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Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 5  |  Issue : 4  |  Page : 357-363

Effect of COVID-19 pandemic on the outcome of training for surgical residents in Saudi Arabia


Department of Surgery, College of Medicine, King Faisal University, Al-Hasa, Saudi Arabia

Date of Submission14-Apr-2022
Date of Decision26-May-2022
Date of Acceptance11-Sep-2022
Date of Web Publication12-Oct-2022

Correspondence Address:
Abdulwahab Abdullatif Alyahya
College of Medicine, King Faisal University, Al-Hasa
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jnsm.jnsm_40_22

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  Abstract 


Background: Several health-care measures were taken during the coronavirus disease-2019 (COVID-19) pandemic that may affect surgical residents' exposure and training. Objectives: The objective of this study is to assess and measure the impact of the COVID-19 pandemic on surgical residents' education and their burnout level during that time. Materials and Methods: A cross-section questionnaire-based study was conducted among 417 residents in various surgical specialties in Saudi Arabia from April 2021 to July 2021. Results: A total of 135 residents (32.4%) were level 1, and 112 residents (26.9%) were level 2. During the pandemic, 41% of the residents reported that the number of educational didactics was lower than before, and 24.9% indicated more didactics now. The proportion of residents who attended clinics and surgical cases was higher before the pandemic compared to during the pandemic. However, 36.2% of the residents were concerned that the changes in surgical training during the pandemic could lead to unpreparedness for the next career step. In addition, most of the residents were more burnout during the pandemic compared to before. Conclusion: Surgical residents were concerned that they might be less competent in their specialty due to a reduction in educational didactics during the pandemic. In addition, a higher level of burnout and stress was observed in the majority of residents.

Keywords: Coronavirus disease-2019, future carrier, pandemic, Saudi Arabia, surgical resident, training


How to cite this article:
Alessa MY, Alyahya AA, Buhalim RA, Albahr AW. Effect of COVID-19 pandemic on the outcome of training for surgical residents in Saudi Arabia. J Nat Sci Med 2022;5:357-63

How to cite this URL:
Alessa MY, Alyahya AA, Buhalim RA, Albahr AW. Effect of COVID-19 pandemic on the outcome of training for surgical residents in Saudi Arabia. J Nat Sci Med [serial online] 2022 [cited 2022 Nov 30];5:357-63. Available from: https://www.jnsmonline.org/text.asp?2022/5/4/357/358412




  Introduction Top


In late 2019, an emerging outbreak of infections caused by the severe acute respiratory syndrome coronavirus-2 referred to as coronavirus disease-2019 (COVID-19), began in Wuhan, China. Its spread continued globally, causing the World Health Organization (WHO) to declare public health emergencies of international concern on January 30, 2020.[1] Locally, Saudi Arabia documented the first positive COVID-19 case on March 2, 2020.[2] This was followed by a series of social media efforts to educate the population about the importance of social distancing and following the instructions issued by the Ministry of Health.[3]

Consequently, hospitals and health-care centers started to adjust their services to reduce the spread of infection, which would otherwise compromise the health of patients. Hence, surgical services were reviewed to manage acute life-threatening conditions while canceling or reducing elective surgeries. This also included reducing the use of outpatient clinics and referring patients for telemedicine consultations instead.[4] As a result, surgical teams were asked to reduce inpatient personnel, which included surgical residents. This led to lower bedside exposure and affected the progress of the residents' training. Concurrently, teaching hospitals shifted toward online learning to compensate for the reduced real-life exposure to patients. Overall, this affected the overall training experience, given the importance of direct contact between clinicians, patients, and their families.

The effects of these measures not only affected the communication skills of the residents but also reduced their hands-on surgical learning due to a lower number of surgeries performed during the pandemic.[5] On a more personal level, the consequences of this pandemic impose a burden on residents, which may lead to poor learning experiences and even mental health issues. Residents are considered the direct connection between consultants and patients, so they are at greater risk due to a higher likelihood of coming into contact with positive cases that can lead to more mental stress. During this pandemic, residents experienced more problems associated with work, including burnout, depression, medical errors, sleep deprivation, and fatigue. All of these factors, in addition to the possibility that a resident could get infected, resulted in prolonged absences, which reduced their exposure to clinical settings and learning ability.[6]

This study aims to compare the number of surgical cases performed by residents during the COVID-19 pandemic to the prepandemic period. Furthermore, we assessed the impact of COVID-19 on educational curriculum changes, resident perspectives on the pandemic's cumulative effects on their preparedness for their next career phase, and their effects on resident well-being and burnout.


  Materials and Methods Top


A cross-sectional study was conducted among residents of various surgical specialties in Saudi Arabia from April 2021 to July 2021. All the selected participants were surgical residents from the Saudi Board Program, determined using Stephen Thompson's formula for sample size with a 5% margin of error and a 95% confidence level. Out of 4215 surgical residents from different surgical specialties in the Saudi Board Program and as a result of these considerations, 417 residents were included. The study was approved by the Institutional Research Board at King Faisal University, deanship of scientific research on October 05, 2021, with number Ref. No. KFU-REC-2021-OCT-EA0006.

A closed-ended self-administered online questionnaire was adapted from Aziz et al.'s study.[5] The questionnaire was taken from a previously published article which they were developed after a comprehensive review of current literature and validated instruments. The questionnaire was used to gather information on the following variables: demographics, training program type and site, operative and clinical duties before and during the COVID-19 pandemic, fellowship training plans, and effects of the pandemic on education and burnout. Each participant provided informed consent in the survey; no identifiable information was documented on the questionnaires, and the personal information of the participants was kept confidential with complete privacy.

Data analyses were performed using the Statistical Package for the Social Sciences, version 21 (SPSS, Armonk, NY: IBM Corp.). Descriptive statistics were presented using numbers and percentages. The residency levels and specialties were compared to the effect of the COVID-19 pandemic on the burnout and well-being of the residents using Chi-squared tests. Categorical paired t-tests were performed using McNemar's test and the Wilcoxon signed-rank test. A P < 0.05 was considered statistically significant.


  Results Top


The current study enrolled 417 surgical residents to measure the effects of the COVID-19 pandemic on their training. [Table 1] presents the sociodemographic characteristics of the residents. The most common age group was 26–30 years (73.4%), with nearly one-third (32.4%) being level 1 residents and 26.9% being level 2. With respect to their specialties, 36.2% of the residents were in general surgery and 20.4% were in orthopedic surgery, whereas other specialties (e.g. plastic surgery and trauma) constituted 8.4% of the population. Furthermore, 43.4% were doing their residency at hospitals that were not university affiliated, 26.4% were in university-affiliated community hospitals, and 25.9% were in university hospitals. With regard to their residency location, 30.7% of residents were in the Eastern Region, 25.2% were in the Central Region, and 23.5% were in the Western Region. In addition, the proportion of residents who reported being exposed to COVID-19 patients was 62.8%.
Table 1: Sociodemographic characteristics of residents (n=417)

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In [Figure 1], using McNemar's test, we found that the proportion of residents performing 1–3 surgical cases per week was statistically significantly higher during the COVID-19 pandemic (Z = 12.128, P < 0.001). Conversely, in [Figure 2], the proportion of residents who attended 1–3 clinics per week was statistically significantly higher before the COVID-19 pandemic (Z = 9.648, P < 0.001).
Figure 1: Number of surgical cases per week before and during the COVID-19 pandemic. COVID-19: Coronavirus disease-2019

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Figure 2: Average of attended clinic days per week before and during the COVID-19 pandemic. COVID-19: Coronavirus disease-2019

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[Table 2] describes the effects of the COVID-19 pandemic on the training and education of the residents. It can be observed that the most frequently mentioned changes in training during the pandemic were a smaller team of in-house residents covering more patients (40.8%) and residents being completely removed from some services (28.1%). Similarly, the most commonly reported change to operating room (OR) protocols during the pandemic was that residents were allowed into the OR only on a case-by-case basis (38.1%), whereas the main change in examining patients during rounds was a reduction in the frequency of patient examinations (33.3%); however, half of the respondents indicated that no changes occurred between the rounds. Furthermore, 36% reported having <4 days off per month during the pandemic, and 34.5% had 5–7 days off per month. The proportion of residents who reported duty hour violations at the time of the pandemic was 36%. Similarly, 40.5% felt comfortable graduating with fewer cases than the traditional number required by the Accreditation Council for Graduate Medical Education. Moreover, 36.2% and 31.4% were concerned or very concerned, respectively, that the changes in surgical training during the pandemic could lead to unpreparedness for their next career steps. When asked what effect the pandemic had on the number of educational didactics provided by the program, 41% indicated that there were fewer didactics than before, whereas 24.9% indicated that there were more didactics. When asked about changes in the educational curriculum, 55.4% reported that some didactics had been moved online but others remained in person.
Table 2: Effect of coronavirus disease-2019 pandemic on the training and education (n=417)

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In [Table 3], the Chi-squared test was used to measure the effectiveness of the COVID-19 pandemic on residents' burnout and well-being. It was revealed that burnout was more prevalent among level 6 residents (P = 0.009). Level 6 residents also reported spending time with family, significant others, and friends during the pandemic (P = 0.003). However, level 6 residents experienced significantly less stress from the fear of potentially transmitting COVID-19 to family and friends (P = 0.037).
Table 3: Effect of coronavirus disease.2019 pandemic on resident burnout and well-being (n=417)

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[Table 4] is meant to evaluate the effect of the COVID-19 pandemic on residents' burnout and well-being in relation to respondent specialties. Based on the results, it was found that the obstetrics–gynecology residents were most likely to report changes in training schedules that resulted in a smaller team of in-house residents attending to a larger number of patients (P = 0.026). Similarly, orthopedic residents were least likely to report having no changes to their schedules (P = 0.027). Furthermore, residents in other specialties (e.g. plastic surgery and trauma) were more likely to have experienced other changes in training schedules during the pandemic (P < 0.001), whereas neurosurgeons had significantly more instances of duty hour violations during the pandemic (P < 0.001). There were no other statistically significant differences in the other parameters that we used to measure the effectiveness of the COVID-19 pandemic on the training and education of the residents (P > 0.05).
Table 4: Effect of coronavirus disease-2019 pandemic on the training and education (n=417)

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  Discussion Top


Since the declaration of COVID-19 as a global pandemic, several precautions have been implemented, such as the cancelation of elective surgeries.[1],[3] These precautions could have negatively impacted the teaching and clinical volumes of surgical residents.[7] Therefore, in this study, we aimed to determine the impact of COVID-19 on the outcome of surgical resident training in Saudi Arabia. A total of 417 surgical residents of different surgical specialties were involved. The study findings suggest that there was a relative decline in the residents' operative experience, the number of surgeries performed, and the number of outpatient clinics attended. There was also a substantial decrease in the number of educational didactics during the pandemic compared to before. In addition, the study was limited by its small sample size and cross-sectional design.

Our study findings revealed a considerable decline in the number of surgical cases per week per resident during the COVID-19 pandemic compared to before the pandemic, which is similar to the results reported by a previous study done by Balhareth et al.[8] The decline is likely due to the cancelation of elective surgical cases and the precautions required during the pandemic. However, that study was only performed on general surgery residents, unlike ours, which was conducted on most surgical specialties. Moreover, our surgical residents reported reductions in the number of outpatient clinics attended compared to before the pandemic. This is similar to a previous study, but our study exhibited this to a smaller extent.[9] Like a previous article, the surgical residents were concerned about the operative experience and volume during the pandemic. The number of educational didactics decreased by 41% compared to before the pandemic, which is higher than previously reported.[10]

An essential part of this study was to assess surgical residents' well-being and burnout during the pandemic. It is not uncommon for surgical residents to experience burnout, as was the case in Robinson et al.'s study, which demonstrated that 59% of surgical trainees had burnout.[11] In our study, the mean percentage of residents reporting more burnout was about 55%, which is significantly higher compared to the prepandemic period. Moreover, Aziz et al.'s American study suggested that a significant stressor for residents is the fear of potentially transmitting COVID-19 to family and friends, which was also significant in our study.[5] Conversely, the one positive significant impact of the pandemic was that the residents were able to spend more time with their families and friends, which is believed to be due to reduced time spent in the clinic during the pandemic. However, many residents reported spending more time on their hobbies, educational activities, and research.

Several questions were asked about the residents' surgical training and education to assess the effects of the COVID-19 pandemic. In terms of training schedule, Kapila et al. stated that exposure had been affected in different ways; some trainees (16%) were removed entirely from medical services, whereas ~29% had significantly lower exposure to clinical training, albeit to varying degrees.[12] A significant finding was that a smaller team of residents was assigned to cover a large number of patients. Overall, with all these changes, it was noticed that no changes had been made to the program. Another area of change was in OR policies, which differed by country and hospital. For example, the American College of Surgeons recommended postponing all elective and nonurgent surgeries, which could significantly affect the surgical training and exposure of residents.[13] Some residents reported that they were not allowed in the OR, whereas others reported that only interns and junior residents were not allowed; some other residents reported decreased exposure. Another significant variable was that the incidence of duty hour violations during the pandemic was 37%, compared to 26.6% in Aziz et al.'s study.[5]

As with most cross-sectional studies, they find a correlation, but not causation. Therefore, the authors recommend that this study should be used as a base for future prospective cohort studies to gain the cause of these problems. Besides the direct communication might be difficult in such situations, the study would be better if it was structured by an interview to enhance the quality of data.


  Conclusion Top


Surgical residents from a variety of surgical specialties were concerned that they would be less competent in future. Furthermore, a reduction in educational didactics may lead them to a sense of unpreparedness. Most of the residents from different levels believe that there was a difference between their surgical and patient exposure in terms of lower cases during the pandemic compared to before. Moreover, a higher level of burnout and stress was observed in the majority of residents. Hence, these problems should be investigated further as they might affect the eagerness and preparedness of future surgeons who will be future stakeholders. In addition, more educational programs and symposiums should be implemented to prepare the residents for such issues that affect the educational pace.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Wu YC, Chen CS, Chan YJ. The outbreak of COVID-19: An overview. J Chin Med Assoc 2020;83:217-20.  Back to cited text no. 1
    
2.
Alsofayan YM, Althunayyan SM, Khan AA, Hakawi AM, Assiri AM. Clinical characteristics of COVID-19 in Saudi Arabia: A national retrospective study. J Infect Public Health 2020;13:920-5.  Back to cited text no. 2
    
3.
Alkhamees AA, Alrashed SA, Alzunaydi AA, Almohimeed AS, Aljohani MS. The psychological impact of COVID-19 pandemic on the general population of Saudi Arabia. Compr Psychiatry 2020;102:152192.  Back to cited text no. 3
    
4.
Chok AY, Kontovounisios C, Rasheed S, Kelly ME, Agj A, Abdul Aziz N, et al. The impact of the COVID-19 pandemic on the management of locally advanced primary/recurrent rectal cancer. Br J Surg 2020;107:e547-48.  Back to cited text no. 4
    
5.
Aziz H, James T, Remulla D, Sher L, Genyk Y, Sullivan ME, et al. Effect of COVID-19 on surgical training across the United States: A national survey of general surgery residents. J Surg Educ 2021;78:431-9.  Back to cited text no. 5
    
6.
Dimitriu MC, Pantea-Stoian A, Smaranda AC, Nica AA, Carap AC, Constantin VD, et al. Burnout syndrome in Romanian medical residents in time of the COVID-19 pandemic. Med Hypotheses 2020;144:109972.  Back to cited text no. 6
    
7.
Wise CE, Bereknyei Merrell S, Sasnal M, Forrester JD, Hawn MT, Lau JN, et al. COVID-19 impact on surgical resident education and coping. J Surg Res 2021;264:534-43.  Back to cited text no. 7
    
8.
Balhareth A, AlDuhileb MA, Aldulaijan FA, Aldossary MY. Impact of COVID-19 pandemic on residency and fellowship training programs in Saudi Arabia: A nationwide cross-sectional study. Ann Med Surg (Lond) 2020;57:127-32.  Back to cited text no. 8
    
9.
Ostapenko A, McPeck S, Liechty S, Kleiner D. Impacts on surgery resident education at a first wave COVID-19 epicenter. J Med Educ Curric Dev 2020;7:2382120520975022.  Back to cited text no. 9
    
10.
Collins C, Mahuron K, Bongiovanni T, Lancaster E, Sosa JA, Wick E. Stress and the surgical resident in the COVID-19 pandemic. J Surg Educ 2021;78:422-30.  Back to cited text no. 10
    
11.
Robinson DB, James OP, Hopkins L, Brown C, Bowman C, Abdelrahman T, et al. Stress and burnout in training; requiem for the surgical dream. J Surg Educ 2020;77:e1-8.  Back to cited text no. 11
    
12.
Kapila AK, Farid Y, Kapila V, Schettino M, Vanhoeij M, Hamdi M. The perspective of surgical residents on current and future training in light of the COVID-19 pandemic. Br J Surg 2020;107:e305.  Back to cited text no. 12
    
13.
Wady H, Restle D, Park J, Pryor A, Talamini M, Abdel-Misih S. The role of surgeons during the COVID-19 pandemic: Impact on training and lessons learned from a surgical resident's perspective. Surg Endosc 2021;35:3430-6.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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