Our study showed a negative impact of COVID-19 pandemic on the clinical and surgical training of the participants, with increased anxiety (100%) and depression among them (77%). Most respondents reported significant reduction of patient flow during outpatient consultations (96%) and elective surgeries attendance (88.5%), during the pandemic. Implementation of didactic teaching programs based on theoretical courses with clinical case discussion sessions via teleconferences was reported by only 42% of respondents. Unfortunately, no measures have been taken by the different surgical specialty colleges to improve the psychomotor aspect of training.
Many studies go in line with our findings, showing the negative impact of the pandemic on surgical training across all specialties [2,3,4]. Through a cross-sectional survey in the UK and Republic of Ireland, including 810 completed responses, only 9% of surgical trainees reported that they would definitely meet all required competencies during the pandemic [5]. The reduction of outpatient consultations and complete suspension of elective non-oncologic surgery and endoscopy significantly reduced the training opportunities during that period.
Teleconferences and webinars have been developed during the pandemic to continue clinical education. Reciprocal teaching conferences with interaction between different institutions were useful tools. Virtual meeting multimedia such as Zoom®, Google Meet® and GoToMeeting® was useful to implement didactic clinical education sessions, including case discussions, guidelines updates, new article lectures, etc [6]...
Chick et al. [7] have reported the usefulness of social media by creating a closed Facebook group to provide daily practice questions for board exam preparation and discuss surgical topics without a requiring in-person meetings.
Flipped virtual classroom has proven beneficial for continuing education during the pandemic. Didactic material in the form of prerecorded video is provided to learners who can watch during any free time before the conference. The latter aims to synthesis, application and case-based discussion [6,8]. It has been widely demonstrated that this active pedagogic technique is preferred by trainees [9] and among our respondents.
Traditionally, surgical training has been based on an apprenticeship model [10]. Since the advent of laparoscopy and minimally invasive surgery, other techniques have been implemented to learn surgical skills based on simulation. The latter ranges from the basic table-top box trainer to simulators combining simulation-based training and digital tools. Incorporating simulation-based training within the academic surgical curriculum has been highlighted in literature and shown to translate into improvements in surgical performance with superiority over traditional models [11,12,13].
Medical simulation has experienced a considerable boom. Touch surgery (TS) is a free interactive surgery simulator application on iOS that uses a touch screen interface. This program aims to teach and test operative procedures step-by-step in a realistic surgical environment using three-dimensional (3D) graphics. TS provides easy navigation of surgical procedures in a vast amount of specialties. The user can access a "tutorial" module then take a "test" module to assess his understanding of the component steps and techniques. Tulip et al. [14] have shown great satisfaction in trainees with this training tool. Several studies have proven the validity of this application to improve cognitive surgical skills which may allow trainees to focus more on the psychomotor aspects of surgery [14,15]. However, direct transfer to operating room efficiency should be confirmed by further studies.
Recently, a new wave of digital technologies has emerged including, Virtual Reality (VR) and Augmented Reality (AR). VR can be a partial or a full. The latter requires three components: a computer for interactive 3D visualization, a head-mounted display and controllers equipped with position trackers. Haptic feedback through handheld controllers provides a more realistic environment [16]. AR combines VR with a 3D real environment specific to individual patient providing a “live view” in the real world [17].
VR/AR simulation is a flexible tool that allows trainees to learn basic skills in a secure and controlled environment with regular feedback. Furthermore, training programs with specific goals can be designed and proposed to novice trainees before performing in the operating theatre. Numerous specialties have incorporated VR simulation into resident training programs in recent years, particularly orthopedic surgery (TraumaVison®, OssoVR®), neurosurgery (Immersive Touch®) [18], laparoscopy (LAP Mentor®) [17], plastic surgery and endoscopy. A Cochrane systematic review has demonstrated that VR simulation training is advantageous over no training and can supplement conventional endoscopy training [19]. In addition, VR simulation seems to reduce real-life error rates through skill acquisition and improve patient safety [20].
Digital simulation training should be used through programs with clear goals and prompt instructions. Supervision, surgical skills assessment based on appropriate scoring systems and feedback are mandatory to achieve the targeted competence.
The main drawbacks of using digital technologies are the difficulty and cost of creating high-fidelity virtual reality environments, especially in resource-limited countries like Tunisia. Unfortunately, there are few published literature evaluating simulation-based training in low-income countries [13]. We believe that the use of simulators for surgical training in our country is very limited because of logistical and financial shortages.
Interestingly, some experiences of academic collaboration between African countries and international institutions assured the implementation of simulation-based laparoscopic training programs using low-cost simulator models with promising results [13,21]. For example, Tenwek Hospital in Kenya presented to 10 general surgery residents a laparoscopic skills curriculum created and validated at the University of Kentucky (USA). Simulation materials and curriculum were purchased for 50 USD/participant. At the end of the curriculum, a significant improvement in performance has been shown [21].
To improve surgical training during residency in Tunisia, we propose some measures: First, medical universities should promote simulation-based training and provide low-cost trainer boxes as much as possible. Simulation-based programs should be designed and implemented with a referent mentor in each specialty, clear goals, assessment and feedback. These programs should be integrated in the academic surgical curriculum. Collaboration between Tunisian and international institutions should be encouraged to provide low-cost trainers and facilitate low-cost access to international simulation-training programs. Second, medical universities should facilitate access to online surgical video libraries. Third, we encourage self-review of prerecorded surgical videos (laparoscopy, endoscopy) and discussion of learning points with mentor during periodic medical staff. Finally, we recommend that residents use the TS application which is free to install on smartphones via the Apple store or Google store, to prepare for their surgical intervention before attendance or practice in the operating theatre, especially for novice trainees.
Advantages Of The Study
This study is the first to evaluate the impact of COVID-19 pandemic on training in Tunisian surgical residents. The authors proposed useful measures to improve surgical training during residency in resource-limited countries such as Tunisia.
Limitations Of The Study
The study was monocentric, and the sample was relatively limited in number. In addition, the majority of respondents were in the first two years of training which may influence the perception of the impact of the pandemic on their training.