Surgical training during the COVID-19 pandemic - the cloud with a silver lining?

Regional Elective Day Procedure Centre Pilot- the solution to waiting lists and trainee deficit in the reshaping of services following COVID-19?

Background

Consequences from the COVID-19 pandemic have resulted in the secondary impact of cessation of elective surgical services, amplifying the waiting list problem with devastating patient and surgical training repercussions. With the introduction of the first regional inter-trust daycase elective care centre pilot in Northern Ireland, we aim to assess the impact of this pathway on elective inguinal hernia waiting lists, patient outcomes, and influence on surgical training.

Methods

Data was collected prospectively over a 10-week pilot of consecutive elective day case hernia lists at a newly established regional day surgery centre. Key operative time points for each patient were collated via the Theatre Management System (TMS). Retrospective patient feedback was collected from participating patients via 26-question telephone survey at 6 weeks post-operatively. Trainees allocated to the participating units during this pilot received a retrospective electronic survey.

Results

Fifty-five patients underwent open unilateral elective inguinal hernia repair, 54% of cases were trainee led. Median trainee operating time of 53 minutes compared with 51 minutes for consultant led procedures, with no significant difference consultant vs non-consultant as primary operator (p>0.05). On completion of the pilot, waiting list numbers were reduced by a third, 75% of trainees feedback reported increased confidence with surgical operative exposure, and high levels of patient satisfaction reported.

Conclusion

Inter-trust day surgery at a dedicated green site could successfully contribute to resuming and reforming surgical services, addressing the impact on mounting waiting lists with positive patient impact as well as providing an excellent training opportunity to narrow the observed training deficit.

Surgical training during the COVID-19 pandemic at a designated 'cold' site: are we meeting the challenge?

INTRODUCTION

There has been a marked reduction in surgical operative training opportunities during the COVID-19 pandemic. This may be improved by the establishment of 'cold' sites for NHS elective surgery. We investigated the training opportunities at a newly designated elective surgery cold site in the West Midlands, UK.

METHODS

An observational retrospective study was undertaken to include all gastrointestinal and urological elective surgery at a single 'cold' site during the first peak of the COVID-19 pandemic. Patient demographics, details of surgery and data relating to surgical training such as primary surgeon and portfolio index procedure were collected. Factors affecting the likelihood of trainees being the primary surgeon were analysed using logistic regression models.

RESULTS

There were 880 patients, with a median (interquartile range) age of 62 (48-74). Some 658 (74.8%) procedures were defined as 'index procedures' for specialty training year 4 (ST4) level: 409/509 (80.4%) for urology, 155/235 (66%) for colorectal and 94/136 (69.1%) for upper gastrointestinal (GI). Only 253/880 (28.8%) procedures were performed by a trainee as the primary surgeon: 201/509 (39.4%) for urology, 21/235 (8.9%) for colorectal and 31/136 (22.8%) for upper GI. The likelihood of a trainee being the primary surgeon was reduced for major surgery (p<0.001) and for GI surgery when compared with urology (p<0.001).

CONCLUSIONS

Surgical training was facilitated at an elective surgery 'cold' site during the COVID-19 pandemic, but at lower levels than anticipated. Type of surgery influenced trainee participation. Surgical training should be incorporated into 'cold' site elective surgical services if trainees are to be prepared for the future.

A Low-cost model of breast biopsy for the training of surgical residents during COVID-19 pandemic

We describe a low-cost simulation model for teaching core needle biopsy to surgical trainees in Low- and Middle-income countries (LMICs). Pre-session and post-session surveys showed that correct core sampling (ability to hit the beetroot) after training was 91.4% compared to 75.7% before demonstration and improved adequacy (68.5% before v. 85.7% after). This low-cost model using locally available products is designed to simulate a palpable breast lump and can easily be incorporated into surgical training in LMICs, where a palpable breast lump is the commonest presentation of breast cancer.

The quantitative impact of COVID-19 on surgical training in the United Kingdom

Background

COVID-19 has had a global impact on all aspects of healthcare including surgical training. This study aimed to quantify the impact of COVID-19 on operative case numbers recorded by surgeons in training, and annual review of competency progression (ARCP) outcomes in the UK.

Methods

Anonymized operative logbook numbers were collated from electronic logbook and ARCP outcome data from the Intercollegiate Surgical Curriculum Programme database for trainees in the 10 surgical specialty training specialties.

Operative logbook numbers and awarded ARCP outcomes were compared between predefined dates. Effect sizes are reported as incident rate ratios (IRR) with 95 per cent confidence intervals.

Results

Some 5599 surgical trainees in 2019, and 5310 in surgical specialty training in 2020 were included. The IRR was reduced across all specialties as a result of the COVID-19 pandemic (0.62; 95 per cent c.i. 0.60 to 0.64). Elective surgery (0.53; 95 per cent c.i. 0.50 to 0.56) was affected more than emergency surgery (0.85; 95 per cent c.i. 0.84 to 0.87). Regional variation indicating reduced operative activity was demonstrated across all specialties. More than 1 in 8 trainees in the final year of training have had their training extended and more than a quarter of trainees entering their final year of training are behind their expected training trajectory.

Conclusion

The COVID-19 pandemic has had a major effect on surgical training in the UK. Urgent, coordinated action is required to minimize the impacts from the reduction in training in 2020.

The Impact of the COVID-19 Pandemic on Head and Neck Surgery Training: A Brazilian National Survey

Introduction  The COVID-19 pandemic has had a high impact on surgical training around the world due to required measures regarding the suspension of elective procedures and the dismissal of nonessential personnel.

Objectives  To understand the impact the pandemic had on head and neck surgery training in Brazil.

Methods  We conducted a 29-question online survey with head and neck surgery residents in Brazil, assessing the impact the pandemic had on their training.

Results  Forty-six residents responded to the survey, and 91.3% of them reported that their residency was affected by the pandemic, but most residents were not assigned to work directly with patients infected with the new coronavirus (71.4%). All residents reported decrease in clinic visits and in surgical procedures, mostly an important reduction of ∼ 75%. A total of 56.5% of the residents described that the pandemic has had a negative impact on their mental, health and only 4 (8.7%) do not have any symptoms of burnout. The majority (78.3%) of the residents reported that educational activities were successfully adapted to online platforms, and 37% were personally infected with the virus.

Conclusion  Most surgical residencies were greatly affected by the pandemic, and residents had an important decrease in surgical training. Educational activities were successfully adapted to online modalities, but the residency programs should search for ways of trying to compensate for the loss of practical activities.

A review of participant recruitment transparency for sound validation of hip surgery simulators: a novel umbrella approach

Malposition of implants is associated with complications, higher wear and increased revision rates in total hip replacement (THR) along with surgeon inexperience. Training THR residents to reach expert proficiency is affected by the high cost and resource limitations of traditional training techniques. Research in extended reality (XR) technologies can overcome such barriers. These offer a platform for learning, objective skill-monitoring and, potentially, for automated certification. Prior to their incorporation into curricula however, thorough validation must be undertaken. As validity is heavily dependent on the participants recruited, there is a need to review, scrutinise and define recruitment criteria in the absence of pre-defined standards, for sound simulator validation. A systematic review on PubMed and IEEE databases was conducted. Training simulator validation research in fracture, arthroscopy and arthroplasty relating to the hip was included. 46 validation studies were reviewed. It was observed that there was no uniformity in reporting or recruitment criteria, rendering cross-comparison challenging. This work developed Umbrella categories to help prioritise recruitment, and has formulated a detailed template of fields and guidelines for reporting criteria so that, in future, research may come to a consensus as to recruitment criteria for a hip "expert" or "novice".

The need to preserve surgical training

Surgical trainees have found their training opportunities disrupted throughout the COVID-19 pandemic. With an uncertain future and potential impeding second wave considerations should be made on how surgical training can be preserved.

Silver linings: a qualitative study of desirable changes to cancer care during the COVID-19 pandemic

Introduction

Public health emergencies and crises such as the current COVID-19 pandemic can accelerate innovation and place renewed focus on the value of health interventions. Capturing important lessons learnt, both positive and negative, is vital. We aimed to document the perceived positive changes (silver linings) in cancer care that emerged during the COVID-19 pandemic and identify challenges that may limit their long-term adoption.

Methods

This study employed a qualitative design. Semi-structured interviews (n = 20) were conducted with key opinion leaders from 14 countries. The participants were predominantly members of the International COVID-19 and Cancer Taskforce, who convened in March 2020 to address delivery of cancer care in the context of the pandemic. The Framework Method was employed to analyse the positive changes of the pandemic with corresponding challenges to their maintenance post-pandemic.

Results

Ten themes of positive changes were identified which included: value in cancer care, digital communication, convenience, inclusivity and cooperation, decentralisation of cancer care, acceleration of policy change, human interactions, hygiene practices, health awareness and promotion and systems improvement. Impediments to the scale-up of these positive changes included resource disparities and variation in legal frameworks across regions. Barriers were largely attributed to behaviours and attitudes of stakeholders.

Conclusion

The COVID-19 pandemic has led to important value-based innovations and changes for better cancer care across different health systems. The challenges to maintaining/implementing these changes vary by setting. Efforts are needed to implement improved elements of care that evolved during the pandemic.