Perspectives of Residency Training Amid The COVID-19 Pandemic: Impact on Mental Health and Training

COVID-19 has affected the training programs and the clinical schedules of surgical wards in many countries, including Iran. Also, the continuous involvement with COVID-19 patients has caused stress in health care workers; among them residents are on the frontlines of care delivery. Therefore, we designed a study to assess mental effects of these circumstances, and the effects on General Surgery and Obstetrics & Gynecology residency training. Methods We used a questionnaire consisting of 47 questions about personal, familial and demographic characteristics; training activities, and mental effects of COVID-19.


Introduction
COVID-19 conditions have affected people emotionally all over the world; emotional consequences derived from these circumstances have been termed as "Coronaphobia" [1]. Health care workers continuous challenge in the frontline of the anti-COVID battle put them at higher risk [2]. A systematic review by Muller et al [3] about health care workers during the pandemic showed sleep disturbance, depression, anxiety, and distress.
Considering the direct and rst line contact of residents with COVID-19 patients, the situation could impose emotional disruptions on them. Therefore, we carried out a study to investigate the effects of dealing with COVID-19 cases on the mental health of the residents of General Surgery (GS) and Obstetrics and Gynecology (OG) in Tehran University of Medical Sciences (TUMS), and the impact on their work and education as perceived by the residents.

Materials And Methods
The study protocol was approved by the Deputy of research of TUMS (Code 99-2-100-48539), and the ethical approval was issued by the Ethics Committee of TUMS (Code: IR.TUMS.VCR.REC.1399.499). All methods were carried out in accordance with relevant guidelines and regulations.
A researcher-made questionnaire was handed to all the residents of GS and OG of TUMS. The questionnaire included 15 questions about personal, familial and demographic characteristics; 10 questions about the conditions of the residency activities and training as well as the provided hygienic facilities; 10 questions about the mental effects of COVID-19 based on the validated questionnaire of Khodabakhshi et al [4] and the study of Abdessater et al [5]; and 12 questions from the short General Health Questionnaire (GHQ-12) which has previously been validated in Iran [6,7]. Residents were requested to answer the last 12 questions by considering the changes they felt in each item due to the COVID-19 conditions. According to the standard GHQ-12, these consisted of 6 positive questions, for example enjoying daily activities; and 6 negative questions, like feeling sad or depressed. We used the 4point Likert scale to rate the answers. In positive questions, the a, b, c and d choices in the answers were rated 3, 2, 1, and 0, respectively. In negative answers the sequence was reversed, so that choice a got zero and choice d was scored as 3. Therefore, the highest score would be 36. According to Yaghubi et al [7], a cut-off point of 15 was de ned (maximum speci city score of 95.8%), where scores less than 15 were considered healthy, and scores above 15 indicated disturbed COVID-related mental health status (CMH).
We used mean ± standard deviation (SD) to describe quantitative variables, and frequency (percent) to describe qualitative variables. The Chi-square test was used for assessment of the association of quantitative variables with CMH, and logistic regression was used to nd variables that affected CMH. The signi cance level was considered p < 0.05 for all analyzes. All statistical tests were performed by SPSS 26.

Results
Among the 200 distributed questionnaires, 127 were recruited; showing an answer rate of around 63.5%. Table 1 shows the demographic and personal features, past history and COVID-19 history of the residents.

Discussion
We performed a study to investigate the conditions of residency training as well as the CMH of GS and OG residents during the COVID-19 pandemic, and nd out a high level of changes in both training and mental health status. To our knowledge, no similar study has been performed about residents in Iran, and studies in other countries have not considered training conditions and mental health status of residents as we did. However, several studies about effects of the pandemic on residency training have been performed in different countries. Brito et al [8] investigated the status of OG residents in Brazil, and found that nearly a third were assigned to activities not related to their eld of study, around a quarter complained about defective supplies of PPE, and a third had not got instructed about the management of COVID-19 cases. Bitonti et al [9] studied 476 OG residents in Italy and found out that around 6% had tested positive for COVID-19, only 80% had been instructed about preventive protocols, and nearly half had been provided with adequate PPE. Aziz et al [10] studied 1102 GS residents in the USA and detected a signi cant negative impact on surgical training of the residents, who also were worried about contracting the disease by themselves or their family. He et al [11] examined the concerns of GS residents about the pandemic in USA, and detected that they were worried about getting COVID-19, transferring the disease to their family or to the patients. Collins et al [12] surveyed residents of GS and plastic surgery in USA regarding anxiety at time of COVID-19. They found that residents were worried about their training, but also had signi cant anxiety about their family and self-health. Osama et al [13] assessed the subject in 112 surgery residents of a tertiary care hospital in Pakistan, a high percentage of whom reported impaired surgical training during the pandemic. Their next concern was about their family health, and then fear of death from COVID-19.
Except for the assessment of the worries and anxiety of residents about their health and that of their family, or about defective training, none of these studies examined the mental health status of the residents during COVID-19 by validated methods. However, use of GHQ-12 gave standard results in our study, con rming high levels of stress and emotional affection in the residents.
All the investigations in other countries showed a decrease of training opportunities, which is fairly expected in the COVID-19 era and similar results were driven from ours. Emotional consequences or Coronaphobia was very prevalent in our small population of GS and OG residents.

Conclusion
Our study shows the negative impact of COVID-19 on the mental health and on the training of residents.
We recommend serious planning in order to provide adequate emotional support for residents during the present circumstances, and suitable arrangements by the academic staff to compensate for the current de cit in residency training.

Declarations Ethical Considerations
The study received ethical approval from the Ethics Committee of TUMS (Ethics CODE: IR.TUMS.VCR.REC.1399.499), and informed consent forms were handed to the residents with the questionnaires and signed by them.

Con ict of Interest
The authors have no con ict of interest to declare.

Funding
This study was not supported by any funding.

Consent for publication
All the authors consent to the publication of this article in BMC Medical Education.
Availability of data and materials Data and materials are in SPSS format and are in possession of the authors; they are available by request from the corresponding author at sadafalipour@yahoo.com.