Discussion
Otolaryngology trainees have been faced with the challenge of achieving
clinical knowledge and technical competency in the midst of lost
clinical volume and new threats to personal safety caused by the
COVID-19 pandemic. Herein, we report the results of a survey of North
American Otolaryngology residents and fellows, providing additional
insight into their perspective on the effects of the pandemic on their
education, safety, and future. Building on current published
reports,4 we found a near-unanimous reduction in
clinical volume, a dominant feeling that the pandemic has negatively
affected surgical training as has been previously
reported.4 In addition, we found that use of
technology in high COVID prevalent areas was able to alleviate some
concerns in receiving adequate educational knowledge and further
describe how the pandemic may impact future career.
Otolaryngology programs have experienced vast reductions in surgical
case load in response to the American College of Surgeons and the
Surgeon General’s encouragement for cancellation of elective
cases.1,4,14 Atop a lighter case load, resident
participation in the operating room (OR) at more than 60% of
institutions in a recent survey limiting cases to faculty alone or
senior level trainees.4 Two-thirds of survey
participants expressed concern regarding their ability to receive
adequate surgical training, representing one of the most prevalent
concerns across trainee level and geographic area. This apprehension
appeared to be more closely related to personally developing surgical
expertise rather than fulfilling administrative case requirements, as
concern around ability to graduate and complete key indicator cases were
only around half as prevalent. Indeed, a survey of surgical head and
neck fellows showed 82% had already reached adequate case numbers for
certification by mid-April of 2020.15 The ACGME issued
a special communication to address resident concerns regarding training
requirements in the current context wherein the reduction in elective
operations and the potential for training extension was recognized.
Graduation of trainees will be based on the discretion of the program
director of the trainee’s surgically competency.7,16
A lower proportion (43%) of participants were concerned about training
in clinical decision-making. Although almost all participants
acknowledged a reduction in in-person clinic participation, about a
quarter of respondents reported participation in telemedicine visits.
For trainees, telemedicine visits allow for engagement in patient care,
and familiarity with a new patient care setting that may be a part of
their future practice. With the reduction in surgical caseload, the
inpatient census has likewise seen a decrease. Half of trainees in the
survey reported reduced participation in call or inpatient duties, which
remain a critical aspect of training.17,18 Call duties
present new challenges to personal safety, with potential high risk
exposures through performance of aerosol generating procedures, where
residents are at the frontline of initial
evaluation.3,19 If adequate PPE is not immediately
available, trainees must weight their duty to patients with a duty to
protect themselves from undue risk of harm.20 Given
the risk of aerosol generation during common otolaryngology procedures
including flexible laryngoscopy and mucosal surgery, multiple sources
have recommended the use of at least N95 or equivalent mask, surgical
masks, gown, gloves and eye protection.21,22 Some
institutions are limited by resource availability, and 93% of
otolaryngology residents reported concerns regarding PPE shortages in a
recent publication.4 Some hospitals have requested the
re-use of N95 masks, and sterilization techniques have been
described.23
It is thus heartening to note that more than 80% of respondents had
been provided with adequate PPE. On the other hand, up to 50% of survey
respondents indicated that they acquired their own PPE. We did not
explore the reasons for this, but postulate that reasons may include
differential hospital PPE guidelines, availability, and personal comfort
level. From the results of our survey, it is apparent that safety is the
top concern for trainees. Similar to prior survey findings,
communication and transparency is critical to allay trainee concerns and
impart a sense of control.4
In response to the pandemic, many institutions have rapidly transitioned
to use of technology for delivery of didactic or interactive lectures,
including strategies such as “flipped classroom”, social media-based
platforms with online practice questions, and
teleconferences.7,24 Examples of tremendous
collaborative efforts to supplement otolaryngology resident education
include the Collaborative Multi-Institutional Otolaryngology Residency
Education Program (CMIOREP, University of Southern
California),25 Great Lakes Otolaryngology Consortium
(GLOC, Case Western Reserve University),26 and the
Consortium of Resident Otolaryngology kNowledge Attainment (CORONA,
University of Kentucky).27 These programs boast wide
participation—CORONA, for example, includes 42 collaborator
institutions, and reports over 400 daily participants globally.
Interestingly, we found that trainees in high COVID-19 prevalence
regions had a greater increase in didactic activities, more often had a
required curriculum and felt technology was used to good effect for
educational activities. Accordingly, we found that trainees whose
programs utilized technology well, had fewer concerns in regards to
obtaining adequate education knowledge. These differences may reflect
that regions with high COVID-19 prevalence were prescient towards the
education needs during this changing environment, and implemented
curricular changes at an earlier time. We also found there was a trend
towards junior residents expressing greater concern towards their
ability to receive adequate training in clinical and surgical
experiences. This may reflect preferential case coverage by senior
residents, or concern about the effects of the pandemic lasting longer
than these few months, potentially impact their training in the long
term. While increased didactic activities had an impact in allaying
concerns about adequate educational knowledge, the concerns regarding
adequate surgical training were prevalent across all levels and regions.
In the setting of limited clinical operations, surgical training may
require supplements through developing virtual simulation-based
training, cadaver courses, and increased involvement of trainees in the
operating room when restrictions ease.
Trainee responses were heterogeneous regarding research productivity.
Various national research institutions including National Institute for
Health Research (NIHR), biotechnology, and pharmaceutical companies
across the world have had to suspend clinical
trials,28,29 and research laboratories across the
country have likewise suspended non-essential research. As expected,
trainees in our study pursuing laboratory based and research requiring
contact with clinical research subjects felt a decrease in their ability
to continue research work, but others were able to increase clinical
research activities. For surgical trainees who have seen their clinical
volumes reduced, devoting time to clinical research may represent a
valuable opportunity to develop an important skill set during this time.
Lastly, otolaryngology trainees are looking to begin their future
careers at a time when companies conduct massive layoffs and many
hospitals are imposing hiring freezes.30 Our study
found a majority of senior trainees felt a negative impact on their
ability to secure a job or fellowship at the completion of training.
Some decided to “choose (a) job that I wouldn’t have necessarily
chosen” or defer entering the job market while entertaining the idea of
further training to “increase certain exposure of surgical cases”.
Several respondents reflected that private physicians with a career
performing elective surgeries may be more affected by a pandemic and
economic pressures, and have begun rethinking their career goals. As a
major goal of training is preparing for the next steps in future career,
training programs will need to consider how to support their senior
level trainees during this time of uncertainty.