COMMITTEES
Impact of the COVID Pandemic on Neuroanesthesia Fellowship Programs: A Global Survey
Shobana Rajan, MD; Val Luoma, MD; Girija Rath, MD, DM
On behalf of the Trainee Engagement Committee
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Shobana Rajan, MD |
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Val Luoma, MD |
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Girija Rath, MD, DM |
Introduction
The COVID-19 pandemic has been an overwhelming emergency particularly within various hot spots around the world. Program directors in neuroanesthesiology have channeled their energies to cope with a new and rapidly expanding medical emergency that has serious implications on intensive care units (ICUs), both in terms of quality and quantity of delivered care. At the same time, they have faced the challenge of restructuring education for their trainees and fellows within the limited available resources and time.
On behalf of the Trainee Engagement Committee of SNACC, we sent out a brief email survey to various programs around the world to see how the program directors approached the challenges they were faced with in terms of disruption of clinical cases, education, and trainee well-being. We also surveyed some of the fellows to see how they were impacted. At the outset, we would like to give our heartfelt thanks to all those program chairs and fellows who responded and contributed their valuable time to create this article.
Methods
We contacted program directors in some of the harder hit areas including Italy, Spain, China, Chicago, London, and Iran. Then we contacted a few less affected (not so hard-hit to-date); Cleveland, Toronto, Vancouver, Canada, Delhi, Qatar, and Brisbane. We asked the program directors and core faculty the following questions via email:
- Do you feel that your fellows’ training has been adversely affected due to the COVID-19 pandemic?
- What have you done to address your fellows’ educational concerns and emotional well-being?
For the fellows in neuroanesthesiology, we asked:
- Do you feel that your clinical training has been adversely affected by the COVID-19 pandemic?
- Do you feel that online modalities would be helpful to steer yourself through this pandemic?
- Do you feel anxiety and helplessness, and if so, what have you been doing that has eased your anxiety?
- How would you like departments to help with questions one and two?
Discussion
Clinical Training During the COVID-19 Pandemic
Program Directors in the hard-hit regions felt that their fellows’ education had been affected adversely while programs in the not so hard-hit areas felt that it was difficult to give a simple yes/no answer to this question and felt that training was adversely affected to some extent.
In the Sapienza University of Rome, Italy, the program director felt that the ongoing emergency brought together limits and opportunities. Certainly, the elective case load was rapidly and extensively reduced. This implied a huge reduction in the clinical opportunities for fellows. Furthermore, the presence of doctors in the early phase of training had been minimized in order to decrease healthcare worker crowding. The most experienced physicians did all the procedures. At the same time, reorganization of the entire hospital and doubling of ICU beds with the purpose of managing a "mass casualty" like situation opened up some opportunity for the fellows who were redeployed and trained to tackle the COVID-19 pandemic--an emergency of great magnitude.
In the Universitat de Barcelona, Spain, the University officially suspended any kind of clinical practice for trainees from graduate and masters, by the end of March 2020. Therefore, the fellows had to abruptly stop their work and get back to their hometown. However, the program, while following the online teaching, was in touch with them through email and WhatsApp to keep them updated.
At the University College of London and St. George’s University Hospitals, London, the majority of the clinical workload in March and April had been in the intensive care (COVID/non-COVID) units. Their work was yet to resume to normal at the time we conducted this survey. However, the department of anesthesiology is now in touch with the ICU to try and get the fellows back to clinical training. As per national guidelines, they were reviewing logbooks/completion of training units, keeping the impact of COVID-19 in mind, to identify any gaps in training so that once they return to more normal working, any training needs can be addressed. With the increase in urgent/elective neurosurgical workload, fellows are being matched to appropriate lists to maximize their training despite the disruption of the pandemic.
In Beijing Tiantan Hospitals, China, at the beginning of the COVID-19 spread in January, they had already realized that training would be affected by the pandemic so they initiated online teaching modalities early. No one was redeployed during the pandemic and clinical work continued with the effective use of category III PPE particularly in suspected cases.
In Canada (Vancouver General Hospital and University Health Network, Toronto), the program directors felt that the clinical volume of neurosurgery, spine surgery and neuro IR had been reduced since the COVID-19 pandemic started; however, they were maintaining a reasonable volume of emergency and urgent cases as a major trauma and neuromuscular referral center. Now that numbers are stable, their fellows are assigned to the neuroanesthesia rooms most of the time. They felt that this was a great opportunity for fellows to learn and adapt to a difficult environment quickly.
In the USA, at Cleveland Clinic, the approach to preoperative optimization had been affected. Anesthetic technique has also been affected in emergency cases since some have not had enough time to rule out COVID-19 infection, examples are acute strokes or carotid endarterectomies. The above puts a different set of stress on education for trainees. At Northwestern University, strokes and other emergent interventions continued, but even these experiences were tempered by the concerns for COVID-19 exposure. The fellows had been deployed on an intermittent basis to the COVID-19 critical care units, to serve the clinical needs there.
In Princess Alexandra Hospital, Queensland, Australia, a large proportion of trainees were seconded to ICU to assist with the COVID-19 pandemic; however, the Australian situation had rapidly come under control and the majority of elective surgeries will resume soon. They endeavored to match the available clinical experiences to those at greatest need for completion of units of training. Some adverse effects were more substantial and could not be mitigated. For example, the final exams were post-poned and this has led to a large cohort of advanced trainees potentially delaying advancement to fellowship year and completion of training.
In Hamad Medical Corporation Hospitals, Qatar, they felt training was adversely affected but that this was an extraordinary, probably once in a lifetime opportunity for the trainees to learn something different in medicine. Trainees had a discussion with the program director and chairman about the situation and the need to help with airway management, anesthesia or intensive care management of COVID-19 positive patients.
In Tehran University of Medical Sciences, Iran, with the report of the first cases of COVID-19, a fear and panic started to emerge amongst all. The fellows preferred to stay home and did not report to their duties as the entire hospital, including the ICUs, had patients of COVID-19. Naturally, their training received a set back and they had to stay away from the hospital environment in their homes for almost two and a half months.
Academics and Education
At the All India Institute of Medical Sciences, India, they felt that the academics which included regular seminars, case presentations, journal clubs were abruptly stopped with the sudden announcement of the lockdown and social distancing as a strategy to fight the pandemic. There was hardly any clinical teaching; usual postoperative ICU rounds were curtailed during this period since elective surgeries were withheld. The mandatory research work as a part of fellowship training was also stopped. Three weeks after the lockdown, online classes were started and currently, are being conducted on a regular basis.
While some hospitals around the world were already using some web-based modalities to teach, many created a new start. Most hospitals switched to web-based initiatives such as Zoom, Ding Talks, Microsoft platforms, etc. to promote educational training which included both problem-based and case-solving discussion, journal clubs online, developing individual literature search projects which were discussed with written and "face to face" (through the web media) discussion. There was a lot of focus on training the fellows on safety issues of donning and doffing PPE (personal protective equipment) as well as provide learning material if there was need for redeployment in the ICU setting with patients infected with COVID-19. At Northwestern University, they felt that online modalities have not only been helpful, but vital to their ability as faculty to teach and communicate with trainees in an effective and efficient way.
In China, they established a task force for education during the pandemic and updated information to fellows every day. Some residents had to shelter at home, and to address their educational concerns, they used the communication app Ding Talk to support live-video communication. They also adapted online video training projects for fellows.
Emotional Well-being of Trainees
In London, well-being leads were named in the department and a team was identified to send a weekly newsletter. The newsletter includes information on resources (food, accommodation, parking), contact details for the wellness leads and available wellness resources for support- psychological or online support. In addition, they created wellness boxes with snacks should they need it. In another hospital in London, they set up twice weekly well-being Zoom meetings for the department provided by the staff support services and the NHS trust psychiatrist and psychologist. The resting areas had been revamped with sofa beds and better lighting for rest with food and drinks and essentials like phone chargers. Fellowship program directors had been in constant contact with their fellows to ensure that they were coping with the challenges faced.
In Australia, they created an open forum for fellows to raise well-being concerns anonymously. They have also undertaken surveys to determine how their trainees felt about the changing workload. A consultant group faculty took the front line with any COVID-19 patient management and trainees had been shielded. One of their staff had developed a wellness area in the department for relaxation.
In the USA, at Northwestern, the Graduate Medical Education office is very committed to trainee well-being and offers a variety of resources to their fellows (including various opportunities for mental wellness, coping strategies, and financial benefits and other amenities). Similarly, at Cleveland Clinic, there were multiple well-being initiatives. Interestingly, one of the main concerns for fellows was not anxiety but not being clear about their future after graduation.
In China, for emotional and well-being issues, everyone in the department reported their temperature to the task force and their status was monitored. The task force was available 24- hours a day, on standby, if needed. For some fellows who reported abnormal temperature, the task force helped them to be quarantined in the hospital (away from family members), arranged their dinners, helped with their daily necessities, and communicated with them every day to ease their anxiety. They also supplied adequate PPE for staff in their department for different settings. Everyone in the department was trained on how to wear and take off PPE to decrease the risk of infection. Generally speaking, staff were nervous at beginning of the pandemic, but with gradually understanding, they were alert but not anxious.
In Canada, the program directors personally talked to their fellows and asked them how they were coping with the situation. Since many trainee families lived outside the country, they inquired about the family’s well-being and encouraged them to take the time to talk to their family members.
In Qatar, trainees had been provided multiple resources to deal with emotional well-being by the department of medical education and the hospital and were in contact with their supervisors on a personal level.
In Iran, during this period of social distancing, the program director had been in contact with the trainees either by phone or through webinars/virtual classes. Meanwhile, they were assigned to literature search of keywords as envisioned in the curriculum.
Fellows Responses
Clinical Training During the COVID-19 Pandemic
We had some replies from fellows in India, Australia, China, USA, and Iran. Fellows felt that clinical training was definitely affected in the context of decreased exposure to elective subspecialty cases. However, they felt that the COVID-19 pandemic was an unprecedented situation. It was an opportunity to learn something new on pandemic preparedness, management, and coping skills as a healthcare professional. In Australia, trainees felt that there were decreased opportunities to complete workplace-based assessments and training portfolio requirements, cancellation of examination preparation courses, delayed exams, and uncertainty about whether exams would even be held for the remaining sittings of 2020.The prospects of entering extended training time was also of concern in view of the above issues.
Academics and Education - Online Modalities of Teaching
Although fellows found online modalities a refreshing break and the opportunity to learn with adequate social distancing ultimately, they felt that there was no substitute for clinical and hands-on experiences. Fellows did not want to waste time with unproven questionable online modalities and would like online teaching to be engaging and interactive.
Emotional Well-being of Trainees
Some fellows were utilizing their quarantine breaks to sleep, read novels, watch online series, and play video games. All of them felt that they were fortunate enough to be part of a supportive anesthetic department, which has continued to maintain clear lines of communication about pandemic preparedness and COVID-19 response. Some had morning talks and working groups dedicated to staff welfare which had altogether been very reassuring.
In China, they investigated 20 fellows in their program and found that 17 (85%) felt that the clinical training had been adversely affected during the COVID-19 pandemic, and only three fellows’ (15%) felt that everything went well. Nineteen fellows (95%) agreed that the online modalities are helpful with their training through this pandemic. Seven residents (35%) felt anxious and one felt helpless during the pandemic. The way to ease the negative emotions included communicating with other residents and family members, physical exercise, good sleep and reading, and making a study plan.
In Iran fellows were very anxious, although it was not because of a lack of facilities or work pressure, it was because of stress for the safety of their families. They felt that they had enough personal protective equipment and never felt helplessness since they had the support of their program director.
How Should Departments Help Trainees?
Trainees would like online virtual learning to not only focus on the training itself, but also evaluate if it was effective. In Australia, consultant led exam focused teaching sessions are being held twice a week and opportunities to complete workplace-based assessments with COVID-19-related tasks such as donning and doffing PPE procedures. Trainees would like online modalities to include clinical technique demonstrations and some countries have excellent video demonstrations to achieve this.
Conclusion
We had a wide variety of responses which helped us realize how different neuroanesthesia fellowships were structured throughout the world. While some fellowships are one year after residency, other fellowships were enfolded into the residency and they are considered as fifth year fellows, such as in Italy and Australia. Typically, the last quarter of the academic year brings about the anticipation of graduation and preparedness for clinical practice. Many of the fellows by this time of the year may have developed the core skills to practice at an appropriate level. Yet the COVID-19 pandemic has created many unforeseen anxieties and fears for the future. The truncated training of this year will likely heighten this feeling, especially because their clinical training and education had been adversely impacted.
Acknowledgements
Thank you to all the program directors who responded to share their valuable experience.
Thank you also to Drs. John Bebawy, Rafi Avitsian, Alana Flexman, Lashmi Venkatraghavan, Tumul Chowdhary, Girija Rath, Val Luoma, Audrey Tan, Federico Bilotta, Ricard Valero, David Highton, Neeraj Kumar, Zahid Hussain Khan, and all the trainees who responded.
