key: cord-326657-zzvmj5qy
authors: James, Dr Hannah K.; Pattison, Mr Giles T.R.
title: Disruption to surgical training during Covid-19 in the United States, United Kingdom, Canada and Australasia: a rapid review of impact and mitigation efforts
date: 2020-06-25
journal: J Surg Educ
DOI: 10.1016/j.jsurg.2020.06.020
sha: 
doc_id: 326657
cord_uid: zzvmj5qy

The global Covid-19 pandemic has the potential to lead to significant training disruptions affecting surgical residents across all specialties. There has been lively social media discussion about the impact of cancelled training activities under the twitter hashtag #NoTrainingTodayNoSurgeonsTomorrow. We present a rapid scoping review synthesising the current evidence of pandemic-related impact on surgical training in the United States, United Kingdom, Canada, Australia and New Zealand. We describe and compare strategies that have been put in place to mitigate disruption, and reflect on how the challenges of the pandemic may present the opportunity to improve on how we select, assess and train surgeons in the future.

The Covid-19 pandemic caused by the novel zoonotic coronavirus 'SARS-Cov-2' is currently wreaking medical(1), social (2) and economic (3) havoc across the globe. The published academic literature of the impact of covid-19 has justifiably concentrated on the global scientific and clinical efforts to address the many threats of the pandemic(4, 5) . No facet of healthcare systems have been untouched by the disruption and this includes postgraduate surgical training, the impact on which has received minimal attention so far.

As surgical educators we are facing a uniquely challenging set of circumstances in delivering effective training, assessment and selection. Healthcare and education systems share a complex interdependent relationship where a delicate balance exists between population needs, health-system demands for professionals and supply of qualified individuals from education programs (6) .

As the output from our residency schemes are the future global surgical workforce, it is important to consider the effect of the pandemic on the training of postgraduate surgical residents both in the short and long term.

Selection into training, assessment and progression within residency schemes must continue to be robust despite the adverse circumstances, to ensure a continued supply of suitably competent surgeons.

Surgical training bodies have recently faced the considerable and unenviable challenge of having to rapidly mobilise the surgical resident workforce to augment the frontline clinical staffing response, whilst simultaneously safeguarding trainees and minimising disruption to established training systems.

The impact of the pandemic has the potential to lead to significant training disruptions affecting all resident levels and surgical specialties. The aim of this review is to synthesise the current evidence of pandemic-related impact on surgical training internationally and describe strategies that have been put in place to mitigate disruption.

A rapid scoping review was undertaken of the publically available published pandemic-related web literature from the surgical training bodies of five large English-speaking countries; United States(7), United Kingdom(8-10), Canada(11), Australia and New Zealand (Australasia)(12). Recent press releases, position statements and correspondence from the major training bodies were hand searched (last accessed 09 June 2020). A rapid review method was chosen to deliver a timely evidence synthesis within a quickly evolving situation. By mid-April 2020, three months after the director general of the World Health Organisation declared a public health emergency of international concern(13), most surgical training organisations had communicated or published their respective mitigation strategies. This time point in the pandemic was therefore considered optimum to deliver this review.

The differences in resident numbers, pandemic epidemiology and status of elective surgical activity by country is summarised in table 1. The US has by far the largest number of active surgical residents (14) and also the largest Covid-19 burden(15).

Non-urgent elective surgical activity, a key source of training opportunity for residents, has been entirely stopped in the UK for a minimum of three months (16) . The American College of Surgeons (17) and Ministry of Health (18) has recommended reduction of elective surgical activity in the US and Canada respectively, but this mandate is to be implemented regionally based on local healthcare need. Australia and New Zealand (19) , with the smallest Covid-19 disease burden(15) of the included countries, is the first to reopen elective surgical services, in a phased manner from early May 2020.

The current surgical training operational status and mitigation measures by country are presented against five key domains of activity; 1) recruitment and selection into residency programmes, 2) board examinations, 3) assessment, progression and certification within residency, 4) resident operating privileges and 5) didactics (table 2) .

Recruitment and selection are pressing ahead for the 2020 residency intake in all reviewed countries (20-23). In the US, residents may start their placements early without any fear of redress from contract breach(20). In the UK, the pandemic hit part way through the specialist training recruitment cycle, which forced training bodies to rapidly rewrite the rulebook on selection procedures(21). This has been streamlined to involve matching residents based solely on self-assessment scores submitted as part of the application, which is a minority part of the usual National interview-based selection process.

Canada will be conducting interviews by videoconference for second iteration interviews(20). Australasia will be piloting currently undisclosed non face-toface recruitment methods for the 2021 residency selection process (23) . The 2020 US residency match was completed relatively uneventfully(20). (31) . In the UK(32) and Australasia (23) , speciality training boards are considering issues of lost-training opportunity on a case-by-case basis. If training extensions are required, these will be non-punitive and the maximum time to complete training will be extended.

No statements on resident operating privileges during the pandemic were found for any country. In the US, there is a recent report of an emergently reconfigured surgical residency program (33) , which has been skilfully designed to maximise training opportunity, including OR time, and minimize risk to residents. The American Board of Surgery has said they will accept a 10% reduction in logbook numbers for the 2019-20 training year in recognition of the difficulties residents may have in accessing the OR (29) .

Face-to-face didactics such as courses and conferences have been widely postponed across the included countries until at least September 2020 (23, 34) . Curricular teaching provision is being made available using webinars or remote conferencing technology, and appears to be locally driven by individual training programmes. In the UK, the Royal College of Surgeons virtual learning environment resources have been made open access during the pandemic to facilitate e-learning (35) . The American College of Surgeons has recommended that programmes document their didactic provision during the pandemic (36) .

Surgical residency in the included countries remains largely time based rather than competency based (37) , with the notable exception of Canada(11) who have a thriving portfolio of competency based residency programmes (38) .

Assessment for progression in time-based models of training is highly dependent on exposure to, and performance of, a prescribed 'minimum indicative' number of surgical procedures during residency training(39).

Surgical residents may be particularly badly affected by pandemic related service reconfiguration as compared to their medical counterparts, as many of the required competencies for surgery can only be obtained in the elective setting. The widespread suspension of elective surgical services in the US, UK and Canada, and a rumoured unofficial moratorium on residents operating during the pandemic will inevitably jeopardise the attainment of competencies required for progression within surgical training programmes.

Despite widespread assurance(21, 40) that surgical training bodies do not wish to penalise residents for situations beyond their control, training extensions will be inevitable in a prolonged epidemic scenario. Clearly a balance needs to be struck between ensuring quality and maintaining progression without any imposed extensions being unduly burdensome. The introduction of a special covid-19 'no-fault' training extension outcome code for the Annual Review of Competence Progression assessment in the UK is a creative example of how the traditional stigma associated with training extensions can be avoided. It is anticipated that in the UK training extensions will be largely restricted to residents at critical progression points or at the very end of training(41). Accreditation bodies will need to demonstrate flexibility in how they sign off residents who are at the end of their training but who have been denied the opportunity to sit board examinations in the conventional timeframe. Whilst passing these exams continues to be a requirement for completing training in Canada(22), local mechanisms can be invoked to provide graduating residents with provisional licenses until they can be given the opportunity to sit examinations.

Similarly, recruitment into residency has had to continue to ensure an uninterrupted supply of doctors. The pandemic has exposed weaknesses in the recruitment systems in the UK, who have become suddenly reliant on using self-assessment scores alone to appoint new residents(21). The predictive validity of self-assessment from previous recruitment rounds has not been formally examined or reported, which has led to concerns amongst prospective UK surgical residents that selection may be unconsciously biased.

Canada (42) has managed to set up remote-interviews for prospective residents, and fortunately the US(20) and Australasian(23) resident recruitment rounds were largely complete before the onset of the pandemic and have hence been relatively unaffected.

The principle challenges for surgical education bodies in a rapidly evolving pandemic are to safeguard residents whilst minimising disruption to training in the short term and to continue to recruit, assess and certify residents to ensure the supply of high-calibre surgeons in the long term. The collective response to these challenges by the main surgical training bodies in the US, UK, Canada and Australasia has been agile and resident-centred.

Positive change in the postgraduate surgical education community may result from this difficult time. Perhaps the convenience of using webinar to deliver some aspects of didactic teaching in surgical residency will continue once life returns to normal. The pandemic has also exposed the continued reliance on time-based training, the weaknesses in existing recruitment systems and has brought the gift of opportunity to study the progress of the 'Covid cohort' of residents. This is certainly fertile ground for training systems improvements once the pandemic is over.

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 (42) Interviews being held remotely by videoconferencing.Incoming residents due to start in July 2020 as planned Aus/NZ Selection for 2021 entry to continue subject to further updates (23) Selection for 2021 entry will be subject to alternative, non-face-toface mechanisms 2. Board Examinations US May general surgery qualifying exam to be delivered virtually (28) Board eligibility to be extended for this exam diet and will not be counted as a missed exam opportunity. Disrupted candidates to be given advance priority to schedule for 2021 UK All examinations cancelled until November 2020 (45) All cancelled bookings to be honoured at next available examination diet.Guidance awaited on impact of cancelled exams on residency progression or appointability Canada Spring 2020 exams postponed until September 2020(22).Oral exam not required for delayed spring 2020 cohort. Failure at delayed exam will not exhaust a sitting attempt. Test sites will be expanded so less travel is required. Test sites will adhere to current social distancing and PPE protocols. Aus/NZ All examinations postponed until midseptember to end-november (27) Candidates will be provided with a minimum of 3 months notice when a decision to reinstate exams has been made ARCP priority given to trainees who need to revalidate or at a critical progression point. A more flexible approach to the available workplace based assessments will be taken. New 'outcome 10' metric for pandemic-related training extensions Canada Provincial regulatory authorities will invoke mechanisms to provide graduating residents with provisional/temporary/restricted licences to practice(22)Residents will be credited for redeployment time.Residents should not be required to extend training as a result of redeployment (31) Aus/NZ Surgical logbooks and competency assessments should be used to judge progress against curricula (23) Speciality training boards to consider issues of lost training opportunity in judging progress on a case-by-case basis. Should an extension to training be required, the maximum time to complete training will also be extended (23) (23) Webinar programme available from RACS website (23) 
