1. Staffing, safety and clinical service organization (resident safety, emotional and psychological integrity amid COVID-19)
Nine documents have reported on resident staffing and safety amid COVID-19(6, 10-14, 16-18). Reorganizing residents staffing to ensure health and safety during the pandemics is a priority. Besides residents must be trained in infection prevention in a clinical setting including appropriate use of personal protective equipment (PPE) and personal hygiene(16, 20). This training can be conducted online via different virtual platforms(10, 11, 20). Many recommend creating social media platforms communications such as Twitter, Instagram, and Slack to keep residents and staff stay in communication with each other to ease fear and anxiety about the pandemic(16, 17). Crosby and Sharma on Otolaryngology residency training recommended virtual sessions for social connectedness to help residents suffering from the added mental tax of worrying about not only their own safety, but also for the safety of family, friends, colleagues, and patients(17). To preserve the workforce and minimize transmission of the virus among residents many residency programs have designed different innovative staffing mechanisms. Most of the resident staffing techniques amid COVID-19 involves significantly reducing the number of residents staying in hospital by dividing them into two groups and rotating every 1-2 weeks. One group involved in clinical service(active inpatient or on service group) and the other group will stay at home remotely providing tele supervision, consultation, and arrange different virtual teaching programs(6, 11-13, 16-18). Naser et al reported experience of restructuring of general surgery residents during pandemics into three exclusive groups (inpatient, operative, and clinic) rotating weekly to practice appropriate physical distancing and reduce the possibility of transmission among residents (14).
2. Resident clinical education (Morning, case presentations, bedsides, round, seminars (management session), journal club)
Few residency programs suspend resident clinical teachings(10) while many residency training programs designed alternative innovative technologies to maintain resident clinical education during COVID-19 pandemic(6, 11, 13, 15-19). Bambakidis reported experience of neurosurgery at Cleveland Medical Center that one or two residents to be in place with patient discussion with the team by teleconference(11). Similarly, Schwartz et al recommended post-clinic virtual conference between attendings and on-service residents (video-enabled telemedicine) for clinical education(6). Ground round webinars live interactive virtual visiting professor sessions, virtual academic conference, case-based conferences and morning session webinar, journal club webinar, email-based clinical vignettes with associated questions and clinical images, virtual live or recorded conferences were being used for clinical education in a different residency program(8, 13, 15-19). In these different virtual teachings used in different residency programs, many recommended using different mechanisms such as using tools that promote interaction and audience participation, using the platform in which users can submit questions through a live chat function to decrease participant talk-over and allows for a more fluid presentation(7, 16)
3. Resident surgical education (Hands-on training).
The shutdown of elective surgeries caused a significant decrease in the amount of time in the operating room which will not be replaced by simple academic conferences and telehealth. Many residency programs had instituted alternative surgical teaching methods during COVID-19(6, 8, 10, 11, 13, 17, 19). For example, Stambough et al reported on orthopedic surgical education by using surgical video databases, such as the Orthopedic Video Theater (OVT) and Orthopedic Video Theater plus (OVT plus), cadaver and bone-substitute simulations(10). Tomlinson reported Neurosurgical Atlas and 3D models and web-based simulations as innovative neurosurgical hands-on training amid COVID-19 at the University of Rochester Medical Center, New York(8). Neurosurgical Atlas is a free, online, multimedia resource focused on operative techniques and microsurgical anatomy. Vargo et al reported on the experience of Cleveland Clinic on videoconference teaching of high-priority elective” robotic cases with intraoperative surgical principles for general urology residency program’s(13) Department of Orthopedics, Emory University School of Medicine are using virtual reality or simulation training for orthopedic surgical education. Surgical simulators and virtual reality (VR) platforms have been developed for total hip and total knee arthroplasty surgery(6). Tele mentoring of surgical procedures simulation, online training modules, skills labs, online practice questions and facilitated use of surgical videos were among other methods used for surgical education by different residency programs(7, 17, 19).
4. Resident didactic teaching(Lectures)
Nine of identified records reported on alternative virtual didactic residency education during COVID-19(6, 7, 10, 11, 13, 15-18). These virtual didactics include virtual lectures, journal clubs, flipped virtual classrooms, and teleconferences. The University of California uses novel methods of social-media-based Facebook platform group titled “ABSITE Daily,” to provide daily practice questions to prepare residents for the American Board of Surgery In-Training Examination (ABSITE). This platform not only allows for daily exposure to practice questions but also allows for another avenue of discussion of surgical topics without a requirement for in-person meetings(7).
5. Resident research activity.
Research has been suspended at many institutions with laboratory closures and IRB mandates to stop in-person participant visits during the pandemics. To overcome such factors, some residency programs are using alternative ways of continuing residency research programs (6, 16-18). Video enabled virtual research meetings and encouraging residents working from home (nonclinical resident) to develop research projects or Practice Quality Improvement (PQI) projects with faculty during off-work time is recommended. This can be done by video conference with their research mentor weekly to develop a plan. Southern Illinois University School of Medicine Otolaryngology Department is using such methods to maintain resident's research activity. They designed in a way that, at the end of each week, a virtual research meeting is held for all residents. One resident provides an in-depth update on their project and they review details of the research techniques and statistical analyses specific to that project(17). Four USA based radiology residency programs encourage trainees and their research mentors to have continued discussions regarding other projects able to be worked on during the pandemic, securing grant funding for future studies, and reshaping disrupted works-in-progress into publishable or presentable material so as not to lose value from the work already performed (18).
6. Accreditation process.
The pandemic is affecting the current accreditation process and will have an undue effect to get minimum case log or minimum activity volume (MAV) required to graduate and sit for board examinations(20). America Board of Orthopedic Surgery(ABOS) suspended all current accreditation process but states that graduation is left to the discretion of the program director(10). ABOS swiftly responded to the pandemic crisis by increasing the "time away" from residency training activities from 4 to 6 weeks per academic year to provide flexibility and also stressed that program directors to work to make sure residents meet Accreditation Council for Graduate Medical Education (ACGME) minimum case requirements necessary to graduate and sit for board examinations(10, 20). As of March 9, ACGME has also decided to indefinitely postpone all scheduled and requested accreditation site visits(20). The American Board of Radiology (ABR) has postponed the board certification exam until at least September 1, 2020 (21). Delayed graduation and credentialing might impact subsequent start time for incoming residents. Radiology and Otolaryngology residency programs in the USA suggested minimum requirement for graduation, using additional didactic sessions to fulfill the requirements and closely working with accreditation bodies and with their local clinical competency committee to solve the problems(16-18).