Plastic Surgery Trainee and COVID-19: A Quest and a Quandary

by Dr. Shivangi Saha
Plastic Surgery Resident, Department of Plastic, Reconstructive and Burns Surgery, All India Institute of Medical Sciences, New Delhi, India


The COVID-19 pandemic is accelerating at an unprecedented rate. This poses countless uncertainties for the Plastic surgery resident. There is also an intangible impact of the pandemic on their routine clinical teaching, acquisition of plastic surgical skills, completion of their ongoing research projects and advancement in their careers beyond residency. Preparations to mitigate the crisis have been underway in hospitals all over the world. It was initially estimated that a time period of 3 months to halt the routine hospital activities and focussing all the resources and healthcare staff to manage COVID would be a prudent plan. However, at the moment, the situation still seems fragile with no success in predicting how long the pandemic will last.

The burning problems in a residents life:

A toll on mental health: The residents who have been deployed in emergency services are shrouded with trepidation of keeping themselves safe while displaying their commitment to patient care. Once off duty they return home and prefer to keep themselves in isolation to safeguard their family members from any transmission. Those with aging parents suffer from the added fear of putting them at risk. Thus while being involved in the service of humankind, these warriors have to refrain from doing what is inherently human, i.e., finding solace in the company of their loved ones, in a bid to impart strength through their conversations while their own anxieties and worries are buried somewhere deep down. In the long run such mental and emotional isolation could be exhausting to these doctors who have to fight not only the disease but also the consternation of physical and psychological trauma which is natural at such times (1).

Encumbered surgical training: The impact of this crisis on plastic surgery training cannot be overstated. Most plastic surgery departments worldwide have stopped attending to outpatients and performing non-urgent elective surgeries (2).The lockdown has also resulted in a drastic fall in the emergency and trauma cases. Thus, there is a considerable impact on the surgical training. This is surely a setback to the clinical teaching and hands on training. To meet the growing needs for COVID care, there has been a reconfiguration of most training programs, with de-specialisation of the Plastic surgery super speciality trainees to provide emergency care to COVID inpatients across the hospitals (3).

Changing formats of learning and assessments: The pandemic has changed the format of teaching and learning to a great extent wherein most education systems have adopted E-learning. This format of learning has been around for a while but did not gain popularity earlier because of limited one to one teacher- resident interaction. Another limitation that may arise in developing countries is the limited access to internet connectivity.

The future of the trainees who are about to finish their residency and qualify for board certification is also shrouded in uncertainty. Most qualifying exams require a practical exam which seems to be a challenging task to conduct at the moment (4). Exams have been moved to an online format without involving any doctor patient interaction. To expedite the process of qualifying examinations, most universities are replacing traditional exams with online assessment tools. Although this format seems apt for the moment, it cannot replace the traditional assessment of bedside skills that are quintessential to clinicians. This is a new area for both teachers and students, and assessments will likely have larger measurement error than usual. Use of simulation could be a constructive alternative, however planning it in limited timeframe could be challenging.

The effect on research – both swings and roundabouts: Laboratory based researches have been ramped down due to unavailability of support staff and material resources amidst the lockdowns, and those involving human subjects have been completely halted (5). Prospective subject recruitment is nearly impossible in this situation. With shutting down of the libraries, institutional resources are also limited at some universities.

We must accept finite disappointment, but we must never lose infinite hope.

-Martin Luther King, Jr.

Clearly every cloud has a silver lining, as in a recent survey of three thousand ResearchGate users showed that about half the researchers globally are getting more time to read, write and review academic articles (6). Also, the increased use of preprints and doing away with the slow and archaic system of peer reviewing is changing the way research is conducted and shared. Most research in today’s times is exclusively focused on COVID and even case reports and series are published rapidly. However, this transformation may propel science towards a faster mode of operating which can be a boon in future.

The e-learning format has brought the entire plastic surgery community closer, where residents can get access to lectures from the Doyens at the click of a button on their laptops and iPads. The virtual grand rounds, clinical case discussions, surgical vignettes and videos from the experts are invaluable resources which should be optimally utilised. Although a one on one surgical mentorship is irreplaceable, discussions with the experts also gives opportunities to solve our queries with certain surgical procedures.

This hard situation is forcing us all to make hard choices. The trainee workforce needs to adapt to the changing demands and challenges. The crisis is unanticipated and calls for unconventional solutions. in the words of Albert Einstein: “We cannot solve our problems with the same thinking we used when we created them.”

Some survival tips and practical solutions could be:

  1. To cope with mental stress, support groups could be utilised. Trainees may connect with one another remotely, and share their own apprehensions, experiences and suggest solutions.

  2. Taking time to rejuvenate oneself and practice meditation (7). Recreation and sports helps to distress and also to regain fitness. Catching up on activities one has always wanted to do like reading a book, cooking, writing, singing, bonding with old friends over FaceTime/Skype may help to unwind and refresh. We need to be mindful that this is not a sprint but a marathon.

  3. Most surgical programs have been restructured in a way that reduces non-productive attendance of doctors in the hospital at a time, and staggered their rota to decrease the exposure risk. Also those trainees who have been deployed in COVID emergency / screening facilities and ICUs go for a period of isolation after a couple of weeks of duty. This extra time that we find for ourselves can be used to refresh our knowledge and equip ourselves for the time to come. Taking up online courses on research writing, analyses, illustrations, and communication skills could be nice additions to our portfolios.

  4. Refreshing the existing knowledge on anatomy and various surgical techniques, keeping a tab with newer advances and learning new professional skills would help us be better prepared to hit the ground once we put the blip behind.

The ways the situation can be best managed will continue to evolve at every stage. Even though the surgical bit of our training seems to suffer at the moment, we will emerge out with a broader and deeper experience. The changes are certainly an opportunity to pave new paths that we will follow tomorrow.


References:

1.         Liu Z, Han B, Jiang R, Huang Y, Ma C, Wen J, Zhang T, Wang Y, Chen H, Ma Y. Mental health status of doctors and nurses during COVID-19 epidemic in China. Available at SSRN 3551329. 2020 Mar 4.

2.         Wang Z, Wang W, Bai T, Di M, Zan T, Gu B, Li S, Li Q. Our Experiences on Plastic and Reconstructive Surgery Procedures during COVID-19 Pandemic from Shanghai Ninth People’s Hospital. Plastic and Reconstructive Surgery–Global Open. 2020 Apr 14.

3.         Hourston GJM. The impact of despecialisation and redeployment on surgical training in the midst of the COVID-19 pandemic. Int J Surg. 2020 Jun;78:1–2.

4.         Kamali P, van Paridon MW, Ibrahim AM, Paul MA, Winters HA, Martinot-Duquennoy V, Noah EM, Pallua N, Lin SJ. Plastic surgery training worldwide: part 1. The United States and Europe. Plastic and Reconstructive Surgery Global Open. 2016 Mar;4(3).

5.         Servick K, Cho A, Couzin-Frankel J, Guglielmi G. Coronavirus disruptions reverberate through research. Science. 2020 Mar 20;367(6484):1289–90.

6.         (13) Report: COVID-19 impact on global scientific community [Internet]. ResearchGate. [cited 2020 Apr 22]. Available from: https://www.researchgate.net/institution/ResearchGate/post/5e81f09ad785cf1ab1562183_Report_COVID-19_impact_on_global_scientific_community

7.         Yanyu J, Xi Y, Huiqi T, Bangjiang F, Bin L, Yabin G, Xin M, Junhua Z, Zhitao Y, Xiaoyun C, Changsheng D. Meditation-based interventions might be helpful for coping with the Coronavirus disease 2019 (COVID-19).

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