This study was performed with prior consideration from the Internal Ethics Review Board as well as Science committee, and was performed in accordance to institutional regulations which are in accordance to national regulations established in the “Ley Mexicana General de Salud en Materia de Investigación, Artículo 17” (Mexican General Health Law) and abides by the norms established in the Declaration of Helsinki of 1964 as well as its revision in 2012. All surveyed participants agreed to the recollection of their data and signed an informed consent. Within the explanation of the study, it was clearly expressed that their participation or decline would have no effect on their grades or treat from the researchers.
The term “burnout” was first introduced in 1974.12 Maslach later defined burnout as a psychological syndrome involving emotional exhaustion, depersonalization, and a diminished sense of personal accomplishment that occurred among various professionals who work with other people in challenging situations.13 The Maslach Burnout Inventory (MBI) is the most commonly used instrument for measuring burnout.14 The MBI captures three dimensions of burnout: emotional exhaustion (EE), depersonalization (DP), and personal accomplishment (PA). The MBI has demonstrated in literature to be an excellent research tool to evaluate Burnout.15, 16
The undergraduate surgical clerkship department constantly collects consenting student’s data for continuous academic improvement and student wellbeing. This is completely optional and students who decline to participate face no consequence or point deduction. Baseline Maslach Scores are obtained at the start of every rotation, and surveys are reapplied every 6 weeks. Gathered student data include age, gender, alcohol and tobacco consumption, whether they are local, out of state or international students, average amount dedicated to studying, hospital and leisure activities and cohabitants. The order of their rotations is also registered. Clinical data gathered includes the amount and type of patients seen in the outpatient clinic, as well as how many surgeries they participated in, type of surgery and various other clinical activities. Academic data includes midterm and final exam scores as well as their performance in weekly tests, class attendance, workshop attendance and case simulation scores. Midterm and Final exams are heavily clinically focused and seek to assess student’s diagnostic and therapeutic capabilities. These assessments tend to be different for every rotation by modifying variables such as patient data, grammar, shuffling answer options and rephrasing each question. Learning objectives, difficulty allocation and topic distribution have been conserved through exams. Difficulty is measured by historic percentage of wrong and right answers, Blackboard’s own differential index and by our own metric on the amount of knowledge integration steps required to answer each question. This data has been gathered for over 5 years, totaling a data pool of over 500 students.
Prior to their first ever clinical rotation, consenting fifth-year students (MS3 US Equivalent) assigned to the surgical clerkship were surveyed prior to their beginning using Maslach’s Burnout Inventory (MBI) amongst other data items. These students form Group 1 (n=47). Following a baseline evaluation at the beginning of the study, Group 1 was surveyed again at 1 and 3 months follow-up. Additionally to the MBI, students were asked to answer a simple survey regarding their interest in surgery as a career path at the beginning and after their rotation ended. Pooled data from Group 1 was compared to pooled data from historical, previous fifth-year medical students (traditional face-to-face learning) during their first clinical rotation assigned to the surgical clerkship whose rotations were not affected by the current Covid-19 pandemic (Group 2 (historical control)) made up by 42 students, in an attempt to compare burnout rates as well as academic performance, as seen in figure 1.
Group 1 was the first to participate in our institution’s hybrid teaching model, in which clinical activities were reinstated partially in order to abide local sanitary regulations and to protect students from unnecessary contagion risk. The latter done under the premise of achieving maximum clinical training exposure. Group 1 attended two institutions, one public and one private as part of their normal training in university hospitals, both designated as Covid free, thus minimizing the risk of exposure.
Students on Group 1 were assigned on a Q4 on-call schedule. Those on-call attended the hospital, while those off-call students participated in online activities. During their ~12-hour calls, students were able to participate in surgeries of patients with negative SARS-CoV-2 PCR results. They were also involved in Emergency Department patient evaluation as well as preoperative and postoperative care when deemed safe. Students off-call participated in various online lectures, cases and grand rounds. Group 1 students, whether physically or via telecom attended grand rounds from 7:00 to 8:30 hrs., afterwards, attended fellowship lectures, journal clubs and academic lectures from 11:00 to 13:00 hrs., followed by interactive online surgical cases with expert physicians from 13:00 to 15:00 hrs. with alternating simulated handoffs every other day, all in which the main protagonist was the student. These sessions were followed by dynamic and interactive activities (i.e. surgical imaging evaluation, identifying key images and performing radiological dictation) watching surgical videos, identifying critical procedural steps as well as anatomical landmarks and performing postoperative notes. In total, Group 1 totaled ~7 hours of online “clinical” experience per day, while on-call students achieved 12 hours of clinical exposure per day. On average, Group 1 students achieved ~50 hybrid hours per week. Surveys were reapplied after one and three months of their surgical rotations.
Group 2 (historical control), involved daily clinical attendance and a Q3 on-call schedule, in which students spent over ~70 hours per week in a clinical setting, and per requisite to obtain a passing grade, participated in over 30 surgical procedures. These lower limit requirements were dropped for Group 1 by both a decrease in elective surgical procedures and to safeguard students.
For Group 2 (historical control), classes were held each Thursday at the same classroom from 08:00 to 14:00 hrs., with two 1-hour breaks scheduled by the attending professor’s convenience. For Group 1, classes were held remotely every Thursday for the same time length through online platforms. Clinical performance evaluations were modified, with minimum procedure attendance cut out entirely. Academic curriculum and requirements were unaltered for the entirety of the study.
Academic performance was assessed with a midterm exam amid the 7th week and a final exam on the 12th week. The exam consisted of a 0 to 100 scale with a passing score of 70 and number of questions, complexity level (as reported by the testing platform’s question-answer analysis) and subject allotment were not changed between groups. Exam’s questions had equal distribution of content, level of difficulty and were based primarily on clinical cases. Only modifications in clinical scenario variables such as patients’ gender, age, time of presentation as well as adding or subtracting non relevant details to avoid plagiarism were done. Students were offered a review session one week prior to the midterm exam, which was given by the same teacher utilizing the same slides. Our academic plan for the 12th week rotation and a sample weekly schedule are displayed in supplementary tables 1 & 2.
Statistical analysis was performed using SPSS v25 (IBM Corp, NY, US). Normality testing was performed through Kolmogorov-Smirnov. T-Student and ANOVA were used for parametric and Mann-Whitney-U and Kruskall Wallis for nonparametric testing. Chi-Square and Fisher’s exact test were employed to compare frequencies.