The COVID-19 outbreak is an unprecedented challenge with ripple impacts throughout health care systems globally. During this study, conducted during the peak of the pandemic in Saudi Arabia, we sought to determine how COVID-19 has disrupted the practice of otolaryngology residency training programs and affected trainee residents’ learning curve, especially in clinical and surgical skills.
To the best of our knowledge, this is the first nationwide survey providing insights into the impact of COVID-19 on otolaryngology residency training programs, which have been hard hit by the emergency pandemic period. In this study, participants reported a large magnitude in Cohen’s d effect size in some of their training activities, such as outpatient clinics, elective operations, consultations, and their working hours. These significant deficiencies have to be considered to ensure that the residents are given the optimum qualified training that they require.
Among physicians, otolaryngologists have been one of the most affected groups during this global pandemic. Moreover, they have been recorded as having the highest proportion of contagion spread due to the nature of their work as they have the closest contact with the upper respiratory tract mucosa where the high viral load exists.6-9 In addition, patients with COVID-19 may present with symptoms mimicking those that appear in patients who are seeking medical advice about the ear, nose, and throat (ENT) region, which also puts otolaryngologists at high risk compared to other specialties.9 Accordingly, urgent measures were implemented in order to minimize the transmission of COVID-19 in health care settings, which included reducing specialist clinics, outpatient procedures, and the use of operating theatres. In response, telemedicine has been implemented in the majority of hospitals, allowing face-to-face consultations to be cancelled and replaced by telephone consultations and virtual clinics. Moreover, all non-urgent cases should have been postponed, as per the European Rhinology Society’s recommendations, as should all elective surgery cases that did not require immediate intervention, with priority reserved for oncology and obstructive airway cases.10 Likewise, outpatient procedures were stratified by urgency. Importantly, in such cases, crucial personal protective equipment (PPE), such as N95 masks, fluid resistant gloves and gowns, goggles/face shields must be worn. Furthermore, adequate PPE should be provided by hospitals to handle this crisis, with all trainee residents trained in the proper usage of this equipment. Taken together, these precautions will maximize the residents’ protection from the COVID-19 risks, including the physical and psychological aspects.11 At the same time, this will affect the practice of residents as well as their mental health, as elective cases have been suspended and residency examinations delayed, which will surely have a stressful impact on training residents.12
Despite all those issues residents were facing because of this pandemic, the training residency program continued. For this reason, Saudi board program members have discussed changes to national health care systems and the impact on otolaryngology residents to initiate a new plan for their residents in response to the COVID-19 pandemic to ensure their safety and provide maximum clinical practice.13
A slowdown of the learning curve for residents was inevitable, so residency teaching switched to online learning and attempts to maintain training were applied through online smart-learning circuits, webinars, and video calls. Based on the different central tendency statistics of trainees’ attitudes’ item scores, our study reported satisfaction with the residents’ academic development among the different resident levels. In general, R5 level residents were found to have the highest satisfaction mean scores toward their training activities, which can be explained by their seniority and years of experience.
In addition to the activities and attitude effects, as a new disease with limited information about its characteristics, COVID-19 has had a significant impact on residents' physical and mental health.14 Currently, few studies have been conducted on mental health among residents during this crisis. In our study, we used GAD-7 scores to measure otolaryngology residents’ anxiety; we found that around half of the residents were understandably anxious. However, their anxiety was not immoderate in terms of its intensity, frequency, or ability to control it. Overall, there was no difference between trainees who covered the frontline service against the pandemic or trainees who remained in their duties with regard to the severity or the characteristics of these worries. Yet, the current pandemic and changes in work plans will no doubt contribute to residents’ burnout.15 During the crisis, it is important to offer psychological counseling for trainees to cope with the situation.16
Residency training programs are facing the same crisis with an overall reduction in their activities and increase in stress and concerns. It was clear from our results that the highest concern level is the absence of a clear training rotation plan because of the unexpected appearance of this pandemic. Nevertheless, there were no differences in the other types of concern except in that of personal experience, which showed a high level in some training levels, such as R2 and R4, while R3 and R5 residents showed a low level of concern, which was controversial. Although we have dedicated our careers to otolaryngology surgery, in times of need, otolaryngologists have played a role in serving society and public health.
As with all studies involving surveys from volunteers, selection bias is hard to avoid and may not necessarily represent the majority opinions of every trainee resident around the world. To help overcome these limitations, private social media networks were utilized specifically targeting otolaryngology residents to participate in the surveys. Other drawbacks include the absence of objective indicators, for example, log books and details about surgical skills, as otolaryngology is a surgical specialty. Accordingly, further studies are needed to elucidate the effects of other variable factors.