First gaining worldwide attention in February 2020, COVID-19 has
infected 500,000, and taken the lives of 21,000 as of the
27th March 20201. In response to the
rapidly escalating global crisis, most countries have employed drastic
measures such as travel bans and nationwide lockdowns in an urgent
attempt to slow down viral spread so as not to overwhelm limited
healthcare resources. “Social distancing” is the catchphrase of the
day. Singapore saw her first imported case on the 23rdJanuary 20202 and felt déjà vu , having
experienced the Severe Acute Respiratory Syndrome [SARS] outbreak in
2003.
Singapore’s response to SARS demonstrated two key priorities:
sustainability of patient care and protection of healthcare
professionals [HCPs]. While manpower was reorganised into teams
segregated by time, place and expertise, many important hospital
functions such as medical education and intermediate exam preparation
for specialist trainees [STs] were ignored3 4. The
only training was “on-the-job,” focusing on essential care. Both
specialist and general training for junior doctors was neglected despite
their frontline role. The situation with COVID-19 is no different, and
globally we are already witnessing a negative impact on education and
training5. While understandable, work-arounds do
exist. In Singapore, we have been preparing for this6and our unit made it an early priority to continue medical education
while balancing increased service needs and the requirement to avoid
congregation. With the COVID-19 pandemic expected to last until the end
of 2020 and possibly beyond, we share our strategies.
To safeguard HCPs and ensure continuity of services in the inevitable
event that HCPs contract COVID-19, hospitals nationwide have implemented
team segregation. In our department, different teams work shifts to
cover five geographically distinct service areas- outpatient services
[two teams], emergency department [four teams], labour ward
[four teams], sonography unit [two teams] and inpatient services
[two teams]. The greatly increased manpower needs, non-standard
working hours, the need to avoid congregation and depletion of staff
through illness initially stopped our morning didactic sessions.
However, within two weeks, we started using videoconferencing methods
for synchronous distance teaching. While the use of videoconferencing in
medical education is not new7 8, it has found revived
utility in these times. The lead and assistant program directors created
a timetable with topics blueprinted to the Royal College of
Obstetricians and Gynaecologists membership examination [MRCOG]
syllabus incorporating Green Top Guidelines, NICE guidelines, TOG
articles and other RCOG documents such as consent advice, good practice,
scientific impact papers, audits and key publications. This timetable
was divided amongst the STs who committed to 1-2 sessions each per
month. They were encouraged to select topics which represented personal
knowledge gaps. The format comprises a 30-minute presentation with
assessment of learning through Q&A, EMQs or SBA. These sessions are
facilitated by senior faculty with our programme coordinators tracking
education hours and attendance by verifying on-screen presence. We hold
sessions at 0730hrs as it constitutes a quieter period prior to hand
over and when most STs are awake. Those who are commuting, off work, or
on quarantine / stay home notice still find it easy to participate.
Zoom® [Zoom Video Communications Inc., San Jose,
California, USA] has several features which have greatly assisted our
mission. The most significant is its stability over a wide variety of
platforms [i.e. smart phones and computers] running different
operating systems over local 4G networks. Presenters found the “Share
Screen” function very user friendly to allow voice-over teaching with
their presentation slides. A pre-determined, recurrent meeting code is
fixed for the morning session. Zoom® also allows
recordings of the session which are stored on a hospital-based intranet
server together with the presentation slides and the source guideline or
article. This serves as a form of asynchronous teaching for those who
missed the session or wish to revise.
Comical usage of virtual backgrounds and participation of some our STs’
very young children at home brought in humour and gave a sense of
solidarity at a time of isolation. Senior STs revealed themselves as
natural peer trainers regarding exam technique. Interestingly, some of
our junior STs felt that this style of teaching was more interactive
than our typical Departmental didactic sessions. One remarked,
“Zoom® meetings are more fun and meaningful because
they are directed at what is really important for us to know and it is
easy to ask questions fearlessly.” This is a positive consequence as
many cultures fear “losing face” by asking questions in an audience of
senior faculty. The end of the meeting also allows for any “on the
ground” operational issues to be raised while serving as a conduit to
pass on information from department leaders.
A vital aspect of Singapore’s response to COVID-19 was to cut all
non-time-sensitive surgical cases in order to boost surge critical care
capacity and redistribute manpower and resources. In our unit, there is
an 80-90% reduction in operating for benign gynaecology cases with only
obstetric and gynaecologic oncology cases proceeding. Due to manpower
constraints, all surgeries and on-table consultations are being
undertaken by consultants with house officer assistance. As a result,
STs’ gynaecological operative training has been greatly reduced. To
partly address this, we started Zoom®-based surgical
sharing sessions by experienced faculty, taping segments of current
surgical cases or using archived videos to train on anatomy, surgical
principles and pre- and post-operative care. A session on the management
of ovarian cysts in pregnancy coincided with three recent cases and was
particularly well received. Although videoconferencing has a role in
surgical training9, it is very clear that it will not
entirely remedy case-log deficiencies and the loss of hands-on
experience. Simulators housed within the Department are available for
individual use and we plan to incorporate these into “live” sessions.
The MRCOG examinations, which are used to certify competence for
progression within Singapore’s obstetrics and gynaecology specialist
training programme, have been postponed10. To keep our
exam candidates’ preparedness honed while waiting for the next exam
window, we have also continued in-house Zoom® OSCE
practice sessions. Prior to this pandemic, our STs were supported to
take up RCOG Associate status in order to facilitate access to the
RCOG’s excellent e-learning11 12 portal. We strongly
recommend it as a staple for asynchronous learning as it is a repository
for a wide array of modules pertaining to core knowledge, case
discussions, technical skills and professionalism. Many Colleges
globally have similar material, and these should be explored.
This pandemic will undoubtedly affect the training and psychosocial
wellbeing of STs who constitute a major component of the frontline
staff. Disruption to training affects confidence and exam cancellations
instil fear for the future as key purchases and family plans are put on
hold. However, while this pandemic is expected to last until the end of
the year, women’s health issues will continue to exist. It is important
for the global community of obstetricians and gynaecologists to start
seeing how to ensure continuity of training in this new environment. We
offer a few simple suggestions on how to achieve this despite
dyssynchronous rosters, home stay notices, anxiety, exhaustion and
illness. Anecdotally, our STs report have found solidarity in a time of
isolation through these morning sessions and it probably contributes to
their ability to cope. The pandemic of today is daunting. We need to
support our STs because to do so is to invest into the future of women’s
health.