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.