key: cord-344682-4vpm7m1h authors: Ellison, E Christopher; Spanknebel, Kathryn; Stain, Steven C.; Shabahang, Mohsen M.; Mathews, Jeffrey B.; Debas, Haile T.; Nagler, Alisa; Blair, Patrice Gabler; Eberlein, Timothy J.; Farmer, Diana L.; Sloane, Richard; Britt, L.D.; Sachdeva, Ajit K. title: Impact of the COVID-19 Pandemic on Surgical Training and Learner Well-Being: Report of a Survey of General Surgery and Other Surgical Specialty Educators date: 2020-09-12 journal: J Am Coll Surg DOI: 10.1016/j.jamcollsurg.2020.08.766 sha: doc_id: 344682 cord_uid: 4vpm7m1h BACKGROUND: The COVID-19 pandemic disrupted the delivery of surgical services. The purpose of this communication is to report the impact of the pandemic on surgical training and learner wellbeing and to document adaptations made by surgery departments. STUDY DESIGN: A 37-item survey was distributed to educational leaders in general surgery and other surgical specialty training programs. It included both closed- and open-ended questions and the self-reported stages of GME during the COVID-19 pandemic as defined by the Accreditation Council for Graduate Medical Education (ACGME). Statistical associations for items with Stage were assessed using categorical analysis. RESULTS: The response rate was 21% (472/2,196). U.S. Stage distribution (n=447) was Stage 1 22%, Stage 2 48%, Stage 3 30%. Impact on clinical education significantly increased by Stage with severe reductions in non-emergency operations (73%and 86% vs.98%) and emergency operations (8% and 16% vs. 34%). Variable effects were reported on minimal expected case numbers across all stages. Reductions were reported in outpatient experience (83%), in-hospital experience (70%), and outside rotations (57%). Increases in ICU rotations were reported with advancing stage (7%and 13%vs.37%). Severity of impact on didactic education increased with stage (14%and 30% vs.46%). Virtual conferences were adopted by 97% across all stages. Severity of impact on learner wellbeing increased by Stage: physical safety (6%and 9%vs.31%), physical health (0% and 7%vs.17%), emotional health (11% and 24%vs.42%). Regardless of stage most, but not all, made adaptations to support trainees’ wellbeing. CONCLUSION: The pandemic adversely impacted surgical training and wellbeing of learners across all surgical specialties proportional to increasing ACGME Stage. There is a need to develop education disaster plans, to support technical competency, and learner wellbeing. Careful assessment for program advancement will also be necessary. The experience during this pandemic shows that virtual learning and telemedicine will have significant impact on the future of surgical education. The COVID-19 pandemic has been inherently unique in that it affected our entire country and the global community. It impacted nearly all facets of daily life and work, including the need to drastically adjust healthcare systems, patient care, and healthcare delivery, (3) as well as health sciences education. (4) The need for medical professionals to rapidly respond to infection control and containment challenged by resource constraints, prioritization, and utilization have resulted in a drastic shift and reduction in hospital-and outpatient-associated clinical care across the country. This has called into question the breadth and scope of training and education of medical students, residents, and fellows, across all medical disciplines including the surgical specialties. (5, 6) Some argue that learners in procedural specialties may be at greatest risk to experience deficiency in training and skills acquisition. (7) Accrediting and certifying entities have emphasized the need for continuously maintaining quality, and programs have pivoted to alternative approaches to maintain the integrity of surgical training. (8, 9) Virtual technology has J o u r n a l P r e -p r o o f emerged as an important tool for delivering both patient care and educational curricular content. (10) Individual programs have shared strategies and practical tips focused on innovative education and training, the promotion of resident wellness, (11, 12) and creative interventions and flexibility necessary to successfully transition medical students and surgical residents to the next phase of their training. (13, 14) In response to the extensive and far-reaching challenges imposed on training programs and surgical educators during the COVID-19 pandemic, the American College of Surgeons Special Committee aims to support surgical educators by communicating shared experiences, emerging trends and innovations, and best practices to sustain themselves and their learners throughout the course of COVID-19 pandemic. It is also hoped that the work of this Special Committee of the ACS Academy will help in preparing for future disasters and support transformation of surgical training once the pandemic is over. The over-arching goal of the ACS Division of Education and the Academy's Special Committee is "to address challenges and opportunities relating to post-graduate surgical training during the COVID-19 pandemic." The Special Committee developed an electronic survey using the Survey Monkey, Inc (San Mateo, California) platform that was communicated to surgery chairs and program directors (PDs) and the Academy members using available email distribution The 37-item survey (15) was distributed to general surgery and other surgical specialty programs, on three occasions during a six-week period (General Surgery: April 24 -May 29, 2020) and an eight-week period (Other Surgical Specialties: May 4 -June 26, 2020). The survey to general surgery and related specialties was sent via list-serves to the Association of Program Directors in Surgery (APDS), the Society of Surgical Chairs (SSC) and program directors in pediatric surgery, surgical oncology, and thoracic surgery with their approval . The survey was also sent via list-serves to associations with their approval representing the other surgical specialties as listed in the acknowledgements. The survey was also sent to the Academy. Both closed-and open-ended questions were used to gather quantitative and qualitative information regarding the impact of the COVID-19 pandemic on surgical education and training. Further, the J o u r n a l P r e -p r o o f three-stage categorization of the pandemic's impact on clinical care and education, as defined by the Accreditation Council for Graduate Medical Education (ACGME) -"Stage" -was used in analysis of the data obtained through this survey. Respondents reported the Sponsoring Institution's (SI)ACGME Stage as either Stage 1: business as usual; Stage 2: increased but manageable clinical demand; or Stage 3: crossing a threshold beyond which the increase in volume and/or severity of illness creates an extraordinary circumstance where routine care education and delivery must be reconfigured to focus only on patient care. (16) Data collected via the online survey were exported for statistical analyses using SAS v9.4 (SAS Inc., Cary, NC). Given the variable email control of the majority of email distribution lists used, the ACGME 2018-2019 Data Book (17) was used as a reference to determine the absolute number of training programs which served as a surrogate for the total number of possible chair and PD respondents to determine survey response rates. Data provided a cross-sectional analysis of ACGME Stage by respondent and institution, and for a subset of key items and sub-items that assessed overall Impact (7 sub-items); Adaptive Steps (6 sub-items); Clinical Change (7 sub-items); Operative Volume (4 sub-items) and Operative Autonomy (4 sub-items). The impact on levels of learners was also reported. Responses were described using five-level ordinal Likert -type scale, ranging from extreme impact (5) to no impact (1), except for the binary (Yes/No) Clinical Change items. Responses were dichotomized for analysis as severe impact (5 or 4 on the Likert-type scale) or moderate or less impact (3,2,1 on the Likert-type scale). Learner levels were defined as Fellows, Chief Residents (CR), Senior Residents (SR) and Junior Residents (JR). ACGME-Stage, as previously described, was considered an ordinal variable. The location of the primary teaching institution was reported according to United States census regions and divisions. To evaluate the association of Stage with the analytic items, two types of analyses were conducted. First, correlational chi-square values were generated to explore the increase of threelevel Stage with an increase in the five-level Likert-type responses. Second, odds ratios (OR) with Stage 3 (Crossing a Threshold) used as a reference were generated using logistic regression to compare Stage 1 and Stage 2 with Stage 3. (16) Region was considered as an adjustment variable, but was determined to be highly confounded with Stage, and so is not presented here. Significance was defined as p<0.05. In addition to quantitative questions, open-ended questions were used to gather information on institutional efforts to "innovate in surgical education" and "support the wellness of learners" during the pandemic. Open-ended responses were coded and analyzed by two experienced qualitative researchers, and themes were identified. The overall survey response rate was 21% (472/2,196) as calculated using a derived total survey estimate from members of the APDS and the other surgical specialties included in the 1,836 programs from the ACGME 2018-19 Data Book , SSC ( n=187) and the Academy members (n=173). The final analytic dataset contained 472 responses and the total surveyed was determined to be 2,196. (Table 1) The response rate estimates for those indicating general surgery specialties and other surgical specialties were 25% (n=233/918) and 22% (n=239/1,105), respectively, whereas the response rate for the Academy was 45% (78/173). ( An initial analysis of the proportion of dichotomized severe impact responses from department chairs and PDs in programs with increasing ACGME Stage demonstrated no significant differences according to their role or discipline and were therefore pooled for subsequent analyses. More than half of the respondents (54%) had greater than 20 years of educational experience, 29% had 11-20 years of experience, and 17% had 10 or less years. Overwhelmingly, respondents indicated that their primary teaching hospitals were University or University Affiliated (89%) with a Level 1 Trauma Center (81%). Approximately two-thirds had a Safety Net Designation (61%), and greater than 500-bed capacity (65%). Almost 20% had an associated Children's Hospital. Of the total sample of 472 respondents, 447 reported Stage and U.S. region. There were 15 respondents from other locations: Canada 9, and 6 other locations outside the U.S. and 10 respondents who skipped the question on location of primary institution and Stage. The numbers of respondents were the same in the Northeast and Midwest (N=121, 27% for each), were highest in the South (N=140, 31%), and lowest in the Western (N=65, 15%) regions of the US. As shown in Figure 1 , reports of Stage 3 were most frequent in the Northeast region: Stage 1 8% (10/121), Stage 2 31% (38/121) and Stage 3 61% (73/121). As such, region was determined to be highly confounded with Stage. Importantly, the educational impact of the pandemic was considered to be the greatest on medical students (n=461, 78%) as compared to surgical trainees (n=462, 56%) and faculty (n=455, 40%). This report specifically focuses on surgical trainees. Not surprisingly, the volume of surgical procedures was severely reduced by the pandemic. Non-emergency operative experience was reported as being greatly reduced in 87% (354/405) across all stages. However, the reduction was significantly more severe with advancing Stage (73% and 86% vs. 98%). Emergency operative volume was affected less but was reported to be greatly reduced by 20% of the respondents and was also significantly associated with advancing Stage (8% and 16% vs. 34%). (Figure 2 ) Minimal Expected Program Operative Requirements, Autonomy, and Remediation (Table 2) J o u r n a l P r e -p r o o f Although a majority of respondents indicated that neither the program expectations for minimal operative requirements nor the progression to operative autonomy were severely affected, it is striking that minimal operative case expectations were reported as being severely impacted for trainees in the following categories : Fellows (30%), CR (30%), SR (44%) and JR (43%). These were not consistently related to stage. (Table 2 ) In addition, there was a severe negative impact on expected progression of operative autonomy across all stages reported by 14-18% of respondents. These were unrelated to stage with the exception of Fellows in lower stage programs who were reported to be impacted less than those at Stage 3. ( Table 2) Respondents believed that remediation was necessary for some trainees: Fellows 18% It is not known whether this was done in consultation with the program. This was most evident in programs with advancing ACGME Stage and included assignment of trainees to the emergency room (1% and 3% vs. 14%) ; ICU rotations (7% and 13% vs. 37%); and nonsurgical duties (11% and 14% vs.47%) and to a lesser extent reassigning faculty to non-surgical J o u r n a l P r e -p r o o f duties( 6% and 6% vs. 33%). Reductions in outpatient experience was marked (74% and 84% vs. 89%) as was in-hospital experience (58% and 75% vs. 71%). Outside rotations were described by the respondents as severely reduced (40% and 56% vs.67%). This was more prevalent in other surgical specialties 63% (117/185), as compared to general surgery specialties 51% (92/182). (Table 3 ) Nearly one third of all respondents reported severe challenges in didactic education, with some activities suspended and many switched to a virtual format. Reports of high impact on didactic education were significantly more frequent with advancing stage: Stage 1 (14%), Stage 2 (30%) and Stage 3 (46%). reported issues with the virtual platforms. The most frequent problems reported were general technical issues (47%) and band width (25%). There were fewer concerns about privacy issues (10%), faculty resistance (11%), learner resistance (6%), and attendance (14%). Despite the clinical and didactic educational challenges that resulted from the pandemic , the respondents indicated that they were able to continue to address the major ACGME competencies by the use of national curricula : Core Knowledge ( 92%;358/388) , Problem Solving (64%;247/388) , Professionalism ( 53%; 204/388), Communication (49%;189/388), and Technical Skills ( 32%;122/388). Surgical trainees' end of rotation evaluations (n=404) were able to be conducted in the usual manner in 54% (218/404). Evaluations were expanded to include pandemic specific concerns in 19% (76/404) of programs. The respondents were able to continue assessment of the ACGME competencies as evaluations were reported as being infrequently suspended (13%;51/404) or reduced (29%;118/404) and the ability to maintain formative assessments was reported by 55% (221/403). However, the survey did not assess the overall quality of the evaluations. Several themes emerged from the qualitative analysis as shown in Table 4 . Strategies being used included pivoting to online conferences, use of national programs and curricula, use of simulation/labs/robotics, adjustment of exposure to clinical work, modified schedules and virtual mentoring and testing. We assessed the perceptions of the educational leaders on surgical trainee wellbeing and not the opinions of the trainees. Sixty-one percent of respondents reported that surgical trainees J o u r n a l P r e -p r o o f were involved with the treatment COVID-19 patients, 30% reported that trainees were not caring for these patients, and 9% were uncertain. Across all Stages respondents reported a severe impact on trainees' physical safety in 15%, physical health 9% and emotional health 27%. These numbers increased with advancing Stage: physical safety (6% and 9% vs. 31%), physical health (0% and 7% vs. 17%) and emotional health (11% and 24% vs. 42%). (Table 5) Institutional adaptations reported as occurring to a great extent were significantly related to stage including the provision of coping assistance to trainees (60% and 71% vs. 77%) and increased sensitivity to learners (59% and 76% vs. 76%). Respondents reported the adoption of safety measures (86%) and sensitivity to the needs of faculty (58%) occurred regardless of stage. Several themes emerged as related to institutional initiatives to support the wellness of learners. These included: program check-ins or huddles, accessing existing or institutional and national resources, scheduling to reduce exposure to COVID-19 and allow more free time, enhanced communication, and additional amenities. (Table 6 ) The majority of the 472 respondents surveyed were aware that an institutional disaster plan existed and were aware of its content (62%); however, 26% were made aware during the pandemic, while 12% were left uncertain. Whether the plan included an education statement was uncertain for nearly half of respondents (46%), and either assuredly present (29%), or absent (22%) for the remainder of respondents. Seventy-nine per cent of respondents believed their institutional disaster plan should include an educational statement in the future, although 11% did not believe it necessary and 10% were uncertain. The global COVID-19 pandemic has created unprecedented disruption to the delivery of surgical services throughout the United States (5,6,7) and internationally (19) with a profound effect on surgical training. The ACS Division of Education through the Special Committee of the ACS Academy of Master Surgeon Educators has been assessing the short-and long-term impact of COVID-19 on learners in surgery and is developing new strategies and programs to address various challenges. As part of this effort, the survey that forms the basis of the current study included a sample of all surgical specialties , department chairs, PDs , and selected members of the Academy with the goal of taking a "snapshot" in time of the impact of the pandemic on surgical education and learner health. This study is unique in that it samples the "house of surgery" and as such the results may bring forth common strategies that may mitigate the impact of future pandemics or disasters on surgical training and learner wellbeing. In addition, to our knowledge this is the first study to analyze the association between the severity of impact on surgical training and ACGME Stage. The survey results were stratified by geographic region and by self-declared SI ACGME pandemic stage on educational programs. Because the survey was administered in the late April- While the pandemic has significantly altered the educational experience of learners, most of the respondents indicated that the circumstances allowed for continued development of most of the ACGME core competencies except technical skills. The normal rotation schedule at most institutions required significant revision including restrictions on rotations at outside institutions. Increases in ICU and non-surgical experiences were particularly common in Stage 3 programs and there was a trend that these were more common in general surgery specialties as compared to the other surgical specialties. At Stage 3 institutions, redeployment of trainees, and, to a lesser extent, faculty to non-surgical services was common. The outpatient experience for residents and fellows was severely impacted irrespective of institutional stage or surgical specialty. White and colleagues observed that the rapid adoption of telephone and video visits at many centers was independent of learner involvement and thus represented a loss of multiple face to face learning opportunities. (20) Because video visits are likely to remain a significant mechanism for outpatient patient care, there is an urgent need to share best practices to enhance resident participation. The reduction of non-emergency operations significantly impacted the operative experience of trainees across all surgical specialties in an ACGME-stage-dependent fashion. Reductions in operative experience have been noted in general surgery (20) as well as neurosurgery (21, 22) , ophthalmology (23), orthopedic surgery (24) and otolaryngology (25) . Alternatives to increase exposure to technical skills development include the use of simulation centers and cadaver labs, both of which had limited access during the pandemic (7, 24) . It is striking that three quarters of Stage 1 ("business as usual") institutions still reported high impact reductions which is difficult to understand. This may be the result of the sponsoring institution (as a whole) declaring itself as doing "business as usual" despite the surgical programs within the institution struggling to provide clinical education. The decrease in surgical volume may have also been in preparation to free beds for a possible COVID 19 surge which may or may not have materialized. It also may have reflected patient self-avoidance of elective procedures during the pandemic. Although the reasons may never be fully understood, it is important to note for future national disasters of this magnitude that the operative volume can be severely impacted in institutions that have not self-declared an emergency declaration. Although many respondents indicated that progression to operative autonomy was not negatively affected, 14-18% perceived it was severely impacted. Concerns about the ability to achieve program expectations for case minimums for both residents and fellows across all surgical specialties were evident in half of the Stage 3 programs and also, to a great extent, in lower stages.( Table 2 ) Indeed, the educators surveyed believed that remediation was necessary for many trainees which seemed to be more of a concern for less experienced trainees: Fellows 18% (62/340), CR 25% (93/377), SR 47% (177/380), JR 53% (204 /383). Contrarily, when general surgery chief residents were surveyed in the study by Zheng and colleagues, they were found to be not as concerned about achieving minimal case numbers and were more concerned with the potential delay in board examinations and adequate preparation. (5) It is difficult to reconcile the discordance between the high impact on operative volume and expected case numbers and the lower impact on expected progression to operative autonomy. A goal of surgical training is the ability of the graduating resident or fellow to practice independently and case numbers do not necessarily predict readiness for independent J o u r n a l P r e -p r o o f practice. However, they are a surrogate for surgical experience and exposure. In situations in which institutional operative volume is severely reduced such as was the case in the pandemic, there is a clear opportunity to better address development of technical competence and operative autonomy through competency-based education models. As highly impacted institutions gradually restore surgical volumes, program directors will likely need to find ways to adjust post-pandemic rotation schedules such that junior and senior residents can achieve case minimums over the course of a multiyear training program. It may be much harder for fellows and chief residents to achieve adequate case volumes depending on the timing of institutional disruption in the academic year. In the case of one-year clinical fellowships, such as colorectal surgery, the pandemic could reduce operative experience by as much as 25% The survey was completed in the last quarter of the academic year. Although many respondents thought that remediation to provide more clinical experience and cases was not necessary, concern over readiness for fellowship training or to enter independent practice may be justified, and it may prove necessary for some individuals to extend their training or undergo additional proctoring as they transition to new positions. It remains the responsibility of individual PDs (supported by their clinical competency committees) to complete the summative evaluations that support decisions regarding progression to the next level of training or program completion and readiness for independent practice. While the pandemic introduced significant challenges to didactic education, rapid innovation, and transition to virtual (video) formats was evident irrespective of surgical specialty or institutional stage. While some educational activities were suspended, a shift to video conferences was almost universally adopted. Nearly half of respondents reported technical problems with the transition. Video-based approaches were also adopted for oral examinations, interviews, and mentoring. Whether the use of video technology becomes the "new normal" remains to be seen but anecdotal experiences strongly suggest this will be the case. The pandemic forced innovation in didactics, accelerating the implementation of distance/videobased virtual learning which may ultimately prove to be more efficient and less disruptive to clinical workflows. Interestingly, increased participation in educational conferences including morbidity and mortality conferences has been observed. According to the survey of educators, it was perceived that learner emotional health and sense of physical safety were more severely impacted at Stage 3 institutions. It must be clear that residents and fellows were not surveyed in this study. However, this is consistent with surveys by other investigators of residents during the pandemic which document increased stress , burn out and health concerns . ( 26, 27) While there was a high proportion of institutional adaptations that included assistance with coping mechanisms and the provision of safety measures beyond personal protective equipment, this was not universal even in Stage 3 institutions. The sample is this study was disproportionately represented by academic health centers which have access to institutional wellness programs. Conversely, availability of such programs including childcare, housing and virtual mental health services has been reported to be significantly less in independent programs. (20) An opportunity for enhanced sensitivity to learners and faculty was evident, suggesting that the impact on provider wellness may have been underestimated. The pandemic has inflicted substantial and distressing morbidity and mortality on its victims and their caregivers, exacerbated by stringent visitor restriction policies. Many of the respondents represent safety net institutions in vulnerable communities that have been disproportionately impacted by COVID-19 against a preexistent backdrop of disparities to access and care. The results also indicated that, while many institutions had effective disaster plans to respond effectively to clinical disruption, most institutions either had no provision for educational disruption or the respondents were unaware of such plans. The experience with the COVID-19 pandemic highlights the need for institutions to develop disaster plans that include disruption to educational programs that not only include the "rules of engagement" around clinical redeployment but also the continuation of didactics and psychological counseling and other supportive infrastructure including childcare that are critical to sustain the wellness of learners. In previous disasters such as Hurricanes Katrina and Sandy, or mass casualty events such as the Boston Marathon bombing, the disruption was regional or local in nature; experience with the pandemic highlights the need to consider national and global disaster planning. Although the ACGME has sunset its "Three Stages" effective July 1, 2020 and is migrating to a binary approach to characterize GME operations during a pandemic with a Non-Emergency Category and an Emergency Category (28) , the results of this study support the linkage of future institutional planning to an ACGME-like staging system. Also, we must call attention to the observation that lower Stage institutions had a substantial reduction in operative volume that could derail surgical training independent of an emergency declaration. As the qualitative data illustrate, the response to the impact of the pandemic in the education of surgical trainees and their wellness was timely and may well change the future of surgical education and training. It is obvious that some of the changes in response to the pandemic may in fact prove to be more effective and efficient than the old ways of training and supporting surgical learners. As illustrated, the use of technology to deliver virtual education is arguably just as successful as live conferences. Similarly, many of the efforts to support resident wellness may address the longstanding issue of burnout and better prepare us for future disasters. Perhaps most telling is the fact that the innovative training and wellness programs implemented are not new, extremely costly, or disruptive to patient care and hospital systems. In many cases, these resources existed but were not utilized. The conclusion of this study must be interpreted in the context of its limitations. As with most surveys, the results may well be affected by response bias based on self-selection and the relatively low response rate. Because department chairs and PDs from the same institution may have completed the survey (and because there was no obvious difference between their responses as a group), there may be overweighting of some institutional experiences. Those most affected by the pandemic may have had increased motivation to participate in an assessment of its impact. University and university-affiliated programs represented nearly 90% of the responses, also indicating the possibility of response bias. The survey solicited opinion rather than actual institutional data, and it is possible that responses could be skewed to overestimate or underestimate the true impact. There was a variable response from each of the other surgical specialty groups outside of the general surgery specialties. Although there were no obvious differences among combined responses from other surgical specialties, the sample size was insufficient to draw meaningful comparisons between specialty groups (e.g. comparing obstetrics and gynecology to orthopedic surgery). As the surgical community increasingly digests the lessons learned during the COVID-19 pandemic, a number of conclusions are already clear. Few, if any, institutions were truly prepared to address the crisis in surgical training programs in the wake of the pandemic. There was a severe impact on surgical training across all surgical specialties and common themes have emerged. Non-emergency operative experience was severely impacted as were emergency case numbers, but to a lesser extent. Many perceived that some trainees did not achieve the expected training numbers and as a result there was a variable degree of the trainee achieving the expected progression of surgical skills to predetermined levels. As a result, there was the perception of the need for remediation for some surgical trainees, particularly those in more junior years As such during a crisis such at the COVID-19 pandemic , it is ever more important for individual PDs (supported by their clinical competency committees) to complete the summative evaluations that support decisions regarding progression to the next level of training or program completion or independent practice and to consider options for remediation when necessary . A real opportunity for surgical educators is to design and implement innovations that could help ensure continued development of optimal technical competence of surgical trainees during future pandemics or other global disasters. The pandemic has forced innovation in clinical experiences and didactic learning, especially with respect to virtual learning and telemedicine, that has been generally well accepted and likely to become permanent. Opportunities are also evident for institutions to increase support for coping and learner safety. The ACGME Staging system is associated with the severity of educational impact at each institution. Thus, stage may be predictive of the impact of a future widespread national disaster and as such its consideration in disaster planning may permit a more graduated and individualized approach. Finally, institutional disaster plans should include statements regarding education that are reviewed by PDs and department chairs. Use of nationally available curricula to a much greater extent; city-wide shared lecture/educational sessions; virtual score curriculum; using national OBGYN curriculum; national webinars on surgical training; collaboration with other institutions on virtual meetings Simulation/lab/robotics Increased use of wet lab for technical surgery practice; developed take-home simulation kits for certain procedures; structured individual trainee sessions in fundamentals of laparoscopic surgery simulation; boot camp remotely including simulation at home; live video of wet lab monitored remotely by an attending; increased use of surgical simulators to keep from getting "rusty" Continued exposure to clinical work Virtual clinical rounding; more involvement in the ICU rotations; increased experience with remote consultation; live streaming of OR cases with residents able to ask questions; telehealth participation by residents in pre and postoperative care Scheduling Modified rotations to give more cases to residents with fewer cases; created teams of residents that would work in clinic at same time so that there was less likelihood of all the residents being exposed; moved some residents to our suburban locations; dynamic scheduling to maximize surgical exposure; improved planning of staffing with rotating key individuals; modified schedule to mirror weekends: teams get work done and sign out to a call team who stays Virtual mentoring/mockorals/exams Virtual mock oral exam that allowed us to use examiners from other institutions; virtual interviews for residents and fellows; virtual oral board preparations Surviving disaster: Assessment of Obstetrics and Gynecology training at Louisiana State University-New Orleans before and after Hurricane Katrina Crises and turnaround management: Lessons learned from recovery of New Orleans and Tulane University following Hurricane Katrina Managing COVID-19 in surgical systems The impact of COVID-19 on medical student surgical education: implementing extreme pandemic response measures in a widely distributed surgical clerkship experience General Surgery chief residents' perspective on surgical education during the COVID-19 pandemic Optimization of Surgical Resident Safety and Education During the COVID-19 Pandemic-Lessons Learned The detrimental effect of COVID-19 on subspecialty medical education. Surgery ABS Statement on Training Requirements During COVID-19 Accreditation Council for Graduate Medical Education Practical Techniques to Adapt Surgical Resident Education to the COVID-19 Era COVID-19-considerations and implications for surgical learners Lessons in flexibility from a general surgery program at the epicenter of the pandemic in New York City Emergency restructuring of a general surgery residency program during the coronavirus disease 2019 pandemic: The University of Washington experience together: a training program's response to the COVID-19 pandemic Archived) Three Stages of GME During the COVID-19 Pandemic "ACGME Response to Coronavirus (COVID-19) Graduate-Medical-Education-Data-Resource-Book Table A ACGME's Early Adaptation to the COVID-19 Pandemic: Principles and Lessons Learned Disruption to Surgical Training during Covid-19 in the United States, United Kingdom, Canada, and Australasia: A Rapid Review of Impact and Mitigation Efforts Surgical Education in the Time of COVID: Understanding the Early Response of Surgical Training Programs to the Novel Coronavirus Pandemic Impact of COVID-19 on an Academic Neurosurgery Department: The Johns Hopkins Experience Letter to the Editor "Changes to Neurosurgery Resident Education Since Onset of the COVID-19 Pandemic Reshaping ophthalmology training after COVID-19 pandemic The Past, Present, and Future of Orthopedic Education: Lessons Learned From the COVID-19 Pandemic Impact of the COVID-19 pandemic on Otolaryngology trainee education Stress and the Surgical Resident in the COVID-19 Pandemic Effect of COVID-19 on surgical training across the United States : A Survey of pf General Surgery Residents Sponsoring Institution Emergency Categorization https://acgme.org/COVID-19/Sponsoring-Institution-Emergency-Categorization Stage 1: Business as usual; Stage 2: Increasing but Manageable; Stage 3: Crossing the threshold. Communication Solid information flow; increased communication and reassurance; weekly town hall meetings and daily email updates to keep people informed; we are maintaining open lines of communication to the residents, ensuring that their voices are heard; daily communications; DIO town halls, wellness emails from hospital leadership; daily PD calls during peak surge, weekly check-in Zoom with hospital leaders that could directly answer questions, daily contact in some fashion through Zoom; sending large numbers of emails with supportive phrases; ongoing conversations regarding the impact of COVID-19 on institutions, programs, individuals; weekly GME town halls with infectious disease doctors explaining changes Amenities (food, housing, childcare) Providing additional childcare assistance; lots of food!; hazard pay, transportation allowance, housing assistance; providing massages; free food and parking, sharing discounts from stores; lunch and dinner provided to all floor/ICUs, free haircuts by a barber The authors wish to acknowledge Susan Newman, MPH without whom we could not have completed the project. In addition , we wish to thank the following organizations which gave us Daily PD calls during peak surge, weekly check-in Zooms with hospital leaders that could directly answer questions, daily contact in some fashion through Zoom; open access to the DIO, PDs and APDs for any and all concerns, bi-directional conversations to provide support and solutions; PD at sign out virtually twice a day; weekly Zoom meeting with program directors, chair, residents to discuss issues and concerns, more frequent feedback and contact w/ mentors; buddy system (one person on is paired with someone who was off); text check ins with residents by PD and APD; PD weekly 'fireside' chat with residents to address concerns, provide forum for open discussion etc; special wellness task force with weekly meetings Use of existing institutional and national resources Information for wellness opportunities (free virtual yoga, meditation, etc); 24/7 availability for residents through Employee Assistance Program, weekly wellness webinars; virtual meet and greets, access to therapists, psychologists and psychiatrists, virtual wellness camps and meetings; wellness center 24/7 hotlines, wellness bulletins; increased wellness sessions, access to online resources; access to free wellness apps; Department Wellness Committee; meditation rooms, increased access to counseling; mindfulness sessions, chaplain counseling; lists of resources and free items for healthcare providers SchedulingReduced hospital time -more personal time; Agreeable to a relaxed clinical schedule; can take a wellness day when needed, rotating groups of residents for 2 weeks of educational time at home; increased time away from hospital, decreased shifts (no 24h), increased number on team at a time; rotation of fellow with residents to give more time at home; ensuring scheduling is not overburdensome; created care teams to limit hours of exposure in hospital; rotational approach to clinical coverage with additional time out of clinic; time off after redeployments; minimizing COVID exposure and thus, fear, by offering "call team only" attendance with academic assignments on days "working from home"; protected time between scheduled shifts, rotating people between locations frequently so that they do not stay too long in any high-risk areas