\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[T2A]{fontenc}
\usepackage[ngerman,polish,english]{babel}



\usepackage{float}








\begin{document}

\title{Residency education in Coronavirus Disease 2019 (COVID-19) times:
Experience of a Chilean Otolaryngology Program}



\author[1]{Matias Alvarez}%
\author[2]{Antonia Lagos}%
\author[3]{Valeria Sepulveda}%
\author[3]{Carla Napolitano}%
\author[3]{Claudia Gonzalez}%
\affil[1]{Pontificia Universidad Catolica de Chile Facultad de Medicina}%
\affil[2]{Pontificia Universidad Catolica de Chile}%
\affil[3]{Pontificia Universidad Católica de Chile}%


\vspace{-1em}



  
  \date{May 08, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup








\sloppy




\textbf{KEY POINTS}

\begin{itemize}
\tightlist
\item
  The COVID-19 pandemic has presented the Otolaryngology community with
  new challenges.
\item
  Exposure to outpatient attention, endoscopic procedures and surgeries
  has been significantly reduced for residents worldwide.
\item
  Our Otolaryngology residency program has implemented different
  measures to reduce residents' exposure to high-risk infection
  situations.
\item
  Concomitant measures have been taken to increase simulation training,
  and up-to-date seminars and courses for residents.
\item
  Adaptation and flexibility of regular training curricula are required
  in order to diminish the negative impact in residents ' education.
\end{itemize}

\textbf{Keywords} : COVID-19, SARS-CoV-2, residents, residency
education, otolaryngology.

\textbf{INTRODUCTION}

The outbreak of Coronavirus Disease 2019 (COVID-19), an acute
respiratory illness caused by the Severe Acute Respiratory Syndrome
Coronavirus 2 (SARS-CoV-2), has become a global pandemic. This disease
emerged in December 2019 in Wuhan, China, and the virus was first
identified in January 2020, proven to be transmitted through contact and
droplets\textsuperscript{1}. The pandemic has spread worldwide; up to
May 5th 2020, the World Health Organization (WHO) reported 3,517,345
cases, and 243.401 deaths\textsuperscript{2}.In Chile, the first
COVID-19 case was confirmed on March 3rd 2020; up to May 5th 2020, the
Chilean Health Ministry reported 22,016 cases, and 275
deaths\textsuperscript{3}.

The most frequently reported symptoms are fever, cough, malaise,
dyspnea, anorexia, and myalgias. Other less common symptoms are
odynophagia, nausea, diarrhea, headache, and abdominal pain, and in some
cases it may even be asymptomatic\textsuperscript{1}. Several cases of
olfactory and gustatory dysfunction have been reported in association to
SARS-CoV-2 infection, yet further studies are required to establish
their prevalence and natural history\textsuperscript{1}.

Otolaryngologists are at a high risk of SARS-CoV-2 infection, given the
high viral loads reported in the upper respiratory
tract\textsuperscript{4}, which is the main area examined and
manipulated in endoscopic procedures by the specialty, increasing the
risk of viral aerosols generation and
propagation\textsuperscript{5}.\emph{Givi et a} l. recommend that
non-urgent appointments or endoscopic examinations of the upper airway
mucosa should be postponed to limit the chance of SARS-CoV-2 infection
in patients and healthcare professionals, as well as postponing elective
procedures that can be safely delayed. They also recommend a proper and
optimal use of personal protection elements (PPE), with appropriate
doffing and elimination techniques\textsuperscript{5}.

In response to the emerging challenges for the specialty,\emph{Vukkadala
et al} . suggest major changes in department activities, including
reducing the number of residents on service, exclusion of residents in
staff clinics and surgeries to reduce risk of exposure, and remote
department meetings and resident education sessions\textsuperscript{6}.

This article aims to show the implemented strategies in a Chilean
Otolaryngology residency program to overcome the challenges presented by
the COVID-19 pandemic in our specialty.

\textbf{MATERIAL AND METHODS}

\emph{Study design and methodology}

Descriptive study of the implemented measures in a Chilean
Otolaryngology residency program in order to reduce the impact on the
residents education. The measures include hands-on surgical teaching,
in-patient care, outpatient care and in-person didactics.

\textbf{RESULTS}

We present the measures taken by a chilean Otolaryngology residency
program, summarized in \textbf{Table 1} .

\emph{Daily Schedule and rotations}

The Universidad {[}Blinded for review{]} Residency is a 3-year program,
currently including five residents per year, divided in four teaching
hospitals in Santiago, Chile. In the COVID-19 pandemic, where limiting
the exposure of healthcare professionals and maintaining the quality of
attention to patients is the top priority, our Department implemented
the following measures: optimal use of PPE according to aerosols
generation risk; cancellation of all elective rotations outside the
Otolaryngology Department; voluntary quarantine for residents with
chronic pulmonary disease, pregnancy and immunosuppression; division of
the available residents into ``7 days on'' and ``14 days off'' shift
schedules, with everyday monitoring of respiratory symptoms appearance.
Unfortunately, this resulted in a decrease of the overall procedures and
surgeries performed by the residents over a month, as seen
in\textbf{Table 2} .

Finally, by the university's Postgraduate Committee order, all annual
evaluations were suspended for at least 3 months.

\emph{Surgical exposure and simulation}

Following the literature's recommendations\textsuperscript{5}, all
elective cases were suspended, and urgent or time dependent surgeries
were only performed by attending Otolaryngologists. In order to deal
with the absence of surgical exposure, during their ``on'' week,
residents are expected to perform pre-established simulation training
programs for nasal endoscopic surgery, and myringotomy with ventilation
tubes placement. Other simulation training programs, such as
microphonosurgery and septoplasty, are under development and validation,
however, residents are expected to complete these courses as well.

\emph{Didactics and Academics}

Keeping an up-to-date and continuous learning is fundamental for the
Otolaryngology residency, and the COVID-19 pandemic has allowed
alternative teaching methods to arise. For instance, all chilean first
and second year Otolaryngology residents have mandatory unified core
curriculum lessons twice a week between april and november, previously
performed in-person by teachers from the Sociedad Chilena de
Otorrinolaringolog\selectlanguage{ngerman}ía y Cirugía de Cabeza y Cuello. However, since the
COVID-19 outbreak all the lectures and evaluations were changed to an
online platform.

In the same way, our residency program introduced a dynamic academic
schedule during the pandemia, hosted through a virtual platform:

1.- Seminars regarding a topic of interest for residents are held twice
a week, hosted by an assigned attending. The attending previously
chooses bibliography for the seminar, where the topic is addressed and
discussed according to the literature's clinical relevance and
application.

2.- Every wednesday a Department meeting takes place, where a topic of
interest is discussed and presented by a resident.

3.- The residents joined the ``Collaborative Multi-Institutional
Otolaryngology Residency Education Program'', aiming to attend four
conferences per week\textsuperscript{7}.

4.- One module from Otosource was designated for each resident per week.
The theme was decided according to the residency
year\textsuperscript{8}.

5.- The learning progress is objectified through formative pop quizzes
once every two weeks using the CANVAS platform. These quizzes evaluate
subjects addressed the previous week.

Finally, residents were encouraged to complete all the ongoing research,
and create new retrospective studies during their ``Off period''.

\emph{Residents wellness}

The current pandemia can be challenging for personal wellbeing,
considering conditions of self isolation, anxiety about the future, and
concern about personal and loved ones health. In order to cope with
these problems a virtual reunion is held once a week, only for
residents, to discuss the pandemia's impact on residents, and assess the
need for schedule adjustments, and peer or professional support.

\textbf{DISCUSSION}

The Otolaryngology residency program is facing many challenges due to
the suspension of the elective clinical procedures and surgeries in
light of the high risk of infection, affecting the residents
participation in the OR. In this descriptive study we present the report
of an Otolaryngology residency program adapting to the ongoing pandemia.

This topic is also addressed by \emph{Crosbyet al.} where the impact of
SARS-CoV2 on American Otolaryngology residency programs is analyzed in
terms of the expected decline in overall experience and accomplishment
of the minimum key indicators established by the Accreditation Council
for Graduate Medical Education. This especially affects residents
coursing the last two years of their program. Other subjects are also
discussed, particularly the implementation of online consortia didactic
sessions, changes in the American Board of otolaryngology requirements,
and the flexibility requested from supervision
organizations\textsuperscript{9}. Moreover, \emph{Comeret al.} discusses
how COVID-19 induced limitations have affected Otolaryngology training,
and as a result three consortia have been developed in Otolaryngology
residency education, including the ``Collaborative Multi-Institutional
Otolaryngology Residency Education Program''. They also mention the
possible need of at-home simulation models depending on the quarantine's
duration\textsuperscript{10}.

The COVID-19 pandemic is now affecting most residency programs, but
specifically the Otolaryngology program due to the risks involved in
upper-airway manipulation. There is no knowledge on how long the
pandemic will last and how deeply it will affect the current resident
cohort. We believe that adapting the program and keeping a close
follow-up on indicators regarding residents participation in outpatient
practice, procedures, and surgeries should be addressed in the future so
we can design a further personalized reinforcement resident to resident.
At the moment our program is considering as future options: rural
surgical operatives to increase the number of surgeries performed by
residents, case by case extension of the formative period, among others.

\textbf{CONCLUSIONS}

The SARS-CoV2 pandemia represents a novel and important challenge for
the Otolaryngology residency education. Adaptation and flexibility of
the regular training curricula are required in order to diminish the
negative impact on residents' education. We describe the experience of a
Chilean Otolaryngology program facing the impact of COVID-19, that may
be useful for other programs during this pandemic, or in the event of
future pandemics, natural disasters or wars.

\textbf{REFERENCES}

\begin{enumerate}
\tightlist
\item
  Krajewska J, Krajewski W, Zub K, Zato\selectlanguage{polish}ń\selectlanguage{english}ski T. COVID-19 in
  otolaryngologist practice: a review of current knowledge.
  EurArchOtorhinolaryngol. 2020. doi:10.1007/s00405-020-05968-y
\item
  World Health Organization. Coronavirus disease 2019 (COVID-19)
  Situation Report -- 106.
  WHO.\emph{https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports/}Accessed
  May 5 2020
\item
  Ministerio de Salud de Chile. Casos confirmados en Chile COVID-19.
  MINSAL\emph{https://www.minsal.cl/nuevo-coronavirus-2019-ncov/casos-confirmados-en-chile-covid-19/}Accessed
  May 5 2020
\item
  Zou L, Ruan F, Huang M, et al. SARS-CoV-2 viral load in upper
  respiratory specimens of infected patients. \emph{New EnglandJournal
  of Medicine}. 2020. 382(12), 1177-1179
\item
  Givi B, Schiff BA, Chinn SB, et al. Safety Recommendations for
  Evaluation and Surgery of the Head and Neck During the COVID-19
  Pandemic. J\emph{AMA Otolaryngol Head NeckSurg}. 2020.
  doi:10.1001/jamaoto.2020.0780
\item
  Vukkadala N, Qian ZJ, Holsinger FC, Patel, ZM, Rosenthal E. COVID-19
  and the otolaryngologist--preliminary evidence-based
  review.\emph{TheLaryngoscope}. 2020
\item
  Oghalai J. Collaborative multi-institutional otolaryngology residency
  education program. https://sites.usc.edu/ohnscovid/. AccessedMay 5
  2020
\item
  OTOsource, American Academy of Otolaryngology Head and Neck Surgery
  Foundation.\emph{https://www.otosource.org/}AccessedMay 5 2020
\item
  Crosby DL, Sharma A. Insights on Otolaryngology Residency Training
  during the COVID-19 Pandemic. \emph{Otolaryngology--Head and
  NeckSurgery}. 2020
\item
  Comer BT, Gupta N, Mowry SE, Malekzadeh S. Otolaryngology Education in
  the Setting of COVID-19: Current and Future
  Implications.\emph{Otolaryngology--Head and NeckSurgery}. 2020
\end{enumerate}

\textbf{Hosted file}

\verb`Table 1 .docx`  available at \url{https://authorea.com/users/319565/articles/449289-residency-education-in-coronavirus-disease-2019-covid-19-times-experience-of-a-chilean-otolaryngology-program}

\textbf{Hosted file}

\verb`Table 2.docx`  available at \url{https://authorea.com/users/319565/articles/449289-residency-education-in-coronavirus-disease-2019-covid-19-times-experience-of-a-chilean-otolaryngology-program}

\selectlanguage{english}
\FloatBarrier
\end{document}

