteria has acquired a frantic pace and people’s hope and aspirations are taking a merciless beating. The uncertainty of a new and relatively unknown infection increases the anxiety, which gets compounded by isolation in lockdown. As global public health agencies like World Health Organization (WHO) and Centre for Disease Control and Prevention (CDC) struggle to contain the outbreak, social distancing is repeatedly suggested as one of the most useful preventive strategies. It has been used successfully in the past to slow or prevent community transmission during pandemics (WHO, 2019). While certain countries like China have just started recovering from their three-month lockdown, countries like Iran, Italy and South Korea have been badly hit irrespective of these measures and those like India have initiated nation-wide shutdown and curfews to prevent the community transmission of COVID-19. Ironically however, the social distancing is a misnomer, which implies physical separation to prevent the viral spread. The modern world has rarely been so isolated and restricted. Multiple restrictions have been imposed on public movement to contain the spread of the virus. People are forced to stay at home and are burdened with the heft of quarantine. Individuals are waking up every day wrapped in a freezing cauldron of social isolation, sheer boredom and a penetrating feeling of loneliness. The modern man has known little like this, in an age of rapid travel and communication. Though during the earlier outbreaks of Severe Acute Respiratory Syndrome (SARS), Middle East Respiratory Syndrome (MERS), Spanish flu, Ebola and Plague the world was equally shaken with millions of casualties, the dominance of technology was not as much as to make the distancing felt amplified (Smith, 2006). In this era of digitalization, social media, social hangouts, eateries, pubs, bars, malls, movie theatres to keep us distracted creating apparent ‘social ties’. Humankind has always known what to do next, with their lives generally following a regular trail. But this sudden cataclysmic turn of events have brought them face to face with a dire reckoning – how to live with oneself. It is indeed a frightening realization when a whole generation or two knows how to deal with a nuclear fallout but are at their wit’s end on how to spend time with oneself. Ironically, however, it has stranded them with their families (those who are unaffected by the illness) and are expected to strengthen the bonds of relationship. But, as mentioned before, the ‘virtual connectedness’ provided by social media has probably made us forget what proximity in relationships feel like. This can be a double-edged sword, that can either mend or strain relations, based on the pre-existing intimacy and communication patterns. It feels like a monumental task to stay stuck with yourself and your loved ones, while the pandemic looms large over the world. Loneliness during a pandemic: the impact and social variations Loneliness is often described as the state of being without any company or in isolation from the community or society. It is considered to be a dark and miserable feeling, a risk factor for many mental disorders like depression, anxiety, adjustment disorder, chronic stress, insomnia or even late-life dementia (Wilson et al., 2007). Loneliness is common in the old-age group, leading to increased depression rates and suicide. It has been well-documented that long periods of isolation in custodial care or quarantine for illness has detrimental effects on mental well-being (Stickley & Koyanagi, 2016). Loneliness is proposed to break this essential construct and disrupt social integration, leading to increase in isolation. This is a vicious cycle which makes the lonely individual more segregated into his own ‘constricted’ space. Loneliness is also one of the prime indicators of social well-being (Cacioppo & Patrick, 2008). Most people cringe at the idea of this social isolation. They will do anything to keep themselves preoccupied or distracted, from acts of outrageous indulgences to preposterous shows of vanity and depravation. Besides, loneliness has also shown to be an independent risk factor for sensory loss, connective tissue and auto-immune disorders, cardio-vascular disorders and obesity. If this self-isolation and lockdown is prolonged, it is likely that chronic loneliness will decrease physical activity leading to increased risk of frailty and fractures (Mushtaq et al., 2014). This COVID-19 pandemic seems to have brought our frenzied speed of modern society to a grinding halt and has literally crushed the wings of unlimited social interaction. Under these social restrictions, individuals are forced to reconcile with this terrifying reality of isolation which can contribute to domestic inter-personal violence and boredom. Similar trends of increase in isolation and loneliness have been noticed among emergency workers and quarantined population in Wuhan, China. This has increased the prevalence of depression, anxiety, post-traumatic stress disorders and insomnia in the population. It also contributes to fatigue and decreases performance in health-care workers (Torales et al., 2020). But neither life nor the society had probably readied us for this task. The concept of boredom and loneliness leads to anger, frustration on the authorities and can lead for many to defy the quarantine restrictions, which can cause dire public health consequences. Emotional unpreparedness for such biological disasters have detrimental effects, as this situation is unprecedented in all measures. It also makes us take a step back and question: is social distancing only for a specific social class; as millions of migrant labourers, homeless individuals and daily wage workers stay stranded in their workplaces, railway and bus stations and factories with overcrowding and poor hygiene. When basic amenities of life are scarce, it is far-fetched myth to think about distancing or hand sanitization according to the prescribed standards (The Print, 2020; www.theprint.in). Isolation or loneliness for them is thus different. It is being away from their origins, their families and being deprived of basic human rights and self-dignity. Segregation from self-identity can also form the basis for loneliness, just that it reflects differently in different socio-economic strata (Valkenburg & Peter, 2008). It is again ironic, how the construct of loneliness varies based on the social strata giving rise to dimensional psycho-social needs. The way forward First step in this journey is to transform this devious loneliness to solitude. Loneliness, which on one hand is an emotion filled with terror and desolation, solitude, its cousin is full of peace and tranquillity. The primal answer to loneliness has always been in our roots: the ability to be at peace with oneself. This however has been a habit long lost by the humanity in the trends of globalization. Many great works of art, philosophy, literature have emerged from solitude. This comes with enjoying one’s existence and ability to cherish the bonds with others. This might be a good time to engage in long-forgotten hobbies, neglected passions and unfulfilled dreams. Improving proximal bonds with family and loved ones is another opportunity. Distancing from social media will be beneficial, as during times of pandemic it can contribute to ‘infodemic’ causing information overload. COVID-19 by all means is a ‘digital epidemic’ where the related statistics spread faster than the virus itself. Only relevant and updated information about the situation outside helps relieve anxiety during isolation (Hyvärinen & Vos, 2016). It is vital that the virus does not invade us ‘psychologically’ which can last much beyond the resolution of this pandemic. As mental health professionals, we need to be sensitive to the personalized needs of those in quarantine and cater to them. Their personal and psychological needs are to be adhered to. Digital communication needs to be maintained with their loved ones. As mentioned, before social connectedness matters. Similar protocols in China during the first stage of outbreak had shown to improve quality of lives of those isolated (Duan & Zhu, 2020). Need for community-based and brief psycho-social interventions have also been stressed upon by Torales et al. (2020) in their recent article, acknowledging the chronic mental health impact of the ongoing pandemic situation. Furthermore, research has shown that as simple as weekly telephonic sessions can help reduce anxiety at the time of pandemics. These sessions need to be brief and solution-focused (Yang et al., 2020). Social integration forms another important aspect, in which involvement of the associated people in life matters. Taking care of the domestic helpers, the vendors, the security personnel, etc. or even a simple exchange of greetings with neighbors or strangers can give a feeling that ‘we are all in this together’. The bonds of humanity turn even more important at such times, when the whole world shares the same threads of anxiety. Similar sensitization needs to be done for the allied specialities to understand and appreciate the mental health needs of a biological disaster. The pandemic will eventually be over giving rise to two important lessons: the emotional preparedness for solitude at times of such crisis and psycho-social well-being forming the cornerstone of public health.
To systematically review the methodologic rigor of the research on volume and outcomes and to summarize the magnitude and significance of the association between them. The authors searched MEDLINE from January 1980 to December 2000 for English-language, population-based studies examining the independent relationship between hospital or physician volume and clinical outcomes. Bibliographies were reviewed to identify other articles of interest, and experts were contacted about missing or unpublished studies. Of 272 studies reviewed, 135 met inclusion criteria and covered 27 procedures and clinical conditions. Two investigators independently reviewed each article, using a standard form to abstract information on key study characteristics and results. The methodologic rigor of the primary studies varied. Few studies used clinical data for risk adjustment or examined effects of hospital and physician volume simultaneously. Overall, 71% of all studies of hospital volume and 69% of studies of physician volume reported statistically significant associations between higher volume and better outcomes. The strongest associations were found for AIDS treatment and for surgery on pancreatic cancer, esophageal cancer, abdominal aortic aneurysms, and pediatric cardiac problems (a median of 3.3 to 13 excess deaths per 100 cases were attributed to low volume). Although statistically significant, the volume-outcome relationship for coronary artery bypass surgery, coronary angioplasty, carotid endarterectomy, other cancer surgery, and orthopedic procedures was of much smaller magnitude. Hospital volume-outcome studies that performed risk adjustment by using clinical data were less likely to report significant associations than were studies that adjusted for risk by using administrative data. High volume is associated with better outcomes across a wide range of procedures and conditions, but the magnitude of the association varies greatly. The clinical and policy significance of these findings is complicated by the methodologic shortcomings of many studies. Differences in case mix and processes of care between high- and low-volume providers may explain part of the observed relationship between volume and outcome.
Publisher:
SAGE Publications
(Sage CA: Los Angeles, CA
)
ISSN
(Print):
2292-5503
ISSN
(Electronic):
2292-5511
Publication date
(Electronic):
12
July
2021
Publication date
(Print):
November
2021
Publication date PMC-release: 12
July
2021
Volume: 29
Issue: 4
Pages: 294-302
Affiliations
[1
]Division of Plastic and Reconstructive Surgery, Ringgold 7938, universityUniversity of Toronto; , Toronto, Ontario, Canada
[2
]Division of Plastic and Reconstructive Surgery, Hospital for Sick Children, Ringgold 7938, universityUniversity of Toronto; , Toronto, Ontario, Canada
[3
]Division of Plastic and Reconstructive Surgery, Sunnybrook Health Sciences Centre,
Ringgold 7938, universityUniversity of Toronto; , Toronto, Ontario, Canada
Author notes
[*]Jana Dengler, Division of Plastic and Reconstructive Surgery, Sunnybrook Health Sciences
Centre, University of Toronto, M1-500, 2075 Bayview Avenue, Toronto, Ontario, Canada.
Email:
jana.dengler@
123456mail.utoronto.ca
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and Open Access pages (
https://us.sagepub.com/en-us/nam/open-access-at-sage).
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