key: cord- -d fo lsn authors: ostapenko, a.; mcpeck, s.; liechty, s.; kleiner, d. title: impacts on surgery resident education at a first wave covid- epicenter date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: d fo lsn background: this study aims to identify the effects of the covid- pandemic on surgical resident training and education at danbury hospital. methods: we conducted an observational study at a western connecticut hospital heavily affected by the first wave of the covid- pandemic to assess its effects on surgical residents, focusing on surgical education, clinical experience, and operative skills development. objective data was available through recorded work hours, case logs, and formal didactics. in addition, we created an anonymous survey to assess resident perception of their residency experience during the pandemic. results: there are surgical residents at our institution; all were included in the study. resident weekly duty hours decreased by . hours with the majority of clinical time redirected to caring for covid- patients. independent studying increased by . hours ( . %) while weekly didactics decreased by . hours ( . %). the operative volume per resident decreased by . % from . to . cases for the period of interest, with a disproportionately high effect on junior residents, who experienced a . % decrease. unsurprisingly, % of residents reported a negative effect of the pandemic on their surgical skills. conclusions: during the first wave of the covid- pandemic, surgical residents' usual workflows changed dramatically, as much of their time was dedicated to the critical care of patients with covid- . however, the consequent opportunity cost was to surgery-specific training; there was a significant decrease in operative cases and time spent in surgical didactics, along with elevated concern about overall preparedness for their intended career. the covid- pandemic has had a multitude of unprecedented effects on healthcare systems across the united states. danbury hospital is located in western connecticut, an area considered to be one of the epicenters of the first wave of the pandemic from march-may of . within the healthcare system, alterations to usual operations and changes in the allocation of human and material resources dramatically changed everyday workflow in hospitals. , , examples of this include the cancellation of non-emergent operations, the transition of various sectors to telehealth medicine, and the redistribution of surgical residents to non-surgical services. other effects on surgical residents have involved modification of duty hour limitations and adjustments to resident education. around the world, institutions have transitioned to virtual platforms for academic sessions. many local and national research conferences have been postponed or cancelled, and requirements for standardized exams have changed. the effects of these revisions in the long term are challenging to predict, particularly because the response to these singular events has varied significantly across states, healthcare systems, and hospitals. we aim to utilize both quantitative and qualitative data to analyze these effects in the short term, and postulate how this may evolve over time. specifically, we hypothesize that surgical residents are working fewer hours and logging fewer operative cases, and that along with changes in education and academic opportunities, this has led to rising concern regarding preparedness for future surgical careers. methods: within the nuvance health network, major changes to usual operations due to the covid- pandemic were instituted between march rd and may th , . we therefore chose this as the period of interest. we focused on three components of surgical education: clinical experience, didactic conferences, and operative volume. . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted august , . . https://doi.org/ . / . . . doi: medrxiv preprint for clinical experience, we compared the number of duty hours logged by residents during the period of interest with the same time in , and calculated a gross difference and percent change. to evaluate didactic conferences, we calculated the average weekly hours of scheduled didactic lectures during the same period in and . additionally, we developed a survey to assess resident perception of changes in didactic structure during this time. we examined total major surgeries logged by residents through the acgme portal during the period of interest, compared to , and calculated a gross difference as well as percent change in order to assess operative opportunities. the survey was administered anonymously through surveymonkey® to all surgical residents at danbury hospital between june th and june th , . for questions regarding hours, we calculated the perceived difference in hours for each individual response. mean and standard deviation for the change were calculated for each question. the survey also contained five-point likert questions, for which the percentage of residents who responded positively with "agree" or "strongly agree" was calculated. our institutional review board deemed this study exempt (irb# ) and waived the need for participant consent. results: there were surgical residents in and in , respectively. clinical experience: clinical experience was assessed in two ways: first, we examined the duty hours logged for clinical work and number of outpatient clinics attended, and second, through several anonymous survey questions, completed by % of surgical residents. surgical residents worked an average of . hours/week before the covid- pandemic, and . hours/week during the pandemic, a . % decrease (table ) . a significant portion of the clinical experience for surgical residents was . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted august , . . redirected to caring for covid- patients during the pandemic. in the survey, residents reported working between - (sd= . ) hours/week caring for covid- patients (table ). in regards to outpatient clinics, in for the period of interest residents averaged . clinics, while in this decreased by . % to . clinics per resident. educational experience: an average of . hours/week were spent on organized didactics before covid- (table ). this included hours of protected time for resident education based on the score curriculum, morbidity and mortality conference, grand rounds, specialty attending conferences, and trauma review conference. during the pandemic, all conferences were done remotely through teleconferencing, and the average time spent on organized didactics was . hours/week -a reduction of . % (table ). residents were split on whether the quality of didactics improved, with % reporting an improvement, and % perceiving a decrease in quality. despite a significant drop in clinical work of . hours per week, residents reported an increase in independent studying of only . hours per week: from . to . hours per week ( table ) . operative experience: from march rd to may th , , residents at danbury hospital logged operative cases. for the same period during the covid- pandemic, residents logged cases, a % decrease (table ). since the number of residents in each post-graduate year (pgy) position varied from to we calculated number of cases per resident. on average there were cases per resident before the pandemic, which decreased by . % to . cases per resident during the pandemic (table ) . junior residents in pgy , , and positions were disproportionally affected during the pandemic, with a . % decrease from . to . cases per resident for the study period. senior residents in pgy and pgy positions saw a . % decreased in operative cases, from . to . cases per resident. overall, % of residents felt their surgical skills have been negatively affected by the pandemic. . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted august , . this restructuring of the program is similar to that reported by institutions in other highly affected areas. unlike this study, prior literature did not address the effect of this restructuring on resident training, but discussed their experience and offered recommendations on how to safely and effectively prepare hospitals and programs. , in this study, we demonstrate that surgical residents had a significant contribution to the overall covid- response at danbury hospital, with an average resident spending - hours per week caring for critical covid- patients (table ). this contribution resulted in a decrease in clinical duty hours by . %, from . to . hours per week, in addition to fewer outpatient clinics attended, and less operative experience. however, surgical residents spent more . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted august , . conditions. abs has no specific requirement for duration of icu rotations; instead, it requires a log of critically ill patients. prior studies describe a wide variability in surgical critical care training and fund of knowledge of graduating residents. , therefore, this sudden increase in critical care training is one of beneficial effects on surgical training. one of the ways to enhance resident clinical experience to supplement the drop in clinical duties and outpatient clinic attendance through resident involvement in telehealth clinics. at our institution there were several barriers to this proposal, including a lack of infrastructure to transition to telehealth and the uncertainty of the timing of elective surgeries resumption. both of these factors resulted in low volume of appointments initially; however, as telehealth became more common incorporation of residents became more feasible. more widespread incorporation of resident involvement in telehealth clinics can potentially be an invaluable supplementation to clinical experience. educational experience: the covid- pandemic changed surgical resident didactics, resulting in a decrease in protected time for academics. this was a surprising finding, given the implementation of video conferencing and noted reduced clinical responsibilities of residents. all conferences at our institution transitioned to video platforms, allowing presenters to share screens from remote locations and facilitating assembly of large groups of peers in a safe manner. other advantages of video platforms include the ability to record lectures for viewing outside of scheduled time, and increased ease in . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted august , . . https://doi.org/ . / . . . doi: medrxiv preprint inviting leading experts and educators from prestigious academic institutions to present and discuss topics within their specialty. another surprising finding in our study was that despite a decrease in clinical duties by hours per week, independent studying only increased by only . hours/ week. given this significant decrease in clinical hours, we expected a larger increase in time spent studying independently. several factors may play a role here. given the timing of the national surgical in-training exam (absite), residents may have felt less pressure to increase their time in independent study. residents who formerly utilized independent study time to prepare for elective cases naturally would decrease time spent on this endeavor. operative experience: perhaps most obviously, the covid- pandemic significantly impacted the operative component of surgical training (table ). the cancelation of all elective cases resulted in a % reduction in total major cases logged by residents. this disproportionally affected junior residents, who went from . to . cases per resident, a . % decrease during the periods of interest. meanwhile, senior resident cases decreased by . %, from . to . cases per resident. the american board of surgery (abs) decreased the number of required operative cases for graduating seniors as a direct consequence of the pandemic. however, such a dramatic decrease in surgical volume will likely affect residents at all levels moving forward. in the survey, % of residents reported that the pandemic has negatively affected their surgical skills and % reported concern about preparedness to become an attending. the long-term impacts of the pandemic remain to be seen, yet surgery residents still have a limited five years to acquire the clinical knowledge and operative experience to become surgeons. abs . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted august , . . deems the requirement to qualify for board certification is weeks of surgical clinical experience and logged procedures in defined categories. therefore, the significant drop in operative volume is concerning, as physical skill is fundamental to surgical education. one solution to supplement the growing deficit of operative experience is simulation-based training (sbt). prior studies demonstrated that surgical residents value the ability of sbt to expose them to new procedures, but conclusions were divided on the best ways to implement sbt within curricula. through sbt, residents can improve dexterity and speed in operative maneuvers and enhance their technical skill. resident performance can even be assessed by attendings or colleagues observing remotely through videoconferencing. this provides a unique opportunity to progress physical skills while maintaining social distancing, and additionally provides another outlet for independent study while clinical hours are reduced. high quality surgical videos can also help compensate for diminished operative volume. although not a tactile exercise, when viewed in a group setting with discussion driven by faculty, these sessions can supplement resident operative education. videos can also play a role in flipped classroom models in which pre-recorded lectures are watched prior to conferences, which enhances knowledge acquisition and enriches discussion. the main limitation of this study was that it was limited to a single surgical residency program. therefore, the results may not be generalizable to residents in other programs in the united states. however, as one of the earliest areas affected by covid- , we are able to analyze its effects in a timely fashion that may benefit other geographic areas affected similarly in the future. while residents in states with lower incidence of covid- may not be as significantly impacted as residents at our institution, continued evolution of the covid pandemic and the rise of new epicenters of disease may make these results more generalizable over time. despite the limitations, these results are integral in critically thinking about the future of surgical education. the covid- pandemic will continue to . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted august , . . https://doi.org/ . / . . . doi: medrxiv preprint affect residency programs across the country with changes to clinical work, didactics, and operative experience of surgical residents. as physicians, our highest mandate is patient care. we have an ethical and moral responsibility to take care of covid- patients, and there is a great deal to be learned from such experiences. nonetheless, the cultivation of surgical knowledge and physical skills is integral to the development of future surgeons, and the short duration of residency education is an incomparably formative time. it is important to keep in mind that the role covid- as a disease will have in the future of medical care is impossible to divine, and that regardless of the role it plays, medicine will still need the specific capabilities for which surgeons are trained. during the first wave of the pandemic, surgical residents had a significant contribution to care of patients with covid- . the impacts of the pandemic on surgeon training continue to evolve, and undoubtedly will have complex long-term effects, both positive and negative. it is important to continually assess how resident training is affected, and to consider innovative approaches to maintain clinical, operative, and educational experiences. . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted august , . . https://doi.org/ . / . . . doi: medrxiv preprint i am attending the same amount of outpatient clinic % % *the variable was acquired from the survey. . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted august , . . https://doi.org/ . / . . . doi: medrxiv preprint the quality of didactics increased during the pandemic . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted august , . . https://doi.org/ . / . . . doi: medrxiv preprint american college of surgeons asoa, association of perioperative registered nurses, association tah coronavirus disease (covid- ): situation report immediate and long-term impact of the covid- pandemic on delivery of surgical services. the british journal of surgery residency and fellowship program accreditation: effects of the novel coronavirus (covid- ) pandemic impact of covid- on neurosurgery resident training and education covid- : elective case triage guidelines for surgical care emergency restructuring of a general surgery residency program during the coronavirus disease pandemic: the university of washington experience restructuring of a general surgery residency program in an epicenter of the coronavirus disease reforming our general surgery residency program at an urban level trauma center during the covid- pandemic: towards maintaining resident safety and wellbeing. the american journal of surgery critical care education in general surgery residencies general surgery resident rotations in surgical critical care, trauma, and burns: what is optimal for residency training? a survey of critical care training amongst surgical residents: will they be ready using technology to maintain the education of residents during the covid- pandemic modifications to training requirements -covid- update. american board of surgery residents' perspectives of the value of a simulation curriculum in a general surgery residency program: a multimethod study of stakeholder feedback an overview of research priorities in surgical simulation: what the literature shows has been achieved during the st century and what remains key: cord- -oryjjoiw authors: detterline, stephanie; hartman-hall, heather; garbow, katherine; rawal, himanshu; blackwood, david; nizialek, gregory; nashaat, zayd title: an internal medicine residency’s response to the covid- crisis: caring for our residents while caring for our patients date: - - journal: nan doi: . / . . sha: doc_id: cord_uid: oryjjoiw background: in response to the covid- pandemic, internal medicine residencies have had to develop new teaching strategies and attend to wellness concerns. providing front-line care for patients in a time of widespread crisis while maintaining attention to training has created unprecedented challenges. objective: our large community hospital based internal medicine residency sought to develop and evaluate a crisis response to the demands of the covid- pandemic to meet our residents’ educational and wellness needs. methods: in march , our residency developed a crisis plan for functioning during the covid- pandemic. a brief survey was sent via email to our residents to obtain their evaluation of how well their needs were being met by this response. results: ( %) residents completed the survey. % indicated their well-being needs were well met. other components were also rated as successful: effective communication ( %), scheduling/staffing ( %), preparing residents for clinical service ( %), and educational needs ( %). conclusions: our residency crisis response to the covid- pandemic was favorably evaluated by our residents in meeting their training and well-being needs. in future work we plan to seek longer-term and more objective measures to assess how residents fare during these challenging times, and to use lessons learned to prepare for future crisis situations. in response to the covid- pandemic, graduate medical education (gme) programs have had to develop new teaching strategies and attend to the well-being needs of both faculty and residents. internal medicine (im) residency programs have been faced with providing front-line care for patients in a time of widespread crisis while attending to training, creating unprecedented challenges. guidance on how to respond to a large health crisis includes effective communication, resources that facilitate reflection on the effects of stressors, and tangible support from institutions [ ] . in the current crisis, institutions are advised to help their healthcare workers feel heard, protected, prepared, supported, and cared for [ ] . medstar health took many steps during this crisis including providing adequate personal protective equipment (ppe), hotel rooms, transportation assistance, low-cost child care resources, up-to-date information and guidelines, and easily accessible mental health services. in the context of this system wide response, our im residency program also initiated a crisis plan to meet the clinical needs of surging patient volumes as well as maintain education for our residents. in march , our community hospital residency program had residents rotating through four hospitals in the baltimore area; our residents are organized into four firms each with an assigned chief resident. prior to the covid- crisis, our residency program had in place a wellness program led by a faculty psychologist who serves as our wellness director (additional details can be found in the supplemental materials). adapting our functioning, soliciting ongoing feedback, and adjusting our plan as the crisis developed allowed our program to provide for well-being and learning needs of residents while providing critical clinical services in our hospitals. we describe our residency's response to the covid- crisis along with our early outcome data as a contribution to what we expect to be a new body of scholarly work: how residencies might best navigate a worldwide pandemic that creates strains on healthcare systems and gme programs. guiding principles for our crisis plan included responsiveness, transparency, and prioritizing wellbeing. this plan was initiated in march as the first patients with covid- were identified in our hospitals and continued through june as the pandemic affected our region with surging numbers of positive cases. a brief survey of our residents was utilized for early evaluation of our crisis response. effective and timely communication within our program was an early goal. copious information was coming from our system and we recognized the need to summarize and distill the rapidly changing information that was coming from multiple sources, as well as to provide transparency and messages of support. we also needed to continuously seek input from residents and faculty to be sure their needs were being addressed. we instituted weekly conference calls for program leadership, daily emails to program faculty and residents from the progam director, weekly firm check-ins with their chief resident, and weekly virtual house staff meetings with residents and program leadership. it was decided, with strong support from our chairs of medicine, that only attendings would be expected to go into rooms of patients with covid- for routine exams to minimize resident exposure risk and to preserve ppe. all residents and faculty were repeatedly instructed to take care when donning ppe for safety, particularly in rapid response and code blue situations. our crisis scheduling model included decreasing the number of residents on ambulatory rotations and reassigning residents on electives. by focusing mainly on staffing core inpatient teams, we were able to schedule most residents to work seven consecutive days, alternating with being off duty for seven days. this provided a cohort of rested, healthy residents to work each week as well as a reserve for back-up coverage that allowed us to immediately remove from service residents who had concerning symptoms or signs of unsafe fatigue. to maintain academic engagement for our residents during their off weeks, we created a weekly 'at-home curriculum' (additional details can be found in the supplemental materials). this typically included a journal review, online modules, assigned readings, and individual study as well as the virtual conferences and well-being check-ins described below. our didactics moved to an online interactive platform and included lectures or panel discussions each week on emerging topics related to covid- (e.g., infectious disease, critical care, palliative aspects). as the crisis continued, we continued this content while returning to some of our core im topics. regarding attendance levels and the amount of dialogue during conferences, we saw more engagement than typical for our in-person lectures earlier in the academic year. residents expressed early on a need for additional training in having difficult discussions about covid- diagnosing, care planning, and end-oflife issues. in addition to providing virtual conferences and panel discussions on these topics, we curated resources and reading materials related to this topic and housed them online for easy access. consultation on these topics was made readily available by our faculty psychologist and our palliative teams. program leadership provided consistent messaging to residents and faculty that their well-being and safety continued to be the primary concern. all were regularly invited to raise any concerns without fear of negative consequences. the program director, chiefs, and wellness director made themselves available to field any questions or concerns and encouraged residents to reach out any time of day. residents were consistently reminded to have a low threshold for reporting possible fatigue or illness to their chiefs. as noted above, a benefit of our staffing model was a sufficient reserve to cover residents who needed to have time off. we initially continued to offer lunch for our residents four days a week as we have usually done. we transitioned to individually wrapped food that was made available to residents at lunchtime at all of our hospitals for residents to take and go, with a couple of faculty members present to offer in-person friendly greetings and check-ins with appropriate social distancing. feedback from residents indicated that on busy services, they were having trouble getting away to eat meals on days lunch was not provided, so faculty and staff began providing meals to residents at all four hospitals on the fifth weekday and during weekend shifts on a volunteer basis (with funding donated by faculty). in response to this emergency, our usual small group wellness sessions (see supplemental materials for a description of these) were changed to online virtual meetings and the frequency was increased so each resident had the opportunity to participate at least every other week. these included guided mindfulness and relaxation exercises, coping skills, and discussions about their experiences. residents also used these discussions as another mode to provide feedback and raise concerns which were shared with program leadership. these sessions were replicated for faculty, offered as a weekly virtual drop-in session for several weeks during the height of our clinical volumes. our residents and faculty always have easy access to individual well-being consultation and support from our faculty psychologist by phone/email or inperson meetings at any of our locations, and her availability for phone contact during this crisis time increased to hours a day, days a week. information about system, local, and national wellbeing resources were gathered and made easily available online as well as periodically emailed to the program and reviewed in meetings. a residency wellness card (including crisis phone numbers and qr codes to access online resources) designed to be worn on the badge clip had already been created for the residency; these cards were again made readily available in common areas. we solicited ongoing feedback from faculty and residents during house staff meetings and smaller checkins, which was used to refine our response in real time (e.g., scheduling adjustments, additional food provided, topics for didactics selected based on this feedback). the online didactics have had higher attendance than previous live lectures with active engagement of participants. comments from residents have indicated that they have felt supported, have trust in our program leadership, and believe their safety is prioritized. a brief survey was conducted in weeks and of the crisis response. all residents were invited by email to participate anonymously; the survey was kept open for two weeks and several reminders were sent. residents were assured the program would have no way of knowing who participated or to link responses to them personally. the only demographic information collected was pgy, which was collected to assess representation of each cohort. residents were asked to evaluate how well the residency addressed their well-being, communication, scheduling/staffing, preparing residents for clinical service, and education on a five-point likert type scale ( -very well, -somewhat well, -neutral, -somewhat poorly, -very poorly). there was also a free text comment box for any suggestions or comments. the survey was approved by medstar's institutional review board. our survey response rate was % ( out of ) with all pgy levels represented (pgy = , pgy = , pgy = ). the highest response rate was from pgy residents ( / ; % responding) with the lowest response rate from our largest cohort, the pgy residents ( / ; % responding). as we did not collect other demographic data, we are limited in being able to draw conclusions about other patterns as to who participated and who did not. an overview of how residents responded to each item on the survey is presented in table . residents evaluating our program as responding 'very well' or 'somewhat well' in each area evaluated were as follows: well-being needs ( %), effective communication ( %), scheduling/staffing ( %), preparing residents for clinical service ( %), educational needs ( %). mean survey responses by cohort are presented in table . all mean item ratings were above the midpoint in the positive direction. the only mean rating below (which equates with 'somewhat well') was the pgy rating for how well the program prepared them for clinical work during the covid- crisis. the majority of text comments collected were positive and reflected appreciation for the program's response and leadership. themes in constructive comments that were collected included specific food requests, wanting to know their work schedule more in advance, and suggestions about team composition. none of the respondents who endorsed items as 'very poorly' offered comments or suggestions in the free text box. early resident feedback suggests that our crisis response was successful in addressing residents' needs. our program likely benefited from already having in place processes for fatigue mitigation and wellbeing support. the covid- crisis and its aftermath may be an impetus for programs across the country to continue to explore creating or further developing wellbeing programs, both for ongoing burnout prevention as well as for better preparedness for crisis situations. future work includes our continued response which will evolve as our clinical and educational landscape changes through the current crisis. we plan to continue to gather feedback from our residents and use objective measures of how they are faring, both during the crisis and in the longerterm. one area for future research may be to better understand how residency programs meet the needs of pgy s, our least experienced senior residents, to feel prepared to provide clinical services during a crisis like that experienced during our covid- surge. learning more about how other im residencies have responded and their outcomes will also add to our understanding of how we can best train and care for our residents on a regular basis as well as during times of significant crisis. as the gme community continues to explore and share best practices for meeting the well-being needs of our im residents and faculty, we can continue to change the culture to one that supports wellness while remaining effective in teaching residents and caring for our patients, particularly in a time of widescale crisis. our results reflect only one im residency and may not generalize to other settings or populations. the data collected were subjective and collected early in our pandemic response. more objective data of desired outcomes after a longer period (e.g., wellbeing measures) would be a useful next step in this line of study and would bolster conclusions about the efficacy of our interventions. preliminary feedback from our residents indicates an overall positive evaluation of our crisis response to meet their well-being and educational needs during the first weeks of our system's surge during the covid- pandemic. our program may have benefitted from having already had a wellness program in place. continued monitoring of outcomes and lessons learned will help guide future residency responses to widespread healthcare crises. the experience of the sars outbreak as a traumatic stress among frontline healthcare workers in toronto: lessons learned understanding and addressing sources of anxiety among health care professionals during the covid- pandemic the authors gratefully acknowledge the strong support of our chairs of medicine, dr. dana frank and dr. stephen selinger, and dr. nehna abdul majeed for her work in implementing our residency crisis response. no potential conflict of interest was reported by the authors. heather hartman-hall http://orcid.org/ - - - x key: cord- - eppgxo authors: brungardt, joseph g.; schropp, kurt p.; mammen, joshua m. v. title: impact of covid- within a midwestern general surgery residency date: - - journal: kans j med doi: nan sha: doc_id: cord_uid: eppgxo nan coronavirus disease (covid- ) has caused an impact on american and international society unlike anything our or any recent generation has ever seen. some countries have been affected more significantly than others, though the response and fallout have been international. besides large-scale restructuring from "stay at home" directives and other measures, the department of surgery at the university of kansas medical center in kansas city implemented several measures and procedures to limit staff exposure, continue surgical care throughout the hospital, and create opportunities for learning for its surgical residents. similar to many midwestern communities, our hospital did not see the early surge experienced by other systems. simultaneously, the volume of surgical procedures was decreased to allow for the conservation of personal protective equipment and allow for possible re-deployment of personnel and space in hospitals. the immediate and long-term effects of this pandemic on surgical resident education remain unclear. the department, early on, worked to continue grand rounds, utilizing video chat technology to maintain senior resident presentations throughout this spring season. unfortunately, the department had to cancel a visiting professor resulting in a week-long hiatus after the immediate shelter in place order. nonetheless, protected time of resident conferences has been well adhered-to, with ongoing surgical council on resident education (score) curriculum presentations by surgical faculty, and morbidity and mortality conferences during their regular times. while the ability to participate actively in utilizing these new electronic hipaa compliant modalities was limited at first, it is increasing as residents get accustomed to the new norm. immediate feedback sometimes is limited as the host often needs to mute everyone's microphones due to background noise and not all computers have video due to the utilization of hospital desktops that typically lack video equipment. future conferences may bring a new appreciation for meeting in-person once restrictions are lifted. self-directed learning from question banks, textbooks, and literature review continues to be the crux of surgical resident education, with possibly more time available as surgical case load and clinical schedules lighten. some residents have been recruited to continue medical student lectures and to lead clinically case-based discussions. the operative experience of our residents, as with other programs, has been impacted. our surgical oncology and colorectal surgery services have moved two to three residents to home call from a five to six-person team. similarly, decreases in resident complement have occurred in the vascular surgery and acute care surgery services as volumes have decreased. unlike some other institutions, a line service was not instated, since there was not the need due to the relatively limited number of covid- patients. conference calls in the morning kept the entire team up to date (even the residents who are in "reserve") as they rotated through the service on rounding days or in-house call. the team members at home continued to update the in-house residents with relevant labs or chart review by utilizing the electronic medical record. weekly pre-operative conferences and indication conferences (reviewing the cases for the coming week) continued with the involvement of those residents at home. while those in-house continued to operate, volumes decreased by approximately half, limited mainly to oncologic operations that cannot be delayed or urgent or emergent procedures. the active clinical learning experience and technical aspects of resident education is no doubt affected. telehealth visits, an entirely new skill being learned by staff and residents, have allowed for ongoing clinic visits, although significantly limited by lack of proper physical exam. two major clinical rearrangements were within the acute care surgery and trauma/critical care division. more electively focused general surgeons assumed responsibility for the acute care surgery/ emergency general surgery service from the trauma/critical care surgeons. the rationale was to avoid cross-contamination of patients and teams, thereby limiting overall exposure. the other significant change in the trauma service was with regards to how residents participated in trauma activations. typically, the senior and a mid-level resident respond to level traumas with the intern assisting in the level traumas. to limit exposure further, the mid-level resident assumed responsibility for all patient contact in traumas, with the intern or senior available as a backup. this arrangement has so far been successful. the clinical education of our residents has continued, though at a distinctly decreased volume and pace, with the silver lining being in the care of the patients. more time can be dedicated to them on rounds, during their preoperative check-in, or post-operatively on the floor. with minimal visitation, the healthcare team collectively seemed to be more attentive to the patient and their personal needs as they go through major and minor operations with no family present. this time of decreased surgical demand seemed to allow us to be overall more attentive to the patient. as the stay-at-home orders begin to lift and elective surgeries begin to resume, it is difficult to predict the lasting impact this time will have on surgical resident education. precautions will no doubt be necessary for some time before we can return to "normal." while this is hard to foresee, a lasting impact hopefully will be seen in a renewed focus on staff well-being, greater attentiveness to conference time, and a continued zeal for patient care. impact of the covid- pandemic on urology residency training in italy using technology to maintain the education of residents during the covid- pandemic orthopaedic education during the covid- pandemic nimble, together: a training program's response to the covid- pandemic key: cord- -wa hdg u authors: pennington, zach; lubelski, daniel; khalafallah, adham; ehresman, jeff; sciubba, daniel m.; witham, timothy f.; huang, judy title: letter: changes to neurosurgery resident education following onset of the covid- pandemic date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: wa hdg u abstract background the covid- pandemic has led to the postponement of a large proportion of neurosurgical cases with an accordant radical change in resident experiences. as residents rely upon operative exposure and in-person didactic lectures for education, the disruptions caused by the pandemic have forced programs to revise how they educate residents. here we surveyed program directors (pds) to ascertain how they have altered the education and clinical care responsibilities of residents in response to the covid- pandemic. methods surveys were sent to the pds of all acgme-accredited neurosurgery programs. survey questions targeted changes in resident staffing and coverage, changes in didactic material delivery, and changes in resident wellness initiatives. pd concerns were also elicited. results of the program pds invited, responded ( . %). we found that most programs have reduced resident work weeks ( %) and in-hospital resident shift census ( %). few have redeployed residents and most are increasingly relying on teleconferencing solutions for meetings and resident education. most commonly programs are using faculty- ( %) or resident-led ( %) lectures, though nearly % are supplementing resident education with materials from the congress of neurological surgeons (cns). continuing education in spite of decreased case volume and maintaining resident morale are cited as the most common concerns of pds. conclusion here we find that there is great homogeneity in the responses of neurosurgical residency programs to the covid- pandemic. programs are increasingly incorporating teleconferencing platforms and third-party education materials, most commonly materials from the cns. additionally, most respondents indicated that their program has not redeployed residents in the care of covid- positive patients. the results of the present study may assist program directors in developing a uniform resident curriculum and consider wellness initiatives during this time of crisis. the covid- pandemic has led to the postponement of a large proportion of neurosurgical cases with an accordant radical change in resident experiences. as residents rely upon operative exposure and in-person didactic lectures for education, the disruptions caused by the pandemic have forced programs to revise how they educate residents. here we surveyed program directors (pds) to ascertain how they have altered the education and clinical care responsibilities of residents in response to the covid- pandemic. methods surveys were sent to the pds of all acgme-accredited neurosurgery programs. survey questions targeted changes in resident staffing and coverage, changes in didactic material delivery, and changes in resident wellness initiatives. pd concerns were also elicited. results of the program pds invited, responded ( . %). we found that most programs have reduced resident work weeks ( %) and in-hospital resident shift census ( %). few have redeployed residents and most are increasingly relying on teleconferencing solutions for meetings and resident education. most commonly programs are using faculty-( %) or resident- led ( %) lectures, though nearly % are supplementing resident education with materials from the congress of neurological surgeons (cns). continuing education in spite of decreased case volume and maintaining resident morale are cited as the most common concerns of pds. conclusion here we find that there is great homogeneity in the responses of neurosurgical residency programs to the covid- pandemic. programs are increasingly incorporating teleconferencing platforms and third-party education materials, most commonly materials from the cns. additionally, most respondents indicated that their program has not redeployed residents in the care of covid- positive patients. the results of the present study may assist program directors in developing a uniform resident curriculum and consider wellness initiatives during this time of crisis. with the onset of the covid- pandemic and the resultant cancellation of elective surgical cases nationwide, there have been significant changes to how neurosurgery is taught and practiced. the dramatic decrease in operative cases has significantly impacted the training of neurosurgical residents, who depend on elective surgical volume to hone their clinical and operative skills. as residents must meet minimum case volumes to demonstrate proficiency upon program completion, there is concern among both residents and program directors regarding the severity of the impact of covid- on neurosurgical resident education. recently, several centers have reported the significant changes that their departments have undergone as a result of the covid- pandemic. [ ] [ ] [ ] [ ] included in these changes are alterations to the methods for educating residents and the clinical care duties of residents. for example, weber et al at the medical university of south carolina and burke et al at the university of california san francisco described reorganizing their services to reduce the number of residents in the hospital at any one time. face-to-face patient handoffs have also been minimized and usual didactic programs have been shifted to videoconferencing platforms to reduce resident-to- resident contact. in spite of these single institution experiences, there has yet to be a description of how residency programs on the whole are dealing with the pressures exerted by the covid- pandemic. here we sought to address this outstanding need by polling program directors with the goal of using the information to help inform residency directors about how programs across the country are addressing resident education during the covid- pandemic. methods survey of program directors after obtaining irb approval, a survey was developed using redcap software (supplementary figure ). domains addressed by the survey included: program details (residency size, location, hospital size), covid- burden in the catchment area of the associated hospital/health system, changes in case volume and resident duties (e.g. shift changes, responsibility for care of covid- positive patients), and changes in resident wellness/support. we also included items about the exact interventions being employed to continue resident education during the covid- pandemic, including changes to regular meetings (e.g. grand rounds, morbidity and mortality (m&m) conferences), changes to didactic lectures, utilization of outside materials (e.g. materials published by the american association of neurological surgeons (aans) or congress of neurological surgeons (cns), and usage of tools to track resident participation/progress within the updated curriculum. the survey was sent to program directors of all acgme-accredited neurosurgery programs using redcap electronic data capture tools hosted at our institution. the survey elicited responses from ( . %) programs ( table ) . the median program size was residents per class, and the majority of programs were located in the midwest ( . %), northeast ( . %), or southeast ( . %). for responding programs, the median health system size was beds (interquartile range - beds). the inpatient burden of covid-positive patients at the time of response was that most programs had < covid-positive patients ( . %), or - covid-positive patients ( . %); few programs had > covid-positive patients. current case volume for most programs was < % of pre-covid volume ( . %); only a small minority of programs had > % of their baseline case volume ( . %). while programs with higher covid burdens tended to have greater reductions in their surgical volume, this difference was not statistically significant (χ²= . ; p= . ). there was no significant interaction between case volume and either geographic region or residency program size. changes in resident workload the majority of programs have reduced resident covid exposure risk by reducing the number of residents in the hospital at one time ( . %) and by reducing the number of days per week that each resident works ( . %) ( changes in resident support more than a third of programs ( %) reported that they have provided additional benefits to their residents since the onset of the covid pandemic. the most common newly added benefits were providing counseling or wellness smartphone application resources ( %), hotel vouchers ( %), and child care vouchers ( %). there was no significant association between covid patient burden and the odds of a program offering any of these additional benefits. of note, a significant proportion of programs were already offering counseling or wellness smartphone applications to their residents prior to the onset of the covid pandemic. changes in resident education nearly all programs were conducting grand rounds ( %) and m&m conferences ( %) using teleconferencing software ( table ) . the remaining programs either completely cancelled ( %) or had some small in-person meetings ( %). pds reported that didactic lectures were primarily live-streamed lectures led by faculty ( %) or residents ( %). a substantial percentage endorsed also sourcing lectures ( %) or grand rounds from outside institutions ( %), or previously recorded sessions ( %). in general, lecture materials were being selected by the program director ( %) or by the residents ( %), rather than by the speaker or a previously formalized curriculum. across all respondents there was a relatively equal distribution regarding the change in the quantity of lectures delivered ( % increased the number of lectures, % decreased), with the majority ( %) of programs delivering - hours of didactic material per week. there was no association between covid-positive patient burden and either the absolute number of hours of didactic material delivered per week or the reported change in the quantity of didactic material delivered from pre-covid onset to post-covid onset. resident participation was predominantly assessed via direct engagement of resident attendees by the lecturer ( %). some institutions also indicated that they were using mock oral boards ( %) and virtual polling ( %) features to further ensure resident engagement. the majority of programs were incorporating outside resources to supplement the education of their residents, most commonly in the form of the freely available complimentary online education offered by the cns ( %). program size was not significantly associated with odds of using any of the outside resources listed (all p> . ). roughly half of programs were including advanced practice providers ( %) and medical students ( %) in their resident didactic sessions. program director concerns program directors overwhelmingly reported that increased utilization of teleconferencing solutions is the biggest change to the methods employed to educate residents. the majority state their biggest concerns regarding the current crisis are: maintaining resident education in the face of decreased case volume, attempting to maintain resident morale, and reducing resident risk of developing the covid- infection. pds note one positive effect of the covid pandemic is increased utilization of teleconferencing solutions, which many report has increased attendance by both residents and faculty. consequently, some see these teleconferencing sessions as team- building exercises and a majority ( %) indicate that moving forward they will likely increase their use of teleconferencing systems to either improve attendance or increase the number of potential lecturers. additionally, while the covid pandemic has decreased operative volumes, several pds find that the increased off-service time has led to increased resident productivity in terms of clinical research activities. discussion here we present the results of a survey of pds for acgme-accredited neurosurgery residency programs regarding their responses to the covid- pandemic. in general, we found that most programs made similar changes to resident duties in response to the covid pandemic; most reduced the number of days per week worked by each resident and the number of residents in the hospital at any one time. additionally, redeployment of neurosurgery residents to care for either covid-positive or non-covid patients did occur. a percentage of programs newly introduced access to wellness/counseling apps in response to the covid pandemic, though most ( %) had already offered these benefits prior to the covid pandemic. at present, pds are optimistic that the covid pandemic will not prevent either current or incoming chief residents from reaching acgme case minimums. however, they also reported that residents would be transitioned from an in-person didactic program to a videoconferencing-based system with a minimum of -minutes of lecture led by senior residents using material assembled by staff neurosurgeons or sourced from online material. carter and chiocca described the implementation of similar curriculum changes at the harvard-affiliated programs. they described the implementation of daily "lunchtime lectures" using videoconferencing software. during these lectures, department staff and medical students are instructed using a combination of operative video, journal club, and didactics. in a separate publication, the authors additionally reported the continuation of normal resident lectures and m&m sessions using videoconferencing software. though less specific, similar changes were endorsed by eichberg and colleagues at the university of miami. lastly, bray and colleagues described the impact of covid- on resident education at emory. as with the above centers, they reported transition of grand rounds and didactic lectures to videoconferencing software. they additionally reported using this platform to stream daily case conferences for residents, fellows, and medical students, and for streaming third-party materials provided by the cns. in sum, the interventions reported by these programs appear to be similar to those reported by the majority of the survey respondents in the present study and demonstrate a strategy that could likely be implemented in all neurosurgical residencies. there has been a reported uptick in the number of electronic resources made available to neurosurgical residents. these include resources offered by professional societies, for example the grand round webinars and virtual visiting professor series offered by the cns and the free resident courses offered through the neurosurgery research & education foundation of the aans. additionally, there has been increased use of third-party resources, including the neurosurgical atlas, which has reported more than a % increase in users/viewers since the onset of the pandemic. here we found that a majority of programs are embracing lecture delivery via teleconferencing materials. additionally, nearly three-quarters of programs are incorporating the cns complimentary online education into their educational programs. this finding that programs are increasingly relying on video and other online materials is expected and reassuring given the limitations imposed by the covid crisis. while such education will never replace operative experience, video instruction has substantial precedent in both us academic centers as well as in limited resource settings. the authors reviewed the most popular applications and found them to be high-quality overall, with few instances of incompleteness and no instances of false statements. however, they did caution that care must be taken with widespread usage of the mobile applications, as they are not subject to the same rigorous peer review used for the primary literature. in the present survey we found that mobile applications appear to be only minimally utilized, with only % of programs reporting using them as part of their didactic curriculum. while it is possible that individuals are using them on their own, formalizing and raising awareness about such applications may represent an additional means of educating residents at a distance. an additional strategy that was not considered by the survey involves using mobile devices to aid residents in practicing operative skills. huotarinen et al described using a smartphone's camera in conjunction with suture and several household supplies to allow residents to individually improve their microsurgical skills. the authors found this training method to significantly improve resident skill using the conventional microscope. though the tested sample was extremely small, this represents a potential option for residents and programs that have been forced to reduce resident participation in surgical cases due to the covid- pandemic. resident wellness one aspect of the covid crisis that has been largely overlooked in the neurosurgery literature is work to maintain resident wellness. in this time of crisis, it is widely acknowledged that extreme physical and emotional stresses are being placed upon medical trainees at all levels. trainees report stress regarding the physical risks posed by having to care for covid-positive patients , as well as the potential impact that covid restrictions may have on future career prospects. neurosurgical residency is demanding, , and while overall attrition rates are below average ( % between and versus % for general surgery residents), , it has been noted that low operative volume and outside social stressors are associated with higher rates of burnout. this raises concern for increased resident burnout rates during the covid crisis. to address resident burnout, multiple programs have previously implemented resident wellness initiatives (table ) . , , , in the setting of this covid pandemic, it would seem that these wellness initiatives would be increasingly important. previous initiatives outside the covid pandemic have include implementation of gym memberships, group exercise sessions, regular lectures on wellness ( al. in subsequent publications, this group reported that such interventions were seen by residents as "very important," with the vast majority reporting the interventions to have positive impacts on their physical and mental health. they also reported team-building efforts to increase team-cohesiveness, and to improve scores on previously validated measures of anxiety and sleepiness. in response to this, louisiana state university implemented a similar exercise program for residents at their new orleans campus; two-thirds of the residents reported the intervention to significantly improve their job satisfaction. implementation of a mindfulness- based initiative at the university of florida was similarly reported to improve resident motivation and conflict-handling abilities. along these same lines, since the pandemic began, our institution began offering all students and trainees free mental telehealth counseling to deal with some of the new challenges and stressors. in the setting of the current covid pandemic, many of these initiatives may not be possible. however, similar interventions using videoconferencing software (e.g. group online fitness classes, etc.) can help foster the same level of camaraderie that has been found to boost resident performance and quality-of-life. additionally, pds responding to our survey noted that virtual social gatherings, happy-hours, and similar such events via videoconferencing software can help bolster resident morale and sense of community. ammar et al noted similar effects in their report on efforts to maintain wellness amongst neurosurgical residents at a new york city program. they endorsed the increased use of check-ins between faculty and residents and between residents as a means of maintaining contact during these times of social distancing. the authors also reported offering child care resources and flexible work scheduling to help reduce resident anxiety about non-clinical concerns. in the present survey, we found only a minority of programs are currently providing these. limitations the present study has several limitations inherent to all survey-based research. first, we had only a % response rate to our survey. while this is relatively high for such survey studies, it is possible that novel educational interventions being employed at centers are not captured here. additionally, many questions were set up as multiple-choice questions to simplify responding. as this can miss some of the nuances of open-ended answers, we intentionally included some areas for free text response to capture additional details of the response. as a result, there may be interventions being employed at some programs that were missed. conclusion the covid- pandemic has led to drastic changes in neurosurgical training and overall resident experience. here we provide the results of a survey of program directors describing both the interventions being pursued to continue resident education and the changes in resident involvement. we find that most programs have experienced large drops in their case volume and are attempting to compensate by moving didactic lectures to teleconferencing software and increasingly incorporating educational resources from outside sources. additionally, most programs are reducing resident in-hospital time and reducing the number of residents in-house at any one time to reduce risk of covid exposure. we hope that these results can help create transparency and consistency across neurosurgery residency programs for the benefit of all current trainees, as well as generate consideration of how the common adaptations adopted rapidly by programs will impact how neurosurgical education occurs in the future. acknowledgement we would like to thank all program directors who responded to the survey. we appreciate their participation and hope that additional collaborations of this nature will help to foster a unified response to the covid pandemic. tables table : profile of responding programs table : changes in resident roles and deployment in response to covid pandemic table : changes in resident educational sessions in response to covid pandemic table : previously described resident wellness initiatives non-emergent, elective medical services, and treatment recommendations letter: for whom the bell tolls: overcoming the challenges of the covid pandemic as a residency program trends in united states neurosurgery residency education and training over the last decade letter: maintaining neurosurgical resident education and safety during the covid- pandemic letter: adaptation under fire: two harvard neurosurgical services during the covid- pandemic academic neurosurgery department response to covid- pandemic: the university of miami/jackson memorial hospital model letter: the coronavirus disease global pandemic: a neurosurgical treatment algorithm covid- and academic neurosurgery innovations in neurosurgical education during the covid- pandemic: is it time to reexamine our neurosurgical training models? research electronic data capture (redcap)-a metadata-driven methodology and workflow process for providing translational research informatics support the redcap consortium: building an international community of software platform partners proclamation on declaring a national emergency concerning the novel coronavirus disease (covid- ) outbreak. white house proclamations declaration of state of emergency and existence of catastrophic health emergency -covid- complimentary online education american association of neurological surgeons toward the development of -dimensional virtual reality video tutorials in the french neurosurgical residency program. example of the combined petrosal approach in the french college of neurosurgery neurosurgery videos on online video sharing sites: the next best teacher? free-access open-source e-learning in comprehensive neurosurgery skills training virtual reality-based simulation training for ventriculostomy structured online neurosurgical education as a novel method of education delivery in the developing world the use of simulation in neurosurgical education and training mobile applications in neurosurgery: a systematic review, quality audit, and survey of canadian neurosurgery residents efficient, and mobile way to train microsurgical skills during busy life of neurosurgical residency in resource-challenged environment we signed up for this!" -student and trainee responses to the covid- pandemic a neurosurgery resident's response to covid- : anything but routine impact of covid- on neurosurgery resident research training incorporation of a physical education and nutrition program into neurosurgery a comparison of the existing wellness programs in neurosurgery and institution champion's perspectives analysis of national trends in neurosurgical resident attrition prevalence and causes of attrition among surgical residents factors associated with burnout among us neurosurgery residents: a nationwide survey pursuit of balance: the upmc neurosurgery wellness initiative impact of a residency-integrated wellness program on resident mental health, sleepiness, and quality of life perspectives from a residency training program following the implementation of a wellness initiative managing a specialty service during the covid- crisis how question types reveal student thinking: an experimental comparison of multiple-true-false and free-response formats • gym memberships • mind-body wellness sessions • team workout sessions medical university of south carolina • exercise lectures • mind-body wellness sessions • primary care appointments and bloodwork • spouse support programs • team workout sessions • teambuilding exercises tufts medical center • financial wellness lecture series • holiday parties and social events • team bonding experiences university of florida • exercise lectures • mind-body wellness sessions university of minnesota • conflict resolution skill sessions • exercise lectures • personal development and career planning sessions • teambuilding exercises university of pittsburgh • faculty mentorship program • gym memberships • team workout sessions • wellness and mindfulness lectures vanderbilt • exercise lectures • gym memberships • leadership lectures • teambuilding exercises and trips wake forest • exercise lectures • gym memberships • mind-body wellness sessions • quarterly resident/faculty events • team workout sessions • teambuilding exercises sources supplementary figure . survey utilized for gathering program director input on changes to resident education following onset of the covid- pandemic. ( . ) key: iqr -interquartile range †health system defines as all hospitals in institutions health system that are staffed by the program's neurosurgery residents prior to onset of the covid- pandemic ‡case volume defined as proportion of pre-covid case volume key: cord- - yr pant authors: roth, lauren t.; lane, mariellen; friedman, suzanne title: a curriculum to improve pediatric residents' telephone triage skills date: - - journal: mededportal : the journal of teaching and learning resources doi: . /mep_ - . sha: doc_id: cord_uid: yr pant introduction: telephone triage systems are frequently used due to their success in decreasing emergency department utilization, reduction of health care costs, and high levels of satisfaction among patients and providers. despite phone triage's prevalence, few residency programs have designated curricula for residents to learn this vital skill. methods: we designed a phone triage curriculum initially piloted with senior residents at one of our continuity clinics. the curriculum consisted of a didactic session, a just-in-time simulation training session, and an experiential component of being on call during the ambulatory rotation. retrospective pre-post self-assessments evaluated resident perceptions of their skills in taking histories and triaging care over the phone in addition to obtaining qualitative feedback from faculty and residents immediately after the curriculum and – years postgraduation. results: of eligible residents, ( %) chose to participate in the pilot curriculum. residents reported that their skills in history taking over the phone improved from % to % and their ability to triage patients over the phone improved from % to %. this led to a quality improvement initiative to increase patient calls and has continued for years, with continued positive feedback from residents and attendings. discussion: phone triage skills are a necessity for pediatric providers, but few residency programs have training curricula in place. through an experience-based phone triage program, residents significantly improved their self-reported skills at history taking and triaging. similar curricula could easily be adopted at other institutions. due to a worldwide pandemic and shifting of medical resources, telephone triage systems are being utilized more than ever before. telephone triage systems are designed for patients and families to call and have their concerns addressed by a medical provider in an effort to determine whether they require emergent or urgent medical care. they are critical for risk management, are the cornerstone of demand-management, and provide patients with information to assist with decision-making regarding how to appropriately utilize health care services. both physicians and patients have reported high levels of satisfaction with telephone triage services. - by allowing families to call ahead for triage, providers can often eliminate the need for patients to attend in-person sick visits, which can decrease the need for patients and families to miss work or school. telephone triage services have been associated with reductions in emergency department utilization, particularly when available after hours. , , one study specifically showed decreased utilization of the emergency room by uninsured and medicaid patients, which can improve emergency room crowding and significantly decrease health care costs. referrals to the emergency room from telephone triage have been shown to be more appropriate than referrals from elsewhere, and the vast majority of families follow the advice provided, with compliance rates ranging from % to % for recommendations to be evaluated urgently or to be treated at home. , , patients often receive medication refills and referrals for specialty care through telephone triage, eliminating unnecessary inperson visits. thus, telephone triage systems have been shown to be a safe and efficient gatekeeper for health care resources. for many of these reasons, telephone triage systems continue to increase in prevalence. in , an estimated million u.s. citizens accessed telephone triage services, with an expected % increase per year. telephone triage accounts for nearly % of patient encounters in internal medicine and approximately % in pediatrics. the american academy of pediatrics reports that as of , % of pediatricians responded to all after-hours calls, % utilized a call center with an on-call physician, and % had registered nurses perform the initial triage with physician support as needed. even during office hours, office staff or nurses may answer calls, but the majority of pediatricians respond to these messages to triage patients over the telephone themselves. despite the widespread use of telephone triage by physicians, very few training programs have telephone triage curricula in place. , [ ] [ ] [ ] only % of residency programs in the u.s. provide training in telephone triage. in a survey of internal medicine program directors, the majority felt residents were not prepared to perform phone triage, with under % of faculty reporting residents being adequately prepared for these calls. in pediatrics, fewer than half of residency programs offer specific training in telephone triage. , residents have repeatedly cited telephone triage as a significant gap in their training and feel minimally prepared to manage problems by telephone after graduation. [ ] [ ] [ ] since the majority of physicians are required to provide some form of telephone triage, training them for this practice is vital for its success. in the few studies that have been published, specific training in telephone triage has been shown to improve history taking and patient management over the phone. , still, despite significant advances in technology and shifting practices to include more telephone triage, there have been no new published training materials since the early s. given this significant gap in the literature and a perceived gap in knowledge at our own institution, we developed a curriculum to help residents develop phone triage skills and experience taking after-hours phone calls at one of our pediatric continuity clinics. within our urban academic tertiary care hospital, residents see patients in one of four continuity clinics. at all sites, afterhours calls are covered by the attending physician faculty, who are the first line of triage. as part of the mandatory residency curriculum, all residents are required to complete a -month ambulatory rotation each postgraduate year. the telephone triage curriculum was offered to residents during this scheduled -month rotation at their designated continuity clinic. the curriculum was initially optional and piloted with second-and third-year residents at one of the four practice sites in our ambulatory care network. at this site, there are eight attending physicians and residents. residents who opted into the curriculum were assigned to be on call night per week over the course of their -week rotation, thereby having the opportunity to have nights of practice performing phone triage. each resident was assigned a faculty member as backup to assist with any questions that arose and to provide feedback at the end of each session. learners were expected to have some general pediatrics knowledge but no prior experience performing phone triage. the curriculum was designed utilizing kern's six-step approach to curriculum development for medical education. a general needs assessment was based on a literature review, which showed a significant gap in current evidence and material on this topic. at our institution, a targeted needs assessment was based on faculty perceptions and resident desire. all attending physicians surveyed were interested in having residents take call with them and felt that training was necessary for residents to perform telephone triage. we developed goals and objectives based on provider feedback and ensured they upheld the requirements outlined by the accreditation council for graduate medical education for continuity clinic experience. we reviewed various educational strategies and designed the curriculum to be implemented in three parts: a didactic educational session, a secondary one-on-one training prior to initiating call, and the experiential component of being on call for nights during the rotation. given scheduling restraints, we knew that a single lecture for all residents likely would not suffice since each resident had ambulatory rotation at different times during the year. given these scheduling restraints, we decided to combine the didactic session with just-in-time training, which has been shown to be an effective tool for improving clinical skills and is perceived favorably by residents. [ ] [ ] [ ] prior studies have shown that simulation and role-play in telephone triage improve resident history taking and overall management, , , so we aimed to develop a just-in-time training simulation prior to residents taking call. we then piloted the curriculum with a small subset of residents and revised it based on quantitative and qualitative evaluations. the didactic session was a -hour conference for all residents scheduled during their daily educational lecture time. this conference aimed to disseminate telephone triage skills facilitated by a powerpoint presentation and cases to review common scenarios (appendix a). it was designed to be interactive and appropriate for medical students and residents. an element of role-play was used for the various cases even in this large-group setting. either individual residents alternated role-playing the on-call doctor or multiple residents played the same role at once. thus, the conference could be done with both small and large groups. our didactic session was led by a continuity clinic preceptor with experience in telephone triage who utilized a detailed step-by-step facilitator guide (appendix b). using this guide, the conference could be led by any physician with some knowledge of general pediatrics and experience in telephone triage. a second one-on-one just-in-time training was then given to select residents prior to them starting to take call (appendix c). before their first night of call, residents met one-on-one with one of the faculty members to receive an introduction to phone triage, discuss the logistics of taking call, and review triaging techniques. this meeting included common types of calls, specific skills and techniques for accurately assessing the patient over the phone, and discussion of the triage process. the training was led by the faculty member as a question-and-answer session to ensure the resident understood the basic process and how best to assess the history and physical exam findings over the phone. additionally, the faculty member reviewed multiple practice cases via simulation of a call to ensure the resident felt comfortable and would be prepared for a variety of scenarios. the cases simulated were based on prior studies outlining the most common chief complaints from patient calls. , the residents were given a copy of this information for reference in addition to a one-page cheat sheet for quick reminders (appendix d). the experiential component allowed residents to be on call night per week during the course of the -week ambulatory rotation. this entailed providing the clinic's telephone triage system with the resident's direct phone number so the resident could be easily accessed between the hours of : pm and : am. any patient who called during those hours was forwarded to the resident on call. residents were expected to answer any clinical questions and to triage the patients' needs. depending on the complexity of a patient's issue, residents could engage with the assigned faculty member after each call or summarize the next morning to ensure their responses were appropriate and to ask any questions that may have arisen. the following day, residents had the opportunity to debrief all of their calls with a faculty member to ensure maximum skill development. to evaluate the curriculum, we utilized retrospective pre-and postsurveys, which are particularly useful when developing a brand-new curriculum because learners often "don't know what they don't know" and can end up using different internal standards when completing evaluations in the traditional preand postexperience manner. [ ] [ ] [ ] they are also a good method of evaluation to prevent compromising anonymity when there is a small sample size. residents who participated in the curriculum completed a retrospective pre-and postexperience self-assessment of skills and perceptions of the program with a qualitative free-text assessment (appendix e). utilizing a point likert scale, they were asked to evaluate how well they were able to take a history over the phone from a parent both before and after taking ambulatory call, in addition to how well they could appropriately triage a patient over the phone both before and after taking call. they were also asked how well the sessions prepared them for their call and whether they would take ambulatory call if offered again. finally, there was a free-text assessment for any additional comments. the same self-assessment was administered to a convenience sample of residents who received only the didactic portion of the curriculum and did not receive the one-on-one training or participate in ambulatory call (appendix f). these responses were compared with the select residents who had completed the full curriculum and engaged in the after-hours call system to ensure the responses were similar to the study group's retrospective responses, thus eliminating the possibility of recall bias (since the assessments were retrospective) or selection bias (since the study was optional). lastly, we surveyed all general pediatricians and fellows in pediatric specialties who participated in later iterations of this experience for qualitative feedback and relevance to their current practice. preceptors who participated in the phone triage program were also surveyed regarding their experience and perceived skills of the residents. eleven residents were eligible to participate in this optional curriculum. they were second-or third-year pediatric residents who did their ambulatory rotation at the washington heights family health center pediatric practice. of the eligible residents, ( %) chose to participate in the telephone triage curriculum. one hundred percent of these residents completed the end-of-curriculum assessment. six were pgy , and four were pgy . of these residents, % went on to careers in general pediatrics. baseline responses from the residents who completed the curriculum (n = ) were compared with a convenience sample of residents (n = ) who participated in only the didactic portion to ensure there was no selection bias when compared to the residents who opted into the curriculum. this was also done to assess for recall bias in those who completed the curriculum. at baseline, only % of residents who completed the curriculum and % of the convenience sample reported that they could take a history over the phone well or very well (p = . ). additionally, at baseline, % of residents who completed the curriculum and % of the convenience sample reported that they could triage patients over the phone well or very well (p = . ). thus, there was no significant difference in the perceived knowledge and skills of residents who did not complete the curriculum or who did but reported their precurricular attitudes retrospectively. after the full curriculum, % reported that they could take a phone history well or very well compared with the baseline % (p < . ). additionally, after the curriculum, % of residents reported they could triage patients over the phone well or very well compared with the baseline % (p < . ). three residents did not have a one-to-one review session immediately prior to taking call due to logistical reasons, and two of the three stated they would have liked one. one hundred percent of residents who had the one-on-one session with a preceptor felt well prepared to perform phone triage. nine residents ( %) stated they would take ambulatory call again if offered, and one ( %) felt neutral. qualitative feedback was elicited from the residents who participated in the pilot curriculum immediately after the experience. since this curriculum continued for years, residents who participated in later iterations of the curriculum were surveyed - years after graduation to determine its impact on their careers in both primary and specialty care. attending physicians who precepted residents in phone triage were also surveyed regarding their interest in the program and their perceived skills of the residents. common themes included the benefit of the experience, its applicability to a variety of specialties, skill gained, and the need to continue and spread the program (see the table) . as part of the formal ambulatory rotation's evaluation, one resident specifically highlighted the telephone triage system: "overnight call was a good learning experience." attending physicians also provided feedback on how to improve the educational experience for the residents, such as by setting clear expectations about when to call the attending, assessing the experience of the resident to determine how much autonomy to provide, evaluating specific concerns and learning interests ahead of time, and increasing the exposure overall. almost all residents and faculty members were interested in seeing this curriculum continue and expand. this led to the development of a clinic-wide, resident-led quality improvement project to increase the number of patient calls, not only to improve residency learning through increased experience but also because a gap in patient care was seen. this quality improvement project was a -year effort to decrease emergency department utilization by enhancing the phone triage program. the average baseline number of calls was . per week and increased to . per week, with a peak of calls throughout this initiative. telephone triage is now a mandatory part of the curriculum, and over residents have participated. phone triage skills are a necessity for pediatric providers, but few residency programs have training curricula in place. through a simulation-and experience-based phone triage curriculum, residents significantly improved their self-reported skills at taking patient histories and triaging patients over the phone. implementation of this curriculum was met with positivity from both residents and faculty, and postgraduates in both primary care and various specialties have cited the importance of the curriculum in their daily practice and the desire for further training. faculty members need only to have some experience performing phone triage and general pediatrics knowledge in order to train residents on these necessary skills. some of the lessons we learned while developing this curriculum are that not all possible patient concerns could be addressed and practiced prior to residents performing telephone triage. thus, residents were often required to use prior knowledge, skills, and experience to triage phone calls with the option of calling their attending if they had any questions. additionally, call volume varies significantly from day to day, so we could not guarantee how many patient calls a resident would answer in a given night. positive experience "good experience for residents." "good opportunity and exposure that we don't get elsewhere in residency." "being able to take after hours calls as a resident with an attending as backup was an immensely valuable experience." "i really enjoyed the experience because it was a different kind of challenge to assess a situation over the phone with no face to face contact." "[residents are] excellent. do not need to micromanage." "residents should participate in phone triage. it is an excellent preparation for telemedicine." applicability "i think it would be very valuable for anyone, particularly those going into primary care." "good experience at something we will have to do regardless of specialty." "telephone management and triage of pediatric problems is a large part of my daily practice. it is a challenging skill, but one that i have found to be of utmost importance in bringing children the care they need." "as an attending who has now been on call via telephone many times, i can truly appreciate the extra training as telephone calls involve new skills we are not exposed to during residency." "it is important for residents to learn. no matter what specialty residents go into they will need to be able to respond to patient phone calls." "i think it is important for residents to gain confidence in phone triage. it will help with primary care but also make them more confident about dealing with issues after hours even if they go into a specialty." skills attained "helped me learn how to ask questions over the phone to get the information needed to triage." "forces one to think quickly about disposition/triage without seeing the patient." "i had the chance to think critically about my comfort level with patients staying home versus seeking further care." "the phone triage curriculum was instrumental in developing my comfort and confidence in being on call... i received calls across a wide range of outpatient pediatric issues... and was able to think about my own management plan in real time." "i learned how to ask for verbal confirmation of specific exam findings without being able to see the patient." "i think that phone triage is an essential skill for training. it allows the resident to assess symptoms and signs from families and make real time assessments of who needs to be seen, who can be deferred to the next day and give real time advice. these skills also translate into subspecialty care where providers perform phone triage with families/patients." "[phone triage] is a test of their investigatory and communication skills." further spread "i wish we had more calls so we could practice more." "please keep [this curriculum]... everyone should have the option." "there should be more training in phone triage as a medical skill in residency." "part of my job now is taking calls from eds across the region for potential transfer, and triaging a patient without seeing them is a totally unique skill that i wish i had done more of in residency" "it should be part of their rotation in ambulatory" "it would be good to know what residents are concerned about when they take phone calls-what they view as challenging calls and then we can give them feedback or guidance accordingly." "[residents] would benefit from increased experience." abbreviation: ed, emergency department. this is similar to a resident continuity clinic where the patient show-rate often varies. given the interest in furthering these skills, we have made significant efforts to increase the number of patient calls. the curriculum would be more robust if residents had multiple opportunities to practice ambulatory call throughout the year, in addition to expanding to include specialties that frequently use telephone triage. through verbal feedback, we learned that residents found the one-on-one training much more impactful than the larger didactic session since the former was easier to schedule and occurred closer to the experiential component. the didactic portion is now utilized to introduce the curriculum and garner early buy-in from residents. we also learned the importance of preceptors being very clear about their expectations for support (i.e., whether to contact them after every call or at set times in the night, or to debrief in the morning) since preceptors and residents all vary. the simulation is also best done when the facilitator knows the resident well, since the facilitator can more easily assess the learner and tailor the cases to the learner's baseline skill level. as residents gain more experience in telephone triage, the just-in-time training works best when they can build on their prior experiences and refer back to specific calls they have received. this study was limited by its very small sample size-only residents initially piloted the curriculum. however, given the overwhelmingly positive feedback based on this pilot study, the curriculum was spread to all other continuity clinics within our ambulatory care network and is now a mandatory part of the resident curriculum. we did not continue pre-and postexperience evaluation but instead made changes based on real-time feedback. this curriculum has now been used for years, with of those years being a formal quality improvement project to increase patient calls and decrease emergency room utilization that was very successful. another limitation to this study is that we did not formally evaluate all of the objectives. we assessed perceived improvement in history taking and triage as opposed to an actual skills assessment, which would have made the data stronger. in reality, when preceptors perform the just-in-time training, they continue to go through cases and debrief any incorrect management plans until the resident has a clear understanding of the appropriate plan, although this is not formally evaluated. future efforts could focus on performing true skills assessments through either simulation or faculty observation. finally, since our pilot curriculum was optional, the residents who chose to participate may pose a self-selection bias in that they may have been more interested and motivated in learning the skills necessary to triage patients over the telephone. however, after spreading this curriculum to all continuity clinics, nearly all residents have stated they were interested and motivated in improving their phone triage skills. telephone triage has been used in medical practices for decades, but it is now rapidly expanding in the covid- pandemic due to decreasing face-to-face visits to minimize exposure, as well as public fear of viral spread. telephone triage systems allow providers to offer reassurance and answer questions while patients and families remain safely at home. more importantly, providers can assess whether there is a true emergency and emphasize the importance of seeking care during a time when families may fear to utilize the medical system. full virtual appointments are now becoming readily available, but in order to effectively practice telemedicine, providers must be able to triage which patients are eligible for a virtual as opposed an to in-person visit. as technology advances and telemedicine becomes more widespread, training physicians for telephone triage is vital for its success. we believe this curriculum can be universally applied regardless of specialty. almost every specialty uses telephone triage in some capacity. many specialties utilize triage similarly to primary care in that patients can call directly [ ] [ ] [ ] ; some use phone triage when speaking with other health care providers in efforts to determine patient acuity when being referred to the emergency room or need to transfer between hospitals. while this practice may be different from speaking to patients, learning the skill of triaging without performing an in-person history and physical exam is still vital to its success. even in clinics that utilize a call center or nurse as the first line of triage, a physician almost always plays some role in the triage process, often as the final voice. in qualitative feedback, fellows in various specialties who completed this curriculum all expressed gratitude for the experience, and many stated they would have liked more experience prior to fellowship and believe we should continue and broaden this program for future residents. overall, this curriculum showed a significant improvement in resident-reported skills in taking patient histories and triaging over the phone. we believe this curriculum is very important for resident education of phone triage skills and could be easily adopted by other institutions. most pediatric practices already have a phone triage system in place, so adapting it to involve residents is likely a broadly achievable goal. as a result of this pilot curriculum, residents from all clinic sites in our ambulatory care network are now required to participate in the program and continue to express interest and positive outcomes from their training experience. as technology advances and health care utilization continues to shift, training physicians to perform this vital skill should be a priority across residency programs. telephone triage: white paper of the american college of physicians-american society of internal medicine. american college of physicians after-hours telephone coverage: the application of an area-wide telephone triage and advice system for pediatric practices evaluation of emergency department referrals by telephone triage ed utilization by uninsured and medicaid patients after availability of telephone triage pediatric residents' telephone triage experience: do parents really follow telephone advice? how safe is triage by an after-hours telephone call center pediatric resident training in telephone management: a survey of training programs in the united states periodic survey # telephone care telephone management training in internal medicine residencies: a national survey of program directors telephone management curriculum for pediatric interns: a controlled trial a survey of the structure and function of pediatric continuity clinics the university of massachusetts medical center office-based continuity experience: are we preparing pediatrics residents for primary care practice? training gaps for pediatric residents planning a career in primary care: a qualitative and quantitative study pediatric residents' continuity clinics: how are we really doing? development and evaluation of a cd-rom computer program to teach residents telephone management pediatric residents' telephone triage experience: relevant to general pediatric practice? curriculum development for medical education: a six-step approach exploring the value of just-in-time teaching as a supplemental tool to traditional resident education on a busy inpatient pediatrics rotation using just-in-time teaching and peer instruction in a residency program's core curriculum: enhancing satisfaction, engagement, and retention qualitative evaluation of just-in-time simulation-based learning: the learners' perspective an assessment of pediatric after-hours telephone care: a -year experience starting at the end: measuring learning using retrospective pre-post evaluations. aea blog the retrospective pre-post: a practical method to evaluate learning from an educational program response-shift bias: a problem in evaluating interventions with pre/post self-reports standardization of telephone triage in pediatric oncology after-hours call center triage of pediatric head injury: outcomes after a concussion initiative resident responses to after-hours otolaryngology patient phone calls: an overlooked aspect of residency training? laryngoscope key: cord- - nhmusm authors: ricciardi, gabriella; biondi, raoul; tamagnini, gabriele title: go back to the basics: cardiac surgery residents at the time of covid‐ date: - - journal: j card surg doi: . /jocs. sha: doc_id: cord_uid: nhmusm nan indeed, if we put the focus on surgery residents' training, things get further complicated. the best way to improve surgical skills is, of course, practicing in the operating room. nonetheless, presently trainee's schedule has been disrupted in most of the university hospitals. in fact, the number of intensive care unit (icu) beds and ventilation sites has been limited due to their commitment to the covid-patients' handling. therefore, the surgical activity has been redirected towards emergent, urgent, and not delayable cases. eventually, due to the inhospital risk of disease transmission, the number of working doctors has been restricted and some providers have been moved to hospital areas in dire need of physicians experienced in caring for critically ill patients. the post-covid- training schedules, as expected, have been switched towards a different model. giving this challenging setting, surgery residents assisted in a mandatory shift from regular practice in the operation theatre to "home-sitting" and remote meetings and discussions. for sure, their field of interests had to expand to epidemiological, immunological, and pneumological concepts. whether it is true that the pandemic and the correlated diseases still escape complete comprehension of the mechanisms of spreading and tissue-damaging, then every surgery resident, who wants to keep up with this new reality, has to dive deep down into the recent broad literature production hence, how could we, on this as residents, take the pandemic "special" scenario with a grain of salt? it turns out the daily routine should be assessed out of the operation room, trying to get the best from this experience and seizing the opportunity to invest energies and the "extra" leisure on those activities we don't usually have time enough for. on the basis that we are still "rookie" surgeons, regardless of our individual advance in a career, a thorough knowledge of the pathophysiology and the surgical procedures and techniques related to the commonest disorders is crucial. thus, this seems to be the right circumstance to go back to our desk and study, simply opening the "old but not quite gone" heavy and dusty books, and also to work up our personal skills. actually, out of this historical crisis could come a moment of enthusiasm, dedication, creativity, innovations, and ideas. so, we should take out "pen and paper", or laptops, for the high-tech addicted, and get our thinking caps on: time has come to go deeply in scientific literature, write on a new subject or draw/sketch about anatomy or surgery, to mention just a few, taking benefit likewise from the powerful internet-based libraries. the social media platforms (some), such as linkedin or twitter, provide an excellent example of the unique opportunity of coupling personal professional advancement with up-to-date technological breakthroughs. hcps achieve from the some tools to share information, to discuss about healthcare policy and practice issues, to promote health behaviors, to engage with the public, and to educate and interact with patients, caregivers, students, and colleagues. and provide health information to the community. the role of these networks is undisguised also from the pandemic perspective since they have been used by world-famous iconic surgeons and doctors to popularize educational daily tips in form of "tweets" or short messages about the disease itself, the way it spreads, the measurements to minimize its diffusion and other related virus-issues. beyond chasing a deeper knowledge into our specialty, some of us also chose (or have been forced, given the circumstances) to be personally involved in treating covid- patients. though at the beginning this appeared just as a different and more selfless way to use our will and time, straightaway it turned out it was a brave leap from our usual training setting. we are facing a crude reality, in which a still elusive disease sustains a lethality rate of . % in the to -yearage group and % in the to one (data from istituto superiore di sanità, italy). those bare numbers do not account for the frustration of treating a patient without a validated therapy. aside not being academically prepared to face the sars-cov- pandemic, we perhaps stumbled on our psychological stability: the "usual" setting does not prepare us for such a highly lethal disease, against which we are almost helpless. however, after few days of blue mood, the instinct to survive prevails and teaches us the real meaning of resilience: "get up and try, try" should not be just a chorus, but an everlasting lesson for our career. beyond professional and logistical thoughts, despite the self-centered universe in which we usually work and live, we found out and realize how deeply human we are today. the sudden solitary confinement we were dragged into ended up to be an optimal starting point to mug the compulsory burnout of our reality. long duty hours, multiple consecutive shifts, and the price of now that we are entering the so-called "phase two" the given setting is changing again. first of all, the number of covid- patients is slowly decreasing, as well as the number of dedicated icu beds. on the other hand, the virus will remain endemic in the society, with an estimated r value below . as expected, there will be a chance to resume the elective surgical procedures, but especially in this moment, we need a keen eye on deciding which pathologies have to be treated with priority. for example, coronary artery disease showed a higher mortality rate in patients affected by covid- , but it's, however, reasonable to think that all the cardiac pathologies affecting the lung circulation-such as symptomatic severe mitral diseases or aortic stenosis-might deserve a priority access to treatment, to increase the survival rate in case of an acquired-coronavirus infection later on. to the point, the covid- era is teaching us, as doctors and residents, that we are scientists before anything else. as such, medicine is not meant to be experienced passively, but it should be learned with an ever-increasing passion to understand deeply the diseases' mechanisms and the rationale supporting therapies and decisions. as surgeons, even more. it's plain that we feel the hunger to get a knife in our hands all the time. anyway, suturing and sewing is not the only way we can improve as physicians and-especially so-our human side. simply cutting and closing wounds, in a moment in which we are being called upon to show maturity and wisdom, could sound more like a whim. one of the lessons you learn during your surgery fellowship is that our specialty is really multilayered and complex. awareness of the real meaning behind the mere surgical act of stitching reaches out to gain an insight into our resilient role in this emergency. getting through the "childish" need and desire to improve our handy skills, we found ourselves far from the leading actors of this pandemic, alone with our desires and ambitions. in that setting the appropriate adult reaction is to develop our future character, that is the best surgeon we could be. covid- : uk lockdown is 'crucial' to saving lives, say doctors and scientists the positive impact of lockdown in wuhan on containing the covid- outbreak in china cardiothoracic education in the time of covid- : how i teach it a social media primer for professionals: digital dos and don'ts dangers and opportunities for social media in medicine the authors declare that there are no conflict of interests.f i g u r e a authors' brain-storming session on a conference call http://orcid.org/ - - - key: cord- -x uxdi authors: daniel, dennis a.; poynter, sue e.; landrigan, christopher p.; czeisler, charles a.; burns, jeffrey p.; wolbrink, traci a. title: pediatric resident engagement with an online critical care curriculum during the intensive care rotation* date: - - journal: pediatr crit care med doi: . /pcc. sha: doc_id: cord_uid: x uxdi residents are often assigned online learning materials as part of blended learning models, superimposed on other patient care and learning demands. data that describe the time patterns of when residents interact with online learning materials during the icu rotation are lacking. we describe resident engagement with assigned online curricula related to time of day and icu clinical schedules, using website activity data. design: prospective cohort study examining curriculum completion data and cross-referencing timestamps for pre- and posttest attempts with resident schedules to determine the hours that they accessed the curriculum and whether or not they were scheduled for clinical duty. residents at each site were cohorted based on two differing clinical schedules—extended duration (> hr) versus shorter (maximum hr) shifts. setting: two large academic children’s hospitals. subjects: pediatric residents rotating in the picu from july to june . interventions: none. measurements and main results: one-hundred and fifty-seven pediatric residents participated in the study. the majority of residents ( / ; %) completed the curriculum, with no statistically significant association between overall curriculum completion and schedule cohort at either site. residents made more test attempts at nighttime between pm and am ( , / , ; %) regardless of whether they were scheduled for clinical duty. approximately two thirds of test attempts ( , / , ; %) occurred when residents were not scheduled to work, regardless of time of day. forty-two percent of all test attempts ( , / , ) occurred between pm and am while off-duty, with % ( / , ) occurring between midnight and am. conclusions: residents rotating in the icu completed online learning materials mainly during nighttime and off-duty hours, including usage between midnight and am while off-duty. increasing nighttime and off-duty workload may have implications for educational design and trainee wellness, particularly during busy, acute clinical rotations, and warrants further examination. i n busy clinical rotations such as the icu, patients, diagnoses, and clinical acuity vary between rotations, and limited time and competing demands are common for both trainees and faculty ( ) . supplementing the icu rotation experience with a blended online educational curriculum may help improve knowledge and ensure consistent exposure to core content ( ) , but these resources are often superimposed on the demands of patient care and other educational experiences ( ) . for our icu residents, we designed curricula that included short videos with pre-and posttests and hypothesized that residents would use these materials most frequently during breaks in patient care while on clinical duty. however, there is a lack of previously published data that describe when and to what extent resident physicians complete online materials during icu rotations. such understanding would help inform decisions about how to best implement educational interventions for residents rotating in the demanding, high-acuity clinical setting of the icu. we conducted a prospective cohort study examining junior (post-graduate year ) resident use of online curricula during their first rotation in medical-surgical picus at two large academic children's hospitals (boston children's hospital and cincinnati children's hospital) that are similar in size, patient population, and resident scope of responsibility. this study was approved by the institutional review boards at both sites. icu resident rotation directors created individualized curricula for each site that covered core concepts in pediatric critical care medicine. both sites also provided in-person educational experiences (bedside teaching, didactic lectures, and manikin-based simulations). site delivered in-person education between : and : every weekday, and site did so between : and : every monday through thursday. we administered the online curricula from july to june at site and june to june at site . neither site provided protected time for curriculum completion. although residents were informed of the expectation to complete curricula by the end of their icu rotation, there were no formal consequences for failing to complete. at both sites, residents were e-mailed weeks before their rotation and instructed to complete the curriculum before the end of their icu rotation, with e-mail reminders provided at rotation weeks , , and . residents were excluded from the time-of-use analysis if their daily schedule data were unavailable. curricula were delivered on openpediatrics (www.openpediatrics.org), which is based at site . each lesson contained a pretest, video, and posttest. the curriculum contained lessons at site and lessons at site . individual lesson videos ranged in length from to minutes (average length min). the total curriculum video duration at site was hours, minutes and at site was hours, minutes. the website required strictly linear progress; a pretest, then video, then posttest for each lesson needed to be completed before a resident could progress to the next lesson. residents were only able to take the pretest once, but posttests could be attempted multiple times until the minimum passing score (≥ %) was achieved. the platform allowed residents to stop and restart within preor posttests, as well as within videos, if they did not complete a given item in one sitting. during the study interval, residents worked within two different clinical schedules as part of a concurrent trial of resident physician work hours randomized order safety trial evaluating resident schedules ( ), where each schedule operated for year of clinical rotations at each site. one schedule cohort involved daytime and nighttime work shifts limited to a maximum of hours of duration, whereas the second involved traditional extended duration (> hr) work shifts, with daytime shifts alternating with extended duration work shifts every fourth night. on average, residents worked about % more hours per week on the extended duration work schedule ( ) . throughout this article, we refer to these differing schedule cohorts as "short call" and "long call". we collected curriculum completion data for each resident and timestamps for every pre-and the first posttest attempt that occurred during the icu rotation and in the days preceding. we did not include test attempts occurring prior to the icu rotation in the time-of-use analysis due to the significant heterogeneity in resident clinical rotations immediately prior to the icu rotation. we only included the first posttest attempt to avoid over-representing a given time of day if a user attempted a posttest multiple times. video viewing activity is captured only in aggregate, deidentified fashion on the platform, so individual video view timestamps were not available for specific residents. for test attempts during the icu rotation, we cross-referenced timestamps with each resident's schedule to determine whether or not they were scheduled for clinical service in the hospital. we calculated frequencies and percentages for resident and site characteristics and compared data between cohorts and between sites using chi-square tests of independence using a significance level of . . data were analyzed using stata/se . (statacorp, college station, tx) and microsoft excel (microsoft corp., washington, dc). during the study, residents rotated through the icu for the first time, and % ( / ) accessed the curriculum. fifty-three percent of residents ( / ) accessed the curriculum during the icu rotation at least once while on duty. seven residents at site accessed the curriculum during the rotation but did not have daily schedule data available for analysis. we included residents ( / ; %) in the time-of-use analysis. there were no statistically significant differences in demographic characteristics (gender or residency track) between the two sites or between the schedule cohorts within each site. sixty-eight percent of residents ( / ) completed the curriculum ( table ) . a greater percentage of residents completed the curriculum at site ( / ; %) compared with site ( / ; %), p value of less than . . there was no statistically significant association between overall curriculum completion and schedule cohort at either site. we included , test attempts by residents from the two sites in the time-of-use analysis. of the test attempts made during clinical duty, % ( / , ) occurred during daytime shifts versus % ( / , ) at night. approximately two thirds of test attempts ( , / , ; %) occurred when residents were not scheduled to work, regardless of time of day. approximately two thirds of all test attempts ( , / , ; %) occurred during nighttime hours (between pm and am), regardless of work status (fig. a) of all test attempts occurring between midnight and am while residents were not scheduled to work. we observed an association between time-of-use patterns and schedule cohort at site but not at site . at site , residents in the long call cohort used the curriculum more during nighttime hours ( / ; %) compared with residents in the short call cohort ( / ; %), p value of less than . . the long call cohort also used the curriculum more during times when they were not scheduled to work ( / ; %) compared with the short call cohort ( / ; %), p value of less than . . figure b displays the distribution of test attempts by day of rotation, ranging from days prior to the start of the rotation to days after the start date. for test attempts within the icu rotation, a greater proportion occurred in the second half of the rotation ( , / , ; %) versus the first half ( , / , ; %). three hundred and forty-eight additional test attempts occurred prior to the start of the rotation, the majority of which ( / ; %) were in the days immediately prior. using years of timestamped online learning data from two large pediatric residency programs, we found that the majority of residents in our study accessed a supplemental online curriculum during the icu rotation. however, despite designing the icu curriculum to include short lessons that could be completed during breaks from clinical work while on duty, only half of the included residents accessed the curriculum during clinical periods, and they frequently chose to use the materials during nighttime hours and when not scheduled to work clinically. notably, % of test attempts occurred between midnight and am while residents were not scheduled to work. test attempts were made immediately prior to, and throughout the rotation, with a majority occurring in the second half of the rotation. the inconsistent association of completion rate or time of use with schedule cohort makes it less likely that the type of schedule is a main contributor to online curriculum engagement. because both sites provided in-person educational experiences during most workdays in addition to the online curriculum, it is possible that residents were biased against completing online materials while on-duty, since other materials were already being presented during on-duty hours. other studies have supported the notion that medical learners often prefer online learning to be supplementary to in-person learning experiences ( , ) . the greater proportion of on-duty use at night compared with during the daytime may be a consequence of the greater volume of clinical care demands requiring resident attention during the day, including but not limited to rounds and scheduled admissions. the greater number of test attempts in the second half of the rotation may reflect residents catching up on incomplete lessons before the end of the rotation or may be related to residents focusing on getting comfortable in the clinical environment before turning their attention to self-directed learning. several studies have highlighted successful implementation and outcomes of online medical learning, noting improvements in knowledge ( ) and perceived utility and satisfaction from clinicians and instructors ( ) . however, although residents have always incorporated self-directed learning at night and during off hours, blended learning models that increase trainees' obligatory nonclinical workload outside of dedicated educational time may have a different impact. despite our intention to provide short lessons that would provide education during breaks from patient care, residents accessed the curriculum more often during nonclinical hours. previous reports have commented on the need to consider the distinct time constraints and serviceeducation task conflicts in graduate medical education ( ) and on the risk of creating information overload when educational content is shifted to the online environment ( ) . increases in workload added to preexisting stressors of the clinical learning environment can contribute to resident physician burnout ( , ) and sleep deprivation. sleep deficiency is known to adversely impact resident clinical performance ( ) and increases risk of physical harm, such as motor vehicle crashes ( ) and needlestick/sharps injuries ( ) . therefore, program and rotation directors of busy, inpatient rotations may need to consider alternative approaches to implementing online learning, such as incorporating protected time to complete curricula; making the curriculum optional or controlling the volume of content shifted to the asynchronous, self-directed setting ( , , ) . our study has several important limitations. as this was a purely an observational study, we did not qualitatively assess resident motivations for why they accessed the curricula at the times they did nor did we formally survey participant satisfaction with the curriculum or any potential impact on their wellness. these are important areas that warrant further investigation. additionally, not all residents completed the online curricula, and rates of curriculum completion differed between the two sites despite having identical procedures to encourage completion. this may reflect differences in willingness to engage with online curricula during clinical rotations between residents and between the two sites, which may have led to a sampling bias. interestingly, despite the fact that openpediatrics (https:// www.openpediatrics.org/) is primarily based at site , curriculum completion rate was lower at that site, suggesting that there was not increased pressure among residents to use the platform due to the shared institutional affiliation. although we have no reason to suspect differences in resident roles or workload between the sites, we did not directly assess this either. curricular length has also been described as a barrier to curriculum completion ( , ) ; however, we observed higher completion rates by residents at the site with the longer curriculum. our data show that residents will engage with online learning materials during and immediately prior to their icu rotation but do so most often at nighttime and when off-duty, with a portion of use occurring during midnight and am while offduty. this may have implications for resident well-being, including sleep, personal life disruptions, and/or burnout, and warrants further examination. program and rotation directors will need further guidance on how best to implement blended learning models in busy clinical rotations, such as the icu. we wish to thank the residents at boston children's hospital and cincinnati children's hospital for their participation in this study, as well as the administrative staff at both hospitals and at openpediatrics who provided coordination and support for this study. drs. poynter's, landrigan's, and czeisler's institutions received funding from the national heart, lung, and blood institute (nhlbi), and they received support for article research from the national institutes of health. dr. landrigan received funding from midwest hospital association/executive speakers bureau and midwest lighting institute; he reports receiving grants from patientcentered outcomes research institute, consulting fees, and equity from the i-pass patient safety institute, and consulting fees from virgin pulse; and he has received monetary awards, honoraria, and travel reimbursement from multiple academic and professional organizations for teaching and consulting on sleep deprivation, physician performance, handoffs, and safety and has served as an expert witness in cases regarding patient safety and sleep deprivation. drs. landrigan and czeisler report being principal investigators of the randomized order safety trial evaluating resident-physician schedules, which is supported by grants (u -hl- and u -hl- ) from the nhlbi. dr. czeisler serves as the incumbent of a harvard medical school professorship that was endowed in by cephalon, inc., which has been since been acquired by teva pharmaceutical industries ltd., and he is supported in part by funding from the national institute of occupational safety and health r -oh- . dr from ganésco and zurich insurance, and fees for serving as a member of an advisory board from the institute of digital media and child development and the klarman family foundation, holding a number of process patents in the field of sleep and circadian rhythms (e.g., photic resetting of the human circadian pacemaker) and an equity interest in vanda pharmaceuticals, being the incumbent of an endowed professorship provided to harvard university by cephalon, receiving fees for serving as an expert on various legal and technical cases related to sleep or circadian rhythms from casper sleep, comair/delta airlines, complete general construction, fedex, greyhound, hg energy, purdue pharma, south carolina central railroad, steel warehouse, stric-lan, texas premier resources, and united parcel service, and receiving royalties from the new england journal of medicine, mcgraw-hill, houghton mifflin harcourt/penguin, and from philips respironics for the actiwatch and actiwatch spectrum devices. dr. czeisler's interests were reviewed and managed by brigham and women's hospital and partners healthcare in accordance with their conflict of interest policies. the remaining authors have disclosed that they do not have any potential conflicts of interest. this study was approved by the institutional review boards at both participating sites prior to data collection and analysis. for information regarding this article, e-mail: dennis.daniel@childrens.harvard.edu balancing service and education in residency training: a logical fallacy flipped classrooms in graduate medical education: a national survey of residency program directors a systematic review of the effectiveness of flipped classrooms in medical education rosters study group: design and recruitment of the randomized order safety trial evaluating resident-physician schedules (rosters) study effects on resident work hours, sleep duration, and work experience in a randomized order safety trial evaluating resident-physician schedules (rosters) blended learning: how can we optimise undergraduate student engagement the effectiveness of online and blended learning: a meta-analysis of the empirical literature internet-based learning in the health professions: a meta-analysis the impact of e-learning in medical education flipping out: does the flipped classroom learning model work for gme? twelve tips for "flipping" the classroom a narrative review on burnout experienced by medical students and residents effect of reducing interns' work hours on serious medical errors in intensive care units extended work shifts and the risk of motor vehicle crashes among interns resident wellness matters: optimizing resident education and wellness through the learning environment effects of health care provider work hours and sleep deprivation on safety and performance advances in medical education and practice: student perceptions of the flipped classroom impact of required versus self-directed use of virtual patient cases on clerkship performance: a mixedmethods study efficacy of an asynchronous electronic curriculum in emergency medicine education in the united states massive open online course completion rates revisited: assessment, length and attrition key: cord- -h ld authors: wood, d. brian; jordan, jaime; cooney, rob; goldfam, katja; bright, leah; gottlieb, michael title: conference didactic planning and structure: an evidence-based guide to best practices from the council of emergency medicine residency directors date: - - journal: west j emerg med doi: . /westjem. . . sha: doc_id: cord_uid: h ld emergency medicine residency programs around the country develop didactic conferences to prepare residents for board exams and independent practice. to our knowledge, there is not currently an evidence-based set of guidelines for programs to follow to ensure maximal benefit of didactics for learners. this paper offers expert guidelines for didactic instruction from members of the council of emergency medicine residency directors best practices subcommittee, based on best available evidence. programs can use these recommendations to further optimize their resident conference structure and content. recommendations in this manuscript include best practices in formatting didactics, selection of facilitators and instructors, and duration of individual sessions. authors also recommend following the model of clinical practice of emergency medicine when developing content, while incorporating sessions dedicated to morbidity and mortality, research methodology, journal article review, administration, wellness, and professionalism. supporting data, the authors based recommendations on their experience and consensus opinion. the entire cord best practices subcommittee reviewed the manuscript after which time it was posted on the cord website for review by the entire cord community. many factors may influence programmatic decisions regarding timing, frequency, and duration of didactic curricula in addition to the desire to optimize education. these may include regulatory requirements, clinical work schedules, locations of faculty and trainees, personnel (teachers and learners), and space availability. the concentrated blocked weekly didactic format (i.e., a single, dedicated conference half day per week) is highly prevalent in other specialties such as family medicine and neurology, in addition to em. , residents appreciate having protected educational time and, compared to shorter daily formats, the blocked weekly didactic structure has demonstrated higher learner satisfaction, improved attendance, and fewer interruptions. [ ] [ ] [ ] [ ] while learners perceive improved learning with this format, studies have failed to demonstrate differences in objective outcomes such as scores on standardized tests or board examinations. [ ] [ ] [ ] [ ] [ ] however, given the perceived and logistical benefits, including improved attendance, which is essential to maintaining accreditation, combined with the nature of em clinical schedules, the authors recommend the blocked weekly format. the acgme places certain requirements on programs regarding faculty participation in didactics. these include that each core faculty member must attend at least % of planned didactic experiences and that em faculty members must present at least % of resident conferences. while there is limited data evaluating faculty conference attendance and objective learning outcomes, one study found that higher faculty conference attendance was associated with higher pass rates on em oral boards for trainees. additionally, residents perceive that faculty presence at conference facilitates learning. , one approach to increase faculty presence at conference would be to offer incentives for attending conference. providing continuing medical education credit for didactic conferences can also increase faculty attendance. conference didactics are most often presented by faculty or residents. , , , , some have advocated for residents to give didactic lectures to ease the burden on faculty time and sharpen resident public speaking skills. while residents perceive that faculty lectures greatly contribute to their educational experience, ,l limited data has demonstrated that residents can learn from resident-given lectures, and that no difference in learning outcomes (e.g., test scores, board passage rates) were found between resident-given lectures vs faculty-given lectures. , , additionally, it may be appropriate to incorporate other professionals (e.g., nurses, pharmacists) as lecturers depending on the topic. smith et al found no difference between lecture evaluation scores for nurse-given lectures compared to conference didactic planning and structure faculty-and resident-given lectures. given that the specialty of em interfaces with many other disciplines, it may also be beneficial to incorporate multidisciplinary conferences with other medical professionals into the didactic curriculum to enable collaborative learning, coordinated patient care, and a better understanding of the roles of other professions. [ ] [ ] [ ] the acgme recommends the inclusion of multidisciplinary conferences as part of the resident didactic experience. limited research suggests that trainees value this type of experience , ; however, robust objective data on learning outcomes are lacking. instruction should be tailored to the level of the learner. , however, this may be especially challenging in program-wide didactic conferences in which the learners differ significantly in terms of stages of training and faculty are at varying career stages and experience. in recent years, we have seen the development of a national em curriculum specific to the training level and the nearly universal presence of a dedicated intern orientation in residency programs. , to date, there are no objective data evaluating training level-specific didactics on learning outcomes; however, faculty and residents have been shown to view this targeted instruction positively. , resident didactic instruction has traditionally been delivered via lectures despite calls for alternatives. , common criticisms of lectures include lack of engagement due to an emphasis on passive learning, overwhelming students' ability to learn by providing too much information, and waning attention due to the duration of the session. despite calls to minimize the use of lectures, data support their continued effectiveness as a teaching modality. [ ] [ ] [ ] the common criticisms can be overcome through intentional learner-centered instructional design. cognitive load theory states that there are three main components involved in the creation of long-term memories: intrinsic load; extraneous load; and germane load. while intrinsic load and germane load are generally fixed, extraneous load is highly modifiable and heavily influenced by the manner in which material is presented to learners. since the amount of working memory is generally fixed for a given person at a set time, increases in extraneous load (i.e., presenting information in an overly complex manner) will detract from learning and retention. therefore, instructors should focus on ensuring that talks are focused on delivery of information, while limiting unnecessary information or overly complex presentations of the information. multimedia learning theory informs principles of slide design and is one effective method that can be used to increase the long-term retention of taught material (table ) . with regard to the duration of lectures given at conference, the notion that shorter may be better is based on data of learner attention spans. in a classic study of medical students, stuart and rutherford found that the attention span peaked at - minutes and fell steadily thereafter, with the authors recommending that lectures not exceed - minutes. in more recent years, we have seen the implementation of shorter lectures in em both at the local and national level. , limited studies have compared shorter ( -to -minute) segments compared to the more traditional -to -minute lecture and found the learners typically prefer the shorter format [ ] [ ] [ ] ; however, few have looked at objective learning outcomes. one study by bryner did evaluate knowledge acquisition and retention between -minute and -minute lectures and found no significant difference. more research is needed to determine the optimal length of didactic sessions with an emphasis on outcome-based evaluations. when it is not possible to reduce the duration of a lecture, incorporating pauses, interactive questioning, and intermittent summarization can re-engage learners and improve attention to the content. handouts are an additional method to increase the effectiveness of lectures. while many lecturers will distribute copies of their presentations, a more effective technique is the . coherence principle: avoid extraneous words, pictures, and sounds. they can detract from learning. . signaling principle: add cues to highlight the essential materials. on-screen text can detract from learning. people learn better from graphics and narration alone as opposed to graphics, narration, and on-screen text. . spatial contiguity principle: corresponding words and pictures should be presented near each other rather than far from each other on the screen. corresponding words and pictures should be presented simultaneously rather than successively. . segmenting principle: multimedia lessons should be presented in learner-controlled segments rather than as a continuous unit. . pre-training principle: when students already know the names and behaviors of system components, they will learn more from the session. . modality principle: learning is more effective when words are presented as narration rather than on-screen text. . multimedia principle: learning is more effective when words are combined with pictures as opposed to include words alone. . personalization principle: information delivery is more effective when words are presented in a conversational style rather than formal style. . voice principle: learning is more effective when narration is spoken in a friendly human voice rather than a machine voice. . image principle: learning is not necessarily more effective when the speaker's image is added to the screen table . mayer's principles of multimedia learning. , concept of guided notes. guided notes are a hierarchical outline of the presentation with key information intentionally left blank. learners will "fill in the blanks" as the lecture progresses, thus increasing attention and discovering the relationships in the presented material. additionally, the fact that the notes are mostly complete allows for effective note-taking and allows attention to be directed at the presenter instead of the notebook. while lectures can still be effective, active learning has been shown to positively impact objective learning outcomes, by incorporating other instructional techniques. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] active learning is "any instructional method that engages students in the learning process" and can include techniques such as games, flipped classroom, audience response systems, casebased problems, and team-based activities. real-time electronic broadcasts of lectures and video conferencing can be another good use of technology to support resident education. this has been demonstrated to be an effective educational model that is positively viewed by trainees and can improve access and attendance at didactic offerings for both residents and faculty. [ ] [ ] [ ] for training programs with multiple sites or that have struggled with maintaining the required attendance percentage for accreditation, this may be a valuable option to consider. our understanding of how learning occurs has evolved as cognitive scientists continue to refine effective methods for teaching and learning. unfortunately, effective methods are often not incorporated into medical curricula. educators should avoid using or encouraging the use of learner-initiated summarization, highlighting and underlining, mnemonics, imagery, and rereading as these techniques have not been shown to enhance learning. effective techniques with a strong effect size include practice testing and distributed practice. additionally, there is likely some benefit from the use of elaborative interrogation, self-explanation, and interleaving. practice testing is the use of no-or low-stakes tests that can be completed independently by the learners. these can include recall via flashcards, practice problems, or traditional types of test questions. teachers may choose to implement this technique using shared card decks or applications (apps), or web-based asynchronous question banks. anonymous audience-response systems are popular and have also been shown to improve student learning in medical education. , distributed practice (also known as spaced repetition) refers to the spreading out of learning over time as opposed to massed practice or "cramming." implementation of this technique can be accomplished by content mapping that allows for repeated exposure to the concepts from prior didactics, the use of handouts or summarization materials between didactic sessions, or by using email to re-expose learners to the material. elaborative interrogation involves the use of selfquestioning to enhance learning. this would involve the learner seeking out the underlying rationale or etiology using questions such as "why does this occur?" similarly, self-explanation involves directing learners to explain their logic during task completion. educators can easily incorporate this technique through simple questioning exercises during their lectures. interleaving is an education organizational technique in which multiple topics and themes are mixed and covered over time instead of having discrete blocks dedicated to single topics. the flipped classroom, also known as the reverse classroom, is an instructional design method in which independent learning, often via previously-viewed video lectures or pre-reading, is combined with face-to-face classroom activities. when studied, the flipped classroom appears to be effective [ ] [ ] [ ] ; however, caution should be exercised as recent systematic reviews have found high methodological diversity, inconsistent results, and risk of bias. , [ ] [ ] [ ] gamification is another active learning technique, which involves the utilization of games and competition to support learning. as a technique, gamification may support learning of skills, emergency department (ed) throughput, decision-making, and medical knowledge. [ ] [ ] [ ] [ ] team-based learning (tbl) is an instructional method used with increased frequency in both undergraduate medical education and graduate medical education, which is often combined with the flipped classroom model. [ ] [ ] [ ] [ ] prior to tbl, learners are expected to prepare and complete a pre-session test individually ahead of time. during the tbl sessions, learners then work in teams to solve a series of realistic, complex problems. faculty serve as facilitators encouraging peer-learning, cooperation, and ensuring the discussion stays on track. this approach requires upfront training of faculty in discussion facilitation and learner buy-in to prepare for sessions. , best practice recommendations: . didactic lectures should be administered as blocked, weekly sessions (level b; grade b). . encourage faculty attendance and participation in conference (level b; grade b). . lecture can still be an effective method to present didactic content. when this technique is used, the lecturer should ensure that their presentation complies with cognitive load theory, multimedia learning theory, and active learning principles (level a; grade b). . real-time video conferencing can be considered to improve access and attendance (level b; grade c). . educators should incorporate the use of spaced repetition and no-or low-stakes testing into didactic instruction to increase long-term retention of content (level a; grade a). . utilization of recorded lectures, flipped classroom, and gamification can supplement or replace the traditional lecture (level a; grade b). after a thorough review of the literature, we found no prospective studies evaluating which specific topics should be included in the conference didactic curriculum. for this reason, conference didactic planning and structure the core content as described by the model of the clinical practice of emergency medicine, or the "em model," is most commonly used as the de facto foundation of the conference curriculum in most residencies. while this was designed using expert consensus data, it is heavily informed by those areas most relevant to the emergency physician. in fact, during the creation of the em model, hospital data from over million ed visits were compared to its content and found to have % overlap, validating the content of the em model. the em model is further refined every three years to identify new areas to cover. as it is used to inform board certification examinations, it is important for residents to be familiar with all of the topics covered and is a critical initial reference for most conference planners. while there is no strong data to help prioritize specific subject matter during conference time, intraining examination coverage of various areas may help guide emphasis on high-yield topics. while the em model may be used as a guide for resident education, conference didactics should be viewed only as one component of resident education with its unique strengths and weaknesses. as such, rather than focusing solely on "covering" all topics in the em model, the priority of conference didactic design should be on maximizing the learning potential of this modality. additionally, some topics can best be taught through other components of resident education including clinical experience, outside reading, simulation and use of free open access medical education (foam). the acgme program requirements for graduate medical education (gme) in em mandate specific conference content to be taught as part of didactics. these include five main components listed in table . additionally, the acgme requires a number of other specific themes to be included in residency training. we suggest incorporating the following into your conference topics to assure completion of these requirements. residents should be educated in a culture of safety, including understanding safety goals, diagnostic error, response to adverse events, continuous quality improvement, and ultimate accountability of the physician for the care of the patient. this can also be combined with m&m conference sessions. professionalism residents must be aware of their professional responsibilities toward their patients and peers, as well as their relationship with the health system on a local and national level. residents should also appreciate the necessity of their own need for ongoing education after residency and how to obtain and maintain board certification. in recognition of the prevalence of depression, burnout, substance abuse, and suicidality among residents and medical students, the acgme now mandates teaching on the identification and mitigation of these concerning issues. while there is no set curriculum provided or recommended by the acgme itself, materials are available, such as the educational toolkit provided by the resident wellness consensus summit. this incorporates modules on second victim syndrome, mindfulness and mediation, and positive psychology. all residents must be able to recognize limitations in their ability to care for patients due to sleep deprivation and fatigue; they should be made aware of options for fatigue management and transition of care to another provider, should the need arise. given the limited evidence-based data on curricular content of didactics further dedicated research on possible curricular content and the weighting of topics taught may be beneficial. . curriculum presentations . quality improvement/morbidity and mortality . research seminars (including education on how to conduct and understand research in a clinical context) . journal review and evidence-based medicine concepts . administrative seminars (to include operations and administrative practices in emergency medicine) table . main components of conference didactics. . core content topics for conference should be derived from the conditions and skills described in the em model (level , grade d). . curriculum presentations, morbidity and mortality sessions, research seminars, journal review, and administrative seminars should be included as part of the conference design (level , grade d). there are several limitations to consider for this review. first, it is possible that some articles were not identified using our search strategy; however, an experienced medical librarian conducted the search with a broad search strategy using multiple databases. additionally, we searched bibliographies of all included articles, contacted topic experts, and underwent pre-submission peer review by the entire cord community. given the breadth of this topic, we were unable to address all aspects of conference planning and some components (e.g., simulation, journal club) were therefore not included in the current review. however, journal club was previously covered available at: https:// www.acgme.org/what-we-do/accreditation/common-program-requirements acgme program requirements for graduate medical education in emergency medicine pfassets/programrequirements/ _emergencymedicine_ . pdf? journal club in residency education: an evidence-based guide to best practices from the council of emergency medicine residency directors individualized interactive instruction: a guide to best 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confirmed case of covid- in the us was reported in washington state. by march , with over cases confirmed in the us, the american college of surgeons recommended the cessation of elective surgeries. "social distancing" became common lingo, and large gatherings, including educational conferences, were abruptly canceled. medical students were pulled off rotations to protect them from exposure and preserve personal protective equipment (ppe). over the following weeks, most hospitals reduced their nonessential surgery volume, performing only surgeries that were emergent, urgent, or time sensitive. one week later, more than , covid- cases were confirmed, present in all states. the rapid evolution of healthcare delivery into telehealth and telephonebased models changed our clinical landscape drastically. normal inpatient volumes decreased as hospitals prepared for the surge of covid- cases and potential redeployment of physicians into areas of need. we adapted rapidly. however, this was only part of the challenge that academic hospitals would face. those of us at teaching hospitals must balance priorities between patient care and resident education. critical to training the next generation of neurosurgeons is a combination of didactic conferences and experiences as well as hands-on surgical education. when in-person didactics are canceled and surgical volume is significantly reduced, how does a program adapt education rapidly? in addition, with increasing concern for an inadequate supply of ppe, how do we as educators protect our residents from harm while knowing that their knowledge, experience, and grit are exactly what is necessary to help the medical workforce during this crisis? only once in recent history has such a pandemic impacted medical education-the severe acute respiratory syndrome (sars) pandemic in . published experiences out of hong kong, singapore, and toronto represent some of the only accounts of the effect on medical education. in march , both medical schools in hong kong were forced to abruptly transition undergraduate medical education into a recorded lecture format, and students were taken out of clinical rotations until the new cases had ceased. one month later, the university of toronto suspended student education in teaching hospitals. singapore reflected on this opportunity to embrace technological advances in web-based learning and simulation but also noted the importance in training medical students in the use of ppe. a rare perspective on how such an epidemic impacted resident training was written by sherbino and atzema in . their account as residents in the emergency department at the university of toronto highlights the impact on resident education. as with the current pandemic, elective cases were halted, staff was screened for fevers and symptoms at the entrance, out-ofcity electives were postponed, and in-person conferences were eliminated. their altered educational experience spanned one-third of the academic year. our current situation is plagued with another grim reality-the sheer volume of patients and the inadequate supply of ppe to keep everyone safe have significantly altered training. the association of american medical colleges (aamc) issued a statement recommending suspension of medical student-patient contact. the accreditation council for graduate medical education (acgme) reiterated that residents who are managing suspected or confirmed covid- cases should have adequate supervision by faculty who are trained in such protocols, which may impact the availability of supervision. the american board of medical specialties issued a statement that it does not want trainees punished for situations beyond their control and urged the boards to consider this as well. the american board of neurological surgery has postponed both primary and oral examinations. we had the opportunity to gather from several programs information about the impact of covid- on operative volume, modifications to resident rotations to ensure maintenance of a healthy workforce, and alterations in resident didactic opportunities. most programs have seen a significant drop in elective or nonessential surgical volume, impacting the functional neurosurgery cases foremost. unruptured aneurysm surgery, spine surgery, benign tumors, and other less urgent surgical cases have been postponed. new information on the particular risk of nasopharyngeal cases with virus shedding has caused many centers to reconsider offering endonasal surgery. several centers are only continuing with neurosurgical emergencies that are typically limited to neurotrauma, shunts, stroke, malignant tumors, and cord compression. naturally, patients with aneurysmal subarachnoid hemorrhage require treatment as well. in addition, surgeries that will allow patients to leave the hospital continue. overall, programs report a significant decrease in the volume of cases. clinic visits have transitioned to telemedicine where possible, decreasing resident exposure to outpatient encounters. with the decrease in cases, programs have been able to transition their resident coverage models to reduce resident exposure and risk, while also allowing for backup options should any residents fall ill or come under quarantine. many programs report decreasing resident staffing to % of normal, allowing teams to rotate on for a week at a time, while keeping the remainder of the residents at home and away from exposure. surgical cases are limited to a single resident to preserve ppe. resident rounds include only the necessary personnel in person, and communication is largely moving to electronic forms. mitigating exposure risk has extended to resident conferences with many programs reporting a transition to virtual conferences by using videoconference technology and holding more frequent sessions to compensate for decreased operative case exposure. a joint statement from the presidents of the congress of neurological surgeons (cns) and the american association of neurological surgeons mentions the plans for available online education to be rolled out in the coming months, and in fact the cns just started a virtual visiting professor program as part of this initiative. as neurosurgeons, we have been a community known for resilience, grit, determination, and academic curiosity. programs have been forced to make drastic and rapid changes in medical education that highlight our flexibility and determination to provide our residents with the best possible education despite extenuating circumstances. certainly, once this pandemic has concluded, careful retrospective analysis of its impact on resident case volume will be necessary to ensure we are prepared for any future events. in addition, sharing best practices and the willingness of the neurosurgical community at large to step up and provide openly accessible education highlights our dedication to ensuring that we continue to train neurosurgeons of the next generation. https://thejns.org/doi/abs/ . / . .jns sars and its effect on medical education in hong kong fear of sars thwarts medical education in toronto the challenges of "continuing medical education" in a pandemic era sars-ed": severe acute respiratory syndrome and the impact on medical education guidance on medical students' clinical participation: effective immediately acgme guidance statement on coronavirus (covid- ) and resident/fellow education and training considerations covid- ) we would like to thank the following individuals who provided information on resident training impact: sepideh amin-hanjani, daniel eichberg, richard ellenbogen, ricardo komotar, allan levi, brian nahed, julie pilitsis, and ciaran powers. we would also like to thank the following contributors: daniel k. resnick, nader s. dahdaleh, tony asher, and gerald grant. key: cord- - ftpsmx authors: ramirez, david a.; dawoud, salma a. title: resident perspectives on covid- : three takeaways date: - - journal: am j ophthalmol doi: . /j.ajo. . . sha: doc_id: cord_uid: ftpsmx nan we had never felt a greater loss of control. as the novel coronavirus permeated our daily news, our neighborhoods, and our bodies, the world around us changed. social distancing, shields, and masks became the new normal. our governments and businesses shut down, and ophthalmology programs grappled, similarly, with the difficult task of balancing workplace obligations with self-protection. our institution, like many others, swiftly moved to a siloed schedule, separating residents into clinic-based and inpatient teams to minimize potential spread of the virus. our clinics were scaled down to urgent cases only and all elective procedures were canceled. modifying our schedules dampened our anxiety, but this was only a temporary respite. we feared that we would be pulled to internal medicine floors or intensive care units, as we saw happen to colleagues in larger cities. we feared we would not see our colleagues in person for the foreseeable future. we feared that what was already a grueling period of our lives would only worsen. when our leadership announced ophthalmology residents would not be called to manage inpatients, our fear lessened, but feelings of guilt surfaced. we suddenly had time to care for ourselves; any compounded feelings of burnout vaporized. we slowly recovered the sleep debt we had accumulated two years into residency. we began cooking and exercising regularly. we reconnected with family and friends. after several weeks, we commiserated with our co-residents -we shared our feelings of shame that this terrifying global pandemic had restored balance to our life at a time when so many around us were suffering. they hesitantly agreed. the full weight of the quarantine set in, and our face-to-face interactions dwindled. although we had finally prioritized self-care, we realized that this, again, was only a temporary relief. we felt isolated. we needed the sense of purpose derived from work, and we craved the human interactions with our co-residents and attendings. as we navigated these changes in our personal lives, our residency program also adapted to meet our new educational challenges. we took advantage of this time to hone our surgical skills using simulators. our faculty utilized e-learning not only as a way to teach, but as a way to regularly connect. finally, we took time to reflect on how our physical interactions with patients, as ophthalmologists, would be changed. due to clinic restrictions, we began investing more time in surgical simulation. our faculty proactively scheduled simulation training individualized to each resident at their level of training. we took advantage of vacant operating rooms as a means to preserve an authentic surgical experience. our senior residents practiced several techniques, including iris suturing, glued intraocular lenses, iris cerclage, the lasso fixation technique, the yamane technique and placement of capsular tension segments. residents earlier in training utilized simulation eyes to cement the motions of cataract surgery and corneal wound structuring, in addition to honing suture technique with synthetic skin models. it is well known that simulator training positively impacts resident surgical outcomes. in one study, residents who had previously used a surgical simulator demonstrated shorter j o u r n a l p r e -p r o o f phacoemulsification times and used less phacoemulsification power . in addition, residents with simulation exposure are reported to have significantly lower complication rates . training senior residents may also have a residual effect on junior trainees: in a study on internal medicine residents performing central venous catheter insertion, increased resident passing rates on a simulated curriculum was thought to be associated with higher rates of senior resident simulator training completion . although our surgical experience during the coronavirus pandemic was limited, our quick transition to a simulation curriculum allowed us to maintain progress in surgical training and to continue resident-faculty interaction. for many of the residents utilizing modified schedules, although work hours decreased, social supports thinned. feelings of loneliness increased, as occurred in the general population . loneliness among residents is significantly associated with personal and work-related burnout , and, counterintuitively, may perpetuate burnout even as work hours are reduced. in a recent survey of ophthalmology program directors, % of respondents had dealt with resident depression, burnout, or suicide in the prior year, while only half reported an established wellness program . personal and environmental factors influence rates of burnout, but institution-level factors, such as program culture and faculty interest, also play an important role. thematic analyses of medical interns have shown that depressed residents cite higher rates of lacking faculty interest and malignant program culture than their non-depressed counterparts. conversely, nondepressed residents reported higher rates of supportive work environments compared to depressed residents. we believe similar conclusions may be drawn to increased faculty attentiveness during the pandemic, although there are no published studies on this issue. our program is one of several that conducts daily morning rounds, where we present educational topics or cases to the department. these sessions became more important than ever, not only as an educational outlet but as a way to continue communication within our department. our program was also fortunate to host lectures by ophthalmologists from both national and international institutions, and ones who had recently found their schedules cleared. in addition to teaching during rounds, our supervising physicians hosted live lectures in smaller groups, which helped us stay connected to one another. the pandemic not only changed our interactions with others but changed our approach to patient care. the closeness required by the ophthalmic exam is unfortunately highlighted by previous studies. for example, in a meta-analysis of post-intravitreal infections, investigators found that streptococcus, a common oropharyngeal organism, is a frequent cause of endophthalmitis following intravitreal injections . the close proximity of our examination is not easily compatible with masks, face shields, or other barriers. with personal protective equipment (ppe) as a pillar of the healthcare response to preventing nosocomial transmission , we balanced the quality of our examination with limiting exposure to our patients and ourselves. we wore face shields as often as possible and used goggles while using the slit lamp and indirect ophthalmoscopy. we implemented best practices on how to reduce spread in j o u r n a l p r e -p r o o f ophthalmic clinics, published by a group of ophthalmologists in hong kong , which involved careful triage of patients with symptoms suggestive of contagious disease, minimizing micro-aerosolizing procedures, and installing protective shields on slit lamps. although there are no data to confirm whether these practices have reduced clinic staff exposure or patient cross-exposure, such practices have been widely implemented . we have also seen the role of telehealth expand in ophthalmic practice, with the centers for medicare and medicaid services broadening access to telehealth resources and modifying reimbursement procedures, in addition to the department of health and human services allowing physician discretion to guide use of various online video communication platforms . as projections for development of a vaccine for covid- are many months away, this may be the new normal for many practices. the pandemic shook the healthcare community and swift changes occurred in a matter of weeks, both personally and professionally. we have described three major takeaways from our experiences and have found that despite our initial uneasiness, we persisted in achieving our educational goals and are prepared to continue our frontline work. influence of surgery simulator training on ophthalmology resident phacoemulsification performance surgical simulation training reduces intraoperative cataract surgery complications among residents unexpected collateral effects of simulation-based medical education loneliness: a signature mental health concern in the era of covid- getting by with a little help from friends and colleagues: testing how residents' social support networks affect loneliness and burnout assessing and promoting the wellness of united states ophthalmology residents: a survey of program directors meta-analysis of endophthalmitis after intravitreal injection of anti-vascular endothelial growth factor agents: causative organisms and possible prevention strategies priorities for the us health community responding to covid- stepping up infection control measures in ophthalmology during the novel coronavirus outbreak: an experience from hong kong preparedness among ophthalmologists: during and beyond the covid- pandemic covid- moves telemedicine to the forefront. american academy of ophthalmology a. funding/support: no funding or grant support b. financial disclosures: no financial disclosures c. other acknowledgements: none key: cord- - g vpdj authors: bitonti, giovanna; palumbo, anna rita; gallo, cinzia; rania, erika; saccone, gabriele; de vivo, valentino; zullo, fulvio; di carlo, costantino; venturella, roberta title: being an obstetrics and gynaecology resident during the covid- : impact of the pandemic on the residency training program date: - - journal: eur j obstet gynecol reprod biol doi: . /j.ejogrb. . . sha: doc_id: cord_uid: g vpdj objective: to evaluate the impact of the covid- pandemic on the obstetrics and gynecology residency training program in italy. study design: this was a cross-sectional survey study aimed to assess the impact of the covid- pandemic on the obstetrics and gynecology residency training program in italy. an online survey with questions was sent and completed anonymously by residents after accepting an informed consent. the invitation to the online survey was sent to all the italian residents in obstetrics and gynecology. those on maternity leave at the time of the study were excluded. residents were asked about their routinely activity before the covid- pandemic, and to report the reduction in their clinical practice. they were also asked about psychological impact of covid- on their clinical practice. results: italian residents in obstetrics and gynecology, were invited for this survey study. four-hundred and seventy-six ( %) completed the survey and were included in the study. three-hundred and eighty-seven ( . %) were female, and ( . %) were male. residents age ranged from to . in , % ( / ) of the cases residents work in a covid- reference hospitals. one-hundred and eighty-four out of residents ( . %) were tested on rt-pcr assay of nasal and pharyngeal swab specimens, and of them / ( . %) were positive to sars-cov- . regarding the use of personal protective equipment (ppe), ( . %) reported to receive adequate device, and ( . %) felt to be well informed about prevention and management protocols. three-hundred and thirty-one residents ( . %) reported to have managed covid- positive patients. for , % of respondent residents, training activity in general decreased significantly during the covid- epidemic. a one-third reduction was reported in , % of the cases, whereas a total suspension of the training in , % of the cases. in , % of cases the reduction was caused by the reorganization of work. anxiety about the professional future was reported in % of the residents, and % of them had the perception that their training was irreversibly compromised. conclusions: among italian residents in obstetrics and gynecology, covid- pandemic was associated with a significant training impairment. results: italian residents in obstetrics and gynecology, were invited for this survey study. fourhundred and seventy-six ( %) completed the survey and were included in the study. three-hundred and eighty-seven ( . %) were female, and ( . %) were male. residents age ranged from to . in , % ( / ) of the cases residents work in a covid- reference hospitals. one-hundred and eighty-four out of residents ( . %) were tested on rt-pcr assay of nasal and pharyngeal swab specimens, and of them / ( . %) were positive to sars-cov- . regarding the use of personal protective equipment (ppe), ( . %) reported to receive adequate device, and ( . %) felt to be well informed about prevention and management protocols. three-hundred and thirty-one residents ( . %) reported to have managed covid- positive patients. for , % of respondent residents, training activity in general decreased significantly during the covid- epidemic. a one-third reduction was reported in , % of the cases, whereas a total suspension of the training in , % of the cases. in , % of cases the reduction was caused by the reorganization of work. anxiety about the professional future was reported in % of the residents, and % of them had the perception that their training was irreversibly compromised. the novel coronavirus , or severe acute respiratory syndrome coronavirus (sars-cov- ), is a newly emerging virus responsible for covid- ( ). covid- is associated with detrimental health, socio-economic, and psychologic consequences ( ) ( ) ( ) . among all the countries, italy was dramatically affected, with, as of early may, more than , cases, and more than , deaths. as result of the imposed lockdown, public assembly has been banned, and most travel restricted. the j o u r n a l p r e -p r o o f healthcare system has also been reorganized, with elective surgical procedures and most of the outpatient appointments being postponed. many patients will experience long-term effects of the covid- measures, with expected increased number of missed diagnosis, complications of conditions due to delayed treatment, and increased level of anxiety. moreover, residency training programs may be impacted by the covid- epidemic, although limited data have been published so far ( ) . the aim of this study was to evaluate the impact of the covid- pandemic on the obstetrics and gynecology residency training program in italy this was a cross-sectional survey study aimed to assess the impact of the covid- pandemic on the obstetrics and gynecology residency training program in italy. an online survey with questions was sent using an online platform through the italian network of trainee in obstetric and gynecology and was completed anonymously by residents after accept-ing an informed consent. the local irb exempted the study from the ethical review. the invitation to the online survey was sent on april , to all the italian residents in obstetrics and gynecology, regardless of the gender. in italy, the duration of the obstetrics and gynecology residency training program is of five years. residents from the first to the fifth year of the training program were invited to the survey. those on maternity leave at the time of the study were excluded. the online survey included three different part. in the first part, demographic data such as gender, age, and residency's year were collected. residents were also asked about their routinely activity j o u r n a l p r e -p r o o f before the covid- pandemic. specifically, they were asked about number of elective procedures per month, with major and minor surgical operations, and outpatient rotation. in the second part of the survey, residents were asked to report the reduction in their clinical practice ( =nothing, / ; / ; / =total practice suspension), and teaching activity. in the last part of the survey, residents were asked about psychological impact of covid- on their clinical approach to the patients, and on their idea about the professional future. data were collected anonymously from april , to may , . statistical analysis was performed using statistical package for social sciences (spss) v. . (ibm inc). data are shown as means with standard deviation, or as number (percentage). descriptive statistics were calculated for sociodemographic characteristics. questionnaires scores were also analyzed according to residents' gender, year of residency, covid- positivity, and number of residents in the center by using logistic regression analysis. univariate comparisons of dichotomous data were performed with the use of the chi-square with continuity correction. comparisons between groups to test group means with standard deviation were performed with the use of the t-test by assuming equal within-group variances or with the use of the one-way anova. a -sided p value less than . was considered significant. nine-hundred and thirty-three italian residents in obstetrics and gynecology, from all the italian residency training programs, were invited by email. out of the invited residents, ( . %) completed the survey. three-hundred and eighty-six of the respondents ( . %) were female, and ( . %) were male. residents age ranged from to with an average of years. in % ( / ) of the cases residents worked in a covid- reference hospitals. one-hundred-eighty-four residents ( . %) were tested on real-time reverse-transcriptase-polymerase-chain-reaction (rt-pcr) assay of nasal and pharyngeal swab specimens, and of them / ( . %) were positive to sars-cov- . onehundred and ninety-five out residents ( . %) were tested for antibody against sars-cov- with either chemiluminescence immunoassay analysis, or rapid igm-igg combined antibody test. regarding the use of personal protective equipment (ppe), ( . %) reported to have received adequate device, and ( . %) felt to be well informed about prevention and management protocols. three-hundred and thirty-one residents ( . %) reported to have managed covid- positive patients. for . % of the respondents, training activity in general decreased significantly ( / reduction) during the covid- epidemic. although out ( . %) responded declared no reduction in their training activity, a one-third reduction was reported in . % of the cases, whereas a total suspension of the training in . % of the cases. in . % of cases the reduction was caused by the reorganization of work shifts, while . % and . % have reduced their activity because of medical prescription or mandatory quarantine, respectively. the areas most involved from this reduction have been those related to elective surgical procedures, with a . % and . % of residents reporting total suspension of major and minor surgical activities, respectively (figure ). on the opposite, labor and delivery training and prenatal diagnosis were less reduced, with a total suspension of the training in . % and . % of cases, respectively. labor and delivery activity were not reduced at all for . % of cases, while a / reduction was observed in . % of respondents. prenatal diagnosis activity was not reduced at all for . % of cases, while j o u r n a l p r e -p r o o f a / reduction was observed in . % of respondents. invasive prenatal diagnosis was totally suspended in . % of cases while out respondents ( . %) declared that in their centers these procedures continued to be performed unchanged during the pandemic. benign gynecology procedures, infertility treatments, and urogynecology related activities, on the opposite, underwent a very significant reduction, with a reported total suspension in %, % and % of the cases, respectively (figure ). an unexpected reduction was observed in oncological clinical activities. indeed, % of respondents reduced their practice by two thirds, and % totally suspended this act. oncologic screening clinic and colposcopy were totally suspended in . % of cases, reduced by / in . % and reduced by / in . %, while . % of residents did not reduced this activity at all. logistic regression showed that degree of training reduction was not associated with residents' gender (p= . ), year of residency (p= . ), covid- positivity (p= . ), or number of residents in the center (p= . ). residents reported a reduction in teaching activity in . % of cases, although at the same time the time dedicated to their individual study has increased in . % of respondents. research activity continued unchanged in . % of cases during the pandemic, was reduced in . % and increased in . % of cases, respectively. effect of covid- on residents' approach to the patients, was reported as unchanged in . % of respondents, considerably changed in . % of the cases, a little bit changed in . % and totally changed in % of cases. more than half of the residents reported anxiety related to fear of contagion, during invasive and non-invasive procedure. almost all the residents ( / , %), reported that covid- had negative psychological impact in terms of changes in mood, of which % had their mood totally impacted and % considerably impacted by the pandemic (figure a ). fear about the professional future was reported in % of the residents, and % of them had the perception that their training was irreversibly compromised (figure b) . logistic regression showed that degree of mood impairment was not associated with residents' gender (p= . ), year of residency (p= . ), covid- positivity (p= . ) or presence of infected among colleagues (p= . ). at the same time, being a resident in a covid center did not have any effect on the anxiety perception of respondents (p= . ), although the percentage of resident infected was significantly higher in those working in a reference center ( . % vs . % infected residents in covid center and in not-covid center, respectively; p< . ) (figure ). this cross-sectional survey study aimed to evaluate the impact of the covid- pandemic on the obstetrics and gynecology residency training program in italy. to the best of our knowledge, this may be the first study evaluating the impact of covid- on residents training in obstetrics and gynecology. findings from the survey showed that among italian residents in obstetrics and gynecology, covid- pandemic was associated with a significant training impairment. this study was limited by the cross-sectional study design. we included only italian residents, therefore data from this study may not be applicable to other countries. since december , the outbreak of covid- has become a major epidemic worldwide ( ). covid- dramatically impacted patient care ( ) and had far-reaching effects on training in surgical programs ( ) ( ) ( ) ( ) . prior studies showed that covid- epidemic is associated with significant reduction in residents training and reduction in medical education in different specialties ( , ) . the impair-j o u r n a l p r e -p r o o f ment may be more severe in surgical specialties, where hands-on training cannot be replaced by distance education ( ) . a survey among italian urology residents, showed a severe reduction or complete training suppression in up to % of the residents ( ). our study also showed that more than half of the residents experienced some degree of anxiety related to fear of contagion. prior studies have been shown that covid- outbreak had severe phycological impact on different population, including patients and healthcare providers ( , , ) the years spent during medical training programs have a crucial role in healthcare professional growth. according to the european congress of obstetrics and gynaecology (ebcog), an optimal training, should ensure an active participation in clinical practice, laying the foundations for the achievement of specific skills and a minimum number of procedures to be performed ( ) . during the sars-cov- public health emergency, several medical services have been reduced, except for those considered urgent and not deferrable, such as labor and delivery and oncologic procedures. consequently, although with different degrees in the specialties, doctors in training have also decreased their daily activities. this is inevitably leading to a slowdown in training. obstetrics and gynecology residency training program has one of the largest and most heterogeneous programs, in which the acquisition of clinical, surgical and emergency management skills is mandatory. daily practice, together with an adequate theoretical preparation, plays a fundamental role in achieving autonomy in carrying out the clinical activities. in summary, among italian residents covid- pandemic had a considerable negative impact on obstetrics and gynecology residency training program. our findings can be used to formulate new solution to limit the impact of the covid- on the quality of residency training programs. new organizational strategies are necessary to minimize training deficiencies. although not comparable j o u r n a l p r e -p r o o f practical activity, there may be different innovative solutions available, as online practice questions, teleconferencing, involving residents in telemedicine clinics, use of simulators, and the use of surgical videos coronaviruses: an overview of their replication and pathogenesis another decade, another coronavirus defining the epidemiology of covid- -studies needed psychological impact of covid- in pregnant women impact of the covid- - pandemic on urology residency training in italy clinical course of severe and critical covid- in hospitalized pregnancies: a us cohort study the impact of covid- on interventional radiology training programs: what you need to know addressing general surgery residents' concerns in the early phase of the covid- pandemic development of clinical care guidelines for faculty and residents in the era of covid- . head neck using technology to maintain the education of residents during the covid- - pandemic immediate psychological responses and associated factors during the initial stage of the coronavirus disease (covid- ) epidemic among the general population in china psychological impact of the covid- pandemic on health care workers in singapore an audit of european training in obstetrics and gynaecology none. no financial support was received for this study key: cord- -igra q j authors: slanetz, priscilla j.; parikh, ujas; chapman, teresa; moutzas, cari title: coronavirus disease (covid- ) and radiology education—strategies for survival date: - - journal: j am coll radiol doi: . /j.jacr. . . sha: doc_id: cord_uid: igra q j nan radiology practices are facing unprecedented challenges not only in how they are providing care to patients but also in how to continue to educate the next generation of radiologists. although the priority is on providing timely and high-quality imaging to patients, especially those infected with coronavirus disease (covid- ), there is still a need to maintain our educational mission. for many institutions, remote learning has become the solution, although in reality, many radiology educators lack the expertise and experience using these technologies effectively. the key is to be creative and find innovative ways to meet resident educational needs without burdening radiologists who are trying to meet increasing clinical demands. for example, our neuroradiology section now sends out weekly articles (ie, radiographics) with accompanying multiple-choice questions that can be answered on a mobile device. in contrast, our abdominal imaging section hosts a virtual "body club" in which residents discuss body imaging cases encountered when on rotation or on call. . informatics: pacs database and radiologic-pathologic learning. institutions should update their teaching files and accessible databases of existing cases for trainee review. by harnessing the power of informatics, a quick search of the pacs database can quickly identify covid- cases, which could then be reviewed by residents and faculty to "train their eye" on the multimodality appearance of covid- pneumonia. radiology-pathology correlation can be streamlined by creating a module that sends automated e-mails once pathology or operative reports become available for imaging cases, thereby enhancing resident learning and improving accuracy. . residents as teachers. as medical schools transition to a virtual platform, radiology trainees can play a prominent role in teaching, particularly using imaging as a means to teach anatomy and disease pathology, possibly in an interdisciplinary setting. perhaps a "virtual radiology elective" would offer students a structured learning platform. , president and chief executive officer of the acgme, acknowledged the many changes we are experiencing across the country and specifically addressed the use of telemedicine and the impact of covid- on clinical volume [ ] . his communication emphasizes that as needs and policies evolve, the program director, with consideration of the program's clinical competency committee, will assess the competence of each individual trainee before graduation. program directors must remain committed to providing excellent training to residents and fellows despite our current challenges. in response to the need for social distancing, the first adaptation in our educational environment was to eliminate side-by-side supervision and to reduce congestion in reading rooms by establishing remote office spaces and home workstations. faculty and trainees have quickly become facile using screen-sharing software for teaching. this rapid and widespread change in behavior has both immediate and long-lasting benefits. the ability to share a teaching session allows medical students and visiting learners to participate remotely. furthermore, setting up a text page system for announcing upcoming interesting case conferences can bring residents together, thereby benefitting education and overall well-being. postponing nonurgent and elective procedures has led to a profound decrease in clinical work for some subspecialties leading to a reduced daily workforce, including trainees. while at home, residents are available to assist at any moment and can also participate in readout sessions, lectures, and multidisciplinary sessions remotely. multiple radiology societies, including the acr, aur, apdr, q and rsna, quickly organized and disseminated free learning material for residents with the aim of providing a core resident curriculum. in addition, senior residents with an interest in radiology education can help develop curricular materials in their area of interest when they are on a remote study rotation. the impact of decreased clinical volumes as it relates to meeting graduation and program requirements is of concern to both trainees and program directors. acgme has posted communications from several specialties, including radiology [ ] . accrediting and certifying bodies, including the abr, acgme, fda, and nrc q , recognize the impact of this pandemic on trainees' education, and specific allowances may be granted for those residents impacted by covid- . for example, creative solutions such as interpretation of blinded, historical patient cases may become necessary for some senior residents. as always and especially at this time, program directors should pay close attention to senior residents' clinical experiences and ensure their readiness to practice independently. how do we adapt to the restrictions related to this pandemic in a way that allows us to continue to support the educational mission? continuing educational activities preserves some "normalcy" for residents and can decrease anxiety, given the current uncertainty. first, do what is easy. keep the lecture schedule and use technology to allow all parties to participate irrespective of physical location. a virtual platform such as zoom, webex, or goto q meeting can facilitate virtual meetings. assigning one or two technologically savvy residents to support faculty can facilitate rapid adoption. for faculty uncomfortable talking to a computer screen, the session could still take place in a conference room provided on-site attendees are socially distanced. with medical students, virtual learning can be as interactive as inperson learning provided the faculty explicitly encourages questions. this can be accomplished by either stating up front that questions are encouraged at any time or pausing frequently and asking for questions. sometimes providing prompts, such as asking for the modality, plane of imaging, or imaging finding, can engage students more successfully. with workstations spread out and sometimes in different buildings, faculty must find new ways to provide meaningful feedback and facilitate learning. most pacs systems have direct messaging that can allow faculty to provide case-specific feedback. faculty can also share interesting cases and provide trainees with a list of teaching cases to review at their convenience. finally, having a virtual town hall can help trainees reconnect, share updates, and express concerns. these conversations can break the feeling of isolation and remind us that we are all in this together. in summary, the covid- pandemic has challenged the status quo but has led to rapid adoption of virtual and experiential learning opportunities that none of us could have imagined just a few months ago. most institutions have embraced technology as a means to maintain normalcy. virtual meetings preserve dedicated teaching conferences for both trainees and medical students, facilitate ongoing workstation feedback to residents, and bring the community together in this era of social distancing. this rapid and exponential integration of distance learning has great promise to reach learners across the globe and potentially attract the best and brightest students into the field. for residency programs and trainees, although there remains some uncertainty around how to best meet expected case logs and rotation requirements, we must all remain adaptable, embrace innovation, and continue to add value to patient care. in fact, covid- may just be revolutionizing how we teach in the future. teresa chapman, md, is a member of the acgme radiology review committee; written contributions reflect her experience as a residency program director q and are not intended to represent the acgme. the other authors state that they have no conflict of interest related to the material discussed in this article acgme response to the coronavirus (covid- ) acgme radiology review committee. special communication to diagnostic radiology residents, interventional radiology residents, subspecialty radiology fellows, and program directors ujas parikh, md, is from the department of radiology key: cord- - bhoyg o authors: tolu, lemi belay; feyissa, garumma tolu; ezeh, alex; gudu, wondimu title: managing resident workforce and residency training during covid- pandemic: scoping review of adaptive approaches date: - - journal: adv med educ pract doi: . /amep.s sha: doc_id: cord_uid: bhoyg o objective: to review available adaptive residency training approaches and management of the resident workforce in different residency programs amid covid- pandemic. materials and methods: websites of different professional associations and international or national specialty accreditation institutions were searched. we looked for english studies (any form), reviews or editorials, perspectives, short or special communications, and position papers on residency education during the covid- pandemic. pubmed, embase, and google scholar were also searched using keywords. two independent reviewers extracted data using a customized tool that was developed to record the key information relevant to the review question. the two authors resolved their difference in data extraction by discussion. results: we identified documents reporting on residency education during pandemics. three were articles, short or special communications, and the rest editorials and perspectives. we divided the data obtained into six thematic areas: resident staffing, clinical education, surgical education, didactic teaching, research activity, and accreditation process. conclusion: residency programs must reorganize the resident’s staffing and provide appropriate training to ensure the safety of residents during the pandemic. there are feasible adaptive approaches to maintaining residency training in the domains of didactic teaching, clinical education, and some research activities. although some innovative virtual surgical skills training methods are implemented in limited surgical residency disciplines, their effectiveness is not well examined. guidance and flexibility of the accreditation bodies in ensuring the competency of residents is one component of the adaptive response. the world health organization (who) declared the covid- outbreak as a pandemic on march . , since then many countries have implemented different covid- mitigation measures including physical distancing and lockdown. as part of international crises in the health care system, many residency trainings are being affected by sars-cov- and mitigation measures implemented. any gathering with more than people recently recommended to be avoided by the centers for disease control. as a result, in-person residency academic activities should be avoided disrupting all pillars of residency education. the clinical education and handson training are affected by the disruption of formal health care delivery like elective surgeries, disruption of skill-based teaching activities, and deployment of residents to covid- related service. many government institutions and professional associations including the american college of surgeons (acs) is recommending against the continuation of elective surgery and minimizing participants in any operation which will undoubtedly decrease resident case volume. academics and didactic teaching of residents were also disrupted because of the interruption of bedsides, morbidity and mortality conferences, rounds, and seminar teaching. the same is true for the resident's research activity. additionally, the rotation of residents between different hospitals and between two sites within the same hospital should also be limited. many programs have restructured their call schedules to reduce their number of in-house residents, while others face the possibility of resident redeployment to service with greater demand (eg, trauma, intensive care). residents during their dedicated research years grapple with institutional suspensions of critical research activities, which threaten their scientific progress. given all these sudden changes, residents, especially in the surgical discipline, will see a significant reduction in resident's exposure to all pillars of their training, with no clear endpoint. this might result in an overall reduction in the experience and competency of the residents posing a problem on the accreditation process. this huge burden for residency directors and consultants, yet there are no universal or multi-institutional recommendations. these unfathomable circumstances require flexibility and creativity with novel interventions to ensure training is provided without compromising quality. these need to be done while maintaining the safety of the residents, consultants, and patients. although there is no substitute for time in the operating room for surgical disciplines, residency programs have been quick to migrate the didactic components of the training curriculum online. webbased educational platforms have become the frontier of innovation in the era of covid- . learning experiences well suited for online platforms include video teleconferencing, lectures, case conferences, and journal clubs, among many others. there have also been efforts to ameliorate the for the diminished surgical exposure by implementing virtual surgery atlases, live surgical video. considering the above facts, we did a scoping review to synthesize evidence on adaptive (innovative) ways of maintaining residency education activities during the covid- pandemic. we looked for websites of different specialty associations and international or national specialty accreditation institutions. we looked for the website and publication of the following: additionally, we also developed a search strategy using keywords residency, residents, education, training, covid- to look for available documents. we searched the following databases: pubmed, embase, and google scholar (table ) . we prepared this scoping review according to preferred reporting items for a systematic scoping review (table s ). we used the following inclusion parameters: we included residents on training programs in different specialty programs. the review considered studies, reviews, position statements, or recommendations addressing the resident's education program during the pandemic. included worldwide records or recommendations addressing resident's education programs during the pandemic. we considered studies (any form), reviews or editorials, perspectives, short or special communications, and position papers on residency education during the pandemic. the search is limited to the past year as the outbreak happened in december . two independent reviewers extracted data using a customized tool that was developed to record the key information relevant to the review question. types of record, author of the document, field of residency training, the domain of residency education, month and year of publication, and recommendations of the documents were extracted. the difference between the two authors on data extraction was resolved by discussion. we searched for the resident's clinical teaching, didactic, and research activity during the covid- pandemic. we categorized identified evidence into the following thematic areas: staffing, safety, and clinical coverage, clinical education, surgical education, didactic teaching, research activity, and accreditation process. we described findings narratively ( table : data extraction table) . formal ethical permission is not required for this review and all data used were included in the manuscript and supplementary material. we reviewed different websites, google scholar, pubmed, and embase. we identified a total of records. after removing duplicates, we screened titles and abstracts of documents and retained papers for full-text review. based on the inclusion criteria, we included records in the scoping review ( figure ). we retained documents for scoping review according to predefined inclusion criteria. three were articles, short or special communications and the rest editorials and perspectives (table below) staffing, safety and clinical service organization (resident safety, emotional and psychological integrity amid covid- ) we identified nine documents reporting on resident staffing and safety amid covid- . , , [ ] [ ] [ ] [ ] [ ] [ ] [ ] reorganizing residents staffing to ensure safety during the pandemics is very important. besides residents must be trained in infection prevention in a clinical setting including appropriate use of protective equipment and personal hygiene. , these trainings can be conducted online via different virtual platforms. , , many recommend creating social media platforms communications to keep residents and staff stay in communication with each other to ease fear and anxiety about the pandemic. , crosby and sharma on otolaryngology residency training recommended virtual sessions for social connectedness to help residents suffering from the added pandemic anxiety of worrying about not only their safety but also for the safety of patients, friends, and family. 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- involves significantly reducing the number of residents staying in hospital by dividing them into two groups and rotating every - 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. , , , , [ ] [ ] [ ] 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. resident clinical education (morning, case presentations, bedsides, round, seminars (management session), journal club) few residency programs suspend resident clinical teachings while many residency training programs designed alternative innovative technologies to maintain resident clinical education during covid- pandemic. , , , [ ] [ ] [ ] , 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. similarly, schwartz et al recommended post-clinic videoenabled telemedicine between attendings and on-service residents for clinical education. 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. , , [ ] [ ] [ ] , 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. , resident surgical education (hands-on training) the shutdown of elective surgeries caused a dramatic reduction of case volume and operating room exposure time which will not be replaced by simple academic conferences and telehealth. many residency programs had instituted alternative surgical teaching methods during covid- . , , , , , for example, stambough et al reported on orthopedic surgical education by using videos, such as the orthopedic video theater (ovt) and orthopedic video theater plus (ovt plus), cadaver and bone-substitute simulations. tomlinson reported neurosurgical atlas and d models and web-based simulations as innovative neurosurgical hands-on training amid covid- at the university of rochester medical center, new york. 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. department of orthopedics, emory university school of medicine are using virtual reality or simulation training for orthopedic surgical education. exemplary virtual reality and surgical simulators platforms have been developed for total knee and total hip arthroplasty surgery. 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. , , nine of identified records reported on alternative virtual didactic residency education during covid- . these virtual didactics include virtual lectures, journal clubs, flipped dovepress virtual classrooms, and teleconferences. the university of california uses novel methods of social-media-based facebook platform groups titled "absite daily". the platform is used to provide practice questions and discussion platforms to prepare trainees for the american board of surgery in-training examination (absite). this platform in addition to allowing daily exposure to practice questions provides an avenue of discussion of surgical topics without any need for in-person meetings. research activity has been disrupted at many institutions during the pandemics. to overcome such factors, some residency programs are using alternative ways of continuing residency research programs. , [ ] [ ] [ ] video enabled virtual research meetings and encouraging residents working from home (nonclinical resident) to develop research projects during the off-work week is recommended. this can be done by weekly virtual meetings with their research mentor. southern illinois university school of medicine otolaryngology department is using such methods to maintain resident's research activity. they designed in a way that, weekly virtual research meeting is held for all residents. on each meeting, one resident presents details of the update on their project and they review all the in-depth of the research methodology including statistical analyses specific to that project. four usa based radiology residency programs encourage research mentors and their trainees to have ongoing discussions on other projects during the pandemic, including securing funding and reshaping works-inprogress into publishable or presentable material. 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 sit for board examinations graduate. america board of orthopedic surgery (abos) suspended all current accreditation processes but states that graduation decisions should be decided by the program director. abos swiftly responded to the pandemic crisis by adding the "time away" from residency training per academic year to dovepress provide flexibility and also stressed that program directors to work to make sure residents meet acgme minimum case requirements. , as of march , acgme has also indefinitely postponed all scheduled and requested accreditation site visits. the american board of radiology has delayed the board certification test up to september , . such postponed graduation and credentialing might impact subsequent onboarding 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. [ ] [ ] [ ] conclusions the undue effect of the covid- pandemic on residency training is well recognized across many residency programs. residency directors must reorganize residents staffing to ensure health and safety during the pandemics. besides residents must be trained in infection prevention in a clinical setting including appropriate use of personal protective equipment (ppe) and personal hygiene. different innovative alternative teaching methods were evolving to substitute the former face to face teaching to maintain residency didactic, clinical, surgical education, and research activity. during covid- pandemic alternative teaching methods such as video teleconferencing, virtual lectures, virtual ground rounds, virtual case conferences, journal club webinars, e-learning modules, online textbooks, email clinical vignettes with associated questions and clinical images, live interactive virtual visiting professor sessions, video database platforms, podcasts, online blogs, webinars, e-literature searches, surgical simulators, and virtual reality (vr) platforms can be used to maintain all pillars of residency education. residency directors also must closely work with accreditation bodies and with their local clinical competency committee to ease the impact of covid- on the accreditation process. one drawback of innovative teaching methods is the necessity of having a good internet connection. therefore, residency directors in developing where there is no stable connection should work with responsible bodies to make sure that residents have access to the internet. this scoping review is very timely putting together evidence for keeping residency training amid covid- pandemic. however, the current review has its limitations that worth considerations. the documents included in this scoping review were mainly from surgical areas such as orthopedics, neurosurgery, urology, otolaryngology, and radiology residency. this is because of a paucity of data published on the subject matter with the possibility of publication bias. besides, the included studies where not critically appraised. nevertheless, with the above limitations in mind, the scoping review provides insight into the necessity of innovative and alternative methods of residency education. such preliminary evidence might be an input to generate hypothesis or design rigorous research projects that will inform practice and policy decisions. therefore, we recommend the generation of more evidence on innovative alternative teaching methods used worldwide across different residency programs which might be used to shape future residency education. conceptualization a pregnant woman with covid- in central america clinical characteristics and intrauterine vertical transmission potential of covid- infection in nine pregnant women: a retrospective review of medical records centers for disease control and prevention communities, schools, workplaces, & events clinical analysis of pregnant women with novel coronavirus pneumonia managing resident workforce and education during the covid- pandemic: evolving strategies and lessons learned using technology to maintain the education of residents during the covid- pandemic innovations in neurosurgical education during the covid- pandemic: is it time to reexamine our neurosurgical training models? prisma extension for scoping reviews (prismascr): checklist and explanation the past, present, and future of orthopaedic education: lessons learned from the covid- pandemic residency and fellowship program accreditation: effects of the novel coronavirus (covid- ) pandemic cleveland clinic akron general urology residency program's covid- experience emergency restructuring of a general surgery residency program during the coronavirus disease pandemic: the university of washington experience radiology residency preparedness and response to the covid- pandemic insights on otolaryngology residency training during the covid- pandemic the impact of covid- on radiology trainees lack of vertical transmission of severe acute respiratory syndrome coronavirus , china. emerg infect dis five questions for residency leadership in the time of covid- : reflections of chief medical residents from an internal medicine program impact of the covid- pandemic on urology residency training in italy common-program-requirements/summary-of-proposed-changes-to-acgme-common-program-requirements-section-vi american board of radiology . coronavirus information we authors did not receive any funding support from any organization for this review. the authors have no conflict of interest to declare. advances in medical education and practice is an international, peerreviewed, open access journal that aims to present and publish research on medical education covering medical, dental, nursing and allied health care professional education. the journal covers undergraduate education, postgraduate training and continuing medical education including emerging trends and innovative models linking education, research, and health care services. the manuscript management system is completely online and includes a very quick and fair peer-review system. visit http://www.dovepress.com/testimonials.php to read real quotes from published authors. key: cord- - mwv f authors: miranda, stephen p.; glauser, gregory; wathen, connor; blue, rachel; dimentberg, ryan; welch, william c.; grady, m. sean; schuster, james m.; malhotra, neil r. title: incorporating telehealth to improve neurosurgical training during the covid- pandemic date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: mwv f • telehealth clinic provides learning for residents. • resident education achievable during covid- . • learning model adaptable based on local viral burden. training in neurological surgery has evolved significantly since its formalization in . training is highly regulated, both by the accreditation council for graduate medical education (acgme) and the american board of neurological surgeons (abns), and curricular structure has evolved over the years to accommodate changes in healthcare and ensure proficiency upon graduation. in , the acgme mandated that all residents must work no more than hours per shift, hours per week, and required day per week without patient care responsibilities . at the time, residents and faculty believed this mandate would make it difficult for residents to be adequately trained, similar to the acgme work hour restrictions in , the covid- outbreak presents a significant challenge to residency training in neurosurgery. as an initial response to the covid- pandemic in the united states, the american college of surgeons (acs) recommended suspension of all elective surgical procedures . further, in an attempt to manage both healthcare provider personal protective equipment (ppe) and human-to-human contact, outpatient clinics at many institutions have been substantially reduced, or pivoted to telehealth. these measures have almost immediately eliminated the traditional educational experiences available to neurosurgical residents. this communication aims to outline how one academic department has adapted to meet the highest standards of neurosurgical education possible given the unique circumstances of the covid- pandemic. at present, education in neurosurgery is based primarily upon the neurological surgery milestones, a document created by the acgme to guide evaluation of resident performance . the milestones are multi-faceted, focusing on attitudes, skills, knowledge and other attributes included within the acgme developmental framework (table ) . each milestone is arranged in levels, from to , which signify movement from novice to expert in the given sub-competency. these milestones do not necessarily correlate with post-graduate year, and residents can potentially advance early or even regress in their milestones based on their performance. level is considered a goal for resident graduation, while level is considered an expert resident or fellow level, above the expectation for graduation in a given sub-competency . although operative training is the main focus of most patient care sub-competencies, with specific procedures detailed by subspecialty, many of the other educational objectives can be met despite the limitations dictated by the covid- crisis. with limited operative time available for trainees, it is exceedingly important for residency programs to optimize all available learning opportunities. at our institution, we have leveraged telehealth to focus on clinical experiences that are traditionally underrepresented in residency training, using educational theory as the underpinning for our activities. a number of educational theories are relevant to training in surgical sub-specialties, and these remain applicable during the covid- era, despite limited in-person patient interaction. for example, surgical educators are well aware that trainees develop expertise through deliberate practice and regular reinforcement (ericsson's theory), with guidance from more experienced experts (vygotsky's theory), and by sharing their knowledge within communities of practice (lave and wenger's theory) , . as time in the operating room has grown scarce, we have found that these ideas can easily be applied to education outside of the operating room as well. it is easiest to conceptualize educational models by grouping them either into explicit "mastery" models of instruction that lead to expertise, and implicit "constructivist" models that consider the cognitive and social perspectives of the learner . mastery models are readily apparent in surgical training, in which skills acquisition and technical proficiency are primary goals. for instance, ericsson's theory outlines that deliberate practice is a key factor in achieving expertise, with the specific intention and motivation to improve, as opposed to rote repetition. however, it is often underappreciated that this approach is most effective when coupled with constructivist strategies, including experiential learning methods that include targeted feedback from instructors. experiential learning theory involves learning through direct encounter, reflecting on experiences to develop concepts, and receiving feedback, so that behaviors can be modified for application to new situations. vygotsky's theory identifies a "zone of proximal development" (zpd), in which learning tasks that are outside of learner's current abilities are achievable with guidance from a more knowledgeable teacher, who provides observation and feedback that serves as a "scaffold" for progression through the zpd, before deliberately "fading" when no longer needed , . these concepts are beginning to be utilized more formally by neurosurgery programs for procedural training: duke neurosurgery has recently implemented a surgical autonomy program that applies the zpd concept to the development of operative skills among their residents . this type of learning can be enhanced further within communities of practice, which allow for shared repertoire, joint enterprise and mutual engagement among peers. as lave and wenger described, learning is not a process of individual experience, rather it is an integral aspect of social practice, achieved through increased knowledge, competency and involvement in the surrounding community . finally, during instruction, it is also important to consider individual learning styles of each student. there is precedent in general surgery and other disciplines for using the kolb learning style index, a -item questionnaire developed by david kolb, to characterize individual learning styles into groups: accommodating, assimilating, converging, and diverging . emotional and interpersonal relationships are the main features of the accommodating learning style, whereas assimilating learners thrive with abstract logic. individuals categorized as converging learners work best by actively solving problems, whereas diverging learners excel through observation . prior work has shown that optimal learning styles tend to be generalized across professional groups, and can predict success in surgical residency . while general surgery trainees have been characterized by accommodating and converging learning styles, early work in taiwan has shown that neurosurgical residents typically exhibit diverging learning styles and progress toward an assimilating learning style as training progresses . further study of learning styles in neurosurgical training is required for educators to generalize these findings to other settings. at our institution, we have found that involving residents in telehealth clinic and supplementing this time with virtual, case-based conferences have already enhanced resident education, by taking learning models classically used in surgical skills training and applying them to surgical decision-making and management instead. it is well understood that some of these "softer" skills in residency training, just like surgical skills, are not necessarily natural abilities. however, these skills can also be taught, learned and practiced in a structured fashion . traditional neurosurgical training heavily emphasizes hands-on operative experience and associated inpatient care, limiting curricular space for outpatient clinical experience. as a result, neurosurgeons anecdotally report that one of the more difficult aspects of transitioning to independent practice is learning how to develop their "style" in clinic: identifying appropriate candidates for surgery, engaging in shared decision-making, managing patient expectations, developing longitudinal patient relationships, managing complications in the short and long term, and so forth. the skills learned during inpatient care are not directly transferable to this setting, because of the fragmented way in which care is delivered by residents coming on and off service, and the hierarchical nature of decision-making in the hospital. clinic experience in residency is highly variable from program to program, and depends on attending availability and program logistics, including work hours, as most residents are primarily responsible for managing the inpatient service. nevertheless, outpatient clinical experience provides a critical opportunity for trainees to develop the non-operative skills emphasized by the acgme milestones, including information gathering and interpretation, evidence-based practice, critical thinking for diagnosis and therapy, and awareness of healthcare systems (table ) . these skills are necessary to become certified as an attending neurosurgeon, as evidenced by the fact that the oral board examination itself requires candidates to apply their medical knowledge to sample case scenarios, and to review their own decision-making for patients they have taken care of, instead of asking candidates to perform surgical tasks. while operative training is certainly required to become a neurosurgeon, these additional skills are necessary for a successful practice. in response to the covid- outbreak, our department has pivoted quickly to develop a robust clinical pathway for outpatient evaluation using telehealth . the telehealth format is optimal for seamlessly incorporating residents into clinic. with operative volume limited to emergencies at each of our clinical sites, residents have been reassigned to virtual clinics across a number of disciplines, from peripheral nerve and spine to brain tumor and vascular neurosurgery. prior to covid- , the curriculum only allowed space for two required outpatient clinic rotations for all residents, both in spine. under the current telehealth system, residents are assigned a clinic day for one faculty member at a time. after patients are screened by medical assistants and all of the relevant clinical data is collected by the outpatient coordinator, the resident is able to review the information and conduct telehealth appointments with each patient. residents are asked to complete documentation in the electronic medical record using a standardized template that automatically incorporates the relevant clinical information and allows the learner to focus on recording their history, virtual physical examination, clinical assessment, and plan. each case is then discussed one by one with the attending using these templates for efficient review of all clinical data, including imaging findings. the resident can then observe how the attending conducts each encounter with the patient by video conference. senior residents have the option to take a more central role in the second encounter, depending on the resident's skill level and relationship with the patient. the format of gradually elevated responsibility used in our telehealth clinic is modeled after the acgme milestones. residents are provided with the opportunity to go from novice level observation to expert level autonomy, in line with the training guidelines ( figure a ). in this format, telehealth outpatient clinic manifests many of the principles offered by educational theory for the development of expertise. residents have the autonomy to conduct clinical encounters and deliberately practice their approach (ericsson's theory, mastery learning model). they then can receive direct feedback from faculty members and reflect on their performance, after either observing the attending conduct the same encounter, and or having the attending observe their performance in a follow-up encounter (vygotsky's theory, experiential learning model). further, telehealth can easily be adapted to all four of kolb's learning styles, affording observation for divergent learners, active problem-solving for convergent learners, logical clinical reasoning for assimilating learners, and relationship building--with both patients and faculty mentors--for accommodating learners. because telehealth is likely going to remain an integral part of care even after the covid- crisis subsides, this format is flexible for adaptation as surgical volume grows, and can even serve as the blueprint for a resident-run clinic (with attending oversight), which is typically difficult to arrange within most health systems. lastly, we have augmented our traditional radiology case conference while operative case volume remains low. prior to covid- , at our weekly case conference with all residents and faculty present, patients from each clinical site are presented and residents have the opportunity to simulate an oral boards examination, practicing surgical decision-making with each case scenario. using videoconferencing, residents now conduct their own case-based conferences three times per week, with an introductory didactic to review a specific topic followed by case presentations, each moderated by a senior resident and a faculty member with relevant subspecialty expertise. so far, this approach has created a community of practice for social learning (lave and wenger's theory) that is primarily resident-driven, not only strengthening relationships between co-residents, but also allowing residents to develop their individual teaching styles while reviewing essential neurosurgical content together. in a manner similar to the telehealth learning structure, the alternative resident learning opportunities provide a means for gradual increasing responsibility, modeling the acgme milestones ( figure b ). of note, the alternative education structure is designed with the capacity to expand as the pandemic deepens and regress as elective practices return to normalcy. ultimately, this makes it possible for our department to maintain the standard of residency education while flexibly adapting to the ebb and flow of the current pandemic. neurosurgical training is complex and constantly evolving. the covid- outbreak so far has posed a significant challenge to resident education by limiting the number of operative procedures and in-person encounters available for resident involvement. however, at our institution, efficient adoption of telehealth clinic and virtual technology has presented a unique opportunity to enhance resident training despite these constraints, by leveraging traditional educational theories. accreditation and approval of residency positions in neurological surgery in the united states: an overview resident duty hours in american neurosurgery results of a national neurosurgery resident survey on duty hour regulations trends in united states neurosurgery residency education and training over the last decade covid- : recommendations for management of elective surgical procedures neurological surgery milestones applying educational theory to simulation-based training and assessment in surgery practical skills teaching in contemporary surgical education: how can educational theory be applied to promote effective learning? how educational theory can inform the training and practice of plastic surgeons simulation in paediatric urology and surgery. part : an overview of educational theory innovation and opportunity: expanding horizons for the duke neurosurgery residency program optimal education techniques for basic surgical trainees: lessons from education theory learning styles vary among general surgery residents: analysis of years of data how residents learn predicts success in surgical residency the preferred learning styles of neurosurgeons communication--the most challenging procedure telemedicine in the era of covid- : a neurosurgical perspective highlights:• telehealth clinic provides learning for residents.• resident education achievable during covid- .• learning model adaptable based on local viral burden. key: cord- -yvj pqh authors: bergman, christian; stall, nathan m.; haimowitz, daniel; aronson, louise; lynn, joanne; steinberg, karl; wasserman, michael title: recommendations for welcoming back nursing home visitors during the covid- pandemic: results of a delphi panel date: - - journal: j am med dir assoc doi: . /j.jamda. . . sha: doc_id: cord_uid: yvj pqh objectives nursing homes became epicenters of covid- in the spring of . due to the substantial case fatality rates within congregate settings, federal agencies recommended restrictions to family visits. six months into the covid- pandemic, these largely remain in place. the objective of this study was to generate consensus guidance statements focusing on essential family caregivers and visitors. design a modified two-step delphi process was used to generate consensus statements. setting and participants the delphi panel consisted of us and canadian post-acute and long-term care experts in clinical medicine, administration, and patient care advocacy. methods state and federal reopening statements were collected in june and the panel voted on these using a three-point likert scale with consensus defined as ≥ % of panel members voting “agree.” the consensus statements then informed development of the visitor guidance statements. results the delphi process yielded consensus statements. regarding visitor guidance, the panel made five strong recommendations: ) maintain strong infection prevention and control precautions, ) facilitate indoor and outdoor visits, ) allow limited physical contact with appropriate precautions, ) assess individual residents' care preferences and level of risk tolerance, and ) dedicate an essential caregiver and extend the definition of compassionate care visits to include care that promotes psychosocial wellbeing of residents. conclusions and implications the covid- pandemic has seen substantial regulatory changes without strong consideration of the impact on residents. in the absence of timely and rigorous research, the involvement of clinicians and patient care advocates is important to help create the balance between individual resident preferences and the health of the collective. the results of this evidence-based delphi process will help guide policy decisions as well as inform future research. visitor guidance for america's nursing homes regarding the abrogation of self-determination and clinical concerns that ongoing restrictions have begun to outweigh any potential benefits. , - cms released phased reopening guidelines on may , , instructing nursing homes to reopen only when the facility had no new covid- cases for a day period and no shortages in ppe, staffing, or testing capacity. , three months after release of these guidelines, many facilities are still far from meeting these criteria. residents, families, clinicians, and advocates are calling for a more immediately actionable, sustainable, balanced, nuanced, and resident-centered approach to reopening nursing homes that respects residents' rights to autonomy, informed risk taking, access to essential family caregivers, and other face-to-face interactions. a group of experts convened to develop a set of evidence-informed guidance statements to welcome back visitors and essential family caregivers to america's nursing homes. in round one, participants voted on the statements, using a three-point likert scale ("agree," "neutral," or "disagree") with an option to offer "absent" due to a lack of perceived expertise. consensus was defined as ≥ % of participants voting "agree" (green statements). we grouped non-consensus statements into ≤ % (red statements) and - % (yellow statements) for purposes of facilitating discussion after each round. the whole panel discussed statements not reaching consensus in a videoconference, starting with statements that had the highest degree of uncertainty (red statements). in preparation for round two of voting, participants also suggested additional statements for consideration. following the second round of voting, a final videoconference discussion collected comments on the non-consensus statements to help inform the final document. we report the final count of consensus and non- consensus statements. descriptive statistics and tables illuminated differences in responses among the expert panel. although the present reopening statements cover a wide range of topics, we focused on the statements specific to visitors in order to communicate immediately actionable recommendations to policymakers. those statements reaching consensus shaped our visitor guidance document. we edited the final guidance statements for clarity, aiming to capture the consensus of the delphi aspects of the following topics (see table ): testing of asymptomatic staff and residents, surveillance testing, visitor guidance, immunity from prior covid- infection and associated risk of infecting others. the panel generally agreed on the need for testing of asymptomatic staff ( %); but the panel discussion reflected the importance of understanding community prevalence as a key factor in deciding to test asymptomatic individuals. while the panel mostly agreed j o u r n a l p r e -p r o o f visitor guidance for america's nursing homes ( %) that residents should be allowed to opt out of testing for sole purposes of surveillance, fewer agreed that testing of asymptomatic residents should not be done ( %). most members agreed that an asymptomatic resident who has recovered from the disease need not be tested within weeks from the onset of symptoms ( %) but fewer agreed to extend that to days ( %) or to never test again ( %). this general uncertainty about the time was again reflected when the panel commented on whether an asymptomatic covid- resident who has recovered could be contagious weeks after recovery ( % agreement that they are not contagious), or after days ( % agreement that they are not contagious). a minority of the panel members ( %) agreed that a recovered covid- who remains asymptomatic is not contagious. the delphi process reached consensus on of statements related to visitors. these statements were then merged and expanded into guidance statements (see table guidance that begins to balance the well-being and self-determination of residents and their families with the very real public health concern of preventing nursing home outbreaks. our panel was able to review guideline statements and develop consensus around general statements to help inform a set of suggested visitor guidance statements. the panel strongly agreed on some preconditions that would be essential prior to welcoming back visitors, such as universal masking for staff, sufficient disinfecting supplies, ppe, and written plans around isolation, cohorting, screening, testing, and outbreak investigations. furthermore, our panel had wide consensus on testing of symptomatic residents and staff, the importance of contact tracing, and barring communal and group activities for symptomatic residents. a key finding reinforced by the panel was the future need to assess individual residents' care preferences and level of risk tolerance, something that has been missing in many of the existing reopening guidelines, in part due to cohorting challenges. this was envisioned by the panel as allowing some residents to participate in a risk-accepting group that could be cohorted together for increased social interactions and dining. however, as illustrated in table j o u r n a l p r e -p r o o f agreed that limited physical contact between visitors and residents should be allowed with meticulous hand hygiene before and after resident contact, and the use of masks, gowns and gloves. a lack of visitor access to ppe should not preclude a visit, so nursing homes must be able to provide masks, gloves and gowns when required. the panel had less accord, however, regarding infection prevention strategies during a visit encounter. for example, universal masking for staff was supported but the group did not reach consensus on which type of mask (e.g. surgical vs. cloth) or whether all visitors had to wear a mask all of the time during a visit. similarly, it was agreed that physical distancing be required in public, common spaces such as the lobby, hallways, or nursing stations, but perhaps not applicable during a visit encounter with an asymptomatic resident. regarding visitor guidance logistics, the panel strongly recommended the use of an electronic process to schedule visits and a sign-in log with contact information to aid in potential contact tracing. additionally, the panel recommended allowing the designation of one or two essential family caregivers by the resident or surrogate decision maker. the essential family caregiver(s) and the surrogate decision maker would have priority to visit the resident. these visitors, for example, might provide complex care, such as assistance with feeding or support for responsive behaviors commonly encountered in residents with dementia. all visitors and essential family caregivers must be provided entry during serious illness, including at the end-of- life, irrespective of covid- status of the resident, provided that the visitor dons appropriate lastly, regarding visitor guidance and risk tolerance, the panel acknowledged that essential family caregivers may wish to visit a resident who may be contagious such as ) a symptomatic resident with a positive covid- test, ) a symptomatic resident with an j o u r n a l p r e -p r o o f unknown or pending covid- test, or ) an asymptomatic resident who has tested positive for covid- . after discussion, the authors recommend three steps be followed. first, a shared informed consent discussion between essential caregivers and nursing leadership that would regarding immunity and cohorting, our panel agreed ( %) that cohorting asymptomatic residents who have all recovered for covid- can be safely done and that a resident who has recovered from covid- , remains asymptomatic, and is at least weeks post onset of symptoms is likely not infectious ( % consensus). regarding the role of antibody testing, a modest majority agreed ( %) that antibody testing could be a surrogate marker of individual immunity; but all agreed that a positive immunity test does not currently inform clinical practice and instead one has to rely upon recovery from prior infection. it should be noted that the delphi process occurred before the cdc guidance that recovered covid- residents do not require re- testing or precautions for days had been released . the areas of congruence leading to the suggested visitor guidance statements stem from thoughtful resident-centered debates among a panel of delphi experts. the fact that there are many areas with substantial variation certainly arises from the state of the science but might also be a result of the interaction of certain statements with each other, difficulties with precise wording or statements, or the persistent inability of guidelines to accommodate the wealth of variations in clinical situations. one limitation of this study was that a rapid two-step modified j o u r n a l p r e -p r o o f delphi process may not have allowed enough time for the panel to develop consensus around some of the challenging language or the more controversial topics, but the panel felt the urgency to produce high-quality guidance statements promptly. the use of a modified delphi process to standardize the process, provide iterative feedback, and consensus-gathering strengthens the findings of this study. the delphi process itself limits bias but could be influenced by how panelists were selected . there was some degree of self-selection in the organization of this panel as the group shared a common concern regarding the health and wellbeing of the vulnerable older adults living in nursing homes during the covid- pandemic. additionally, the panel had substantial diversity but did not include all important stakeholders, such as nurse leaders, direct care workers, or residents. nevertheless, the panelists were chosen for their expertise in the field of geriatrics and long-term care medicine, and have all been listed in the acknowledgement section. the objective of this study was to develop a set of visitor guidance statements that could be used to welcome back visitors and essential family caregivers to us nursing homes. even after a structured delphi process, experts in nursing home care still had substantial discord on important elements. however, through rigorous and evidence-informed discussions, a concise and practical set of guidance statements was developed (table ) in order for a nursing home to proceed with phased reopening, there should be no new nh-onset cases for days. ( ) testing a proportion of randomly selected asymptomatic hcp (staff) who have not previously tested positive should be done for surveillance efforts. the frequency and sample size of staff should be guided by size of the nursing home and level of local community spread. in facilities without any positive covid- cases, test % of asymptomatic hcp (staff) who have previously not tested positive weekly for weeks; if no new positives may test % of asymptomatic hcp (staff) every days such that % of the nursing home staff are tested each month. ( ) testing a proportion of randomly selected asymptomatic residents who have not previously tested positive should not be done for surveillance efforts. instead, residents who are asymptomatic should only be tested during outbreak investigations of close contacts of a known covid- positive resident or staff member. residents who are asymptomatic should be allowed to opt out of testing for sole purposes of surveillance. this statement would not be applicable for contact tracing with a known exposure to a covid- resident or staff member. an asymptomatic resident who has previously tested positive for covid- and recovered does not need to be ( ) tested again within an week window of prior onset of symptoms. an asymptomatic resident who has previously tested positive for covid- and recovered does not need to be tested again within a day window of prior onset of symptoms. an asymptomatic resident who has previously tested positive for covid- and recovered does not need to be tested again. a new or returning asymptomatic nursing home resident without a prior diagnosis of covid- and who has remained under isolation in a private room for days since admission tests positive during nursing home testing of asymptomatic residents. not during an outbreak investigation and there has been no exposure to a covid- positive resident or staff. in this situation, re-test the resident only. if subsequently negative and no further suspicion of covid- in the building, this scenario would not warrant nursing home-wide testing or phase regression. ( ) a negative covid- test is not a requirement prior to visiting a nursing home. ( ) visitors who wish to visit a nursing home resident who is actively symptomatic but for whom covid- testing is pending or unknown should have an informed consent discussion with nursing leadership, demonstrate appropriate donning/doffing of ppe and agree to wear appropriate ppe during the visit. allow entry of all essential and non-essential healthcare personnel, contractors, and vendors with appropriate screening, physical distancing, hand hygiene, and face coverings. they would be subject to the same testing and surveillance requirements as the rest of the hcp (staff) cohort. visitors including non-employed caregivers and surrogate-decision makers would be subject to the visitor the nursing home should consider a designated care giver (or dedicated support person, surrogate decision-maker) an essential member of the healthcare team who would not be subject to visitor guidelines if resources (ppe, training, monitoring) are available at the time and the person is directly engaged in compassionate care to alleviate a residents psycho-social stress as a result of isolation. ( ) a resident who engages in a visit with family or friends beyond the nursing home grounds, remains outside, and the visit does not involve close contact with covid+ individuals or symptomatic individuals would not be subject to isolation upon re-entry to the nursing home. after a resident returns from an outside trip beyond the nursing home grounds and prior to the resident resuming activities within a shared space, the resident should be bathed according to accepted practice with soap and have the clothes they were wearing laundered in a standard fashion. immunity a currently asymptomatic individual who has recovered from covid- and is post weeks from onset of symptoms is not considered infectious and should not be tested. if tested and the test returns positive, as long as the resident remains asymptomatic, it would not be considered a re-infection and the resident is not contagious. a currently asymptomatic individual who has recovered from covid- and is post days from onset of symptoms is not considered infectious and should not be tested. if tested and the test returns positive, as long as the resident remains asymptomatic, it would not be considered a re-infection and the resident is not contagious. a currently asymptomatic individual who has recovered from covid- is not considered infectious and should not be tested. if tested and the test returns positive, as long as the resident remains asymptomatic, it would not be considered a re-infection and the resident is not contagious. antibody testing can be a surrogate marker of individual immunity but does not currently inform clinical practice; recovery from prior infection does. color scheme represents level of consensus among panel. yellow represents statements in which - % of members voted "agree" and red represents statements in which < % of members voted "agree." j o u r n a l p r e -p r o o f all staff, residents, and visitors engage in basic hand hygiene and physical distancing in public, shared spaces. all staff wear a medical-grade mask while in the nursing home. all residents and visitors wear a face covering when in shared, public spaces. if a resident or visitor does not own a face covering, one must be provided by the nursing home. the facility has sufficient disinfecting supplies (hand sanitizers, soap, detergent, etc.) and adequate personal protective equipment (gloves, gowns, masks, face shields/goggles). a written isolation and cohorting plan is in place. a written screening and testing plan with adequate capacity for implementation is in place. a written contact tracing and outbreak investigation plan is in place. all persons entering the nursing home (staff, visitors, volunteers, and vendors) undergo the same entrance screening process, including a temperature check and answering an exposure and symptom questionnaire by a trained entrance screener. visitors that do not comply with the screening procedure are not allowed to enter. visitors and volunteers can sign up to visit a resident for a defined time period using an electronic process. the nursing home maintains a sign-in log that includes contact information (name, phone number, email address) of visitors and volunteers to help with contact tracing in the event of an exposure. a nursing home may need to limit the number of indoor visitors to no more than visitors at one time to allow physical distancing between visitor groups. visit frequency and the number of visitors a nursing home is able to accommodate would depend on the physical space, availability to visit outdoors, and ppe availability. visitors must be guided to the designated visit area to limit interactions with patient-care areas, staff, or other residents. gloves and a gown with associated hand hygiene are required if visitors wish to engage in limited physical contact with a resident, such as hugging, hand holding, or direct resident care such as assistance with meals. the nursing home must provide gloves and gowns for this purpose. the nursing home should designate areas for indoor and outdoor visits. ideally the visits would occur outside, conditions permitting. indoor areas should be accessible without walking through a resident care area, must be disinfected between scheduled visits, and should be large enough to facilitate physical distancing between visit groups. a nursing home should allow each resident or surrogate decision maker to choose essential family caregivers who, along with the surrogate decision maker, would have priority to frequently visit a resident, e.g. to provide complex care, aid in feeding, or redirect and reassure those residents living with dementia who have responsive behaviors. visiting a resident with or without symptoms who has a positive, unknown, or pending covid- test result requires the following steps: . the visitor must participate in an informed consent discussion with leadership regarding the risks of potential exposure to covid- and whether they outweigh the benefits of a visit. additionally, visitors should be counseled to understand the covid- test status and encouraged to wait for a pending test result to return prior to a scheduled visit. . the nursing home must provide education and training so that the visitor can demonstrate appropriate donning/doffing of ppe, including a mask, gowns, gloves, and possibly a face shield. . the visitor must agree to wear the recommended ppe during the visit and follow all infection prevention and control procedures within the nursing home. the nursing home should make every attempt possible to work with visitors of residents who are seriously ill, receiving care focused on comfort, and approaching end-of-life. specifically, facilities may waive the visitor limits, offer extended hours, and offer an in-person room visit to help facilitate the psycho-social well-being of the resident and family members. j o u r n a l p r e -p r o o f  social distancing, hand washing, and disinfection practices need to continue in directpatient care areas.  residents, visitors, and volunteers wear cloth face coverings or a facemask when in a shared-space.  all persons entering the facility (including staff, visitors, volunteers, and vendors) should undergo screening to include: temperature check, exposure questionnaire, and symptom questionnaire.  entry screening is performed by a screener who has received training in basic infection control, appropriate education on questionnaires and hands-on practice with thermometer.  all persons attempting to enter the facility who have either recorded a temperature > . f or report having taken a medication to treat fever (anti-pyretic such as acetaminophen) should not be permitted to enter.  all residents should undergo a daily symptom screening and have temperature monitored.  symptomatic residents/staff o test all symptomatic residents and staff but allow individual residents autonomy with an appropriate plan on how to isolate and cohort a resident who is symptomatic but does not wish to be tested. o a symptomatic staff member who does not wish to be tested would be excluded from work until they meet the return to work criteria of a presumed positive individual. o treat a symptomatic resident who does not wish to be tested as a presumed positive. isolate and cohort accordingly. o  asymptomatic residents/staff o all residents, staff should have undergone baseline testing as part of phase and phase . o have a plan for ongoing surveillance testing of asymptomatic staff and residents.  testing a proportion of randomly selected asymptomatic hcp (staff) who have not previously tested positive should be done for surveillance efforts. the frequency and sample size of staff should be guided by size of facility and level of local community spread. - % agreement  in facilities without any positive covid- cases, test % of asymptomatic hcp (staff) who have previously not tested positive weekly for weeks; if no new positives may test % of asymptomatic hcp (staff) every days such that % of facility staff are tested each month. % agreement  testing a proportion of randomly selected asymptomatic resident who have not previously tested positive should not be done for surveillance efforts. instead, residents who are asymptomatic should only be tested during outbreak investigations of close contacts of a known covid- positive resident or staff member. % agreement  residents who are asymptomatic should be allowed to opt out of testing for sole purposes of surveillance. this statement would not be applicable for contact tracing with a known exposure to a covid- patient or staff member. - % agreement o triggers to increase testing:  a trigger to increase testing of asymptomatic individuals would be based on response to an outbreak investigation and contact tracing results.  one covid- + case in staff or residents should trigger the execution of a comprehensive plan addressing contact tracing, isolation/cohorting, and testing within hours of positive test result.  during an outbreak investigation, there should be a low threshold to extend testing of all staff and residents to entire units, floors, buildings if the situation deems it necessary.  asymptomatic residents and staff who have previously tested positive would not be subject to repeat testing.  once one nh-onset case (case definition from cdc) has been identified within a facility, facilities should resume testing of asymptomatic hcp (staff) who have not previously tested positive o the facility should make every effort possible to secure a collection method that is least invasive and uncomfortable if testing residents and staff with a low pretest probability of covid- disease (asymptomatic without known exposure), such as saliva testing or nasal/oral swabs instead of a nasopharyngeal swab. o asymptomatic covid- recovered resident  an asymptomatic resident who has previously tested positive for covid- and recovered does not need to be tested again within an week window of prior onset of symptoms. % agreement  an asymptomatic resident who has previously tested positive for covid- and recovered does not need to be tested again within a day window of prior onset of symptoms. % agreement  an asymptomatic resident who has previously tested positive for covid- and recovered does not need to be tested again. % agreement  a process should be identified for how facilities will actively track staff/ resident and visitor interactions to help facilitate appropriate contact tracing in the event of an outbreak investigation.  in the event of a pui or covid- positive staff or resident, a list of individuals with possible exposures should be able to be generated for the prior days (preferably days) within hours.  facilities should be aware and document individual resident and/or surrogate decisionmakers' care preferences regarding testing, cohorting, and isolation. it may be possible to cohort a certain group of individuals (ie recovered covid- positive patients who are asymptomatic) as long as the risks for other residents is not substantially increased.  new admissions should be placed in a dedicated area of the facility where appropriate isolation and contact precautions are maintained.  there should be a written cohorting and isolation plan for the facility. group activities  do not allow symptomatic residents with an unknown covid- status to participate in group activities in which proper infection control practices cannot be maintained.  make every effort possible to maintain social distancing, practice hand hygiene, and wear a mask during group activities.  try to facilitate indoor group activities in a well-ventilated space that allows for appropriate social distancing.  make an effort to offer residents the ability to join a risk-accepting group that could be cohorted together for activities, provided that the facility can manage them separately. non-medically necessary trips outside facility  residents must adhere to face coverings, hand hygiene, and social distancing during trips outside of the facility.  isolation o a resident who engages in a supervised outside visit with family or friends within the nursing home grounds, remains outside, and the visit does not involve close contact with covid+ individuals or symptomatic individuals would not be subject to isolation upon re-entry to the facility. o a resident that makes a trip outside the facility and is exposed to a covid+ individual, symptomatic individual or otherwise fails the screening questionnaire upon re-entry to the building would be subject to days of isolation. o a resident who engages in a visit with family or friends beyond the nursing home grounds, remains outside, and the visit does not involve close contact with covid+ individuals or symptomatic individuals would not be subject to isolation upon re-entry to the facility. % agreement  infection control o after a resident returns from an outside trip beyond the nursing facility grounds and prior to the resident resuming activities within a shared space, the resident should practice hand hygiene and have their wheelchair and belongings disinfected. o after a resident returns from an outside trip beyond the nursing facility grounds and prior to the resident resuming activities within a shared space, the resident should be bathed according to accepted practice with soap and have the clothes they were wearing laundered in a standard fashion. % agreement  leave of absence o the facility should have a discussion regarding risks/benefits with every resident and family who requests a leave of absence with a bed hold. this would include a discussion on hand hygiene, social distancing, and mask covering as well as subsequent isolation upon return to the facility if deemed necessary at the time of the visit based on level of community spread.  phase regression and facility wide restrictions should not be imposed after one isolated covid- case. rather, a prompt outbreak investigation should occur with further results triggering appropriate restrictions.  response to positive resident o once one nursing home resident tests positive for covid- , an outbreak investigation should include baseline testing of close contacts (to include roommate, neighboring rooms, and staff) o once one nh-onset case (case definition from cdc) has been identified within a facility, facilities should resume testing of asymptomatic hcp (staff) who have not previously tested positive. o during an outbreak investigation of a single case it is determined that there is nh-onset case on an isolated wing with isolated staff. this scenario would warrant testing of the entire wing staff and residents but not warrant facility wide testing or phase regression. o a new snf admission who has remained under isolation in a private room becomes symptomatic within days of admission and tests positive. in this situation, i would re-test and extend testing to close contacts. if no further positive cases, this situation would not warrant facility wide testing or phase regression. o a new or returning asymptomatic nursing home resident without a prior diagnosis of covid- and who has remained under isolation in a private room for days since admission tests positive during facility testing of asymptomatic residents. not during an outbreak investigation and there has been no exposure to a covid- positive patient or staff. in this situation, i would re-test the resident only. if subsequently negative and no further suspicion of covid- in the building, this scenario would not warrant facility-wide testing or phase regression. % agreement  response to positive hcp o an asymptomatic hcp tests positive on routine surveillance testing and is appropriately following work-restrictions. this scenario should prompt an outbreak investigation of close contacts but should not automatically warrant a phase regression as long as the outbreak investigation does not identify new cases among staff or residents who have not previously tested positive. o a symptomatic hcp tests positive. this would warrant testing of close contacts (staff and residents) of the immediate patient care area. o once one nursing home staff member tests positive for covid- , an outbreak investigation should include baseline testing of close contacts (to include roomate, neighboring rooms, and staff)  phase regression o during an outbreak investigation, it is determined that there is > nhonset cases in a building within a short time period (< days). there is concern for wide spread disease in the building. this scenario would warrant testing of the entire facility and phase regression with subsequent restrictions on visitors, communal dining, and group activities. immunity  a patient who has recovered from covid- disease and is weeks post onset of symptoms is likely not infectious to another individual as long as they have not developed new symptoms.  a cohort of asymptomatic individuals who have all recovered from covid- can safely be cohorted together.  antibody testing can be a surrogate marker of individual immunity but does not currently inform clinical practice; recovery from prior infection does. % agreement  covid- recovered individual o a currently asymptomatic individual who has recovered from covid- and is post weeks from onset of symptoms is not considered infectious and should not be tested. if tested and the test returns positive, as long as the resident remains asymptomatic, it would not be considered a re-infection and the patient is not contagious. % agreement o a currently asymptomatic individual who has recovered from covid- and is post days from onset of symptoms is not considered infectious and should not be tested. if tested and the test returns positive, as long as the resident remains asymptomatic, it would not be considered a re-infection and the patient is not contagious. % agreement o a currently asymptomatic individual who has recovered from covid- is not considered infectious and should not be tested. if tested and the test returns positive, as long as the resident remains asymptomatic, it would not be considered a re-infection and the patient is not contagious. % agreement  hairdressers, beauticians, hospice staff and other staff members who work within a nursing home should be included in the cdc definition of healthcare personnel (hcp) and follow the same guidelines regarding screening and testing.  hairdressers and stylists should be considered direct patient care staff and be subject to the same screening and work restrictions as other healthcare facility staff.  patients that are unable to adhere to social distancing or face coverings should be allowed to visit with family in a private isolated area as long as visitors were full ppe.  dialysis patients who leave the facility regularly for hemodialysis will remain under appropriate isolation and contact precautions and not mix with covid-, asymptomatic individuals. j o u r n a l p r e -p r o o f definitions i agree with the following modification of the formal cdc definition of healthcare personnel (hcp). "hcp include, but are not limited to, emergency medical service personnel, nurses, nursing assistants, physicians, technicians, therapists, phlebotomists, pharmacists, feeding assistants, students and trainees, contractual hcp not employed by the healthcare facility, and persons not directly involved in patient care but who could be exposed to infectious agents that can be transmitted in the healthcare setting (e.g., clerical, dietary, environmental services, laundry, security, beauticians and hairdressers, engineering and facilities management, administrative, billing, and volunteer personnel)". (added beauticians to cdc definition of hcp) nursing homes are ground zero for covid- covid- nursing home data covid- in nursing homes: calming the perfect storm coronavirus disease in geriatrics and long-term care: the abcds of covid- presymptomatic sars-cov- infections and transmission in a skilled nursing facility asymptomatic sars-cov- infection in belgian long-term care facilities presymptomatic transmission of sars-cov- amongst residents and staff at a skilled nursing facility: results of real-time pcr and serologic testing epidemiology of covid- in a long-term care facility in king county, washington cms announces new measures to protect nursing home residents from covid- centers for disease control and prevention. preparing for covid- in nursing homes html?cdc_aa_refval=https% a% f% fwww.cdc.gov% fcoronavirus% f -ncov% fhealthcare-facilities% fprevent-spread-in-long-term-care-facilities continued bans on nursing home visitors are unhealthy and unethical. the washington post amid the covid- pandemic, meaningful communication between family caregivers and residents of long-term care facilities is imperative families caring for an aging america essential family caregivers in long-term care during the covid- pandemic detrimental effects of confinement and isolation on the cognitive and psychological health of people living with dementia during covid- : emerging evidence. ltccovid, international long-term care policy network: care policy and evaluation centre (cpec) finding the right balance: an evidence-informed guidance document to support the re-opening of canadian nursing homes to family caregivers and visitors during the covid- pandemic we gratefully acknowledge the time and dedication of our delphi panel experts and other experts who have participated in this process, provided guidance, or critically appraised our manuscript. their names are listed below in alphabetical order. none received compensation, financial or otherwise, for their contributions. j o u r n a l p r e -p r o o f the facility should make every effort possible to secure a collection method that is least invasive and uncomfortbale if testing residents and staff with a low pretest probability of covid- disease (asymptomatic without known exposure), such as saliva testing or nasal/oral swabs instead of a nasopharyngeal swab. immunity q a currently asymptomatic individual who has recovered from covid- and is post weeks from onset of symptoms is not considered infectious and should not be tested. if tested and the test returns positive, as long as the resident remains asymptomatic, it would not be considered a re-infection and the patient is not contagious. immunity a currently asymptomatic individual who has recovered from covid- and is post days from onset of symptoms is not considered infectious and should not be tested. if tested and the test returns positive, as long as the resident remains asymptomatic, it would not be considered a re-infection and the patient is not contagious. % immunity a currently asymptomatic individual who has recovered from covid- is not considered infectious and should not be tested. if tested and the test returns positive, as long as the resident remains asymptomatic, it would not be considered a re-infection and the patient is not contagious. immunity q antibody testing can be a surrogate marker of individual immunity but does not currently inform clinical practice; recovery from prior infection does. key: cord- -yo ebphy authors: holten, john; ramakrishnan, karthika; charlie, abbas; standiford, taylor; maresky, hillel; cohen, gary; kumaran, maruti title: the radiology resident experience at a large tertiary care hospital during the covid- pandemic date: - - journal: j med educ curric dev doi: . / sha: doc_id: cord_uid: yo ebphy the covid- pandemic has created unprecedented challenges in healthcare including pressure to provide efficient and timely patient care while maintaining a safe environment for physicians and staff. radiology plays a vital role as part of a multidisciplinary team in the care of these patients. we address the experiences of our radiology residency at a large urban us academic institution with an underserved population in our fight against covid- . the unprecedented challenges faced during this pandemic has created monumental impacts on our training and allowed for development of skills and resources in order to better handle future situations. the pandemic of covid- caught much of the healthcare world off guard and we, in radiology, were not exempt. what was once a theoretical discussion topic for us radiology residents, quickly morphed into our department's and our institution's primary focus with marked workflow and space alterations, several dedicated lectures, a plethora of emails, and then to seeing an onslaught of cases in a short matter of days. as residents, march th, was our first formal clinical introduction to covid- when the united states had confirmed cases and the virus was plaguing washington state with deaths. during that morning's conference we watched the society of thoracic radiology covid- position statement titled; "covid- update for the radiologist" by jeffrey kanne, md. the lecture was an encompassing overview on the history of coronaviruses (ie, sars and mers), their epidemiology, and the characteristic radiographic features of covid- . by the next day, on march th, the radiology department had a joint conference with the pulmonology department to review the clinical protocols, patient and imaging logistics, and standardized reporting conduct with respect to covid- imaging. within the next week the residency had been drastically restructured with a view to minimize exposure to the residents whilst gauging workload requirements. regular stations were replaced by a skeleton crew of residents and attendings to create social distancing as the first few cases of covid- started trickling in at our main academic hospital. our workflow was in constant flux as our department chair and hospital leadership worked in tandem to provide for the evolving needs of both our patients and healthcare teams. with the growth of covid- patient volume in philadelphia, our processes evolved rapidly to coincide with changes in the medical management of covid- . our hospital established a "hospital within a hospital" design which is unique to the philadelphia environment. in this manner we rapidly relocated all outpatient services from a specific pavilion (a separate building of our hospital) and made this the "covid- only" hospital. leading the covid- charge was the pulmonology department and they wanted rapid reporting of imaging results from patients entering the emergency department for appropriate disposition to either home, the main hospital, or "covid- only" hospital. initially, serologic testing was either not available or took - days to gain results, our institution needed to triage based on degree of suspicion. a decision tree was worked and reworked to largely rely on a combination of symptomatology plus imaging findings of chest ct for deposition ( figure ). as residents, our immediate goals were to continue providing excellent patient care in a rapidly evolving clinical and epidemiological setting. it was of prime importance for us to keep abreast of new evidence regarding the imaging manifestations of the viral infection all while staying safe and healthy to contribute to the effort against covid- . this has been ever more essential as philadelphia has become a "hot spot" for the covid- contagion and our institution has seen the highest volume of cases in our region. initially, cases of covid- were sparse, numbering a few per day and many residents were hesitant and unsure of making this diagnosis. we found the review and commentary perspective "chest ct findings in novel coronavirus ( -ncov) infections from wuhan, china: key points for the radiologist" by jeffrey kanne especially helpful for us to get a sense for how covid- pneumonia presents before cases at our own institution began to rise. initial radiographic reports out of china and italy described journal of medical education and curricular development chest ct findings of covid- as highly nonspecific multifocal ground glass opacities seen bilaterally, with features of organizing pneumonia at around - days. pleural effusion, cavitation, pulmonary nodules, and lymphadenopathy were not reported to be associated with covid- . , however, at our institution; a large, urban tertiary care center that cares for an extremely underserved population and holds the title of the nation's largest lung transplant program, we started seeing not only a much higher volume of cases, but cases of covid- superimposed on patients with chronic cardiopulmonary disease and transplanted lungs. this is where our extensive training in chest radiology has been extremely advantageous for us as we have the knowledge base as well as experienced thoracic radiologists to discern whether the radiographic findings were due to covid- versus post-transplant complications, other atypical infections, or chronic disease process exacerbations. at our institution, it was imperative for both residents and faculty to rapidly become proficient at diagnosing and triaging covid- cases as we are a resident centered radiology program that employs resident coverage / without fellow assistance. additionally, our program utilizes a third shift overnight in-house resident coverage system with nighthawk support. the resident's responsibility is to dictate all preliminary reads and directly call the caring provider to give rapid real time information so that proper precautions can be put into place. initially, we were asked to call the primary team taking care of the patient, the designated infectious disease consultant, and the designated pulmonology consultant when a scan had a positive result. this procedure of calling three separate providers proved to be extremely inefficient and time consuming as the consulting physician usually had not seen the patient yet or even been consulted. we started only calling the primary team taking care of the patient to efficiently relay the essential findings so that precautions and triage could be taken in a timely manner. holten et al. a rapid new order set and picture archiving and communication system (pacs) integrated workflow was also created to assist. orders for suspected covid- cases were made and implemented as a special "ct viral airborne screening" protocol designed for prioritizing cases of suspected covid- patients. the protocol includes axial and coronal lung kernels with a mm slice thickness. we established a color coded "stat covid- " work list visible on pacs to rapidly identify these cases. a goal was established to complete a covid- chest ct and place a preliminary read within minutes. we have been able to meet this goal with high efficiency with our residents fully trained in interpreting these scans. small changes such as these which were borne from resident input created a more streamlined environment which directly improved our resident workflow and allowed us to increase our reading efficiency to meet the escalating demands. due to the rapidly evolving nature of the pandemic, there were immediate changes made to the work structure in order to incorporate a multidisciplinary approach to covid- management. initial efforts were made to integrate major disciplines which included radiology, pulmonology, emergency medicine and internal medicine. priority was established for prompt triage of the suspected covid- patients in order to better expedite care. as with any rapidly evolving emergent situation, prompt and efficient communication between specialties became the hallmark of this new approach. although many academic bodies and radiologic societies debated the utility of screening ct studies for the identification of covid- pneumonia, our providers found meaningful and quick clinical input using ct to efficiently streamline the triage process. in order to unify reporting, we adopted universal terminology for stratifying ct findings in terms of suspicion for atypical or viral pneumonia (ie, covid- ). the creation of a standardized reporting system resulted in expedited triage for clinical teams. this streamlined process ensured effective and efficient multidisciplinary care and allowed for better allocation of precious resources (ie, n masks, respirators, and isolation gowns). working closely with the hospital administration and the department of pulmonology, the radiology department created a standardized process for imaging patients with clinical suspicion for covid- . we have provided our clinicians with a unique simplified chest ct order for patients exhibiting symptoms of covid- . this order directs the patient to a dedicated ct scanner, physically located in the "covid- only" hospital building, and alerts all personnel involved in obtaining the ct scan to don appropriate ppe. the scanner is then decontaminated by a dedicated sanitization team after the examination. this system has proved to be a simple yet effective way for our colleagues on the floor to obtain imaging of suspected covid- patients while minimizing exposure risk and facilitating rapid dissemination of information. just as the impact of the covid- pandemic has presented several challenges to the resident workflow, so too this impact was felt by the resident education. under normal circumstances, the radiology residency education curriculum is centered around in-person teaching conferences which are usually held twice a day and consists of both didactic lectures and case conferences. residents are also typically encouraged to attend and participate in a variety of recurring interdepartmental conferences. however, in order to reduce potential exposure and transmission of covid- , social distancing measures inevitably required changes to the traditional resident education to be made. several in-person conferences and meetings were canceled or postponed, however, many were transitioned to zoom conferences. in addition to these changes, residents were provided with online educational resources including pre-recorded lectures and review articles to supplement learning. there were initial concerns regarding moving our lectures to a predominantly online education revolving around worries that the educational experience would not be robust as our traditional in person lectures. normally, it is easy for an attending physician to interact with us residents who are present within a lecture hall for questioning and discussion during lecture. initially, we found it difficult for the lecturers to engage with residents as an audience over zoom conferences. this was overcome by incorporating web-based audience response systems (ie, polls or multiple choice questions) to encourage active resident participation. additionally, over time, us residents and our attendings felt more comfortable with the technology and lecture format, which improved resident participation. ultimately, a majority of the residents in the program have found the new online learning system to provide an education on par with the previous in person learning experience. the total number of imaging examinations and procedures also decreased due to reduced outpatient throughput. in accordance with the center for disease control and prevention (cdc), the american college of radiology (acr) supported the guidance to reschedule any non-urgent outpatient imaging visits to help control infection risk. , the resultant fewer number of imaging studies inherently posed another obstacle for resident education. residents were left with fewer cases to interpret and perform, ultimately providing a limited caseload to learn from. digital engagement through the means of social media and online forums offers the unique ability to overcome the constraints of social distancing during quarantine. for us residents who grew up in the digital age, social media is an enormous part of our daily life and has impacted the way we work, communicate, and express ourselves. networking sites, such as facebook and twitter, as well as online forums prove useful towards remaining connected to one another. they provide a channel for the exchange of information, offer insight into coping mechanisms, and allow us to share strategies to deal with the uncertainty of the evolving pandemic. therefore, for some, social media served not only as a source of news, but also a sense of community and help preparedness. from the onset of this crisis, resident safety and preparedness was, of course, a top priority at our institution. as residents, we are on the front lines caring for patients with covid- . a healthy resident workforce is paramount in ensuring there are enough providers to tend to the growing as of yet unknown number of patients who are and will suffer from this infection. at our institution, resident safety was tackled in a two pronged approach. the first was to minimize the potential for physical resident exposure to covid- and the second was to teach residents best practices in order to minimize risk for infection while working at the hospital. in order to minimize the potential for resident exposure to covid- , the department created a schedule allowing for a significant percentage of residents and faculty to work from home. this reduced the number of people physically present in the reading rooms to better allow for safe social distancing. this was accomplished by providing faculty with home work stations en-masse and establishing protocols for residents to review cases with attending radiologists remotely. to review cases with our attending radiologists we utilized the zoom screen share function which allowed us to speak to and view each other's computer screens which was an extremely efficient way to remote review cases together. finally, clear guidelines were established to ensure that residents working off site were always able to be contacted by the faculty and were available to report to the hospital in less than one hour if need be. these standardized routes of communication between residents and faculty also ensured that residents were informed of any changes in hospital policy or the radiology department's response to the covid- pandemic in real time. the reduced workload allowed us to pare down the number of residents physically in house each day, thus providing a pool of residents who could be called upon to fill in for their peers if and when they became ill or quarantined. additionally, residents who were on services with severe reductions in volume, such as mammography, were temporarily moved to busier sections, such as chest radiography. in addition to creating a plan for reducing the number of personnel in the reading rooms, hospital administration and the department established protocols to reduce the exposure risk to the residents who are present on the hospital campus. all hospital staff are given a surgical mask and have their temperature taken daily when entering the hospital. instruction and materials have been provided for faculty and staff on how to disinfect work stations at the start and end of each shift. additionally, signs have been placed on the front of each reading room door with our contact numbers, encouraging our clinicians to contact us via telephone rather than in person to discuss cases. while the crisis created by the covid- pandemic is unprecedented in the world of modern medicine, there is however precedent for general crisis management. much of this precedent is derived from the world of business, where crises are not uncommon and a substantial amount of research and thought has been devoted to the handling of crises. according to clark and harman (associates at the atlanta, ga based firm crawford & company), the first principle of crisis management is "not about researching and planning contingencies for every possible crisis that might occur but rather about developing the capability within the organization to react flexibly. . .". in accordance with this principle, our department rapidly implemented changes to provide the highest quality care for our patients and assistance to our clinical teams while minimizing the exposure risk to our residents. additionally, we continuously reviewed our response to this crisis and continue to make changes in the way we practice, in order to best adapt to this rapidly changing landscape of the covid- pandemic. the unique and unprecedented situation created by the covid- pandemic has taught us, as residents, to acknowledge the importance of adaptability and clear and efficient communication. as the pandemic unfolded, we were forced to quickly develop a solid knowledge base of covid- radiographic findings and strategize an effective reporting system so that accurate information could be succinctly reported to the primary providers. in this role, we became an integral part of the multidisciplinary health care team and allowed us to deliver quality care to our patients. the environment also pushed us to collaborate with hospital administration to implement several residency changes such as online platform learning and social distancing, as to preserve resident education and to promote safety. residents and administration drew insight from nontraditional resources such as social media and online fora in developing organizational policies during the rapidly changing nature of the pandemic. as such, we learned that a quick organizational effort that has clear goals with a flexible approach to delivery is essential for transparency and quick dissemination of developing information. the covid- pandemic has created hardships on us as radiology residents and healthcare providers, but has also given us the skills to adapt and rise to future challenges that will undoubtedly present themselves. holten et al. world health organization society of thoracic radiology covid- position statement: covid- update for the radiologist this temple university hospital is ground zero for philly's war on coronavirus chest ct findings in novel coronavirus ( -ncov) infections from wuhan, china: key points for the radiologist radiological fndings from patients with covid- pneumonia in wuhan, china: a descriptive study radiology perspective of coronavirus disease (covid- ): lessons from severe acute respiratory syndrome and middle east respiratory syndrome radiological society of north america expert consensus statement on reporting chest ct findings related to covid- . endorsed by the society of thoracic radiology, the american college of radiology, and rsna interim guidance for healthcare facilities: preparing for community transmission of covid- in the us covid- radiology-specific clinical resources on crisis management and rehearsing a plan we would like to thank our radiology residency program director dr. beverly hershey, assistant program director dr. padmaja jonnalagadda, assistant radiology professors dr. omar agosto and dr. mansoor khan, chief radiology residents dr. alyssa goldbach and dr. nameet patel, and chair of thoracic medicine and surgery dr. gerard criner for their leadership and guidance during this time. mk concieved the idea for the project and assisted in editing the manuscript. jh, kr, ac, ts, hm, and gc wrote and edited the manuscript. by submitting we attest that this manuscript has been solely submitted to the journal of medical education and curricular development for review. our authors have no funding disclosures or conflicts of interest to disclose. we appreciate your consideration and await your review. john holten https://orcid.org/ - - - karthika ramakrishnan https://orcid.org/ - - - key: cord- - gu rnhj authors: collins, caitlin; mahuron, kelly; bongiovanni, tasce; lancaster, elizabeth; sosa, julie ann; wick, elizabeth title: stress and the surgical resident in the covid- pandemic date: - - journal: j surg educ doi: . /j.jsurg. . . sha: doc_id: cord_uid: gu rnhj objectives: the covid- pandemic has drastically transformed the healthcare community and medical education across the united states. the aim of this study was to evaluate the impact of covid- on the surgical resident training experience, assess possible sources of stress or anxiety among surgery residents, and examine how patterns of anxiety vary by resident rank. design: we developed and disseminated a survey, which included the generalized anxiety disorder -item scale (gad- ), to all general and integrated plastic surgery residents in their clinical years of training at the university of california, san francisco. statistical analysis of the survey responses was performed using the kruskal-wallis or wilcoxon rank sum test. post-hoc analysis was performed using the bonferroni-corrected dunn test. survey data were combined with aggregated duty hour information and operative case numbers from select hospitals for march and april of (historical baseline) and . results: the overall survey response rate was . % (n= ). with an estimated operative volume reduction of . % for general surgery cases, over % of residents expressed concern about the decline in operative exposure. while the senior residents tended to work more shifts, they were not more likely to have higher risk perception scores for contracting covid- nor higher anxiety levels about the possibility of contracting covid- . they were, however, significantly more likely to have high gad- scores (≥ ) when compared to interns (z=- . , p-adj= . ). overall, residents were more concerned about the general health of loved ones than about their own risk of contracting covid- (u= , . , p< . ). conclusions: while the work-related experiences of residents varied across a number of factors during the pandemic, residents tended to report similar sources of anxiety. moving forward, surgical residency training programs will need to develop ways to optimize available surgical experiences and address the unique resident anxieties that an infectious pandemic presents. core competencies: practice-based learning and improvement, medical knowledge, patient care surgical education; covid- ; resident well-being; surgical trainee; distance learning; infectious pandemic introduction surgical residency is a formative time in training and is based upon the principles of graduated responsibility and autonomy. residents progress annually with advancement of their roles within patient-care teams and participation in increasingly complex operative cases. these training years are characterized by long work hours and unpredictable schedules, and they are often a transitional period during which trainees are away from family and partners. studies demonstrate a high prevalence of perceived stress and burnout among surgical trainees, as well as high rates of attrition. [ ] [ ] [ ] even within training programs, clinical experiences and exposures vary across service rotations and hospital sites. educational opportunities may be challenging to regain if lost, which makes the graduate surgical training curriculum particularly vulnerable to disruptions. on february , , san francisco was one of the first cities in the united states to respond to the covid- pandemic, declaring a state of emergency. along with five other counties in the bay area, san francisco county issued a shelter-in-place mandate on march , , directing people to remain in their houses, closing schools, parks and restaurants. [ ] [ ] [ ] prior to the shelter in place order, the university of california, san francisco (ucsf) began its response to the covid- pandemic with the development of a covid- surge planning taskforce and implementation of protocols that significantly impacted all aspects of ucsf health. these changes included travel bans, transition to remote meetings and conferences, cancellation of all non-urgent surgical procedures, and reduction of the in-hospital workforce to include only members necessary for essential provision of patient care. this plan was developed with two things in mindreducing the inpatient census to accommodate a potential surge of covid- patients and creating a staff pool that could be redeployed from surgery to care for covid - patients. over the past month, san francisco has been fortunate to avoid the covid- surge experienced by other parts of the country. , therefore, the ucsf department of surgery has not needed to redeploy any of its faculty, trainees, or staff to care for covid- patients. however, the changes that were needed to prepare for the pandemic have significantly impacted surgical training. it is likely that some of these changes will be durable for the foreseeable future, and many of the missed learner experiences may not be recoverable. these unprecedented changes, along with the stresses inherent in the covid- pandemic, create a climate where stress and anxiety are exacerbated among surgical residents. we hypothesized that the covid- pandemic and the resultant surge planning required to prepare for it would have a marked impact on the surgical resident training experience and that the inflexible realities of this time would have a significant emotional toll on surgical residents across different ranks and hospital sites. the goal of this study was to gather information in order to develop a thoughtful, resident-centered approach to adapting the surgical training program to the covid- era. this study took place within the department of surgery at the university of california, san francisco-a large, public academic institution. ucsf general and plastic surgery residents rotate at seven different hospital locations during the course of their training-three ucsf hospitals, a veteran's affairs medical center, a county/level i trauma hospital, and two other non-affiliated, private hospitals. invited survey participants included all clinical general and plastic surgery residents at ucsf (n= ). the plastic surgery residency program was included as the division of plastic and reconstructive surgery is within the department of surgery, and their program's curriculum has substantial overlap with the general surgery program during the first three years of residency. because we were interested in the impact of covid- on clinically active surgical residents, general and plastic surgery residents in protected research years were excluded from the survey. the structure of the surgery residency program includes a first-year resident (intern) pool comprised of categorical general and plastic surgery interns, non-designated preliminary interns, and interns from other programs that require general surgery rotations within their curriculum (i.e. orthopedic surgery, otolaryngology, ophthalmology, urology, oral maxillofacial surgery, interventional radiology, integrated vascular surgery, and neurosurgery). the junior resident group included general and plastic surgery residents in their nd and rd years of residency. the senior resident group included general surgery residents in the th and th (chief) years of clinical training, and plastic surgery residents in the th , th , and th (chief) years of training. we created a -question survey using focus groups of surgical residents and faculty, as well as review of literature from the severe acute respiratory syndrome (sars) epidemic. we then piloted our preliminary questions in a small group of residents to test for relevance. the qualtrics labs online platform was used to develop and administer the final survey instrument. the last portion of the survey contained a previously validated tool for measuring overall anxiety, called the generalized anxiety disorder -item scale or -gad- ‖, which was originally designed to rapidly screen for clinically significant anxiety. , respondents were eligible for a $ amazon gift card if they chose to provide their names at the end of the survey to allow for longitudinal follow-up. participation was voluntary, and all responses were de-identified and confidential. the survey remained open for a total of days. only the first question of the survey, which acquired consent to participate, was mandatory; all other questions were optional. the study was deemed exempt by the ucsf institutional review board. to evaluate the effectiveness of resident schedule changes in minimizing unnecessary hospital exposure, we compared average weekly resident duty hour data from march th to april th , (aggregated by hospital) with pre-covid- baseline data for the exact same dates in . to quantify the potential impact of the institutional covid- surge plan on the resident operative experience, we tabulated the number of operations performed for select resident rotations at the ucsf hospitals between march th to april th for (baseline) and (pandemic). the services audited included: acute care surgery, elective foregut and abdominal surgery (complex abdominal wall and minimally invasive surgery), colorectal surgery, surgical oncology, endocrine surgery, and pediatric surgery. the procedure was only included if a ucsf resident was documented in the epic tm operative log as participating in the case. we used the change in operative volume at ucsf as a proxy measure of operative volume changes throughout all hospital sites. we then correlated the pandemic's impact on operative volume with the level of resident concern about decreased case numbers. all responses were collected within the qualtrics portal and then analyzed using rstudio -an open access programming platform for statistical computing. because many of the responses were ordinal and not normally distributed, a kruskal-wallis test with a significance level of p= . was used to compare distributions of answers across groups (i.e. across hospital sites or across resident groups). if the kruskal-wallis test was significant, post-hoc analysis was performed using the bonferroni-corrected dunn test to analyze one-to-one differences between groups. the wilcoxon rank sum test with continuity correction and a significance level of p= . was used to assess differences in population distributions when only two populations were being compared. prevalence ratios were calculated using unconditional maximum likelihood estimation (wald), and corresponding p-values were calculated using fisher's exact method. the overall survey response rate was . % (n= ). of note, the intern pool was substantially larger than any other residency year and primarily consists of residents from other surgical subspecialties and non-designated, preliminary residents. this group constituted most of the nonresponders. when evaluating only the categorical general and plastic surgery residents, the response rate increased to . %. given the exceptional response rate, the demographics of the underlying population were well-reflected in the respondent pool, allowing for generalization. the first-year residents made up the largest proportion of respondents at . % ( table ) . the junior residents accounted for . % of the respondents. the senior residents filled out the remaining . % of the respondent population. because each question within the survey was optional, there is slight variation in the total number of responses for some outcome variables. however, the average rate of completion for the questions within the survey was . %. in the survey, one shift was defined as a - hour period. the average weekly duty hours for residents during the reference period compared to the study period (both march th to april th ) demonstrated a reduction, on average, of . hours per resident ( = . hours). this decrease in hours resulted from deliberate alterations to rotation staffing and scheduling in an attempt to limit potential resident work-related exposure to covid- . the survey distribution corroborates this reduction in work hours for the majority of residents, but certainly not all of them. nearly % of residents reported working an average of six shifts per week (table ) , which corresponds to approximately the same number of hours per week that they were working prior to the pandemic. direct comparison of historical operative case volumes (march and april, ) with case volumes during the pandemic (march and april ) revealed an expected but profound decrease in the number of surgeries. overall, there were fewer cases performed during the pandemic period compared to the reference period, which represents a . % reduction in expected operative case numbers for residents that month. while the variation in case numbers between the two main ucsf sites was substantial (table ) , the degree of resident concern over the decreased operative load did not vary significantly by rotation site or resident group ( figure ). the vast majority of residents indicated some level of concern regarding the loss of operative experience. when looking at the overall distribution of responses stratified by resident year, the highest based on support-related responses, many residents felt generally well-supported during the pandemic (figure ) . however, despite the overall positive ratings for level of support, there was a substantial number of residents (n= ) with gad- scores that met criteria for moderate or severe generalized anxiety (total score ). when dichotomizing the gad- scale into low and high scores (low = - , high = - ), there were significant differences across resident groups (intern, junior, and senior resident) ( = . , p = . ). post-hoc comparisons revealed significantly higher gad- scores for senior residents compared to interns (z = - . , p-adj = . ) (figure ) . in fact, the senior residents were . times more likely to have a high gad- score than the interns ( % ci: . - . , p< . ). residents who were in a relationship and living with their significant other were also more likely to have high gad- scores when compared to residents who were either not in a relationship or not living with their significant other ( . % versus . %, respectively), but these results were not statistically significant (p= . ). this study illustrates that while the covid- pandemic and the educational program changes necessitated to address it are impacting surgical trainees in different and sometimes unpredictable ways, many surgical residents share common anxieties. although work hours differed among residents, their risk perception scores and anxiety about personal exposure to covid- were not associated with time spent in the hospital. in the context of training-specific concerns, residents remained worried about the decreased operative volume regardless of the case numbers at their current rotation site, suggesting that some of the concern was related to the uncertain future beyond the immediate surge. on a more personal level, surgical resident anxieties seemed to focus on concern for others-specifically, for loved ones whom they are not able to directly care for during this time. they were also anxious about the risk they could pose to loved ones and patients should they become unknowingly infected with covid- . while formats. one hong kong study described the reduction in colorectal surgery cases during the sars epidemic, but long-term consequences could not be assessed at the time of publication. to our knowledge, no studies have assessed the longitudinal impact of infectious epidemics on the education of surgical trainees. surgical trainees need operating room exposure to gain the experiential, procedural knowledge that informs technical competency. while virtual reality and video conferences can reliably reproduce certain aspects of in-hospital medical education, they fall short of the mark for instilling technical expertise within procedural specialties. our survey and case volume analysis illustrate that the in-hospital experience of residents during the covid- pandemic can vary tremendously by hospital site. for instance, surgical residents in some hospitals continued to participate in complex cancer operations, while residents on elective general surgery services witnessed their operative volume virtually disappear. despite the contrasting experience among residents, almost all of them endorsed some level of concern about the decreased operative volumes regardless of the hospital in which they were working. the american board of surgery has responded to the nationwide case reduction with -hardship modifications‖ that include adjusted case requirements for graduating chief residents, but these modifications fail to address the long-term impact that covid- may have upon resident education. our plastic and general surgery residents are distributed across san francisco at several hospital sites-all with different patient demographics and organizational structures. this situation creates marked scheduling challenges due to different restrictions and levels of flexibility at each particular hospital. the variability in work hours reported within the survey reflects this complexity and, at times, inflexibility. we hypothesized that increased time in the hospital might drive higher risk perception and anxiety scores due to the increased opportunity for exposure to covid- . in the end, resident anxiety about exposure to covid- was not related to how much time they worked in the hospital. resident risk perceptions for contracting covid- also did not correlate with subsequent ratings of anxiety about the possibility of exposure to covid- . in fact, all negative and neutral respondents on the risk perception scale (-unlikely‖ and -neither likely nor unlikely‖) reported slight to moderate levels of anxiety about the possibility of covid- exposure. conversely, some residents who thought infection with covid- was -likely‖ or -very likely‖ subsequently reported having no anxiety about the possibility of exposure. simply put, risk perception does not reliably translate to subsequent anxiety scores. even when residents reported anxiety about covid- , responses indicated that their anxiety did not necessarily stem from their own risk of harm. on the contrary, respondents reported anxiety about the risk they would then pose to loved ones and patients, first and foremost, followed by risk to themselves. the higher ratings of anxiety about the well-being of physically distant loved ones reinforces this theme of anxiety rooted in concern for others. the distribution of responses was significantly skewed towards higher anxiety levels for loved ones when compared to the distribution of responses for anxiety about self-contraction of covid- . last, we found that while covid- associated anxiety was evenly distributed among resident training levels, higher gad- scores were disproportionately found among senior residents. although this is a single institution study, senior residents have unique circumstances and stressors during this time that may account for our findings. first, senior residents serve as the leaders of their surgical teams and thus carry the highest burden of responsibility. they likely feel that some of their teammates' anxieties rest on their shoulders. additionally, the senior years of surgical training incorporate a large volume of operative experience to solidify the foundations of surgical knowledge and promote the transition from resident to junior attending or fellow. unlike junior residents, senior residents do not have additional years of training remaining to make up adversely impacted areas of operative exposure. therefore, reduction in case volume may lead to increased anxiety among senior residents that they will not be prepared for the next segment of their career. further, although not statistically significant, those residents who were in a relationship and living with their significant other tended to have higher gad- scores. because senior residents are more likely to be married and cohabitating with a significant other, their higher gad- scores may reflect some anxiety about the risk of giving covid- to a partner. while the presence of children or elderly people in the home was not more common among our senior residents, it may be an important contributor to anxiety in other surgical trainee populations. while our findings are interesting, there are important limitations that should be considered. because surgical residency programs are relatively small in comparison to other groups (i.e. internal medicine), we were constrained in our ability to make statistical claims about trends noted within the survey responses. these results reflect the anxieties and concerns among general and plastic surgery residents within a single institution and may not necessarily be generalizable to other surgical residencies. last, we had no prior gad- scores for residents that would allow for within subject comparisons to isolate the effects that the covid- pandemic has had on generalized anxiety levels. as a result, we cannot definitively state that the high anxiety levels observed in some residents stemmed directly from repercussions of the covid- pandemic. given the high levels of burnout already documented among surgical residents, [ ] [ ] [ ] [ ] surgical training programs may benefit from ongoing monitoring with validated scoring instruments for anxiety, like the gad- . the implementation of wellness programs and resilience training can further address this issue. , [ ] [ ] [ ] [ ] in conclusion, we found that resident work-related experiences during the covid- pandemic have varied substantially across resident groups and hospital sites, yet these differences did not reliably predict subsequent anxiety levels. while we may have only scratched the surface of possible sources of anxiety for surgical residents, a repeated theme centered on a perceived inability to protect and/or care for loved ones during the pandemic. while covid- represents a healthcare crisis, its impact on surgical trainees extends far beyond the walls of the hospital. it is important for residency programs to be aware of these outside stressors such that they can work to ensure adequate support for residents during such an unprecedented and stressful time. the repercussions of the covid- pandemic will likely be far-reaching into the future. it is imperative that healthcare systems and graduate surgical education training programs flex to adapt to this new reality. figure residents endorse concern over decreased operative case load regardless of resident rank or current hospital site. figure the majority of residents feel supported during the pandemic with the most positive ratings for co-residents and external support networks figure senior residents are significantly more likely to have high gad- scores (moderate or severe anxiety) when compared to interns. progressive independence in clinical training: a tradition worth defending entrustment of general surgery residents in the operating room: factors contributing to provision of resident autonomy burnout and stress among us surgery residents: psychological distress and resilience a national study of attrition in general surgery training: which residents leave and where do they go? multiple-institution comparison of resident and faculty perceptions of burnout and depression during surgical training executive order n- - timeline: california reacts to coronavirus. calmatters.org california state government. stay home except for essential needs. covid .ca covid- ucsf task force. covid- digest 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national survey of burnout among us general surgery residents stress, burnout, and maladaptive coping: strategies for surgeon well-being burnout and engagement among resident doctors in the netherlands: a national study stress and burnout among surgeons: understanding and managing the syndrome and avoiding the adverse consequences stress training for the surgical resident implementation of a novel structured social and wellness committee in a surgical residency program: a case study well-being in residency: a systematic review perspective: resident physician wellnessa new hope. academic medicine the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.the authors declare the following financial interests/personal relationships which may be considered as potential competing interests. dr. caitlin collins's research is funded through a training grant from the national institute of diabetes and digestive and kidney diseases. dr. julie ann sosa is a member of the data monitoring committee of the medullary thyroid cancer consortium registry supported by glaxosmithkline, novo nordisk, astra zeneca and eli lilly. she receives institutional research funding from exelixis and eli lilly. dr. elizabeth wick receives institutional research funding from the agency for healthcare research and quality. no other authors have financial or personal interests to declare that could undermine or perceive to undermine the objectivity, integrity, and value of the publication. all three figures should be printed in color to appropriately distinguish between the different groups in the stacked bar graphs and grouped bar graphs. key: cord- -pq fnc c authors: reed, donovan s; hill, marshall d; justin, grant a; giles, gregory b; santamaria, joseph a; hobbs, samuel d; davies, brett w; legault, gary l title: finding focus in crisis: resident-driven graduate medical education at a military training facility during the covid- pandemic date: - - journal: mil med doi: . /milmed/usaa sha: doc_id: cord_uid: pq fnc c nan maintaining the health and safety of residents and attending educators. the accreditation council for graduate medical education (acgme) program requirements for gme in ophthalmology mandate a minimum of hours of didactic sessions on the basic and clinical sciences during years of residency. a minimum of hours of conferences is also required each month, including case presentations, grand rounds, journal club, morbidity and mortality, and quality improvement. the san antonio uniformed services health education consortium (saushec) ophthalmology residency program fulfills the requirements set forth by the acgme through daily conferences with the faculty and residents. in the setting of the covid- pandemic, social distancing regulations prevented the gathering of faculty and residents for conferences and didactics. during the time of sauchec acgme covid- stage status, the recommendation was to continue didactics as feasible. the acgme provided guidance that the decision to graduate or extend a resident is ultimately determined by the program director even if a resident has not completed surgical minimums. this commentary highlights the lessons learned from the saushec ophthalmology residency program during the covid- pandemic in an effort to aid other residency programs at military training facilities currently struggling with similar issues, and to provide suggestions for maintaining the operational readiness of military physicians in training. at the onset of social distancing, the residency program leadership sought ways to effectively transition all resident education to an online platform. while online meetings with video conferencing software are commonplace in many industries, this was relatively a new concept for our program. we quickly realized that this technology was critical to provide appropriate resident education, transitions of patient care, and rapid dissemination of changing covid- guidance to the residency program. video conferencing software considered included zoom (san jose, ca), gotomeeting, and microsoft teams. though all have similar functionality, the defense health agency ultimately chose microsoft teams as the approved conferencing software for resident education activities. on this platform, residents and program leadership were able to seamlessly and securely log on, share audio/video presentations, and actively discuss topics both verbally and in a side-typed messaging format. additionally, participants used online messaging threads to distribute daily educational surgical videos, recently published literature, and high-yield conclusions from the morning didactics sessions, as well as covid- -specific updates. with these changes, the fourth post-graduate year residents (pgy- s), under the direction of the program director, created a new academic schedule for the residency. each day began with a -minute didactic session held on an online meeting platform. monday through thursday of each week, the didactic session consists of two resident-led lectures concerning specific topics of interest. these lectures used a question and answer format, which easily facilitated resident education. friday didactic sessions were dedicated to morbidity and mortality (m/m) conference and journal club, with a resident assigned to lead each of these discussions. in addition, organizers allocated time each week to review high-yield oral board case simulations. to augment the absence of the handson components of surgical education, didactic instruction and videos were utilized. the pgy- residents took turns twice a week administering -minute lectures on the specifics of ophthalmic surgery. the residents assigned to give or lead each of these lectures include all resident levels and were those not scheduled to work at the hospital that week; this group included all resident levels. residents involved in patient care were still expected to attend academics each day, unless they were in the operating room or attending to an emergent consultation. at saushec, m/m sessions are usually held weekly to review surgical and clinical cases, focusing on any complications that may have occurred. with the great majority of surgical cases in ophthalmology being elective cases, the number of operations performed during the initial months of the covid- pandemic decreased drastically. the only surgeries performed during this time were emergent and urgent cases, with an initial transition to elective cases in accordance with the texas medical board guidelines. with this in mind, the focus of the m/m conferences shifted to a more detailed review of the specific steps of each operation performed, in addition to the complication and the steps taken to mitigate the issue encountered. the virtual platform allowed for faculty and residents to attend despite their assignments at multiple locations, including even forward-deployed geographic regions. journal club discussions were also emphasized. lee et al. published an article on structured journal club and the use of a checklist criteria for a structured resident learning experience. the pgy- s and the residency program director worked together to develop a checklist for residents to evaluate journal articles in a structured format for group discussion (see table i ). once a week, a pgy- resident selected two articles, which he/she and a pgy- resident would each present following the structured format. oral case simulations evaluate many key areas of gme education. to avoid the loss of this valuable capability, a pgy- resident compiled an oral board simulation curriculum consisting of a series of over practice cases that covered all topics within the field of ophthalmology. each case consisted of a short background sentence, and at least one photograph demonstrating the pathology in question. additionally, a passing "answer" example was provided, which was to be reviewed by the resident as a self-assessment tool following an attempt at completion of the case without assistance. each example answer followed the "ddamp" format, which stands for description, differential diagnosis, additional testing and work-up, main diagnosis, and plan or treatment for management. in addition to the daily didactics sessions, residents practiced a selection of case simulations in a small group format. the case simulations were chosen to further emphasize topics previously covered and were based on subjects included in the resident-directed didactics sessions. all case simulations were timed in an effort to allow trainees to practice efficiency and time management. in order to assess the efficacy of the new didactics structure and the impact of each individual component, a short question survey was distributed to trainees following implementation of the model. eighteen trainees received the survey, and responded, yielding a response rate of %. regarding the overall academic structure, % of respondents felt the resident-led didactics benefited their education during the covid- pandemic. concerning the individual components, % of respondents felt the resident-led oral board case simulations and ophthalmic surgery lecture series benefited their education. while these lectures did not substitute for more in-depth reading and board-style questions, over % of residents preferred this new method of resident-led teaching. rated on a satisfaction scale of - , the lectures averaged a score of . . additionally, . % of respondents felt the resident-led journal article reviews provided educational benefit. additionally, several respondents requested at least some aspect of the current academic model be continued following conclusion of the pandemic, highlighting the importance of resident-driven education. to determine the generalizability of the methodology presented, program directors of the other ophthalmology residencies affiliated with military training facilities were contacted to define their approach to graduate medical education during the covid- pandemic. each of the military training programs transitioned to a virtual-based learning initiative, and through coordination amongst the ophthalmology residency program directors, similar approaches to graduate medical education were instituted at all facilities. specifically, the naval medical center san diego ophthalmology residency program transitioned to a distance-based state the purpose and type of the study summarize key points in the article discuss the statistical analysis and teach the method used briefly describe the main results of the study highlight the strengths and weaknesses: how could the article is improved? did the authors achieve what they set out to achieve? will the results influence practice beneficially or adversely? what further research might be carried out? open forum group discussion learning initiative with resident-led virtual didactics designed after the model discussed, which effectively maintained resident graduate medical education at the facility. in order to meet acgme requirements, the madigan army medical center ophthalmology residency likewise instituted a virtual academics approach, concentrating on written and oral board preparation, in addition to a specific focus regarding daily personal fitness, wellness, and resiliency training. the national capital consortium ophthalmology residency also transitioned to virtual didactics utilizing microsoft teams. additionally, the traditionally in-person grand rounds with the other washington d.c. ophthalmology programs shifted to a strictly virtual experience, led by the george washington university program. uniquely, an in-person wet lab was organized to practice ophthalmic suturing and wound construction techniques with appropriate social distancing, being a : resident to staff ratio with six-feet spacing requirements. this training did not result in any covid- infection exposures, demonstrating an appropriately socially distanced in-person training experience can be effectively instituted. this approach to surgical training may be vital if the social distancing requirements related to the pandemic are extended, given the concern for maintenance of surgical skills in a prolonged halt regarding elective cases. given the similarities amongst approaches adopted by the other military ophthalmology residency training programs, it is clear the methodology presented is both effective at maintaining graduate medical education and easily instituted by programs affiliated with military training facilities. herein, we offer an academic model that effectively mitigated infection exposure risks while continuing to provide effective gme to military ophthalmologists in training during an infectious disease pandemic. by utilizing a variety of technologies and teaching styles, program leadership effectively preserved the education of trainees during covid- . the virtual academic sessions do not appear to have interfered with the ophthalmology department's ability to continue to administer excellent patient care while maintaining the overall health and safety of the hospital staff. we believe other military training and civilian residency programs can easily and successfully implement the described resident-driven model during pandemics or other catastrophes that limit direct resident-to-patient and resident-to-attending interaction. reflections on a crisis in graduate medical education: the closure of hahnemann university hospital precepting at the time of a natural disaster post-katrina: study in crisisrelated program adaptability pandemic policy and planning considerations for universities: findings from a tabletop exercise acgme program requirements for graduate medical education in ophthalmology stage : increased clinical demands guidance structured journal club as a tool to teach and assess resident competence in practice-based learning and improvement journal clubs: . why and how to run them and how to publish them key: cord- -r wzvpn authors: sizoo, eefje m.; monnier, annelie a.; bloemen, maryam; hertogh, cees m.p.m.; smalbrugge, martin title: dilemmas with restrictive visiting policies in dutch nursing homes during the covid- pandemic: a qualitative analysis of an open-ended questionnaire with elderly care physicians date: - - journal: j am med dir assoc doi: . /j.jamda. . . sha: doc_id: cord_uid: r wzvpn objectives to mitigate the spread of covid- , a nationwide restriction for all visitors of residents of long-term care facilities including nursing homes (nhs) was established in the netherlands. the aim of this study was an exploration of dilemmas experienced by elderly care physicians (ecps) as a result of the covid- driven restrictive visiting policy. setting and participants ecps working in dutch nhs. methods a qualitative exploratory study was performed using an open-ended questionnaire. a thematic analysis was applied. data was collected between april and may , . results seventy-six ecps answered the questionnaire describing a total of cases in which they experienced a dilemma. thematic analysis revealed four major themes: ( ) the need for balancing safety for all through infection prevention measures versus quality of life of the individual residents and their loved ones; ( ) the challenge of assessing the dying phase and how the allowed exception to the strict visitor restriction in the dying phase could be implemented; ( ) the profound emotional impact on ecps; ( ) many alternatives for visits highlight the wish to compensate for the absence of face to face contact opportunities. however, given the diversity of nh residents, alternatives were often only suitable for some of them. conclusions and implications ecps reported that the restrictive visitor policy deeply impacts nhs residents, their loved ones and care professionals. the dilemmas encountered as a result of the policy highlight the wish by ecps to offer solutions tailored to the individual residents. we identified an overview of aspects to consider when drafting future visiting policies for nhs during the covid- pandemic. in the netherlands, the first covid- confirmed case in a nursing home (nh) was reported on march , , and by the first week of april, about % of dutch nhs reported covid- infections (figure ). about people reside in one of the estimated nhs or care homes across the netherlands, for whom medical care is provided by physicians with an elderly care medicine specialty (i.e., elderly care physicians). to mitigate the spread of covid- , strict social distancing policies were implemented by the dutch government as of march , . by march , a nationwide restriction for all visitors of residents of long term care facilities (ltcfs) including nhs was established ( figure ). this decision was made in view of a lack of alternatives as the netherlands was facing shortages of personal protection equipment (ppe) and a lack of diagnostic capacities. the only exception of this restrictive policy included residents in the dying phase to allow a farewell moment for family members (i.e., maximum two visitors per hours). it is inevitable this policy has consequences for the residents, their families and their formal caregivers. involvement of the resident's family through visits to the nh has previously been described to be beneficial for the quality of life of residents. , indeed, family has been reported to promote social engagement and to strengthen identity and dignity of residents. family visits to the nh allow for the monitoring of the provided formal care as well as for additional care tasks for the institutionalized older adults. while the rationale for the restrictive visiting policy imposed to the nhs in the netherlands the data. the analysis included the following steps: ( ) familiarizing with the data, ( ) inductive thematic coding, ( ) searching for themes, ( ) reviewing of themes and ( ) finalization of themes. an iterative approach (i.e., the process of going back and forth between the data, the codes and themes) was followed across the different steps to ensure a systematic analysis. the coding of the first cases was performed independently by two researchers trained in qualitative research methods (es and am). the results of the two independent codings were then merged into a single codebook. the codebook was used to code the remaining questionnaire data. the cases collected within the first two weeks were coded by one of the two researchers (es and am). changes to the codebook (e.g., renaming of codes and addition of codes) were made in consensus between the two researchers during research meetings (es and am). a third researcher (mb) validated the coding by checking for inconsistencies to make sure no relevant information was missed and coded the last cases. doubts were discussed with two other researchers (es and am). regular meetings between the researchers involved with the coding allowed for frequent reflections on the data analysis including the collation of codes into themes and the evolution of the identified themes. the questionnaire data were analyzed using microsoft word and microsoft excel. all participants were informed about the aim of the study and the purpose of data collection. formal ethical approval from a medical ethical committee was not required for this research in the netherlands since it did not subject participants to any medical treatment or impose any specific rules of conduct on participants. the questionnaire was sent to ecps-in-training and ecps and anonymously returned by physicians (ecps or ecps-in-training). these physicians, further referred to as 'ecps', described a total of cases in which they experienced a dilemmas. thematic analysis of open-ended questions revealed four major themes related to the restrictive visiting policy. quotes illustrating the four themes are shown in table . furthermore, we identified dilemmas related to other covid- measures in nursing homes (appendix ). the core dilemma experienced was that on the one hand, ecps wanted to protect residents against covid- infections -implying adherence to the strict visitor restrictions -but on the other hand, as a consequence quality of life of most residents seriously decreased (quote and ). ecps encountered serious suffering as a result of covid- . hence, they wanted to minimalize the risk of contamination (quote ). according to ecps, for some residents, the risk of contamination was acceptable but it was not just about the individual resident (quote ). ecps emphasized infection prevention concerned safety of all residents (quote ) and health care professionals (quote ). the visitor restriction policy contributed to limiting the further spread of covid- . most ecps encountered understanding of the dilemmas they were facing among family members (quote and ), although not in all cases (quote ). j o u r n a l p r e -p r o o f ecps used the words 'loved ones', 'partner', 'family members' and 'next-of-kin' instead of 'visitors'. ecps considered the presence of these 'visitors' as essential to quality of life. as the majority of residents of nhs has limited life-expectancy, ecps estimated quality of life was often considered more important than life duration (quote - ). furthermore, according to ecps, next of kin could have provided company and support in uncertain times (quote ). moreover, ecps described cases where they missed additional care otherwise provided by next-of-kin (quote ) . ecps described cases where the visitor restriction had profound impact on residents. ecps observed loneliness, depressive symptoms (quote ), decreased intake (quote ), increase in somatic symptoms (i.e. pain) (quote ), physical deterioration and in psychogeriatric residents rapid cognitive decline (quote , ) and changes in neuropsychiatric symptoms including agitation and aggression (quote ). the latter was even reported to result in increased psychotropic drug prescriptions for some of the residents. on the other hand, ecps observed visitor restrictions brought peace for some of the psychogeriatric residents (quote ). in addition, the restrictions impacted next-of-kin and nursing staff (appendix ). ecps noted that although protection against contamination was irrelevant for a resident in the dying phase, protection of other residents in the institution, health care providers, next- of-kin and society remained notwithstanding important (quote ). ecps described the presence of visitors in the dying phase implies being surrounded with loved ones and being j o u r n a l p r e -p r o o f able to say farewell (quote and ). we distinguished two types of issues raised by ecps: assessing the dying phase and implementing of the exception. ecps struggle with the timing to diagnose 'dying'. the beginning of the dying phase is not always clear (quote ). ecps describe a grey area classified as 'preterminal phase': life expectancy is short, but the resident is not yet in the dying phase (quote ). in these scenario's, ecps observed residents whose last days, weeks or months were lonely (quote ) and residents with a rapid course of the dying phase, thereby not being able to say farewell to their loved ones (quote ). ecps described that next-of-kin were missing the process of decline and feared this might impact their mourning process (quote ). ecps remarked that concluding too early that the resident was in a dying phase implies more visitors (i.e., higher risk of infection) and may set a precedent for others (quote ). furthermore, in practice several requirements for visits were pointed out by ecps. first, ecps were aware that ppe was scarce, increasing the urgency to limit the exceptions (quote ). the exception allowing for visitors in the dying phase caused struggles with the assessment of dying phase. dutch guidelines for palliative care define dying phase as last days of life. it is well-known that diagnosing dying is a highly complex process. the examples of alternatives for visits (technical and at distance) underscore the urgency to compensate for the absence of visits and in the dutch media was parallel reported on various creative solutions to allow contact at distance (e.g., using a cherry picker, 'coronatainers'). , however, alternative solutions are only suitable for some residents as j o u r n a l p r e -p r o o f many have cognitive impairments, visual or hearing disabilities and/or speech disorders. in addition, the effect of technical solutions in decreasing social isolation in nh is limited. in the dying phase these alternatives could not replace the presence of close loved ones who wanted to say goodbye. consequently, ecps deliberately weighed, whether or not a tailored exception could be made in individual cases. ecps find it reassuring to take these decisions with a group of colleagues. after a significant peak in the number of deaths in early april, the number of covid- cases and deaths in nhs has been declining in the netherlands. on may th, a pilot in nhs allowed for one fixed visitor, which as of may applied to all covid-free nhs; restrictions were further relaxed june to allow for more than one fixed visitor and more frequent visits under certain conditions (figure ). in our study ecps struggled with on the one hand the pressure to adhere to the national visiting policy and on the other hand their wish for tailoring for the individual. at first, they experienced largely understanding for the situation. however, since may families have increasingly been expressing resistance against the visitor policies. , although there is no 'one size fits all' solution for the complex dilemmas faced here, our analysis provides several insights worth considering in assessing and reviewing current and future visiting policies. we observed that the nationwide 'top-down' restrictive visitor policy resulted in resistance and a need for more regional and local tailored visiting policies. important aspects emerging from our study to be considered by policy makers when issuing visiting policies are the regional and local covid- prevalence, the availability of sufficient ppe, the possibility to streamline visits (e.g., separate visiting areas, schedules for visitors), and the possibility to isolate residents. nevertheless, even with visiting policies tailored to the regional and to the local nh organization context, dilemmas may still occur on j o u r n a l p r e -p r o o f an individual level. health care professionals may still have to weigh whether or not the local visiting policy is proportional to the specific circumstances of the resident and his or her visitors. relevant aspects emerging from our analysis to take into account when decisions have to made for those dilemmas are summarized in table . we believe explicitly considering these aspects by health care professionals should contribute to cautious • "covid negative client, displays no symptoms, has to stay in his room because the care unit is closed due to a covid positive client, family member wants to put on ppe and pick up client in ppe, to take them outside so they are no longer in a sad mood and will eat and drink again" • "yes, that too, it would be more pleasant to be able to go outside with a few people to keep the situation on the care unit bearable. in many cases, this prevents agitation and behavioral problems among clients with dementia." isolation and psychotropic drugs • "sedating patients who are infected and don't remain in their rooms. isolating and sedating 'walkers', with as a result: an unpleasant end of life." • "severe agitation with a pg-resident who can be calmed by family and requires more sedating medication out of necessity." • "psychiatric drugs became necessary to improve the quality of life, with drowsiness and decreased mobility as a result." • "sir now receives an increase of clozapine-medication, while it is unclear whether a non-medicated visit of family could be more effective." • the residents' world was already small, now it is even more limited because they can no longer receive family and friends, and are also locked inside the nursing home. the fact that residents cannot go outside themselves is very restrictive and increases psychological complaints. freedom restriction and tailoring to residents • "it would be nice if national policy would be that those to whom it relates, and to whom sitting in the courtyard is not enough, could go for a daily walk around the house or (duo)cycling accompanied by a member of staff." • "i find it difficult that they are not allowed to go outside under the condition that they have no social contact, don't go to the supermarket etc. a stroll around the block of a client with dementia accompanied by a member of staff, without any other form of social contact, should be possible." • "the client with the spinal cord injury has complete autonomy over his life, despite the dependence on care. he would be capable of adhering to social rules. however, he is in a total lockdown and i am in an intelligent lockdown". • "it feels unethical to restrict someone in their freedom, if your expectation is that he would act responsibly." • "in my opinion, riding around on empty parking lots or visiting quiet parks barely increases the risk of infection, but increases the feeling of freedom." • "taking away the option of going out for fresh air from a cognitively competent person on an uninfected care unit, even j o u r n a l p r e -p r o o f when they adhere well to regulations, is something i consider a strong intervention of their right to lead their own life. the risk of spreading corona verses the restriction of freedom is, in my opinion, disproportional. " • "what is difficult is that most of the contact is through telephone, there is no face-to-face contact. it makes communicating different, and more difficult." • "immediate incident with a resident, rectal blood loss. considering the stage of dementia, we will wait and see, and temporarily stop using anticoagulants scared wife on the phone, fears cancer, cries. reassured with difficulty. a personal conversation would have been better." • "there is little deployment of volunteers, spiritual care or psychologists possible, because they are also required to work from a distance as much as possible. this has caused the deployment of help with her mood to be slowed down." alternatives for therapies and care • "she currently does receive a psychologist and spiritual caretaker in her room because of the urgency, but visitors are still not allowed. an attempt will be made to improve that through videocalling or standing on the blacony with a baby monitor." j o u r n a l p r e -p r o o f impact on next-of-kin • "family also found it very hard to hear her speech was declining as a result of als and they could not come to see her, to talk to her about it." • "family is losing autonomy: i can see this is painful for them." • "the powerlessness and frustration of partner and the major worries this caused." impact on nursing staff • "informing families more often and better, many extra reports by nursing staff, use of video calls etcetera. nursing staff experience this impotence too and are not always able to provide extra care." • "the team is more at ease as there is no traffic of various people and professionals across the care units • . therefore, they have more time for residents. " • "this took a lot of effort by phone from my side to maintain a good doctor-patient relationship. " • "guidance of care-teams and explaining decisions take a lot of time. " nos. van dissel: 'corona in minstens procent van de verpleeghuizen aantal bewoners van verzorgings-en verpleeghuizen the dutch move beyond the concept of nursing home physician specialists op advies van verenso scherpt kabinet bezoekregeling verpleeghuizen aan afscheid in de stervensfase en na overlijden family involvement in residential long-term care: a synthesis and critical review quality of life of institutionalized older adults by dementia severity dutch government. new measures to stop the spread of coronavirus in the netherlands handreiking voor bezoekbeleid verpleeghuizen in corona-tijd versie juni using thematic analysis in psychology ethical issues experienced by healthcare workers in nursing homes: literature review amid the covid- pandemic, meaningful communication between family caregivers and residents of long-term care facilities is imperative prolonged social isolation of the elderly during covid- : between benefit and damage loneliness and isolation in long-term care and the covid- the coronavirus and the risks to the elderly in long-term care covid- in older adults: clinical, psychosocial, and public health considerations de impact van sociale isolatie onder bewoners van verpleeg-en verzorgingshuizen ten tijde van het nieuwe coronavirus richtlijn zorg in de stervensfase care of the dying patient: the last hours or days of life white paper defining optimal palliative care in older people with dementia: a delphi study and recommendations from the european association for palliative care video calls for reducing social isolation and loneliness in older people: a rapid review nursing homes or besieged castles: covid- in northern italy the impact of covid- on long-term care in the netherlands ethisch verantwoorde zorg in tijden van corona -een handreiking voor zorginstellingen verruiming van de bezoekregeling in verpleeghuizen: bevindingen van de diepte-monitoring na weken what affected you most in this situation? could you describe what impact it had on you? . did considerations relating to the resident play a role? if yes, which ones? . did considerations relating to the resident's family play a role? if yes, which ones? . did considerations relating to the nursing staff play a role? if yes, which ones? . did considerations relating to the care unit play a role? if yes, which ones? . did considerations relating to the organization play a role? if yes, which ones? . did any other considerations play a role? . what was decided upon regarding the dilemma and who was involved in the decision? . are there any other in my nursing home, i observe how much suffering corona causes and how many people fall victim to it. the risk of spreading should really not be taken measures also protect the professionals in particular: they are very vulnerable to be infected or to spread the coronavirus patient was terminal and visitors were allowed, a maximum of people per day. except, these two would walk in and out throughout the day (…) this made me realise that the policy of 'two people a day in the terminal phase' is not specific enough. are they allowed to walk in and out? how long are they allowed to stay?" for example: • loneliness • depressive symptoms, depression • decreased intake • neuropsychiatric symptoms (increased or decreased) • physical complaints (for example pain) proportional? visitor covid- confirmed? covid- related symptoms? connotation of visiting the resident for specific visitor: • being able to say goodbye to loved one • being involved in resident's disease process/ process of decline • being involved in resident's care process • being involved in resident first confirmed covid- case in national nursing home registry social distancing policies implemented by the dutch government : nationwide restriction for all visitors of residents of ltcfs including nhs start of data collection/questionnaire sent to ecps end of data collection/questionnaire closed start of a pilot with eased visiting policies (i.e., allowing for one fixed visitor) in a selection of dutch nhs eased visiting policies (i.e., allowing for one fixed visitor) in all nhs free from first monitoring results of the pilot published by the collaboration of academic university networks for older adult care in the netherlands stepwise lifting of restrictive visiting policy (i.e., allowing for more than one fixed visitor and more frequent visits) for all nhs under certain conditions including covid epidemiology and organizational factors researchers from two academic university networks for older adult care commissioned by the dutch ministry of health advise against a nationwide visitor restriction and argue that nhs should implement tailored visitor policies upon a second wave of covid- key: cord- -k hchau authors: khusid, johnathan a.; weinstein, corey s.; becerra, adan z.; kashani, mahyar; robins, dennis j.; fink, lauren e.; smith, matthew t.; weiss, jeffrey p. title: well‐being and education of urology residents during the covid‐ pandemic: results of an american national survey date: - - journal: int j clin pract doi: . /ijcp. sha: doc_id: cord_uid: k hchau background: the rapid spread of covid‐ has placed tremendous strain on the american healthcare system. few prior studies have evaluated the well‐being of or changes to training for american resident physicians during the covid‐ pandemic. we aim to study predictors of trainee well‐being and changes to clinical practice using an anonymous survey of american urology residents. methods: an anonymous, voluntary, ‐question survey was sent to all acgme‐accredited urology programs in the united states. we executed a cross‐sectional analysis evaluating risk factors of perception of anxiety and depression both at work and home and educational outcomes. multiple linear regressions models were used to estimate beta coefficients and % confidence intervals. results: among approximately , urology residents in the usa, ( %) responded. among these respondents, had missing data leaving a sample size of . important risk factors of mental health outcomes included perception of access to ppe, local covid‐ severity, and perception of susceptible household members. risk factors for declination of redeployment included current redeployment, having children, and concerns regarding ability to reach case minimums. risk factors for concern of achieving operative autonomy included cancellation of elective cases and higher level of training. conclusions: several potential actions, which could be taken by urology residency program directors and hospital administration, may optimize urology resident well‐being, morale, and education. these include advocating for adequate access to ppe, providing support at both the residency program and institutional levels, instituting telehealth education programs, and fostering a sense of shared responsibility of covid‐ patients. in december , a highly contagious novel coronavirus (sars-cov- ) was identified in wuhan, china , and on march th , the usa became the world's most afflicted nation with , cases of coronavirus disease (covid- ) , . the rapid spread of covid- has placed tremendous strain on the american healthcare system and prompted drastic steps to divert healthcare resources for the treatment of patients with covid- . for example, on march th , the surgeon general advised all hospitals to halt elective surgery . additionally, physicians have increasingly used telemedicine to facilitate social distancing and in some instances, physician specialists, have been redeployed to "frontline" services such as the medical wards, intensive care unit, and emergency room . in addition to clinical practice changes, numerous academic meetings have been cancelled, licensing exams are being rescheduled, and fellowship interviews are being conducted using teleconferencing software . beyond the educational and structural changes experienced, covid- threatens the well-being of residents as nationwide personal protective equipment (ppe) shortages leave frontline workers at increased risk of viral exposure . furthermore, a recent study conducted in wuhan during the covid- pandemic reported that frontline workers were at risk of unfavorable mental health outcomes . despite these monumental changes and the unique challenges presented by the pandemic, the impact on resident well-being, clinical practice, and education are largely unknown. to address this gap, in the current study we aim to assess the well-being, clinical practice, and education of urology residents throughout the usa during the covid- pandemic through the use of an anonymous survey. given that routine urology practice encompasses elements of outpatient clinic, inpatient medicine, and surgery, and the low number of urology trainees nationally relative to other specialties, a national study of urology trainees may provide an important and timely initial assessment. to our knowledge, this is one of the first studies assessing trainees' well-being, clinical practice, and education during the covid- pandemic. the study obtained exempt status from the suny downstate health sciences university institutional review board. an anonymous, voluntary, -question survey was sent to all american council for graduate medical education (acgme)-accredited urology programs in the usa by contacting each program's coordinator and/or director and each american urologic association (aua) section secretary with the request to disseminate it to their residents. additionally, social/professional networks were used to disseminate the survey, which was available from april , until april , . the study is cross-sectional and assessed resident perceptions of personal, institutional and residency program responses to the pandemic. the survey utilized questions that were single-answer, multiple-answer, and likert scales which were graded on a - scale with representing "strongly disagree" and representing "strongly agree." this article is protected by copyright. all rights reserved the study evaluated six likert scale outcomes related to resident mental health and training. perceived severity of anxiety was evaluated using the following statements "i have increased anxiety at work due to the covid- pandemic" and "i am more anxious outside of work due to the covid- pandemic." similar statements were used for perceived severity of depression: "i feel a sense of depression at work due to the covid- pandemic." and "i feel a sense of depression outside of work due to the covid- pandemic." declination of redeployment was measured with as follows: "i would decline redeployment to a covid- service if given the option." concern of operative autonomy was measured as follows: "i am concerned about my ability to operate independently as an attending urologist due to interruptions in training secondary to the covid- pandemic." the objective was to identify independent risk factors of outcomes among urology residents during the pandemic. potential risk factors included: resident age, gender identity, level of training, practice setting (urban/suburban/rural), aua geographical section, perception of local covid- severity (likert), marital status, children, perceived household susceptibility to disease (likert), history of covid- symptoms, months of intensive care unit training, redeployment status, perceptions of availability of ppe (likert) and covid- testing, cancellation of elective cases, number of weekly operations before the pandemic, perceived program and hospital support (likert), perception of shared responsibility with attendings (likert), and perceived difficulty meeting case minimums (likert). data analysis was executed using r. two-sided p-values with alpha= . were used. distributions of characteristics were tabulated using percentages for categorical variables and means with standard deviations for continuous variables. six multivariable linear regressions were fit for the six outcomes using all risk factors as independent variables. models estimated beta coefficients (β) and % confidence intervals (ci) representing associations between risk factors and outcomes. linear regression assumptions were evaluated using plots and hypothesis tests. qqplots verified the assumption of normality. to test for heteroskedasticity, residual plots were generated along with a non-constant variance test. there was strong evidence of heteroskedasticity. to correct this, all outcomes employed a box-cox transformation. lack of multicollinearity was confirmed by estimating variance inflation factors. among approximately , urology residents, ( %) responded. among these respondents, had missing data leaving a final sample size of . table reports the distributions of variables. the average age of the sample was . . of the respondents, ( %) were female, ( %) were married, ( %) practiced in an urban setting, while ( %) practiced in a suburban setting. the most represented aua regions were new york ( %), mid-atlantic ( %), and north-central ( %). a total of ( %) had been redeployed to a different service and ( %) reported a history of covid symptoms. figure reports results of the risk factors associated with severity of anxiety outcomes. perception of ppe availability was associated with lower severity of anxiety at work (β=- . , % ci=- . , - . ) and at home (β=- . , % ci=- . , - . ) whereas perception of local covid- severity was associated with higher severity of anxiety at work (β= . , % ci= . , . ) and at home (β= . , % ci= . , - . ). perception of susceptible household member was associated with higher severity of anxiety at work (β= . , % ci= . , . ) and at home (β= . , % ci= . , . ). urban practice setting (β= . , % ci= . , . ) and suburban practice setting (β= . , % ci= . , . ) was associated with higher anxiety severity at work compared to rural practice setting. personal history of infection with covid- was associated with higher severity of anxiety at work (β= . , % ci= . , . ). amount of prior intensive care unit training was associated with lower severity of anxiety at work (β=- . , % ci=- . , - . ). current redeployment was associated with higher severity of anxiety at work (β= . , % ci= . , . ) while perception of program support (β=- . , % ci =- . , - . ) was associated with lower severity of anxiety at work. availability of testing if symptomatic was associated with lower severity of anxiety at home (β=- . , % ci=- . , - . ). males reported lower severity of anxiety at work (β=- . % ci=- . , - . ) and at home (β=- . , % ci=- . , - . ). figures and report the results for declination of redeployment and concern of operative autonomy, respectively. perception of support from hospital administration (β=- . , % ci=- . , - . ) and shared responsibility between residents and attendings (β=- . , % ci=- . , - . ) were associated with lower declination of redeployment whereas concern regarding ability to reach graduation case requirements was associated with higher declination of redeployment (β= . , % ci= . , . ). having children was associated with higher declination of redeployment (β= . , % ci= . , . ) whereas current redeployment was associated with lower declination of redeployment (β=- . , % ci=- . , - . ). concern regarding ability to reach graduation case requirements was associated with higher concern of operative autonomy (β= . , % ci= . , . ). cancellation of elective cases was associated with higher concern of operative autonomy (β= . , % ci= . , . ) while being married was protective (β=- . , % ci=- . , - . ). residents in pgy (β= . , % ci= . , . ) and pgy (β= . , % ci= . , . ) had higher concern of operative autonomy. the covid- pandemic has placed significant strain on the american healthcare system. in response, major efforts have been made to divert healthcare resources for the treatment of covid-meetings and conferences have been cancelled to comply with social distancing recommendations. we sought to characterize urology resident education, clinical practice, and well-being with a national survey, and identified several important trends. we identified several significant predictors of perceived anxiety and depression, both at work and home. perceived adequacy of access to ppe was inversely related to all four mental health outcomes. that is, urology residents who reported adequate access to ppe reported lower levels of anxiety and depression. similarly, a previous study of healthcare workers during the severe acute respiratory distress syndrome pandemic found that lower stress levels were associated with ppe availability . the relationship between ppe availability and mental health during a pandemic may be related to fear of becoming ill and/or spreading the illness to loved ones. indeed, urology residents who reported the presence of a household member (including themselves) who was susceptible to covid- reported higher levels of anxiety at work, anxiety at home, and depression at work scores. this notion of self-protection is supported by a study of healthcare workers during the avian flu epidemic in which % of respondents cited confidence in the hospital's ability to protect them as the most important factor influencing their willingness to report to work . these findings suggest that ensuring adequacy of ppe availability is important for urology resident well-being during the covid- pandemic. another potentially modifiable predictor of urology resident anxiety and depression was perception of support by the residency program. residents who reported higher levels of program support had lower anxiety at work and depression at work scores. furthermore, previous literature has described the importance of perceived support and appreciation by faculty in mitigating burnout amongst general surgery residents under regular circumstances . thus, it is important for program directors and faculty to regularly engage with residents and offer support and appreciation as this may improve well-being at work. performing surgery is a key component of routine urology practice. however, with the onset of the pandemic, there has been a precipitous decline in operative volume with % of urology residents reporting that non-oncologic cases have been cancelled and % reporting that oncologic cases have been cancelled. the sharp decline is further illustrated by the decrease in percentage of residents reporting participation in or more operations per week since the onset of the pandemic ( % vs. %). this significant decrease in operative volume raises questions about disruption of surgical education. urology residents tend to be the most active in the operating room during their accepted article senior and chief years and accordingly pgy- and pgy- residents reported higher levels of concerns regarding comfort with operative autonomy at the conclusion of training. routine urology practice also encompasses outpatient clinic visits. there has been a radical increase in the reported use of telehealth by urology services since the onset of the pandemic ( % vs. %). however, % of urology residents report that they have not been trained on how to perform effective telehealth visits. given the reasonable possibility that increased telehealth usage will persist beyond the pandemic, urology residents would likely benefit from formal telehealth training. another major change to routine urology practice has been "redeployment" to a "frontline" covid- service. approximately one fifth of the urology residents surveyed have been redeployed, most commonly to the intensive care unit, medical wards, and emergency room. of the redeployed residents, % report that their redeployment was mandatory. for all respondents, we assessed perception of declination of voluntary redeployment. modifiable negative predictors of declination score were perception of institutional support and perception of shared responsibility for pandemic related activities with attendings. that is, urology residents who felt supported by their institution and that additional responsibilities were not being solely placed on the residents would be more likely to agree to voluntary redeployment. it may be helpful for hospital administrators to reach out to residents and inquire what resources they need to feel a greater sense of support (e.g. hazard pay, complementary lodging for self-quarantine, food subsidy). additionally, responsibility for the care of covid- patients should be shared between attendings and residents. implementing these changes may improve morale by making redeployment feel more voluntary than mandatory. our study had several notable limitations. our respondent rate was % and therefore not necessarily indicative of the entire population of urology residents. this may be an inherent limitation of using an optional survey in this population given that by comparison, the aua-sanctioned resident survey conducted over three years from - had a respondent rate of only % . additionally, the survey was predominantly distributed through secondary means (i.e. residency program directors and aua section secretaries) rather than directly to respondents which may result in sampling error. furthermore, a simple - scale was used for assessing depression and anxiety rather than a validated questionnaire such as the patient health questionnaire . the use of a validated questionnaire may have provided more insight into the surveyed population. for example, in our study men reported lower depression and anxiety scores. previous research has found that men tend to underreport anxiety and depression , . without the use of a validated questionnaire, it accepted article is unclear if our findings are due to this known underreporting phenomenon or have another explanation. despite limitations, we have identified several important interventions which could potentially be undertaken by hospital administrators and urology programs to optimize urology resident wellbeing, education, and morale during the course of a pandemic. in summary these are: advocating for adequate access to ppe, providing support at both the residency program and institutional levels, instituting telehealth education programs, and fostering a sense of shared responsibility for covid- patients. interestingly, all of these findings are relatively general in nature and could potentially be applied to all specialties. thus, we believe it is imperative to perform a follow up study across all specialties to assess the generalizability and validity of our findings. furthermore, our study provides a unique and timely prospective, as it was conducted during a critical period of the pandemic in the us, capturing the days leading up to and including april th , (the date that the usa became the nation with the most total covid- mortalities). the covid- pandemic has placed unprecedented strain on the healthcare system and prompted dramatic resource reallocation to minimize patient morbidity and mortality. these resource shifts have resulted in major changes to previous routines of urology residents. our study has identified several potential actions that could be taken by residency programs and hospital administration which may optimize urology resident well-being, morale, and education. these include advocating for access to ppe, providing support at both the residency program and institutional levels, instituting telehealth education programs, and fostering a sense of shared responsibility for covid- patients. our study was limited in scope to urology residents. however, to our knowledge, ours was one of the first national study characterizing covid- pandemic responses among american trainees. importantly, these findings, if appropriately validated, could be applied to nonurology trainees. thus, we recommend further research with a large national study of trainees from all specialties to assess the validity and generalizability of our findings. a novel coronavirus from patients with pneumonia in china accepted article this article is protected by copyright. all rights reserved now leads the world in confirmed coronavirus cases. the new york times hospitals push off surgeries to make room for coronavirus patients to-minimize-contact-with-virus-patients- .) . 'today, we are all covid- doctors'. the new york times role of the urologist during a pandemic: early experience in practicing on the front lines in critical supply shortages -the need for ventilators and personal protective equipment during the covid- pandemic factors associated with mental health outcomes among health care workers exposed to coronavirus disease factors associated with the psychological impact of severe acute respiratory syndrome on nurses and other hospital workers in toronto survey of hospital healthcare personnel response during a potential avian influenza pandemic: will they come to work? accepted article this article is protected by copyright. all rights reserved surgical resident burnout and job satisfaction: the role of workplace climate and perceived support the state of the urology workforce and practice in the united states gender and depression in men toward the reconstruction of masculinity key: cord- -e it nxl authors: alahmadi, adel salah; alhatlan, hatlan m; bin helayel, halah; khandekar, rajiv; al habash, ahmed; al-shahwan, sami title: residents' perceived impact of covid- on saudi ophthalmology training programs-a survey date: - - journal: clin ophthalmol doi: . /opth.s sha: doc_id: cord_uid: e it nxl purpose: to evaluate the impact of the current pandemic on ophthalmology residency training in saudi arabia, focusing on its effects on clinical education, training, and the mental well-being of the trainees. methods: an online self-administered questionnaire was distributed among residents in the saudi ophthalmology training programs between july and , . in this study, we explored residents’ opinions regarding training disruption and virtual education. the patient health questionnaire (phq- ) was used to assess the covid- pandemic’s impact on their mental health. we used descriptive statistics for data analysis. results: out of registered ophthalmology residents, participated in this study. ninety-six participants ( . %) were rotated at a specialized eye hospital during the covid- pandemic, while ( . %) had rotations in the ophthalmology department at general hospitals. those who rotated in both types of hospitals were ( . %). according to the participants, there was a significant decline in exposure to surgical and office-based procedures compared to emergency eye consultations (friedman p < . ). the covid- pandemic’s effect on mental health was reported by ( . %) participants. eighty-five ( . %) respondents were satisfied with the virtual method of education. conclusion: covid- pandemic has disrupted residents’ clinical and surgical training in the saudi ophthalmology training programs. additionally, we believe that covid- may have a negative impact on trainees’ mental health. fortunately, the current pandemic provided an innovative education method that will likely be used even after the pandemic. in december , an outbreak of pneumonia emerged from wuhan, a city in china, caused by a new coronavirus. a few months later, the world health organization (who) declared it a pandemic. this pandemic has affected many sectors, including world economics, lifestyle, and the healthcare system. on march nd, , the first confirmed coronavirus disease (covid- ) case in saudi arabia was reported in the eastern region. as recommended by national and international ophthalmic societies, routine ophthalmic services ceased to operate and, only urgent and emergency services kept running. , unfortunately, this negatively impacted residents' surgical and clinical training. in response to the letter sent by the american academy of ophthalmology to its members about reopening of routine services, some centers have opted to reopen clinics and perform surgeries while implementing precautionary measures to limit the risk of exposure and transmission of the disease. , in addition to disruption in clinical and surgical teaching, didactic teaching programs such as grand rounds and lectures were administered through virtual platforms such as zoom, microsoft teams, and cisco webex. we believed that ophthalmology residents had experienced remarkable limitations in their clinical training and surgical exposure due to these dramatic changes. given the uncertainty of this pandemic's duration and impact on the residents' mental health, assessing residents' perception and well-being is crucial. in saudi arabia, the impact of covid on ophthalmology training was not studied yet. this study aimed to assess the pandemic impact on ophthalmology residency training by obtaining the residents' perspective as we believe that their perception is crucial and valuable to adapt to changes while maintaining a successful residency training. , we believe that identifying the pandemic's true impact on training from the residents' point of view will provide beneficial insight for program directors and decision-makers to implement solutions for disrupted clinical training and insufficient surgical exposure. moreover, exploring the efficiency of virtual teaching is important because of its novelty and the probability of permanently replacing the conventional teaching way. finally, mental health well-being is an essential part of the residents' overall health, and assessing it at the time of crisis is crucial since mental illness can have long-lasting negative effects on them, and recognizing them earlier allows for rapid interventions, subsequently a better outcome. the institutional review board at king khaled eye specialist hospital (kkesh) approved the current study (number: -p). all study conducts adhere to the tenets of the declaration of helsinki. a questionnaire was sent to all residents (n- ) currently enrolled in scfhs accredited ophthalmology training programs, between and july . participation was voluntary and complete anonymity was ensured. all participants provided informed consent to take part in this study. the survey (appendix ) consisted of questions. the questions covered mainly demographics data such as program location, type of hospital general or specialized, level of training, gender, marital status, and whether he/she lives alone or with family or friends. we included questions about the pandemic's impact on the training changes in clinical working hours, surgical exposure, on-call, emergency room coverage, and overall training. regarding the hospital policies/general health guidelines changes, we asked the participants whether the hospital kept operated or services forced to shut down, whether the participant was exposed to covid- cases or deployed to cover other services, personal protective equipment (ppe) availability, and types. specific questions were directed to a subset of residents who were diagnosed with covid- . additionally, the questionnaire included questions related to theoretical teaching and the quality of the virtual teaching. the effect of the pandemic on studying, research, and elective rotations was also explored. finally, we used the patient health questionnaire (phq- ) to assess the impact of covid- on mental health. , in a study conducted by kroenke et al, phq- was found to have a sensitivity of % and a specificity of % for diagnosing major depression. thereby, they concluded that phq- is a valid and reliable tool to assess depressive symptoms. the data was transferred from the surveymonkey platform into a microsoft xl spreadsheet. the data analysis was carried out using the statistical package for social studies (spss ) (ibm, ny, usa). the qualitative variables like gender, training level were presented as numbers and percentages. the quantitative variables like impact on training scores were studied for distribution. if the variables were not normally distributed, the median and interquartile range were estimated. to compare the impact score in subgroups, we used a nonparametric method, and for two independent variables, the wilcoxon p-value was estimated. for more than two independent variables, friedman p-value was presented. a p-value of less than . was considered statistically significant. of the -total number of ophthalmology residents in saudi arabia, ( . %) answered the submitted questionnaire. the comparison between ophthalmic residents and surveyed participants is given in table . those who participated were not significantly different from those who did not. among surveyed residents, eighty-six ( . %) were males, ( %) were unmarried, ( . %) were living with their family. during the covid- pandemic, participants ( . %) were rotated at a specialized eye hospital, while ( . %) had rotations in the ophthalmology submit your manuscript | www.dovepress.com clinical ophthalmology : department at general hospitals. those who rotated in both types of hospitals were ( . %). changes in the participants' clinical and surgical activities during the covid- pandemic are shown in table . only participants responded to these questions. according to the participants, the overall score suggested a significant reduction of . % compared to the pre-pandemic. compared to emergency eye consultations, there was a significant reduction in numbers of surgeries performed, office-based procedures such as corneal cross-linking and intravitreal injections, as well as laser for proliferative retinal diseases and maculopathy (friedman p < . ). the resources to protect health staff against the risk of covid- transmission as perceived by ophthalmic residents are summarized in table . our data indicate that programs provided masks to . % of the respondents. around % received gowns, and . % also received gloves. besides that, built-in shields for slit lamps were provided, as stated by . % of the participants. however, other protective equipment types such as face shields and goggles were only provided for . % and . % of the participants, respectively. additionally, . % of participants stated that programs provided updated protocols and guidelines on limiting sars-cov- transmission; however, according to %, there was a delay in providing these guidelines and protocols. moreover, the majority of the participants reported that the recommended precautionary measures were implemented, such as providing ppe for patients and staff, screening and triaging at entry gates for both patients and staff, practicing social or physical distancing by limiting the number of people sitting in waiting areas or offices to individuals in each room, shifting to telemedicine or virtual consultations. one hundred eight participants replied to the questions regarding the effect of the covid- pandemic on mental health. eight ( . %) residents reported no effect. mild and moderate depressive symptoms were observed in ( . %) and ( . %) of the trainees. sixteen ( . %) ophthalmology residents scored high (severe depressive symptoms) in the phq- scale. as many as ( . %) participants did not respond to this part of the survey. (figure ) ophthalmology resident's feedback on web-based training during the covid- pandemic suggested that one ( . %) resident was highly dissatisfied, ( . %) were dissatisfied, ( . %) were satisfied, and ( . %) were highly satisfied with the web-based ophthalmic education. twenty-four residents did not respond, and three residents said they did not attend any web-based training. the majority of residents ( . %) used zoom, one resident ( . %) used the microsoft team, and three residents ( . %) used other tools. (table ) . regarding the questions related to the covid- duties and infection, ( . %) residents were deployed to covid- areas. the polymerase chain reaction (pcr) test was negative in ( . %) trainees. at the time of conducting the current survey, the test result of ( . %) residents was pending. six ( . %) of the residents were tested positive. regarding the source of infection, one resident got the infection from a family member while the rest did not know its source. one resident was hospitalized, two received supportive treatment. residents with covid- positive status were looked after through the local employee health clinic. also, their program directors frequently inquired about their health. the current cross-sectional study aimed to explore covid- related experiences and perceptions of ophthalmology residents in various saudi programs. additionally, we aimed to assess their mental wellness during the current pandemic. according to the center for disease control and prevention (cdc), and international ophthalmic societies, hospitals were asked to postpone routine services such as outpatient clinics and elective surgical procedures to reduce covid- transmission risk and conserve healthcare resources. our data clearly illustrates the significant impact of these measures on the ophthalmology residency training programs in saudi arabia. the participants in this study believed that their training was severely affected. they reported a significant reduction in routine outpatient care and a dramatic decline in exposure to surgical training and minor procedures such as injections and lasers. however, no changes were noted in residents' emergency care exposure as emergency departments continued to run normally during the lockdown. these findings are in line with the recently published data from various residency programs worldwide. , , [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] in the united kingdom, % were concerned about the impact of covid- on their training, specifically their surgical exposure and postponement of the board certification examinations. globally, the supply of personal protective equipment (ppe) is limited. the who has released guidance on how to optimize the ppe supply in case of shortage. in this study, we investigated the availability of ppe for ophthalmology residents. our data indicated that most participants were provided with ppe, built-in shields for slit-lamps, and updated protocols and guidelines on how to limit sars-cov- transmission. these protocols included providing ppe for all patients and staff, screening and triaging at entry gates for both patients and staff, limiting the number of people sitting in waiting areas or offices to individuals in each room, shifting to telemedicine, or virtual consultations. despite implementing precautionary measures, several studies reported that trainees were afraid of contracting the disease or transmitting it to their families. such fears may negatively influence the physician's critical thinking and decision making. in our survey, we used patient health questionnaire- (phq- ) to measure the severity of depression among trainees. nearly half of the responded participants to this part of the questionnaire demonstrated mild to moderate depressive symptoms, while around % have severe symptoms. civantos et al reported a high prevalence of burnout ( . %), anxiety ( . %), and distress ( . %) among otolaryngology residents and attending physicians. moreover, . % of the participants in their study scored positive for depression symptoms using the -item patient health questionnaire. in another study by robbins et al, the current pandemic negatively impacted the morale of . % of the residents. also, khanna et al found that many ophthalmologists who participated in their study were psychologically affected. overall, the findings in our study are alarming. seeking services that support the mental well-being of the trainees should be facilitated and encouraged. mishra et al also reported that . % of their study participants were stressed. additionally, they also reported that . % of their study participants were "unhappy" during the lockdown. redeployment of trainees to other areas of need during the covid- pandemic was associated with increased anxiety levels, especially if not proceeded with special training. in our study, only % of participants were asked to provide care in areas designated for covid- patients' care. six residents in our sample contracted the disease, and all of them received support and inquiry about their health from their program directors. interestingly, in a study conducted by khusid et al, the residency program's support was associated with a lower level of anxiety and depression. this pandemic has provided a unique opportunity for innovative teaching methods. as part of maintaining physical distancing, grand rounds and lectures are now delivered using virtual platforms and software. moreover, this new teaching method allows recording the lectures to be stored later and accessed by those interested. under the umbrella of the saudi commission for health specialties (scfhs), ophthalmology residency programs have organized and overseen more than virtual teaching sessions in april alone. according to our data, nearly half of the participants were satisfied with the new method. in line with this finding, this distance method of teaching was welcomed by participants in several studies. , , , after the pandemic concludes, medical education will likely adopt this teaching method in addition to traditional face-to-face education. , this study, however, has several limitations that are important to be acknowledged. we did not inquire whether participants tried to contact the scfhs mental health support services "daem" or not. additionally, we did not investigate whether these depressive symptoms are new or due to preexisting mental health conditions. in this study, to mental health. therefore, we cannot exclude the possibility of a non-response bias. those who did not respond to this part of the questionnaire may not have experienced mental health issues. we did not inquire about the reasons for dissatisfaction reported by approximately % of the participants regarding virtual education, whether these reasons were related to technical difficulties or was the time to conduct these activities unsuitable. as these lectures were mostly broadcasted in the evening time, conflicting with family responsibilities. despite these limitations, our study has several strengths. compared to other studies, the response rate in our study is high ( . %). , , , additionally, we used a validated questionnaire, patient health questionnaire- (phq- ), to assess depressive symptoms. in summary, the covid- pandemic has significantly altered the face of medical education and training. during the current crisis, clinical and surgical training has been disrupted. therefore, the adoption of alternative teaching methods is critical. we believe that covid- had significantly impacted trainees' mental health currently enrolled in the saudi ophthalmology residency programs. access to psychological support programs should be facilitated and encouraged. fortunately, the current pandemic provided the ophthalmology community with a great unique opportunity to boost knowledge. in the future, besides traditional teaching, e-learning will continue to be used in medical education. flexibility, embracing changes, and frequent curriculum revisions and evaluation will enable training programs to ensure continuity of a high-quality education even at disastrous events. the authors report no conflicts of interest for this work. outbreak of pneumonia of unknown etiology in wuhan, china: the mystery and the miracle world health organization. who director-general/speeches web site differences in sars-cov- recommendations from major ophthalmology societies worldwide protecting yourself and your patients 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primary and secondary eye care; patient safety and quality of care improvements. this journal is indexed on pubmed central and cas, and is the official journal of the society of clinical ophthalmology (sco). the manuscript management system is completely online and includes a very quick and fair peer-review system key: cord- -b ryvctp authors: chong, alice; kagetsu, nolan j.; yen, andrew; cooke, erin a. title: radiology residency preparedness and response to the covid- pandemic date: - - journal: acad radiol doi: . /j.acra. . . sha: doc_id: cord_uid: b ryvctp this article provides a guideline for radiology residency programs to prepare and respond to the impact of covid- , by offering specific examples from three programs, and provides a list of resources for distance learning and maintaining well-being. impact of the pandemic on residents and fellows ( ) . the aim of this article is to provide specific guidance for radiology residency program leadership to prepare and respond to residency-related impact from the pandemic, with focus on safety and education. the accreditation council for graduate medical education (acgme) has developed an operational framework for graduate medical education (gme) to function at sponsoring institutions and their participating sites, with the safety of patients and residents/fellows as the highest priority ( ) . "the spectrum of acgme stages includes: stage "business as usual", stage "increased clinical demands", and stage "pandemic emergency status." at stage , clinical demand is increased but manageable, with special guidance to include education didactics using remote/virtual settings and innovative tools; faculty members may provide remote supervision through telecommunications technology. at this stage, minimum rotations may not be met, since cancellation of clinics and outpatient studies would affect the normal volume of patients that seek care in those settings. at the stage pandemic emergency status, while requirements such as adequate resources and training (including infection protection), adequate supervision, and work hour requirements are in effect, other common program requirements and specialty-specific program requirements are suspended for acgme-accredited programs to allow for the flexibility of physicians in the clinical care settings. at the time of writing, a number of institutions have activated stage or are in the process of activating stage , while some programs, such as new york city, philadelphia, and boston, have activated stage status, where both diagnostic and interventional radiology residents may be assigned to direct patient care settings outside of the department of radiology. to promote physical/social distancing, ensure the safety of residents, and allow for adequate reserve capacity, a number of residency programs, such as the university of california san diego (ucsd) in california (resident number= in diagnostic radiology, in interventional radiology) and virginia mason medical center (vmmc) in seattle, washington (resident number= in diagnostic radiology) have divided the residents into two clinical groups, with one group reporting to clinical service, and the other assigned to home/distance learning; the two groups alternate every other week (one week on, one week off.) the resident group assigned to home/distance learning may be pulled to cover a resident on clinical rotation who becomes ill or needs to be quarantined. at ucsd, to determine the assignments, the chief residents worked with the division chiefs to determine the minimum number of residents required to support the service, and the maximum number allowed to comply with a six-foot physical distance between persons, as recommended by the cdc guidelines ( ) . other considerations included the need for contrast and call coverage, minimum requirements for graduation, and underlying chronic conditions which may place the resident at a higher risk. at vmmc, residents working on site are paired each day with one of the radiology attendings on service, rather than assignment to a specific rotation, to adapt to unpredictable and fluctuating volumes. assignments to procedural rotations have been postponed to support physical distancing and to conserve personal protective equipment. due to the lower number of outpatient exams (cancelled elective procedures and screening exams) and postponement of procedural rotations, credentialing requirements for breast imaging mammography quality standards act (mqsa) and nuclear regulatory commission (nrc), as well as esir (early specialization in interventional radiology (esir) competency criteria may have to be reassessed; as a specialty, we should look to the radiology rrc for guidance on the effects on these training requirements. ensuring resident health and safety during the pandemic is a priority for the residency program. as an acgme requirement, all trainees must be trained in, and provided with, appropriate infection protection for the clinical setting. refreshing knowledge of infection protection, such as donning and doffing of personal protective equipment (ppe) and hand washing technique, is recommended. these safety protocols are available from the institution employee health, infection prevention, and gme departments. campus courses or video instruction on ppe donning and doffing as well as handwashing should be made readily available to residents; however, the utility of this information may be limited due to the shortage of ppe. program directors also need to advocate for appropriate ppe for residents while on clinical rotations, and the local gme body may have guiding principles for involvement of residents in procedures during the pandemic. for example, at virginia mason medical center in seattle, such principles include reducing unnecessary risk to those individuals with less experience, allowing experienced clinicians to provide the most expeditious care, and the conservation of ppe. under this direction, the radiology program directors at vmmc have made adjustments to resident schedules, not only for radiology resident involvement in procedures, but also for involvement of other learners in the department (such as internal medicine residents rotating through the department to learn image-guided procedures.) these rotations have been deferred until the crisis abates to adhere to the organizational guiding principles. program directors can consult with institutional infection prevention staff to survey work space areas such as reading rooms and provide recommendations on spacing to minimize risk. to promote physical distancing, resident hand-offs and consults can be performed by phone. temporary signs with a telephone number for radiology consults may be placed on reading room doors to further promote social distancing between referring clinicians and radiologists. residency program directors can work with the radiology department to identify new potential work areas and moving workstations to different locations, assigning residents to a specific workstation for the duration of the rotation. remote reading stations can be deployed for any senior resident due to the need for less direct supervision. residents who are immunocompromised or at high risk may be provided institutionalapproved workstations and be allowed to work from home. other supportive resources could also be offered, such as webcams and headsets for video conferencing. at vmmc, employees, including residents, are provided thermometers free of charge. as long as the pandemic continues, residency and fellowship interviews should be conducted virtually using software such as facetime (apple inc, cupertino ca), skype business (microsoft®, seattle wa), or zoom (san jose, ca.) residents should be empowered by residency leadership to promote the safety and health of others in the department, including technologists, nurses and assistants. residents should alert involved staff taking care of patient's suspected of covid- infection to take the necessary precautions. if a resident on call identifies findings on a chest ct or radiographic exam suspicious for covid- , the resident should (in addition to communication of this to the referring physician) notify the technologist to be on alert for subsequent steps regarding potential exposure. a live online document of tips related to staying healthy and safe, with contact information and protocols for resident illness, self-quarantine, and procedures for testing may be helpful. development of back-up call teams (in case the on-call resident falls ill), if not already in place, should be considered. residency programs should have various ways for residents to call in sick during routine times, but if they do not have a robust system in place already, the pandemic may be an impetus for creating one. residency programs could develop a standardized sickness notification email template (with information such as resident rotation) that a resident can send for distribution to a group that includes the program director (s), chief residents, relative attendings on the assigned service, and the program coordinator. an app such as viber (rakuten viber, luxemburg) that the whole program, including program leadership and key faculty, can subscribed to, can provide centralized communication; care must be made to ensure secure communication and hipaa compliance. while limiting exposure is paramount to ensure the safety and health of patients and residents, and radiology clinical volume is reduced in some areas, there is still opportunity for residents to learn and actively participate on the clinical rotations. other than skills related to radiological diagnosis and interpretation, active onsite involvement may be an opportunity for residents to learn about organization, leadership, teamwork, and crisis management. residency program leadership should work with department leadership and faculty to champion continued quality education during the pandemic crisis. to find the balance of on-site learning versus distance learning, soliciting input from different perspectives can be helpful. for example, at ucsd, a workgroup was formed by faculty and residents to address the educational needs of residents, particularly to those assigned to home distance learning. considerations such as the flexibility of independent study versus increased structure, adapting conferences to an entirely virtual format, and attendance/accountability were made to design a program that would ensure continued resident engagement in learning. programs may elect to maintain regularly scheduled conferences and lectures by videocast, and supplement education by compiling additional resources for independent study. table ). the association of university radiologists has recently launched the radiology core curriculum lecture series (table ) . other ideas for off-site education include creating picture archiving and communication system (pacs) teaching folders for remote viewing, and remote one-on-one or group readout sessions using zoom (san jose, ca) or teamviewer (teamviewer ag, germany) technology; privacy concerns need to be addressed and a hipaa compliant platform must be used. residents may be encouraged to develop research projects or practice quality improvement (pqi) projects with faculty during this time. for home/distancing learning, a key component is a system that ensures accountability of the learners; this can include having each resident regularly log their learning activity which then can be reviewed by the program director at a later date. for first-year radiology residents preparing to take call, it may be necessary to allot more on-service clinical days in order to allow exposure to more cases, and adequate assessment by faculty for call readiness. continuation of pre-call teaching sessions, simulations and practical exams may need to be adapted to a virtual format. administrative support is vital to making these changes to the curriculum in a timely and flexible fashion. the distance learning time is also a great opportunity for resident-resident mentoring. at virginia mason medical center, one of the chief residents volunteered to review all overnight call cases daily, and to send the most high-yield cases with learning points to the junior residents. at stage pandemic emergency status, all acgme program requirements can potentially be suspended. program directors and residents should be aware that trainees can be reassigned to clinical service outside of the radiology department, as long as supervision, ppe, and work hours are maintained ( ). with increasing demands for physician and other healthcare workers, radiology residents may be redeployed to deliver services in the emergency room, inpatient setting, or remotely via telemedicine in order to triage patients. mental preparedness is the first step, and a review of donning and doffing of ppe is vital. for additional preparation, the society of critical care medicine is offering online education to healthcare professionals who may benefit from critical care training ( ) . the society of interventional radiology offers a critical care introductory course to reinforce clinical knowledge for residents ( ) . an assessment of resident readiness for deployment can also help in planning. for instance, at ucsd, a survey led by the residents is in progress to collect data on individual clinical skill sets that can be readily available should redeployment to specific clinical areas become necessary. residency program leadership also need to take an active role in hospital interdepartmental surge planning. communication and collaboration within the department and with other sections in the organization are of high importance in disaster preparations; in fact, getting involved with others in this crisis is an opportunity to get involved in health systems ( ) . with a dispersed team, it may be useful to hold periodic, if not daily huddles, as long as physical distancing is maintained (if held in-person ( ) . at mount sinai, there has been interdepartmental collaboration with the hospital mass casualty incident team for residents to participate in drills for preparation; the radiology residents also use whatsapp (facebook, menlo park, ca) to quickly assess the status of all the residents and faculty as part of preparedness for disaster response. the response statement from the acgme and the residency review committee (rrc) has emphasized that the -hour resident work week limit remains in effect for all three stages, as deviation could increase risks for both patients and trainees ( , ) . in addition, the acgme has suspended accreditation activities so that programs can focus on response to the pandemic ( ). many program directors and residents may have questions regarding maintenance of case logs as the case number for resident participate may decrease. the rrc has reiterated that the goal of establishing the acgme case logs was for evaluation of residency programs for accreditation, and not for evaluation of individual resident competence. however, the rrc notes that it is up to each program director in conjunction with the clinical competency committee (ccc) to assess each resident's educational and professional progress regarding ability to practice autonomously by graduation. the actual numbers in the case log may be informative in this process, but should not hinder the program director or ccc in this assessment as an absolute barrier. depending on the length of the pandemic and impact on case volumes, it is possible that certain residents may benefit educationally and professionally from prolonging their tenure to ensure full depth and breadth of case and procedural experience. the ultimate goal is to ensure that safe, competent trainees are graduating as a long-term societal consideration, and adjustments that may be made to resident promotion should keep this goal in mind. residency program directors and program coordinators may find it beneficial to document the ways in which their program has been affected by the pandemic, including its effect on case volume, should there be a need for future review. in particular, it is desirable to have notes updated in the programspecific acgme web accreditation data system (webads) "major changes and other updates" section. this will better enable the rrc to take these factors into account during programmatic evaluation. in their recent communication, the rrc offers special guidance regarding requirements for mammography, nuclear medicine and interventional procedures. options for meeting requirements are offered, such as consideration of telemedicine on nuclear medicine and breast imaging rotations. however, it is important to note that federally mandated requirements for mammography (mqsa) and nuclear medicine (nrc) are still in effect as public safety measures. the rrc also offers guidelines for esir programs, which may prove useful in advising those residents who are anticipated to fall short of completion of the ir cases needed before graduation from dr residency. as long as these residents meet the ir caseload upon graduation from the independent ir residency, the rrc does not foresee any specific delays in training. program directors should support their residents directly impacted by the postponement of the dr and ir/dr core exams. the abr announced that those exams have been rescheduled for november - and - , , and has provided more information on their website, specifically with a statement on the impact of covid- on training ( ) . resident schedules will need to be readjusted to ensure appropriate educational experiences before the exam, and to allow for travel to the testing sites at those times. board review sessions likely will need to be held virtually for a period of time as well. fear and anxiety about the pandemic, as well as adjustments to a change in lifestyle-related physical isolation, can have an adverse effect on well-being for both residents and faculty. social media, such as twitter, instagram, and slack can help residents and staff stay in communication with each other and form peer support groups. social media can also be a useful resource for sharing ideas on how to respond creatively to the pandemic ( ) . while physical distancing is important, so is maintaining social connection via other means. the department and residency community can stay connected through phone calls, video chats, and social media. chief residents can set up a daily resident chat to review cases, discuss educational topics, and connect socially. there are a variety of on-line resources that can aid in wellness (table ). moreover, institutions may offer specific wellness activities that can be accessed by residents. for instance, at mount sinai, in-person meditation sessions have been converted to a virtual format that all are welcome to join. residents and faculty also benefit highly from practicing self-care such as sound sleep and exercise habits during these times of increased stress. if there are institutional funds normally used to support wellness activities, these funds could be offered to residents for use during the pandemic to sponsor virtual wellness gatherings, or to provide small gift cards for food or snacks. other accommodations can be made to diminish resident stress and support well-being. for example, to prevent contamination and to ease laundering of clothes, trainees have been approved to wear scrubs during the pandemic in all sections at ucsd. accommodations should also be made for residents with additional childcare or family needs. close communication with each resident is important to identify those facing stresses such as childcare, potential exposure to family members at high risk, effect on future job availability and any other financial issues; additional resources should be readily available and provided as needed. with uncertainty regarding the length and course of the pandemic, reaching out to the group of future residents should also be considered, to provide reassurance and information about institutional and residency program status. in reality, however, some medical schools in the center of the pandemic just recently decided to graduate students early as a means to rapidly increase the workforce. in these states, licensing and credentialing of this new workforce accordingly has been expedited. communications likely will continue to be plentiful during the crisis. the frequency, volume, complexity and uncertainty in communication can contribute to stress. given the explosion of covid- related emails, news, messages and information obtained through other sources, clarification of the chain of communication during these times is important to address feelings of uncertainty and anxiety. many trainees have also dedicated time and energy to research and educational presentations at national conferences that have been cancelled. "cancelled due to covid- " is a suggested phrase to use on the curriculum vitae to capture an invited lecture, abstract presentation or educational exhibit at a cancelled meeting. some national societies, such as the acr, have restructured their annual meetings into virtual meetings to continue academic endeavors, and have converted all poster presentations into an electronic format. residents should be encouraged to seek out virtual meetings and conferences, not only to supplement education, but also to foster connection and networking during these times of physical isolation. radiology training programs and program directors need to develop a specific plan in response to the covid- pandemic to ensure the safety and wellness of their trainees and preserve a healthy workforce with increasing demands, while also maintaining the educational needs of their trainees as much as possible. while some of the changes in educational format and structure have been implemented as temporary measures, they may result in permanent improvements that can support diverse learning styles and add flexibility. radiology program directors and faculty should advocate for education on proper ppe in their work environments, as well as preparedness for possible redeployment. in the time of social distancing, self-isolation, and postponement of in-person conferences, the use of teleconferencing and social media to stay connected with the radiology community can be helpful to maintain ongoing networking and collaboration. world health organization radiology department preparedness for covid- : radiology scientific expert panel the impact of covid- on radiology trainees acgme response to covid- pandemic crisis ?cdc_aa_refval=https% a% f% fwww.cdc.gov% fcoronavirus% f -ncov% fprepare% ftransmission.html. accessed acgme resident/fellow education and training considerations related to coronavirus (covid- ) resident-fellow-education-and-training-considerations-related-to-coronavirus-covid- ) society of critical care medicine-critical care for non-icu clinicians society of interventional radiology critical care introductory course carpe diem: health systems science-a call to how every hospital should start the day special announcement from the review committee for radiology abr statement on covid- impact on acgme residency training radiology program directors should have an active presence on twitter key: cord- -yrlzxtbw authors: fong, raymond; tsai, kelvin c. f.; tong, michael c. f.; lee, kathy y. s. title: management of dysphagia in nursing homes during the covid- pandemic: strategies and experiences date: - - journal: sn compr clin med doi: . /s - - - sha: doc_id: cord_uid: yrlzxtbw the global novel coronavirus disease (covid- ) pandemic has had devastating effects not only on healthcare systems worldwide but also on different aspects of the care provided to nursing home residents. dysphagia management is a crucial component of the care provided to many nursing home residents. this article presents the dysphagia management strategies applied in hong kong during the covid- pandemic and the related experiences. a two-tier protection system was implemented wherein residents were categorised according to their contact and hospitalisation histories. the provided swallowing management and personal protective equipment level differed between the two tiers. the article also discusses the referral and prioritisation of clinical services for residents requiring swallowing management, as well as the adaptations of swallowing assessment and management during the pandemic. the possible effects of covid- on mealtime arrangements in nursing homes, the implications of the pandemic on the use of personal protective equipment and the use of telepractice in nursing homes were also discussed. this article has summarised the actions taken in this regard and may serve as a reference to clinicians who are responsible for swallowing assessments and dysphagia management in nursing homes. the world health organization (who) declared the novel coronavirus disease to be a global pandemic in march [ ] . covid- has caused widespread devastation in communities worldwide, and even more significant increases in associated mortality in nursing homes relative to the surrounding communities [ ] . residents in nursing homes often have multiple health conditions and are therefore at a higher risk of mortality in a pandemic scenario. in the covid- pandemic, this increased risk of mortality is not only due to the pandemic disease itself but also due to pre-existing medical conditions, regardless of the residents' covid- infection status. dysphagia is a prevalent problem among nursing home residents. previous studies have reported global prevalence rates ranging from to % [ ] [ ] [ ] . if neglected or mismanaged, dysphagia can lead to serious complications such as malnutrition, dehydration, aspiration pneumonia and death [ ] . dysphagia can be assessed using either noninstrumental or instrumental assessment methods. clinicians rely largely on the former methods because the latter are rarely available in nursing homes. non-instrumental assessment methods, which are also referred to as clinical swallow evaluations (cse), include communication assessments, physical examinations and swallowing trials [ ] . the physical examination in a cse includes an assessment of the cranial nerves, voice and laryngeal function. in some protocols, the clinicians elicit a volitional cough from the patients to assess the airway protective mechanism [ , ] . the swallowing management strategies that can be applied in nursing homes are less confined to the setting. for example, exercises of the oromotor and pharyngeal muscles can be performed [ ] . additionally, clinicians can apply surface electromyography, neuromuscular electrical stimulation and expiratory muscle strength training to the residents. compensatory strategies such as dietary, environmental and utensil modifications are also commonly used [ ] . several of these procedures may induce coughing as a reflexive response to protect the airway. the cse was classified as medium risk according to stratification risk for covid- transmission. the risk of the procedure is attributed by the close proximity to the residents' upper mucosa, prolonged exposure and possibility of reflexive cough during the procedures [ ] . compared with the general community, nursing home residents are at substantially higher risk for having bacterial and viral infections [ ] . healthcare workers (hcws) have to provide care to many residents, which further increases the risk of cross-infection. nursing home residents are also more prone to hospitalisation and thus face an increased risk of hospital-acquired infections, as well as exposure to novel viral agents such as severe acute respiratory syndrome coronavirus (sars-cov- ), the causative agent of covid- . the nature of these procedures also places clinicians at a risk of infection with sars-cov- during dysphagia assessments and management [ ] . covid- advisory group of royal college of speech and language therapists also presented that dysphagia assessment should be considered as an aerosol generating procedures based on theoretical and empirical evidences [ ] . however, cses are crucial to the physical and psychological well-being of many nursing home residents, despite the risk of infection, and thus cannot be suspended. below, some practical strategies and considerations regarding dysphagia management in nursing homes are described. these strategies have been applied in hong kong, one of the first regions affected by covid- [ ] . during the peak of the pandemic, nursing home personnel only included hcws, residents and essential administrative staff. although the loosening of public health policies in late may led to the reopening of schools and public facilities [ ] , visiting policy and visitor numbers at nursing homes remained restricted. patients with covid- , individuals who had come in close contact with infected patients and patients under quarantine were not allowed to visit nursing homes. individuals presenting signs and symptoms of covid- , including a fever, runny nose, loss of smell and taste and a travel history within the past days, were also not allowed to enter nursing homes [ ] . these restrictions protected residents by allowing only minimal contact with individuals outside the nursing home. in hong kong, covid- testing efforts were restricted to approximately samples per day until june and were mainly targeted at travellers to hong kong and those admitted to hospitals [ ]. in july , there was an outbreak after relaxation of social distancing policy [ ] . to date, cluster outbreaks in nursing homes have been reported in at least local nursing homes. the re-emergence of the disease, which previously have been largely contained in the community, has affected nursing homes in this wave of outbreak and the following measures were more important to ensure the safety and well-being of nursing home residents. residents requiring dysphagia management were categorised as either 'standard' or 'at-risk'. the at-risk group included those who had been hospitalised within the past days or had been diagnosed previously with covid- and discharged. residents who had been diagnosed with covid- were assessed after discharged to the nursing home as patients with covid- were considered at high risk for oropharyngeal dysphagia [ ] , especially those who have been previously intubated [ ] . these at-risk residents were deescalated to the standard level after days of quarantine in the facility. therefore, standard and at-risk residents should be considered differently with respect to dysphagia assessments and management and personal protective equipment usage. nursing home residents were referred by the medical doctors or nurses to undergo swallowing assessments and/or management or to receive routine assessment under an annual review of the integrated care plan. two additional measures were enforced during the covid- pandemic. for all referrals, the source was asked to indicate whether the nature was urgent or non-urgent. all standard-level residents were assessed and managed, whereas only the at-risk residents whose referrals were deemed urgent underwent assessments. the at-risk residents with non-urgent referrals were assessed after they deescalated to the standard level. in the latter cases, the eating assessment tool (eat- ) [ ] was applied by interviewing residents with the ability to communicate, and the eat- score was computed. those who received an eat- score of or higher proceeded to a swallowing assessment, while those with lower scores were deemed 'not at significant risk' and were seen at a later stage. in addition to screening tools such as the eat- , clinicians also relied more heavily on the residents' medical records and histories when prioritising cases for assessment and management. dementia, a severely dependent functional status, a high nutritional risk status and an underweight status were identified as risk factors for dysphagia in nursing home residents [ , ] . consequently, the residents' medical records were searched for these factors, and the residents were prioritised accordingly for assessment and management. the use of screening tools such as the eat- and well-researched risk factors facilitated the decisions. clinicians should keep in mind that this is far from ideal, but it is a balance between risk and clinical outcome [ ] . the cse comprises several key components, including a physical examination and swallow trials. cognition and dentition have been identified as indicators of dysphagia in elderly residents of aged care facilities [ ] . therefore, these two aspects were emphasised when determining the residents at a higher risk of dysphagia. an assessment of cognition and dentition would not require the clinician to be in close proximity of the patient and would not be an aerosol-generating procedure (agp), unlike an oral motor examination and swallow trials [ ] . clinicians can reduce their risk of exposure by decreasing their involvement in the performance of agps. some clinicians include volitional or reflexive coughing as a possible indication of aspiration during the cse [ ] . some swallowing manoeuvres, such as the supraglottic swallow, also involve volitional coughing after swallowing to eliminate the aspirated bolus in the airway [ ] . these practices are not advocated and should be avoided during a pandemic to reduce the risk of infecting the clinician during the agp, as well as the risk of exposure of other residents if these manoeuvres were recommended to be performed during mealtimes. in nursing homes, cervical auscultation may be used as an adjunct during a swallowing assessment [ ] . during the covid- pandemic, the use of a stethoscope across multiple patients was limited as much as possible to avoid crossresident infection. whenever a stethoscope was applied to a resident, it was thoroughly cleaned with alcohol wipes ( % ethanol content) at least three times before it was used on another patient. similar disinfection procedures were used for pulse oximetry devices. the use of utensils of different sizes, shapes and types is another compensatory strategy implemented in cse and dysphagia management. during the covid- pandemic, utensils and containers were largely switched to disposable options to reduce the risk of infection. therefore, the use of utensils and containers as a compensatory strategy for dysphagia management may be limited in a pandemic setting. in addition to the limitations associated with utensils and manoeuvres, limitations were also placed on exercises or therapy options because of the covid- pandemic. although the use of sensory stimulation in clinical practice is not supported by solid evidence, it is nevertheless used by some clinicians [ ] . the use of a cold and sour stimulant may trigger gagging and coughing responses, and clinicians must remain in close proximity to the patient during these procedures. therefore, sensory stimulation is associated with a higher risk of infection. these practices were completely avoided in patients that were deemed at risk and generally avoided in residents at the standard level of care. expiratory muscle strength training (emst) has been advocated to improve the swallowing functions of patients with dysphagia associated with different aetiologies [ , ] . however, this procedure involves blowing air into the device, and this method and the difficulty associated with device disinfection made it necessary for clinicians to avoid prescribing emst for at-risk patients. emst was only applied to patients at a standard level of care, and they were advised to remain at a distance of at least . m from residents during the procedure. dysphagia management across the two-tiers of residents also differed; the at-risk residents were managed conservatively with diet modification and swallowing manoeuvres [ ] . direct treatments can be considered when these at-risk residents were deescalated to the standard level after the quarantine in the facility [ ] . in nursing homes, mealtimes normally involve a gathering of residents in a dining hall. each resident would receive their meal on their own tray and would eat individually. the covid- pandemic led some nursing homes to change this practice, after which residents were only allowed to eat meals in their own rooms or personal spaces. other homes segregated residents into small groups and only allowed one small group to dine at a time. the lack of olfactory and visual stimulation associated with mealtimes in dining halls may have affected some of the feeding behaviours and patterns of residents, especially those with dementia [ ] . clinicians monitored these behaviours and intake amounts more closely once these changes had been implemented and made any necessary suitable arrangements to overcome the sensory deprivation and social isolation. the recommendations for nursing homes that assessed and managed patients at the standard level of care indicated that face masks and gloves should be considered the minimal level of personal protective equipment (ppe); if available, face shields should be used when interacting with all standardlevel patients. in contrast, face shields and personal gowns should be used in addition to face masks and gloves when interacting with at-risk residents. all clinicians received proper training in infection control, which addressed the use of different forms of ppe and the standard procedures for donning and doffing these items according to training materials from the government website [ ] . hand hygiene was advocated among clinicians and was required before and after visiting the patient and touching any of his/her belongings. existing evidence supports the use of telepractice in dysphagia management. studies on this approach have advocated the use of trained assistant personnel at a remote site to provide the service and achieve valid and reliable results [ , ] . some studies have used videoconferencing software to allow the clinician and patient to interact in real-time and to facilitate the provision of clinical services. many nursing home residents do not have a sufficient cognitive level that would allow them to use electronic communication devices such as tablets independently. these residents would require assistance with device operation from another individual. consequently, a surge in the use of telepractice for dysphagia management in nursing home settings was not observed during the covid- pandemic. however, telepractice may be considered for older adults who live at home with caregivers who could provide assistance with device operation. during the covid- pandemic, nursing home residents were as vulnerable as any other population, given their already fragile state. however, members of this population still required swallowing assessments and dysphagia management, regardless of their covid- status. however, many aspects were considered to minimise the risk of infection among residents and clinicians. this commentary has summarised the actions taken in this regard and may serve as a reference to clinicians who are responsible for swallowing assessments and dysphagia management. clinicians should also remain aware of all changes to guidelines on dysphagia management [ , , ] , for nursing homes [ ] or for certain clinical populations from other specialities [ ] . conflict of interest the authors declare that they have no conflict of interest. ethical approval and informed consent this article does not contain any studies with human participants performed by any of the authors. world health organization ( ) coronavirus disease (covid- ) pandemic covid- : towards controlling of a pandemic prevalence of dysphagia and adequacy of related care for elderly receiving residential care services in hong kong national survey of the prevalence of swallowing difficulty and tube feeding use as well as implementation of swallowing evaluation in long-term care settings in japan nursing homeacquired pneumonia, dysphagia and associated diseases in nursing home residents: a retrospective, cross-sectional study dysphagia in the elderly: management and nutritional considerations dysphagia: clinical management in adults and children. mosby masa, the mann assessment of swallowing ability to cough or not to cough? examining the potential utility of cough testing in the clinical evaluation of swallowing dysphagia in the elderly: focus on rehabilitation strategies dysphagia care across the continuum: a multidisciplinary dysphagia research society taskforce report of service-delivery during the covid- global pandemic moving forward with dysphagia care: implementing strategies during the covid- pandemic and beyond management of dysphagia in the patient with head and neck cancer during covid- pandemic: practical strategy royal college of s, language therapists c-ag. aerosol generating procedures, dysphagia assessment and covid- : a rapid review unique sars-cov- clusters causing a large covid- outbreak in hong kong shedding light on dysphagia associated with covid- : the what and why postintubation dysphagia during covid- outbreak-contemporary review validity and reliability of the eating assessment tool (eat- ) prevalence and associated factors of dysphagia in nursing home residents indicators of dysphagia in aged care facilities the long-term effects of covid- on dysphagia evaluation and treatment aerosol generating procedures, dysphagia assessment and covid- the reliability and validity of cervical auscultation in the diagnosis of dysphagia: a systematic review the effects of sensory stimulation on neurogenic oropharyngeal dysphagia impact of expiratory muscle strength training on voluntary cough and swallow function in parkinson disease expiratory muscle strength training for radiation-associated aspiration after head and neck cancer: a case series dysphagia in covid- -multilevel damage to the swallowing network? factors influencing the pace of food intake for nursing home residents with dementia: resident characteristics, staff mealtime assistance and environmental stimulation validity of conducting clinical dysphagia assessments for patients with normal to mild cognitive impairment via telerehabilitation training the allied health assistant for the telerehabilitation assessment of dysphagia centers for disease control and prevention (n.d.) preparing for covid- in nursing homes ) tracheotomy recommendations during the covid- pandemic publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord- -f e a s authors: porpiglia, francesco; checcucci, enrico; amparore, daniele; verri, paolo; campi, riccardo; claps, francesco; esperto, franceso; fiori, cristian; carrieri, giuseppe; ficarra, vincenzo; mario scarpa, roberto; dasgupta, prokar title: slowdown of urology residents’ learning curve during the covid‐ emergency date: - - journal: bju int doi: . /bju. sha: doc_id: cord_uid: f e a s the coronavirus disease (covid- ), has rapidly been spreading worldwide and italy has been hit hard, forced the italian healthcare system to change and adapt to these extreme conditions. the urology department daily activities were drastically reduced and limited only to non-deferrable procedures and the entire organogram were reorganized following a rigorous flow-chart. it's evident that this unprecedent scenario is having an impact on residents training program, considering that it is very difficult to predict the duration of emergency. the urology residents do not have the opportunity to carry out clinical activities nor to be tutored, as the senior physicians are engaged in the emergency's management. the coronavirus disease (covid- ) has rapidly been spreading worldwide, and italy has been hit hard, forcing the italian healthcare system to change and adapt to these extreme conditions. the daily activities of the urology department have been drastically reduced and limited only to non-deferrable procedures, and the entire organogram reorganised following a rigorous flowchart [ ] . it is evident that this unprecedent scenario will have an impact on resident training programmes, as it is very difficult to predict the duration of the covid- emergency. urology residents do not have the opportunity to carry out clinical activities or to be tutored, as senior physicians are engaged in the emergency's management. in particular, the authorities have limited unnecessary access to urology departments for residents in order to contain the infection. moreover, the procedures most affected by these restrictions are those in which the residents are mostly involved (benign pathologies, lower urinary tract surgery, and andrology); the surgical interventions, when performed, are carried out by expert surgeons, with the aim to standardise the procedures, reduce the operative time and the risk of complications. very conflicting positions have emerged recently in italy about the safety of laparoscopic and robotassisted surgical procedures during the covid- pandemic. this is mainly related to the recently published claims on the potential risk of dissemination of the coronavirus infection through surgical gas [ ] . lastly, case discussions and departmental meetings have been cancelled, to avoid gathering. attempts to systematically analyse and categorise the most affected activities during the -year training programme (e.g. surgical training, research) are impossible, due to the absence of a homogeneous national training programme. therefore, it is clear that urology resident training is affected transversally throughout the -year residency, due to the involvement of ambulatory, outpatient surgery and major surgery (either open, minimally invasive surgery or endoscopic). a recently published survey gives a snapshot of residency training in italy in [ ] , showing a high level of satisfaction amongst the residents, notwithstanding limitations concerning scientific activity and surgical training. in order to limit the impact of the covid- emergency on the residents' learning curves, which can further affect surgical and scientific learning, new alternative teaching methods should be introduced (table ) . so, thanks to new web-based technologies, teaching activity can continue. among the different technologies available, different types of smart-learning can be implemented. the first one is represented by an online dedicated platform, where pre-recorded videos of lessons or surgical procedures are uploaded; these files could be available on-demand for the residents. in this setting, users greatly appreciate the ability to watch pre-recorded surgical procedures commented upon by an expert, with focus on routinely performed urological manoeuvres or new techniques and technologies in urology or, furthermore, expert 'tips and tricks' for challenging cases. the surgery in motion school of the european urology association (https://surgeryinmotion-school.org) represents a well-established video-based educational tool for efficient mentorship in surgical training. the next facet of online teaching is represented by the webinar format. it has already been shown to be useful in this setting [ ] , giving to both professors and students the chance to interact and to enjoy multimedia content in realtime. classes, clinical cases discussion and interactive prerecorded video presentations can be held by an expert, and the residents have the ability to ask questions. moreover, various non-technical skills can be covered. furthermore, exploiting web microblogging services, like twitter online journal clubs can be done. by using social media, residents can engage in critical appraisal of evidencebased medicine with dynamic worldwide shared discussion amongst themselves, having the chance to interact with opinion leaders in specific topics. this format has already proven to change clinical practice in % of young attendees [ ] . lastly, pre-recorded audio files of expert opinion can be shared online, creating dedicated podcast channels. this modality of e-learning is not novel and every week > podcasts are active worldwide. today, for urology there are a total of two podcasts experiences and only one of which was active (i.e. https://www.bjuinternational.com/podcasts). from this examination, it appears clear how the theoretical training of residents can continue with smart-learning modalities. however, in reality the implementation of such clinical smart-learning appears to be more challenging. the daily clinical staff meeting can be web-based and planned by using dedicated webinar slots, opening an interactive discussion amongst the urologists and residents concerning the recovery of patients; a second daily update can be done in the afternoon. the procedures of the day can be discussed jointly: in this emergency period it is important to choose the best surgical approach and surgeon for the selected patient, in order to maximise the efficacy of the procedure and reduce the risk of adverse events. moreover, planning strategies concerning the management of covid- and non-covid- patients should be planned according to the hospital administration decrees. furthermore, thanks to the advent of new telepresence robotic platforms like the intouch vita by intouch health, goleta, ca, usa (https://intouchhealth.com/?gdprorigin=true ), the morning rounds can be potentially shared with online attendees. thanks to advanced features including auto-drive capabilities, remote providers can control or automatically head to a patient care location, having the possibility to livebroadcast images and audio to physicians in their homes. finally, notwithstanding the well-established usefulness of surgical simulation training programmes [ ] , in this particular historic moment, where the authorities have limited unnecessary transfers, the access to simulation platforms usually located in hospitals or universities is difficult. preliminary experiences with home-made simulators have already been presented, but their real clinical utility is still under investigation. in conclusion, we think that the use of smart technology should be maximised and implemented, in order to guarantee continuity in the learning curve of residents. now, during this extraordinary emergency in which it is very difficult to predict the duration of disruption, the current necessity should hopefully be translated into a future opportunity, in which smart-learning can become a useful tool integrated routinely into residency training programmes and urology daily life. urology practice during covid- pandemic erus (eau robotic urology section) guidelines during covid- emergency table summary of the different smart-learning technologies and their respective fields of application. smart-learning technology smart-learning applications pre-recorded videos on-demand • taught class • video library • fundamentals of surgery • surgical procedure's commentary • expert's 'tips and tricks webinar • interactive lessons • discussion of clinical cases • non-technical skills rounds • daily updates (single or multiple) • 'virtual' rounds • collegial discussions of surgical approach • administration's directives simulation • home simulators (experimental) e © the authors bju international © bju international comment urology residency training in italy: results of the first national survey evaluating the usefulness and utility of a webinar as a platform to educate students on a uk clinical academic programme evaluating the effectiveness of an online journal club: experience from the international urology journal club simulation in urological training and education (simulate) -a multicentre international randomised controlled trial assessing the transferability of simulation-based training in surgery: protocol and development of interventional training curriculum none disclosed. key: cord- -lg l gh authors: tang, olive; bigelow, benjamin f.; sheikh, fatima; peters, matthew; zenilman, jonathan m.; bennett, richard; katz, morgan j. title: outcomes of nursing home covid- patients by initial symptoms and comorbidity: results of universal testing of , residents date: - - journal: j am med dir assoc doi: . /j.jamda. . . sha: doc_id: cord_uid: lg l gh objective clinical implications of asymptomatic cases of the novel coronavirus disease (covid- ) in nursing homes remain poorly understood. we assessed the association of symptom status and medical comorbidities on mortality and hospitalization risk associated with covid- in residents of a large nursing home system. design retrospective cohort study. setting and participants , residents from nursing home facilities with universal covid- testing in maryland. methods we used descriptive statistics to compare baseline characteristics, logistic regression to assess the association of comorbidities with covid- , and cox regression to assess the association of asymptomatic and symptomatic covid- with mortality and hospitalization. we assessed the association of comorbidities with mortality and hospitalization risk. symptom status was assessed at the time of the first test. maximum follow-up was days. results among the , residents (mean age . , % female, % black), ( . %) were positive on their first test. residents who were positive for covid- and had multiple symptoms at the time of testing had the highest risk of mortality (hr . ; % ci: . , . ) and hospitalization (shr . ; % ci: . , . ), even after accounting for comorbidity burden. cases who were asymptomatic at testing had a higher risk of mortality (hr . ; % ci: . , . ), but not hospitalization (hr . ; % ci: . , . ) compared to those who were negative for covid- . of sars-cov- positive residents who were asymptomatic at the time of testing and were closely monitored for days at one facility, only ( . %) developed symptoms. conclusions and implications asymptomatic infection with sars-cov- in the nursing home setting was associated with increased risk of death suggesting a need for closer monitoring of these residents, particularly those with underlying cardiovascular and respiratory comorbidities. setting was associated with increased risk of death suggesting a need for closer monitoring of these residents, particularly those with underlying cardiovascular and respiratory comorbidities. based on case reports of covid- submitted to the cdc surveillance network, adults with comorbidities such as diabetes, lung disease, or heart disease had a higher prevalence of covid- and may develop more severe illness - . however, comorbidity data was missing for over half of the reported cases. another study looking at hospitalized patients with covid- showed a relationship between increasing age and number of comorbidities with in-hospital mortality . in particular, a history of chronic kidney disease, lung disease, or cardiovascular disease was associated with higher mortality . literature examining the effect of comorbidities on outcomes has predominantly focused on hospitalized cohorts, or those in middle-age without testing of all individuals regardless of symptoms , , . on april , , the maryland governor mandated that all residents of nursing homes in the state of maryland must undergo testing for sars-cov- . we assessed outcomes associated with sars-cov- infection among residents who were tested for sars-cov- rna across one nursing home system with both long-term and post-acute rehabilitation services. signs and symptoms of illness were obtained at the time of testing, and risk of infection, hospitalization, and death was analyzed based on symptoms and underlying comorbidities. study population. all residents (n= , ) from a large system of skilled nursing facilities who were universally tested for sars-cov- and had recorded test results between march , and june , , were included in our study. data was obtained from respiratory surveillance line list and manual chart review of the skilled nursing facility electronic health record. a cohort of all residents at one facility who were asymptomatic at the time of testing were closely monitored by nursing home staff for development of symptoms over a day period; this was documented in a dedicated line list and included as a sub-analysis. this study protocol was approved by the institutional review board with a waiver of written consent. exposure. nasopharyngeal samples were collected at the nursing homes for reverse transcription polymerase chain reaction testing for sars-cov- rna. when nasopharyngeal swabs were not available or if the resident would only consent to oropharyngeal swabs, an oropharyngeal sample was collected instead. all residents who consented to testing were tested. residents who did not consent to testing were considered positive and isolated accordingly. symptom status at the time of testing was determined based on review of respiratory surveillance line list documentation maintained by nursing facility in the health system. the respiratory surveillance line list is used to monitor staff and resident symptoms during a respiratory disease outbreak or cluster. % black) who were tested at least once for sars-cov- rna; of these ( . %) initially tested positive between march , and june , . of the , residents who initially tested negative, ( . %) had at least additional test, and ( . %) eventually tested positive at some point before the end of follow-up. residents who were positive for sars-cov- on their first test were significantly more likely to be hospitalized and die during follow-up than residents who tested negative (table , p< . ). not at a higher risk of testing positive for sars-cov- (or . , % ci: . , . ). peripheral vascular disease, diabetes, chronic kidney disease, and depression remained significantly associated with increased risk for infection after accounting for age, sex, and facility ( table ) . after accounting for age, sex, race, and facility (model ) among those who tested positive for sars-cov- , coronary artery disease, heart failure, peripheral vascular disease, anemia, diabetes, end-stage kidney disease, and depression were at increased risk of hospitalization ( table ) . only a history of copd/emphysema was significantly associated with higher mortality from covid- after accounting for age, sex, and facility ( table ) . of the residents who tested positive, . % (n= ) had no documented signs or symptoms at the time of testing. of the cases with documented signs or symptoms (n= ), the most common were fever . % (n= ) and cough . % (n= , table ), and . % of residents (n= ) had only documented sign or symptom. among residents with covid- , those with anemia, cancer, or end-stage renal disease were more likely to have signs and symptoms of illness at the time of testing and those with dementia and peripheral vascular disease were more likely to be asymptomatic ( table ) . over a maximum of days of follow-up, there were incident hospitalizations observed among the , residents who consented to hospital transfer from the nursing home system. the -day cumulative hospitalization rate was % among cases with multiple symptoms at testing, % among cases with symptom at testing, % among cases asymptomatic at testing, and % among those who were negative. after accounting for all confounders, cases who were symptomatic at testing remained at significantly higher risk of hospitalization than those who were asymptomatic or negative (figure a) . there were total deaths among the , residents over the day follow up period; ( %) were in those who tested positive for sars-cov- . mortality rates were highest among residents who tested positive for sars-cov- and had covid- signs or symptoms (figure b) . the -day cumulative mortality was % among cases with or more signs or symptoms at testing, % among cases with sign or symptom at testing, % among cases who were asymptomatic at testing, and % among those who were negative for sars-cov- . after accounting for demographics, comorbidities, and resuscitation preference (model ), cases who were symptomatic at testing remained at highest risk of mortality, and cases asymptomatic at testing were at intermediate risk (hr . ; % ci: . , . ) compared to those who were negative (table ) . those with multiple signs or symptoms also had a higher risk of mortality compared to those with a single sign or symptom (model hr . , % ci: . , . ; model hr . , % ci: . , . ). one facility had cases who were asymptomatic at the time of testing and were closely monitored for days for development of signs or symptoms. of these, only ( . %) developed any documented symptoms over the day follow up from point prevalence testing. of the residents that became symptomatic, one developed a non-productive cough at day post diagnosis and remained stable in the facility. three residents were hospitalized: one developed malaise and shortness of breath at day and was transferred to the hospital, then returned days later; one developed an elevated temperature ( o f) on day -he was transferred to the hospital on day when his oxygen saturation reached % and expired the next day. one resident developed chills, shortness of breath, and diminished lung sounds on day and expired during transfer to the hospital. the remaining two residents passed away abruptly in the facility- both were noted to rapidly develop restlessness and shortness of breath and expired shortly thereafter (one on day post diagnosis and one on day ). state reporting data have all demonstrated that mortality from covid- is higher in underrepresented minority groups. our findings suggest that this mortality differential among blacks is predominantly due to increased prevalence, and possibly severity of underlying diseases, rather than a covid- -specific cause. the clinical implications of covid- detection among asymptomatic people remains poorly understood . the published prevalence of asymptomatic cases varies greatly from population to population, ranging from . % in china to % in a boston homeless shelter . in our study population of residents of long-term care facilities undergoing point prevalence testing, over half of the cases detected were asymptomatic at testing, which is consistent with other early reports in this setting , , . despite a lack of documented symptoms at the time of testing, our data shows that residents who are asymptomatic at testing have up to two times the mortality risk of residents who test negative for sars-cov- . however, there was no difference in risk of hospitalization between residents who tested negative and asymptomatic residents who tested positive. this may suggest that staff are unable to accurately elicit symptoms, or that infected individuals are decompensating so rapidly that nursing home staff are not able to identify a clinical decline and transfer them to a higher level of care prior to death. indeed, residents with dementia or cerebrovascular disease or history of stroke were more likely to be deemed asymptomatic than others, suggesting that assessing symptom status in this population is particularly challenging infections with sars-cov- detected on asymptomatic screening in the nursing home setting are not benign, underscoring the importance of universal testing, especially in high-risk subgroups. reliance on signs and symptoms for sars-cov- risk assessment alone may not be sufficient, as residents living with dementia may be at a higher risk of infection but less likely to report or exhibit signs and symptoms, and the natural history of this disease remains to be fully established, particularly in the setting of hypoxia without dyspnea. in addition to the obvious benefits of case identification to assist with infection control practices, our data suggest that asymptomatic residents are at higher risk of death than residents who tested negative and may benefit from close monitoring, such as regular pulse oximetry, as well as any future treatments. hospitalization and mortality among black patients and white patients with covid- prevalence of asymptomatic sars-cov- infection the novel coronavirus pneumonia emergency response epidemiology team. the epidemiological characteristics of an outbreak of novel coronavirus diseases (covid- ) -china prevalence of sars-cov- infection in residents of a large homeless asymptomatic sars-cov- infection and covid- mortality during an outbreak investigation in a skilled nursing facility. clin infect dis couzin-frankel j. the mystery of the pandemic's 'happy hypoxia.' science ( -) why covid- silent hypoxemia is baffling to opinion | the infection that's silently killing coronavirus patients -the new detection of sars-cov- in different types of clinical kidney disease chronic kidney disease key: cord- -fcytebfz authors: lie, jessica j.; huynh, caroline; scott, tracy m.; karimuddin, ahmer a. title: optimizing resident wellness during a pandemic: university of british columbia's general surgery program's covid- experience date: - - journal: j surg educ doi: . /j.jsurg. . . sha: doc_id: cord_uid: fcytebfz objective: the university of british columbia's general surgery program delineates a unique and systematic approach to wellness for surgical residents during a pandemic. summary background data: during the covid- pandemic, health care workers are suffering from increased rates of mental health disturbances. residents’ duty obligations put them at increased physical and mental health risk. it is only by prioritizing their well-being that we can better serve the patients and prepare for a surge. therefore, it is imperative that measures are put in place to protect them. methods: resident wellness was optimized by targeting three domains: efficiency of practice, culture of wellness and personal resilience. results: efficiency in delivering information and patient care minimizes additional stress to residents that is caused by the pandemic. by having a reserve team, prioritizing the safety of residents and taking burnout seriously, the culture of wellness and sense of community in our program are emphasized. all of the residents’ personal resilience was further optimized by the regular and mandatory measures put in place by the program. conclusions: the new challenges brought on by a pandemic puts increased pressure on residents. measures must be put in place to protect resident from the increased physical and mental health stress in order to best serve patients during this difficult time. objective: the university of british columbia's general surgery program delineates a unique and systematic approach to wellness for surgical residents during a pandemic. summary background data: during the covid- pandemic, health care workers are suffering from increased rates of mental health disturbances. residents' duty obligations put them at increased physical and mental health risk. it is only by prioritizing their well-being that we can better serve the patients and prepare for a surge. therefore, it is imperative that measures are put in place to protect them. methods: resident wellness was optimized by targeting three domains: efficiency of practice, culture of wellness and personal resilience. results: efficiency in delivering information and patient care minimizes additional stress to residents that is caused by the pandemic. by having a reserve team, prioritizing the safety of residents and taking burnout seriously, the culture of wellness and sense of community in our program are emphasized. all of the residents' personal resilience was further optimized by the regular and mandatory measures put in place by the program. the new challenges brought on by a pandemic puts increased pressure on residents. measures must be put in place to protect resident from the increased physical and mental health stress in order to best serve patients during this difficult time. wellness; resident wellness; surgical education; resident education; pandemic; well-being in december , a coronavirus (covid- ) struck the city of wuhan and was declared a global pandemic within three months. by early april, the number of confirmed cases surpassed , , and by mid-april confirmed deaths were over , . ( ) on april , two weeks into the pandemic, british columbia had , cases and deaths confirmed. ( ) the pandemic and its repercussions put an increased strain on our already saturated health care system and inevitably, increased pressure on health care workers. across canada, hospitals prepared themselves for a surge in patients; this included the reorganization of residency programs. general surgery program, we have used this model to determine measures that would best support our residents during this difficult time (fig. ). our program directors and two chief residents worked together to create a new program structure reformatting resident schedules, didactic teaching and wellness initiatives. although no formal survey was performed, weekly townhalls gave residents an opportunity to present new ideas and to adjust already implemented changes based on their needs, feedback and experience at the hospitals. this article delineates our systematic and holistic approach to wellness for surgical residents during a pandemic. efficiency of practice refers to the optimization of resources and time. ( ) during a pandemic, this becomes more relevant than ever as manpower can be scarce and contact must be limited. with new information being delivered rapidly, it can be overwhelming and time consuming to stay current. the division of general surgery organized virtual daily meetings with all teaching hospitals consisting of updates on confirmed cases, deaths, icu admissions, new guidelines and individual hospitals' experiences. a brief -minute presentation was given by residents every day on a new covid- -related paper. in addition, residents had their own group townhall meetings with the program directors weekly or more, if needed, for resident-specific protocol updates. guidelines on perioperative care of covid- patients and when to personally get tested for covid- were disseminated. as many residents were redeployed to the icu, a refresher course on icu management was given by an icu staff. routine and scheduled ways of sharing knowledge have taken pressure off the individual surgeon and resident to stay up to date during busy times and allowed sharing of practices province-wide. didactic teaching at ubc was previously divided into separate academic half-days for junior and senior residents. teaching sessions were reformatted to minimize staff and resident's time away from clinical duties by combining the junior and senior teaching sessions. mandatory twice-aweek shorter virtual sessions were given by chief residents and faculty members. the score curriculum, which is an online platform with specific objectives and assignments on general surgery topics, was maintained throughout. for most of our residents, continuing to provide educational tools and teaching sessions provided them with a sense of normalcy. to keep our residents safe and maintain social distancing during covid- , the workflow of our services was modified. covid- suspected or positive patients were only to be examined by one person, either the attending or senior resident. for all patients, only one person was to conduct clinical examinations, to minimize patient interactions. by improving our efficiency, we were able to optimize the wellness of our residents and ensure good patient care. a culture of wellness encourages normalizing attitudes and behaviors that promote self-care to foster a sense of community. ( ) wellness has been a core value in our general surgery residency program, predating the era of covid- . the pandemic required our program to rapidly restructure in order to prioritize the safety of all residents, thus maintaining their overall wellness. the ubc general surgery program rotations are distributed over different hospital sites across the province, with to residents per service. the two largest centres are based in vancouver and cover quaternary services such as acute care, trauma, hepatobiliary, surgical oncology, minimally invasive, colorectal, endocrine, and pediatric surgery. other urban and rural centres have broader general surgery services. early on when the pandemic was first declared, residents were brought back to vancouver from distant sites to increase the workforce at larger hospitals where the covid- pandemic was more prevalent. this also allowed many of the residents to be reunited with their families. the prospect of residents being away from home and being unwell or having a family member fall unwell was a significant stress for all involved. the rotation structure was modified to now include only quaternary services: acute care, trauma and hepatobiliary surgery at vancouver general hospital, general and colorectal surgery at st. paul's hospital, and pediatric surgery at bc children's hospital. this allowed minimization of resident-to-resident contact, spread of the virus and to create a resident reserve unit (rru). residents were equally divided into three groups that would rotate weekly: / for general surgery rotations, / for the rru and / for the icus. in the early phases of the pandemic, there was uncertainty about the board exams for graduating residents. the chief residents were placed in reserve and quarantine until there was certainty about the exam, to ensure illness would not be a reason they could not write. while on the reserve unit, they prepared weekly teaching sessions for the remaining residents, and served important organizational roles. another crucial element in prioritizing wellness is to talk about the signs of burnout and how to face this in the midst of a pandemic. education regarding signs and symptoms of burnout was provided to all residents. residents with any symptoms of illness, including that of burnout, were mandated to stay home and have a resident from the rru fill in for them. this system enabled residents to feel supported if they were unwell. in addition, to maximize the safety of our residents, we scheduled mandatory n fit testing, donning and doffing teaching and ensured every resident had goggles for protection. by helping with the organization of all the necessary equipment to care for covid- patients, the onus and stress was removed from the individual resident. personal resilience refers to an individual's ability to maintain overall mental and physical health and thus, prevent burnout. ( ) personal resilience is often seen as a responsibility placed on the individual, however, there are many organizational changes that can be implemented to facilitate this. in , a formal social and wellness committee was created to foster interdepartmental relationships and well-being. this committee, which is led by residents and includes faculty members and program directors, meets every months to plan activities and implement wellness initiatives in the residency program. part of our regular wellness committee's initiatives already included funding an exercise program membership, maintaining a resident lounge and providing regular snacks. with the pandemic, our residents continued attending virtual workouts as a group with their monthly membership. for the residents in hospital daily meals were provided and paid for by the program. this has helped many of them support each other in staying well and in reducing any stress related to planning meals or exercise time. program directors organized weekly virtual meetings with all the residents and with each of the post-graduate years individually. this encouraged productive discussions around surgical care during the pandemic, and also around physical, emotional and social challenges. regularly scheduled mandatory meetings gave residents a venue to express their feelings and especially useful for those who would otherwise not seek help. furthermore, to help residents express themselves, they were asked to write an anonymous -word paragraph on their covid- related reflections. short format journaling has been shown to help trainees gain insight and stimulate personal reflection for professional growth. ( ) many residents on the reserve unit felt helpless towards the repercussions of the covid- pandemic. in fact, when our department of surgery was working on a covid- response plan, a third of our residents volunteered to be redeployed to icus. being able to help with essential services at the frontline had a positive effect on many of our residents, as it gave them a sense of purpose. residents also worked together to find different ways to fundraise for the vancouver food bank while maintaining social distancing and raised over $ , . this allowed residents to channel their altruism and to gain a sense of fulfillment. by implementing these measures, residents were supported to improve and maintain their wellness during the pandemic. the covid- pandemic placed an increased burden on the physical and mental health of physicians, therefore, it is imperative that measures are put in place to protect them. the general surgery program at ubc optimized the wellness of residents by targeting three domains: efficiency of practice, culture of wellness and personal resilience. efficiency in delivering information and patient care minimizes additional stress to residents that is caused by the pandemic. by having a reserve team, prioritizing the safety of residents and taking burnout seriously, we have continued to emphasize the culture of wellness and sense of community in our program. all of the residents' personal resilience was further optimized by the regular and mandatory measures put in place by the program. it is only by prioritizing the health of physicians that we can then provide the best possible care for patients. as the saying goes, we must put on our own masks before assisting others. figure . resident wellness during a pandemic. coronavirus disease (covid- ): outbreak update british columbia covid- daily situation report site/documents/bc_surveillance_summary_april_ % final cma national physician health survey: a national snapshot canadian associated of general surgery. cags resident's committee symposium: resident fatigue and fatigue-related events amongst canadian general surgery residents factors associated with mental health outcomes among health care workers exposed to coronavirus disease psychological status of medical workforce during the covid- pandemic: a cross-sectional study attending to the emotional well-being of the health care workforce in a new york city health system during the covid- pandemic the mental health of medical workers in wuhan, china dealing with the novel coronavirus. the lancet psychiatry physician well-being: the reciprocity of practice efficiency, culture of wellness, and personal resilience. nejm catalyst from doctors' stories to doctors' stories, and back again key: cord- -zd arwmr authors: sacco, guillaume; foucault, gonzague; briere, olivier; annweiler, cédric title: covid- in seniors: findings and lessons from mass screening in a nursing home date: - - journal: maturitas doi: . /j.maturitas. . . sha: doc_id: cord_uid: zd arwmr background/objective: the covid- epidemic is particularly serious in older adults. the symptomatology and epidemic profile remain little known in this population, especially in disabled oldest-old people with chronic diseases living in nursing homes. the objective of the present study was to comprehensively describe symptoms and chronological aspects of the diffusion of the sars-cov- virus in a nursing home, among both residents and caregivers. design: five-week retrospective cohort study. setting: a middle-sized nursing home in maine-et-loire, west of france. participants: eighty-seven frail older residents ( . ± . years; % female) and staff members ( . ± . years; % female) were included. measurements: mass screening for sars-cov- was performed in both residents and staff. attack rate, mortality rate, and symptoms among residents and staff infected with sars-cov- were recorded. results: the attack rate of covid- was % in residents (case fatality rate, %), and % in staff. epidemic curves revealed that the epidemic started in residents before spreading to caregivers. residents exhibited both general and respiratory signs ( % hyperthermia, % cough, % polypnea) together with geriatric syndromes ( % falls, % altered consciousness). the classification tree revealed % covid- probability in the following groups: i) residents younger than with dyspnea and falls; ii) residents older than with anorexia; iii) residents older than without anorexia but with altered consciousness. finally, % of staff members diagnosed with covid- were asymptomatic. conclusions: the pauci-symptomatic expression of covid- in older residents, together with the high prevalence of asymptomatic forms in caregivers, justifies mass screening in nursing homes, possibly prioritizing residents with suggestive combinations of clinical signs including dyspnea, falls, anorexia and/or altered consciousness. attention should be paid to older people in nursing homes for whom mass screening had been organized. whilst residents of nursing homes seem seriously affected by the sars-cov- infection [ ] , clinical and epidemiological data remain yet fragmented thus far [ , ] . the objective of the present study was to clarify symptoms and chronological aspects of the propagation of the sars-cov- in a nursing home, both in residents and staff members. the study consisted in a five-week retrospective observational cohort study in a middle-sized nursing home in maine-et-loire, west of france, having performed covid- mass screening of residents (n= ) and staff members (n= ). the nursing home is dedicated to patients with major neurocognitive disorders combined with behavioral disturbances. the facility includes apartments (with one couple living in a single apartment), along with communal dining, library, and activity areas. the nursing home is divided into five units: one day care unit, one open unit, and three secured closed units. the open unit is dedicated to patients with mild major neurocognitive disorders but poor autonomy. closed units are dedicated to patients with severe behavioral disturbances including wandering. all residents were allowed to move around the building until march , while social distancing and other preventive measures were implemented. residents were isolated in their rooms with no communal meals or group activities. no visitors, including families, were allowed in the nursing home since march . walks in the garden were organized for the residents one by one, in the presence of one staff member. residents could receive and update their families by phone or video. mail and packages were stored h before being delivered to residents. enhanced hygiene measures were implemented, including cleaning and j o u r n a l p r e -p r o o f disinfection of frequently touched surfaces, permanent face masks, and additional hand hygiene stations for staff members. in total, individuals were working as staff members during the study. the teams change three times a day, i.e. in the morning, in the afternoon and at night. the study was conducted in accordance with the ethical standards set forth in the helsinki declaration ( ) . no participant objected to the use of anonymized clinical and biological data for research purposes. the study was approved by an independent institutional review board under the number / . the study protocol was declared to the national commission for information technology and civil liberties (cnil) under number ar - v . residents' clinical signs and results of the reverse-transcriptase-polymerase-chain-reaction (rt-pcr) tests were retrospectively obtained by reviewing medical records of the nursing home from march . staff members' clinical signs and results of the rt-pcr tests were retrospectively obtained from the nursing home coordinating doctor. data were censored at the time of data cutoff, which occurred on april . infection with covid- was defined for both residents and staff members as a positive result on rt-pcr tests of a specimen collected with nasopharyngeal swab in accordance with the world health organization standards [ ] . five residents had a test in hospital due to suggestive symptoms between march and march , before tests were made available outside of the hospital. other residents and staff members had a test as part of the mass screening on april ( staff members), april ( residents and staff members), april ( residents and staff members), april ( residents and staff members), april ( residents and staff members), april ( staff members), april ( residents and staff members), april ( staff members) and april ( staff members). for j o u r n a l p r e -p r o o f patients who died without rt-pcr test, the cause of death indicated on the death certificate (i.e. related or not to was collected. the following measures were collected for each resident: demographic (age, gender, residence unit), vaccinal status regarding influenza virus for the current year, clinical signs, date and result of the rt-pcr test, hospitalization (all-cause or specifically due to , and mortality (all-cause or specifically due to . finally, medical history of residents was extracted for the whole population using the pathos data [ ] . the mean weighted pathos is used in nursing homes to describe the care profile of residents. in fact pertinent pathological statuses (but not the whole icd ) are described, including major neurocognitive disorders or abdominal pain for instance. each pathological status is qualified by one of the possible care profiles according to the clinical context (e.g., profile t : requiring multiweekly medical supervision and -hour nursing care). the following measures were collected for each staff member: date and result of the rt-pcr test, date of first covid- symptoms if applicable, and position in the nursing home by distinguishing between caregivers (i.e. physician, nurses, assistant nurses, animator, physiotherapist, occupational therapist, psychomotrician), non-caregivers who had contact with residents (i.e. restaurant, laundry and housekeepers), and non-caregivers who had no contact with residents (administrative functions). the participants' characteristics were summarized using mean and standard deviation (sd), median and % confidence interval ( ci), or frequency and percentage, as appropriate. normality of data was assessed using kolmogorov-smirnov test. first, the case fatality rate (i.e., the number of deaths from covid- divided by the total number of people diagnosed with covid- during the study), the attack rate (i.e., the number of new cases during the study divided by the number of residents), and the person-j o u r n a l p r e -p r o o f time incidence rate per person-days (i.e., as the number of new cases during the study divided by the sum of persons exposed each day during the study [considering that each new case was no longer exposed after covid- diagnosis] divided by ) were calculated. each positive case was excluded from people exposed either on the date of the first symptom, or on the date of the positive rt-pcr test for asymptomatic people, or on the date of work disruption for staff members when the two previous conditions were not met. for those with positive rt-pcr test but no symptoms, the date of the screening test was used to calculate the incidence rate. second, participants were divided into three groups according to the covid- status, i.e. the "covid- group" for those with a positive rt-pcr test or death attributed to covid- , the "non-covid- group" for those with a negative rt-pcr test or death not attributed to covid- , and the "non-tested group" for the survivors with no rt-pcr test. comparisons were performed using chi square test or exact fisher test for qualitative variables, and student t test or mann-whitney u test for quantitative variables, as appropriate. third, a classification tree (chi-square automatic interaction detector, chaid) was performed using all available residents' data at once [ ] . the chaid analysis is an algorithm used for discovering relationships between a categorical response variable (i.e., covid- here) and other categorical predictor variables (i.e., all clinical variables collected as part of the study). it splits a parent group into two subgroups ("nodes") within which covariates are homogenous and between which outcome is distinct. the chaid analysis is useful when looking for patterns in datasets with lots of categorical variables and is a convenient way of summarizing the data as the relationships can be easily visualized. here, we forced the use of age years (median) as the first split, and the chaid analysis was adjusted for age. the probability of covid- (relative risk with ci) was calculated for each end node using the end node with the lowest prevalence of covid- as a reference (node ) [ ] . two-sided p-values were considered as significant if < . . all statistics were performed using spss (v . ; ibm corp, chicago, il). a total of residents (mean±sd age, . ± . years; % female) and staff members (mean, . ± . years; % female) were included in the study. as illustrated in figure , the first confirmed covid- cases were reported on and march for residents and staff members, respectively. seventy-seven residents were tested for covid- between march and april ( deaths before testing), and ( . %) staff members between and april . the attack rate was % in residents, and % in staff members. the incidence rate was . per persons-days among residents, and . persons-days among staff members (respectively, . among caregivers, . among non-caregivers with contact to residents, and . among non-caregivers without contact) ( figure ). the case fatality rate was % among residents. the all-cause mortality rate was % among residents, compared % on average during the same period in the preceding five years. no staff members died during the study period. epidemic curves revealed that the epidemic started in residents, and then spread to caregivers, non-caregivers and finally to staff members with no contact to the residents ( figure ). demographic characteristics and medical history of residents are detailed in table . residents exhibited chronic pathological statuses on average. among all residents, had a confirmed infection with sars-cov- (mean, . ± . years; % female). table , the most frequent symptoms retrieved in covid- residents were thermal changes (n= , %); % of patients having hyperthermia (i.e., temperature > °c) and % hypothermia (i.e., temperature < °c). dyspnea was retrieved in % (n= ) of covid- , with % of low pulse oximetry (n= ) and % of polypnea (n= ). twenty j o u r n a l p r e -p r o o f ( %) covid- residents presented with cough (n= ), ( %) with marked asthenia, and ( %) with diarrhea. it is noticeable that the comparison with non-covid- residents showed multiple symptomatic differences, in particular a greater number of simultaneous clinical signs (table ). finally, covid- residents ( %) were totally asymptomatic and finally diagnosed through mass screening. all of them had major neurocognitive disorders related to alcohol use. one had hypertension and mild chronic renal failure, another one had hypertension and moderate chronic renal failure, and the last one had polyvascular disease with brain and heart lesions. the classification tree identified end groups among residents for the prediction of covid- ( figure ). the first split was dyspnea below years of age, and anorexia above years. among individuals younger than and without dyspnea, those who reported no cough formed the end node with the lowest prevalence of covid- ( %; node ). compared to this reference node, the probability of covid- was . -fold higher among those older than without anorexia and without altered consciousness ( % covid- ), . -fold higher among those younger than without dyspnea but with cough ( % covid- ), and . fold higher among those younger than with dyspnea but no falls ( % covid- ). finally, we found a % covid- probability in the following groups: i) those younger than with dyspnea and falls; ii) those older than with anorexia; iii) those older than without anorexia but with altered consciousness. table presents the characteristics of the staff members. in total, had a confirmed infection with sars-cov- (mean, . ± . years; % female). caregivers represented % (n= ) of infected staff members, non-caregivers with contact to residents % (n= ), and staff members without contact to residents % (n= ). most frequent symptoms were fever ( %, n= ), general signs (i.e. asthenia, anorexia, myalgia) ( %, n= ), cough ( %, n= ), and ent signs ( %, n= ). nine staff members were asymptomatic and identified through j o u r n a l p r e -p r o o f mass screening. the present report of covid- mass screening in a nursing home showed a high prevalence of asymptomatic infected staff members, and confirmed that older residents exhibit few and mainly nonspecific symptoms. we were nevertheless able to clarify the symptomatology of covid- residents, and to specify three different clinical profiles of residents with % infection within a nursing home affected by the sars-cov- . this monocentric observational study contributes to emerging understanding of the presentation and trajectory of covid- in nursing-home residents. this case series showed that frail older adults exhibit relatively few symptoms, and notably less often fever, cough [ ] and ent signs [ ] than younger adults. in this sense, our results are consistent with the few previous studies on symptoms met in older adults infected with covid- [ , ] . it is also consistent with the clinical presentation of other viral infections in older adults such as influenza [ ] . here, the residents exhibited both general and respiratory signs ( % hyperthermia, % cough, % polypnea) together with gastro-intestinal signs ( % diarrhea) and geriatric syndromes ( % falls, % altered consciousness). surprisingly, delirium was less frequent compared to one previous report in adults aged and over ( % here versus . % previously) [ ] . this may be explained by the characteristics of the present sample, which involved mainly frail older residents with major neurocognitive disorders and behavioral disturbances. delirium is commonly under-recognized when superimposed to major neurocognitive disorders, especially during the severe stages of the disease since a clear distinction between symptoms attributable to delirium or to underlying dementia proves difficult [ ] . we also found that the covid- disease was asymptomatic in % of the residents. this result is in accordance with recent results reporting % of asymptomatic patients ( / ) in a nursing facility [ ] . it suggests that covid- may have either non-expressive forms, or nonspecific symptoms that have gone unnoticed, or symptoms not expressed by older adults with advanced cognitive disorders. moreover, positive rt-pcr for sars-cov- was found in the absence of any symptom in % of the staff members; a large group likely involving both asymptomatic and presymptomatic individuals [ ] . these findings encourage systematic screening in nursing homes of all residents and staff members, starting with caregivers. our classification tree is thought to be an interesting tool to assist clinicians in prioritizing tests and in rapid decision-making for older residents. three clinical profiles should particularly draw the clinicians' attention as they were associated with % covid- probability in our study. these are residents i) younger than with dyspnea and falls, ii) older than with anorexia, and iii) older than without anorexia but with altered consciousness. thus, even if these results need to be confirmed by further and preferentially prospective analyses, it seems reasonable, in a nursing home affected by covid- epidemic, to quickly isolate residents with one of these combinations of symptoms, and to test them as a priority to make the diagnosis of covid- . we found a case fatality rate of %, consistent with previous findings ranging between % and . % in similar populations [ , ] . such high lethality rate in older patients should be considered in light of the worldwide covid- lethality rate for all ages, which is around % [ ] . the over-mortality in older patients was early reported by wang et al. [ ] and by the novel coronavirus pneumonia emergency response epidemiology team [ ] . it is likely explained by the higher prevalence of severe infections in older patients compared to younger ones, due to the higher prevalence of multimorbidity leading to j o u r n a l p r e -p r o o f cascading decompensation in this population [ , ] . consistently, the studied residents exhibited chronic pathological statuses on average here. finally, we found that the attack rate was % among the residents in our study, which was close to the . % rate previously established in a call center in south korea [ ] , but twice as high as the attack rate among the staff members. this differential was possibly explained by a presymptomatic phase among staff members [ ] as they were affected by sars-cov- later than the residents. in our study, it is noticeable that the epidemic started in the nursing home among residents ( figure ) and then spread to staff. since residents were unable to leave the nursing home, this suggests that the sars-cov- was likely imported into the nursing home by a family member before containment and before visiting bans. thus, the isolation measures from the outside imposed by some governments appear justified to limit and slow down the spread of the virus in nursing homes. however, such isolation of residents also raises questions about the quality of life of those with short life expectancy. many initiatives are proposed in nursing homes to keep social life during this period, i.e. animations in corridors, music playing, individual walks, individual activities in the garden, sports coach, singing activities, or dematerialized communications with relatives; all alternative solutions, the degree of satisfaction of which needs to be evaluated (nct ). our study has some limitations. first, it is an observational study conducted on a relatively limited sample of older adults living in a single nursing home and who may be not fully representative of the general population of residents as they all suffered from major neurocognitive disorders. second, even if data were collected each day during the epidemic in a standardized manner, recall and reporting bias in retrospective studies cannot be ruled out especially regarding the symptoms of staff members. third, the diagnosis of covid- was based either on death certificate or rt-pcr test, although the first one assumes a high clinical j o u r n a l p r e -p r o o f probability but no biological confirmation of covid- , and the second one suffers from a relatively low sensitivity of % with high risk of false negatives [ ] . in conclusion, the pauci-symptomatic expression of covid- in older residents, together with the high prevalence of asymptomatic forms in caregivers, justifies conducting mass screening in nursing homes, possibly prioritizing residents with suggestive combinations of clinical signs including dyspnea, falls, anorexia and/or altered consciousness. moreover, the finding of an initial contamination likely brought by non-professional visitors encourages isolation measures in nursing homes to break the contamination chain. guillaume sacco contributed to study concept and design, analysis and interpretation of data, and drafting of the manuscript. gonzague foucault contributed to study concept and design, acquisition of data, analysis and interpretation of data, critical revision of the manuscript for important intellectual content, and administrative, technical, or material support. olivier briere contributed to critical revision of the manuscript for important intellectual content. cédric annweiler contributed to study concept and design, analysis and interpretation of data, drafting of the manuscript, and study supervision, and has full access to all of the data in the study, takes responsibility for the data, the analyses and interpretation and has the right to publish any and all data, separate and apart from the attitudes of the sponsors. all authors have read and approved the manuscript. no participant objected to the use of anonymized clinical and biological data for research purposes. the study was approved by an independent institutional review board under the number / . the study protocol was declared to the national commission for information technology and civil liberties (cnil) under number ar - v . this article was not commissioned. peer review was directed by leon flicker independently of cédric annweiler, an author and maturitas editor, who was blinded to the process. there are no linked research data sets for this paper. data will be made available on request. for each node: node number; n of residents with covid- within node; proportion of residents with covid- within node (n with covid- / n node). rr: relative risk; ci: % confidence interval. clinical characteristics of fatal and recovered cases of coronavirus disease (covid- ) in wuhan, china: a retrospective study symptoms of covid- among older adults: systematic review of biomedical literature national french survey of symptoms in people aged and over diagnosed with covid- covid- in a long-term care facility -king county detection of sars-cov- among residents and staff members of an independent and assisted living community for older adults asymptomatic and presymptomatic sars-cov- infections in residents of a long-term care skilled nursing facility -king county detection of novel coronavirus ( -ncov) by real-time rt-pcr caisse nationale de solidarité pour l'autonomie the chaid approach to segmentation modeling: chi-squared automatic interaction detection obtaining confidence intervals for the risk ratio in cohort studies novel coronavirus infection (covid- ) in humans: a scoping review and meta-analysis olfactory and gustatory dysfunctions as a clinical presentation of mild-to-moderate forms of the coronavirus disease (covid- ): a multicenter european study age-related differences in hospitalization rates, clinical presentation, and outcomes among older adults hospitalized with influenza-u.s. influenza hospitalization surveillance network (flusurv-net) delirium superimposed on dementia presymptomatic sars-cov- infections and transmission in a skilled nursing facility asymptomatic transmission, the achilles' heel of current strategies to control covid- epidemiology of covid- in a long-term care facility in king county an interactive web-based dashboard to track covid- in real time updated understanding of the outbreak of novel coronavirus ( -ncov) in wuhan novel coronavirus pneumonia emergency response epidemiology team zhonghua liu xing bing xue za zhi zhonghua liuxingbingxue zazhi clinical features of fatal cases a retrospective observational study hospitalization and critical care of decedents with covid- pneumonia in wuhan coronavirus disease outbreak in call center evaluating the accuracy of different respiratory specimens in the laboratory diagnosis and monitoring the viral shedding of -ncov infections the authors have listed everyone who contributed significantly to the work in the acknowledgments section. permission has been obtained from all persons named in the acknowledgments section.-melinda beaudenon, msc, romain simon, msc, and jennifer gautier, msc, from the research center on autonomy and longevity, university hospital of angers, france, for daily assistance. there was no compensation for this contribution. key: cord- -qfpukqwc authors: wooltorton, eric; seale, edward; lewis, denice; noel, kendall; liddy, clare; viner, gary; shoppoff, lina; archibald, douglas title: rapid, collaborative generation and review of covid- pandemic-specific competencies for family medicine residency training date: - - journal: can med educ j doi: . /cmej. sha: doc_id: cord_uid: qfpukqwc background: in march , the covid- pandemic disrupted competency-based medical education in family medicine programs across canada. faculty and residents identified a need for clear, relevant, and specific competencies to frame teaching, learning, supervision and feedback during the pandemic. methods: a rapid, iterative, educational quality improvement process was launched. phase involved experienced educators defining gaps in our program’s existing competency-database, reviewing emerging public health and regulatory guidelines, and drafting competencies. phase involved translation, member-checking, and anonymous feedback and editing of draft competencies by residents and other educational leaders. phase involved wider dissemination, collaborative editing and feedback from residents and faculty throughout the department. results: a total of physicians including residents and faculty from multiple contexts provided detailed feedback, review, and editing of an ultimate list of competencies organized by canmeds-fm roles. broad agreement was obtained that the competencies form reasonable learning outcomes during the covid- pandemic. conclusions: these competencies represent learning objectives reflecting the initial educational mindsets of a wide range of teachers and learners experiencing a global pandemic. the project illustrates a novel collaboration across educational portfolios as a rapid educational response to a public health crisis. the bilingual university of ottawa family medicine program trains family medicine specialists who are competent to provide comprehensive, compassionate care in any canadian community. the exceptional circumstances of the covid- pandemic disrupted health systems internationally and forced sudden changes to many training programs including our own in mid-march . clinical experiences were cancelled or altered abruptly, virtual visits and supervision replaced inperson contact, and resident physicians were redeployed to novel clinical contexts. for example, residents in our program return for a weekly family medicine 'half day back', regardless of their current clinical rotation, allowing a reconnection with a generalist family medicine mindset and practice, and continuity of care and education. however, in march , anticipated surges in patient volumes and physician illnesses and quarantine, and an attempt to minimize clinicians moving between clinical contexts (reducing potential virus spread) led to several major disruptions. half-day backs were cancelled, electives, leave and teaching and examinations (including the spring certification examination by college of family physicians of canada) were postponed or cancelled, and some residents were re-deployed to under-resourced settings which had not previously hosted residents. clinical care in family medicine blocks changed dramatically with physical distancing and personal protective equipment requirements, minimal inperson visits (with reduced physical examination) and patient care delivered mostly virtually (phone or video conference), and physicians working remotely and often indirect supervision. all physicians faced new personal and professional challenges. in response to these changes, we launched an adapted, rapid consensus process to identify and define specific covid- related competencies to guide teaching, learning, and feedback in the new clinical reality simultaneously affecting all departments of family medicine across canada. the uottawa family medicine program is a bilingual (english, french) two-year residency, with a total of residents (pgy , pgy ) assigned primarily to one of several dozen of community-based practices across eastern ontario, or one of seven teaching units (affiliated with five hospitals in the ottawa region and surrounding rural areas). each resident is e assigned a faculty preceptor, who are overseen by educational leaders who report on resident progress monthly to a variety of departmental of family medicine committees. we aimed to engage as many residents, faculty members and leaders in the department as possible using an adapted approach based on the first three steps of the kern model : problem identification and general needs assessment (step ), targeted needs assessment (step ); writing goals and objectives (step ) (or more specifically learning 'outcomes' in this case ); canmeds is a one of the most widely used educational frameworks for organizing health professions competencies [ ] [ ] [ ] and was chosen to organize competencies to allow their use in other canadian family medicine programs, and non-family medicine specialties (royal college of physician and surgeons of canada). traditional group consensus methods, such as delphi and nominal group methods were considered inadequate to meet our urgent timeline to allow for the broad inclusivity needed to capture the contextual relevance of our diverse family medicine training environments and to allow for the timely application of the educational product. instead, a process of writing, internal peer review, and revision, based on the first three steps of the kern approach was utilized. the competencies created are really learning outcomes which are specific, and observable and include cognitive (knowledge), affective (attitudinal), and psychomotor (skill and behaviours) outcomes for residents, patients, the health care system, and society. table provides a summary of the timeline used for the three-phase process that was conducted over a three week period. rapid iterations of consultations with multiple forms of feedback allowed input from expanding groups of reviewers (faculty, residents). anonymous feedback through multiple choice, and open-ended questions was tracked in a six-question survey tool (google form), with four questions covering basic respondent demographics (to ensure responses from a range of respondents), and openended questions collecting suggested changes. a priori, we decided we would progress to the next phase if > % of respondents agreed or strongly agreed with the statement on a point likert scale (anchors: "strongly agree", "agree", "neutral", "disagree", "strongly disagree"). in the phase , . % of respondents "agreed" or "strongly agreed" with the statement "as a whole the competencies form reasonable learning outcomes to guide our teaching, learning and feedback for residents during the covid- pandemic." the process and results are described in table . a total of covid- pandemic-specific competencies were created by the end of the departmental process (figure ; see supplemental data). in phase three, anonymous feedback (n = ) was provided by residents (n = , . %) and faculty (n = , . %) with a range of career experience ( . % < years, . % - years, . % > years) in rural and urban teaching sites. in the phase , . % of respondents "agreed" or "strongly agreed" with the statement "as a whole the competencies form reasonable learning outcomes to guide our teaching, learning and feedback for residents during the covid- pandemic." during a pandemic, clinical care is paramount, and consistent with principles of competency-based medical education. [ ] [ ] [ ] [ ] [ ] we aimed to analyze and capture the evolving professional, societal, patient and educational needs facing our widely distributed department. the sweeping reality of the pandemic forced rapid educational change, urgent reflection on professional priorities, roles and identity, and creative adaptation of educational experiences to ensure educational relevance. the current project complements concurrent work by the college of family physicians of canada, guiding virtual e supervision of learners. rather than a 'laundry list' of new educational requirements, the competencies defined here are a resource to use in a wide range of educational contexts to guide teaching, learning and feedback. although residents and faculty contributed feedback and review of the competencies, the true response rate is undetermined, due to nature of the open invitation to provide input. another limitation is that these competencies, while vetted by faculty from multiple clinical contexts are largely from a single canadian university which may limit their immediate applicability in other contexts. the process decision to use existing feedback forms also limits the ease of tracking competency attainment. our process aimed to rapidly engage a broad range of stakeholders to provide a focused educational response to a public health and medical education crisis. next steps include a program evaluation, after the pandemic. a program evaluation approach will define and judge the success, shortcomings of the pandemic-related changes made across our complex program. we will be able to judge the impact (intended and unintended) and merit of this rapid medical education pivot with clear questions (eg "were the competencies attained?" "were they adequate?" "are there unmet faculty and residents needs?") answered through a review of existing data sources (eg formative and summative feedback in field notes and end-of-rotation evaluations), and new data sources (interviews, surveys). bringing together a wide range of educational stakeholders (departmental leaders, teachers, residents) from across the continuum of medical education (from undergraduate to postgraduate education and faculty development portfolios) produced an integrated approach to curriculum design, implementation and evaluation. this unprecedented collaboration across portfolios (and universities) was an unexpected outcome of this project, and serves as a model for engagement and cooperation during less turbulent times. conflicts of interest: the authors deny any conflicts of interest, or financial or personal relationships that could potentially bias this work. funding: this project received no specific funding. striving for excellence: developing a framework for the triple c curriculum in family medicine education curriculum development for medical education: a six-step approach (third edit) the canmeds initiative: implementing an outcomes-based framework of physician competencies flower power: the armoured expert in the canmeds competency framework? canmeds-family medicine a competency framework for family physicians across the continuum learning outcomes and instructional objectives: is there a difference? using consensus group methods such as delphi and nominal group in medical education research competency-based curriculum for family medicine defining characteristics of educational competencies theory and practice in the design and conduct of graduate medical education competency-based medical education: theory to practice advancing competency-based medical education: a charter for clinician-educators tips for supervising family medicine learners providing virtual care. missassauga program evaluation models and related theories: amee guide no. key: cord- -fn bnnb authors: suyin chalmin-pui, lauriane; roe, jenny; griffiths, alistair; smyth, nina; heaton, timothy; clayden, andy; cameron, ross title: “it made me feel brighter in myself”- the health and well-being impacts of a residential front garden horticultural intervention date: - - journal: landsc urban plan doi: . /j.landurbplan. . sha: doc_id: cord_uid: fn bnnb residential gardens make up % of urban space in the uk, yet unlike many other green space typologies, their role in the health and well-being agenda has largely been overlooked. a horticultural intervention introduced ornamental plants to previously bare front gardens (≈ m( )) within an economically deprived region of north england, uk. measures of perceived stress and diurnal cortisol profiles (as an indicator of health status) were taken pre- and post-intervention (over months). residents reported significant decreases in perceived stress post-intervention. this finding was aligned with a higher proportion of ‘healthy’ diurnal cortisol patterns post-intervention, suggesting better health status in those individuals. all residents derived one or more reported socio-cultural benefits as a result of the front garden plantings, although overall scores for subjective well-being did not increase to a significant level. further qualitative data suggested that the gardens were valued for enhancing relaxation, increasing positive emotions, motivation, and pride of place. the results indicate that adding even small quantities of ornamental plants to front gardens within deprived urban communities had a positive effect on an individual’s stress regulation and some, but not all, aspects of subjective well-being. the research highlights the importance of residential front gardens to human health and well-being, and thus their contribution to the wider debates around city densification, natural capital and urban planning. an increasing body of research demonstrates that urban green space (ugs) has therapeutic value by allowing city dwellers to relax and engage with nature (frumkin et al., ; hartig, mitchell, de vries, & frumkin, ) . especially in urbanised societies, exposure to green space has been shown to generate positive benefits in emotional well-being addin csl_citation {"citationitems":[{"id":"item- ″,"itemdata": {"doi":"https://doi.org// . / . . ″,"issn":" ″,"abstract":"a growing body of empirical research suggests that brief contact with natural environments improves emotional well-being. the current study synthesizes this body of research using meta-analytic techniques and assesses the mean effect size of exposure to natural environments on both positive and negative affect. thirty-two studies with a total of participants were included. across these studies, exposure to natural environments was associated with a moderate increase in positive affect and a smaller, yet consistent, decrease in negative affect relative to comparison conditions. significant heterogeneity was found for the effect of nature on positive affect, and type of emotion assessment, type of exposure to nature, location of study, and mean age of sample were found to moderate this effect. the implications of these findings for existing theory and research are discussed, with particular emphasis placed on potential avenues for fruitful future research examining the effects of nature on well-being.","author": [{"dropping-particle":"","family":"mcmahan","given":"ethan a.","nondropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"estes","given":"david","non-dropping-particle":"","parsenames":false,"suffix":""}],"container-title":"journal of positive psychology","id":"item- ″,"issue":" ″,"issued":{"date-parts": [[" ″]]},"page":" - ″,"publisher":"routledge","title":"the effect of contact with natural environments on positive and negative affect: a metaanalysis","type":"article-journal","volume":" ″},"uris":["http://www. mendeley.com/documents/?uuid = c e f - - b c-b ab- cdddf ″]},{"id":"item- ″,"itemdata":{"doi":"https://doi.org// . /eco. . ″,"abstract":"research indicates that contact with nature elevates positive emotions; however, relatively less work examines the mechanisms responsible for these effects. the present study experimentally tested whether a brief experience in nature promotes specific positive emotions, such as happiness, joy, and feelings of awe because of feeling absorbed and fully involved in its natural features. participants (n = ) were randomly assigned to either sit in a natural environment (i.e., a local arboretum) or a built environment (e.g., an outdoor stadium) for min while focusing their attention on their surroundings, and afterward rated their current feelings. results from structural equation modeling analyses indicated an excellent fit for a mediation model in which experience in a natural environment, as opposed to a built setting, significantly enhanced feelings of awe and other positive emotions, χ ( ) = . , p = . , cfi = . , rmsea = . , % ci (< . , . ). moreover, absorption emerged as a significant mediator of nature's impact on positive emotions. there was a particularly strong effect on feelings of awe ( % of variance explained by the full model). results indicate that nature fosters awe and other positive emotions when people feel captivated and engrossed in their surroundings. the present study extends research on nature's positive emotional benefits and provides implications for nature-based interventions, specifically on the significance of having absorbing experiences in nature. key words: contact with nature-natural environment-positive emotions-awe-absorption. (psycinfo database record (c) apa, all rights reserved)","author":[{"dropping-particle":"","family":"ballew ","given":"matthew t.","non-dropping-particle":"","parse-names":false," suffix":""},{"dropping-particle":"","family":"omoto","given":"allen m.","non-dropping-particle":"","parse-names":false,"suffix":""}],"containertitle":"ecopsychology","id":"item- ″,"issue":" ″,"issued":{"date-parts": [[" ″]]},"page":" - ″,"title":"absorption: how nature experiences promote awe and other positive emotions","type":"article-journal","volume":" ″},"uris":["http://www.mendeley.com/documents/?uuid= b f e - f- -ab e- d f b"]},{"id":"item- ″,"itemdata": {"isbn":" ″,"abstract":"perception and categorization -the prediction of perference -variations: group differences -a wilderness laboratory -nearby nature -the restorative environment -the monster at the end of the book -overview of preference research methodology -preference studies -outdoor challenge program -benefits and satisfaction studies.","author":[{"dropping-particle":"","family":"kaplan","given":"rachel","non-dropping-particle":"","parse-names":false,"suffix":""}, {"dropping-particle":"","family":"kaplan","given":"stephen","non-dropping-particle":"","parse-names":false,"suffix":""}],"id":"item- ″,"issued": {"date-parts": [[" ″] ]},"number-of-pages":" ″,"publisher":"cambridge university press","title":"the experience of nature: a psychological perspective","type":"book"},"uris":["http://www.mendeley.com/ documents/?uuid= a d - - a - cbb- eff c e a ″]}, {"id":"item- ″,"itemdata":{"doi":"https://doi.org// . / . . ″,"abstract":"the physical and social participatory properties of landscapes have been explored using affordance theory but, as yet, the affective dimension of affordances is ill-defined. this paper sets out a framework for integrating affect within the affordance perceptual model. in doing so, it draws on two established models of emotion that identify 'valence' (pleasure-displeasure) and 'arousal' (inactive-active) as basic dimensions underlying an emotional response. ethnographic methods were employed over a six-month period to observe the emotional responses to a forest setting in boys (aged - ) with extreme behaviour problems and confined to a specialist residential school in central scotland. over time, changes in affective responses to the setting were mapped and located both within the physical setting and within the circumplex emotion model. results show an increase in positive affective responses to the forest setting over time, accompanied by increased trust, exploratory activity and social cohesion, dimensions linked in the literature with well-being. the significance of this paper is two-fold: first, it extends research in restorative health by showing how forest settings can, in a rehabilitation context over time, offer opportunities for long-term 'instoration' in boys suffering from extreme mental trauma. second, it is a first attempt at integrating affect within the affordance perception framework providing a conceptual model which can be expanded upon by future researchers.","author":[{"droppingparticle":"","family":"roe","given":"jenny j.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"aspinall","given":"peter","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"landscape research","id":"item- ″,"issue":" ″,"issued":{"date-parts":[[" ″]]},"page":" - ″,"title":"the emotional affordances of forest settings: an investigation in boys with extreme behavioural problems","type":"article-journal","volume":" ″},"uris":["http://www.mendeley.com/documents/?uuid= de aeba-a - c- e- f dbea e"]}],"mendeley": {"formattedcitation":" (ballew & omoto, ; kaplan & kaplan, ; mcmahan & estes, ; roe & aspinall, )","plaintextformattedcitation":" (ballew & omoto, ; kaplan & kaplan, ; mcmahan & estes, ; roe & aspinall, ) ","previouslyformattedcitation":" (ballew & omoto, ; kaplan & kaplan, ; mcmahan & estes, ; roe & aspinall, )"},"properties":{"noteindex": },"schema":"https://github.com/citation-stylelanguage/schema/raw/master/csl-citation.json"} (ballew & omoto, ; roe & aspinall, ) , cognitive functioning , behaviour (guéguen & stefan, ) and physiological responses, including heart rate variability, pulse rate, blood pressure, skin conductance, cortical brain activity and diurnalcortisol profiles (haluza, schönbauer, & cervinka, ; neale,aspinall, roe, tilley, mavros, cinderby, coyne, thin, & ward thompson, ; roe et al., roe et al., , toda, den, hasegawa-ohira, & morimoto., ) . exposure to green space/nature has been linked to enhancement of the immune system (hansen, jones, & tocchini, ) and encouraging physical activity (cameron & hitchmough, ; de vries, ) . despite policy-makers having a growing understanding of the value of ugs from a health and well-being perspective, challenges remain as to where and what type of ugs should be incorporated into city planning. previous research implies that factors including scale, accessibility, quality, biodiversity and activity within ugs influence the relative health benefits (dallimer et al., ; fischer et al., ; keeler et al., ; wood et al., ) . several reports suggest that larger (mitchell, astell-burt, & richardson, ) , more naturalistic landscapes (stott, soga, inger, & gaston, ) with greater biodiversity (cameron, brindley, mears, mcewan, ferguson, sheffield, jorgensen, riley, goodrick, ballard, & richardson, ) promote more positive health effects. this might suggest that planners should prioritise larger, more informal parks or nature reserves over other forms of ugs, when considering 'therapeutic' or health-promoting landscapes (cameron et al., ) . yet recent epidemiological studies also indicate health indices improve when homeowners possess a garden (brindley, jorgensen, & maheswaran, ; dennis & james, ) . this implies that smaller, more intimate and readily accessible green space may also have a role in promoting health for urban citizens, and provide an alternative strategy to providing therapeutic space within the urban matrix. surprisingly, the value of residential gardens (also known as 'domestic', 'private' or 'home' gardens) as a health intervention has largely been overlooked (cameron, blanusa, taylor, salisbury, halstead, henricot, & thompson, ) . in a review of ugs and mental health, only approximately % of studies involved residential gardens (wendelboe-nelson, kelly, kennedy, & cherrie, ) and more information is required on the merits of this landscape type. moreover, in the context of ever-increasing urbanisation and city densification, there is evidence that some city planners see residential gardens as a dispensable luxury (haaland & konijnendijk van den bosch, ) . residential garden size is getting smaller, and some planners/developers are omitting gardens in new housing schemes completely (tahvonen & airaksinen, ). yet this may be folly if such features are enhancing human health and well-being. moreover, residential gardening is a common pastime with % of uk adults (department for culture media and sport, ) and % of usa homeowners taking part in regular garden activities (clayton, ) . thus, gardening holds much promise as an intervention for health and well-being. indeed, the value of private residential gardens as therapeutic landscapes was brought to the fore during the covid- virus outbreak (sofo & sofo, ) , where residents were socially isolated and the only green space that could be accessed for long periods of time, were private gardens (for those that possessed them). despite the dominance of residential gardening as an activity, much of the literature on gardening with respect to health and well-being actually relates to communal gardening on public or semi-public land, possibly because this is easier for researchers to access. communal gardening covers community garden schemes, allotments, hospices, prison gardens and horticultural therapy interventions. although the data is still not extensive, there is a greater evidence-base for benefits associated with communal gardening. these include improvements in: physiological relaxation (hassan, qibing, & tao, ) , stress relief (genter, roberts, richardson, & sheaff, ) , mental health (soga, gaston, & yamaura, b) , mood (grahn & stigsdotter, ) , social skills (himmelheber, mozolic, & lawrence, ) , self-esteem (cammack, waliczek, & zajicek, ) , confidence (eum & kim, ) , creativity (exner & schützenberger, ) , diet (hale et al., ) , and opportunity for physical exercise (soga et al., a) . although it would be logical to assume that benefits associated with communal gardening translate across to residential gardening (cervinka et al., ) , this needs testing, not least as a number of reports suggest that much of the benefits of communal gardening relate to social interactions, encouragement from peers and pride in producing produce. aspects that perhaps, may not be so relevant to private residential gardening, although residential gardens that are overlooked and enjoyed by neighbours or passers-by may have their own distinct socio-cultural influences. the research presented here aims to address the gaps in knowledge relating to private residential gardens and to help inform policy-makers and planners about their potential value in terms of well-being and socio-cultural relations. this is important because not only are gardens being omitted in some new developments, but existing gardens are also changing in terms of their land cover, with many being paved over to facilitate 'off-road' car parking or ease maintenance (chalmin-pui, griffiths, roe, & cameron, ) . in the uk, % of households have gardens (davies et al., ) equating to , km or % of the total urban area (office for national statistics, ), yet recent studies suggest as much as % of this area is now hard-surfaced, with some 'gardens' having no plants at all (bonham, ) . in reality, there is little understanding of how garden design, as well as type and extent of vegetation influences well-being (lin et al., ) . our research specifically focused on small, residential front gardens associated with high-density housing stock as these are the ones most frequently paved over. it looked to investigate the effects of introducing ornamental landscape plants to paved front gardens and then determining effects on the residents' health and well-being. ornamental plants were used exclusively, i.e. food crops were avoided, to ensure impacts related to aesthetics (haviland-jones, rosario, wilson, & mcguire, ) rather than additional material benefits, such as enhanced nutritional value or financial savings associated with growing the plants. previous research has shown that there is a positive relationship between aesthetic preference and well-being (hoyle et al., a (hoyle et al., , b . as the intervention was in front gardens, i.e. adjacent to the public streetscape, we were keen to determine if any wider socio-cultural benefits might accrue too, for example, any influence on neighbours. the research examined diurnal profiles of the hormone cortisol, within the residents who took part. the physiological stress response in humans is regulated by the hypothalamic-pituitaryadrenal (hpa) axis and its synthesis of cortisol (ryan et al., ) . the circadian cortisol pattern in healthy individuals is typified by a rapid rise in cortisol production on waking in the morning, a steady decrease until mid-day, followed by a progressively slower decline until evening; with levels reaching their lowest point just prior to an individual falling asleep at night. variations in this pattern can indicate hpa dysfunction, a consequence of a wide range of mental and physical health problems (adam et al., ) ; for example, less rapid declines may suggest prolonged fatigue or exhaustion caused by chronic stress (roe et al., ) . monitoring these diurnal profiles is important as simply calculating daily averages can be misleading -thus, for example, the assumption that high mean levels of cortisol correlate to enhanced stress and conversely low levels relate to stress-free conditions is an oversimplification (smyth, hucklebridge, thorn, evans, & clow, ) . we compared residents' cortisol diurnal profiles (i.e. the decline phase of the circadian pattern) here, in an attempt to determine if the garden intervention influenced physiological responses. healthier cortisol patterns have been cited previously for those living in areas with higher levels of green space (gidlow, randall, gillman, smith, & jones, ; roe et al., ; ward thompson et al., ) and for participants exposed to a forest setting compared to an urban one (lee et al., ) . based on the above evidence the research examined the following key questions will a front garden horticultural intervention -introducing plants to paved front gardens overtime ( months) affect residents by: q reducing perceived stress? q improving diurnal cortisol profiles, suggesting better hpa function/health status? q improving subjective well-being? q increasing physical activity? q improving connectedness to nature? q providing socio-cultural benefits such as enhanced community cohesion? a front garden intervention was carried out in an economically deprived region of north england, uk with plants and planted containers being introduced to resident's properties. pre-and post-wellbeing measures (subjective well-being, perceived stress, diurnal cortisol) were captured over a -week data collection period prior to and for at least months after each intervention, with the experiment being repeated over a two-year period, using two sub-populations of residents (i.e. groups a and b, fig. ). residents within group a were provided with plants and containers first (may ), with group b acting as a control (i.e. a comparator group without plants/containers) over the subsequent summer and autumn. residents within group b received their intervention the following year (may ). both groups were assessed on outcome measures pre-and post-the horticultural intervention (fig. ) . the experimental design followed reichardt ( ) "principle of parallelism" which recommends making multiple comparisons between groups over time (mark & reichardt, ). the quasi-experimental approach in a real-world setting acknowledged the lack of control over certain extraneous variables, including the lack of completely randomised groups (all residents showed some appetite to have a re-vegetated front garden). the experiment was conducted in salford, greater manchester, uk (grid reference sj ). salford was chosen due to an abundance of th-century terrace houses, with small ( m ) paved-over (non-vegetated) front gardens. the local housing association aided recruitment, with residents informed about the intervention via door to door leaflet dropping followed up via in-person door to door calls. residents who participated were all selected from the same neighbourhood (within km of each other), but divided into the two groups based on the street they lived in. thus group a (n = ) was selected and pooled from streets, and group b (n = ) derived and pooled from different streets. this provided geographic separation between the two groups to avoid either group influencing the other. there was no geographic or obvious socio-economic bias associated with the group distributions, with all residents within socio-economic classes - in the national statistics socio-economic classification (i.e. employment status that varies from semi-routine work to long-term unemployed), and the neighbourhood ranked as within the % most deprived in the uk (rose & pevalin, ) . residents were selected on the basis of willingness to take part in a garden intervention that involved placing containers and plants in their front gardens. participants received the same style of containers, range of plants and growing information, although the layout could vary based on the actual dimensions of individual front gardens or activities therein. for example, access to domestic bins, often situated in front of the property, had to be maintained. residents were consulted on the types of plants they preferred and a standard list developed (table ) , which were then used in the intervention (fig. ) ; all residents receiving the same plant taxa, the exception being choice of tree species -amelanchier or juniperus, or ability to decline a tree completely. residents received one tree, one shrub, one climber, and enough sub-shrubs, bulbs, and bedding plants to fill the two containers. this provided diversity in structure, colour, and seasonality for each resident. containers were planted by the researcher with no obligation for the resident to be involved with planting or subsequent management of these. all containers were 'selfwatering' with a l in-built reservoir of water. although residents were not obliged to maintain the plants, active participation was encouraged and access to horticultural advice provided through the royal horticultural society advisory team. residents were also given an information booklet written in a style accessible to non-gardeners. a number of parameters were measured as indicators of health status through questionnaires and cortisol sampling and are linked to our original questions (q - ). these were-primary health outcome measures: • perceived stress scale (cohen, kamarck, & mermelstein, ) a item scale scored on a likert ranking of (indicating higher stress) to (indicating lower stress) (q ). • diurnal cortisol levels and profiles (adam & kumari, and see protocol outlined below) (q ). • subjective well-being: short warwick and edinburgh mental well-being scale -swemwb (tennant et al., ) ; widely used in the health service sector with self-reported scores ranging from (low) to (high) mental well-being (q ). • physical activity levels (likert - scale, being inactive, being fully active) (q ). the questionnaires were also used to provide additional information on connectedness to nature (mayer & frantz, ) . this was a item scale scored on a likert ranking of (completely agree) to (completely disagree) relating to experiences of nature (q ). salivary cortisol data was collected following the procedures outlined by roe et al. ( ) . this data allows the modelling of trends and changes in the daily lives of research participants (schlotz, ) . diurnal cortisol profiles (declines after waking -see introduction) were monitored by collecting saliva samples four times a day ( , , , and h after waking) for each individual for two consecutive days with cotton swabs and salivette collection tubes (smyth et al., ) . participants were asked to confirm waking time on each day. to maximise participant adherence to the sampling protocol, they were subsequently sent sms text reminders min before a sample was due to avoid eating, drinking, or smoking (which can interfere with cortisol analyses), and when it was time to take the sample. samples were stored in domestic refrigerators for up to h before collection, then stored at − °c within a university laboratory prior to analysis. cortisol concentration was determined by enzyme linked immunosorbent assay (elisa) developed by salimetrics llc (usa). assay characteristics: standard range = . - . nmol l − , assay sensitivity = . nmol l − (lower limit of detection), correlation with serum cortisol = . (p < . , n = samples). after centrifuging thawed samples at rpm for min, duplicate analysis of samples was undertaken. the intra-assay coefficient of variation was < % for all samples. cortisol samples that indicated possible non-compliance with the (▲=garden intervention; ○=cortisol samples; ■=questionnaires and ♦=interviews). data was pooled for pre-and post-questionnaires due to not all residents completing questionnaires on each occasion. where an individual resident repeated the questionnaire, e.g. after the intervention, then mean scores were used in the subsequent analyses. sampling schedule were excluded following recommendations by dmitrieva, almeida, dmitrieva, loken, and pieper ( ) . these were extremely high values (≥ nmol l − ) or samples that demonstrated a rapid increase from the previous value (≥ nmol l − ). four aggregate measures were calculated: . daily average concentration (dac) (nicolson, ) , calculated as the daily mean of the four samples. . daily total secretion -area under the cortisol curve with respect to ground level (aucg), calculated using the trapezoid formula (pruessner, kirschbaum, meinlschmid, & hellhammer, ) . . diurnal cortisol decline (slope profiles of cortisol curves) (adam, hawkley, kudielka, & cacioppo, ) . slope was calculated as the difference between cortisol concentrations at and h post-awakening. . proportion of healthy 'i.e. normal' diurnal cortisol profiles (miller et al., ) . using discrete cortisol profiles (dmitrieva et al., ) , this assesses the proportion of curves that fit the normal diurnal cortisol profile. a cortisol profile is considered to be healthy if it peaks within the first hour of awakening, declines rapidly over the morning hours, and tapers off through the rest of the day, reaching its lowest point at night (saxbe, ) . cortisol reference ranges were used to determine healthy diurnal cortisol profiles. each resident's raw diurnal cortisol profiles pre-and post-intervention were classified into one of four categories following miller et al. ( ) : ) normal or healthy slope, ) low slope, ) irregular slope, ) elevated evening slope. changes in the number of samples showing a healthy profile were related to pre-/post-intervention times. in addition to the formal scores generated for perceived stress, wellbeing, level of physical activity and connectedness to nature, the questionnaire also posed further questions relating to feelings of happiness, relaxation, anxiety or depression experienced over the period of the intervention (q ); and any changes in social-cultural aspects such as perceptions about the local community or neighbourhood (q ) or connectedness to nature (q ). these complemented qualitative data collected via interview (see below). qualitative data was collected through semi-structured in-depth interviews, before and after the intervention. data included how residents felt about their lives, well-being, mental and physical health, street, neighbourhood, community, engagement with nature and gardening, attitudes towards the intervention, motivations for participation in the research and expectations regarding the outcomes of the intervention. throughout the study period, additional qualitative data was collected about alterations to gardens (both experimental and otherwise) and based on informal conversations with passers-by and neighbours. residents were inconsistent in their responses to requests for questionnaire or salivary cortisol data, resulting in a larger population in group a, than group b ( table ). as such, data for cortisol was pooled across both groups before comparing profiles pre-( weeks before) to those post-intervention ( months after). similarly, for well-being and perceived stress, data was pooled across the groups to allow for robust analysis of pre-and post-intervention effects. missing datasets did not fit a pattern, and tended to be related to individuals forgetting to provide samples or not being at home when interviews had been arranged. there was no evidence that any particular socio-economic or health factors were influencing the data sets (e.g. missing values were not restricted to those with the poorest health), so although statistical power was reduced, no obvious bias was linked with this loss of data. a range of statistical tests (using 'r' version . . ) were employed, as appropriate to the data, to determine statistical significance of the intervention. these included paired t-tests, mcnemar's test, linear modelling, single and repeated measures anova for pre-and post-intervention evaluation; a difference-in-difference regression model was used to compare results from intervention and control groups across different times. (table summarises the tests used for each parameter). where appropriate to do so, statistical power was increased by augmenting with additional individuals who provided data at relevant time points or restricted comparisons (see n values below for each specific statistical test/model used in the results section). in the process of this statistical analysis, model checking was performed by consideration of standardised predicted values, standardised residuals and whether the data met the assumptions of homogeneity of variance and linearity. transformations were carried out where appropriate to ensure compliance with these assumptions. for example, to correct for a positive skew in the cortisol data, data was log-transformed prior to statistical analysis. longitudinal qualitative data were analysed using interpretative phenomenological analysis (smith, jarman, & osborn, ) with time (pre-and post-intervention) as the main topic of inquiry. to maintain anonymity yet provide context, residents are cited using their gender and age to illustrate the emerging emotional themes. after a total of house-approaches, ( %) residents took part in the research with the majority of residents ( %) being white (table ). four residents who took part, co-habited, thus there were horticultural interventions in total. only residents chose to have a tree planted ( %). beyond watering, residents actively engaged with their new gardens, such as deadheading flowers or adding plants ( %). in terms of data collection, residents in total ( group a; group b) completed pre-and all post-interviews/questionnaires and ( group a; group b) provided complete cortisol profiles pre-and post-the intervention. pooling data across both groups (n = ) showed there was a significant decrease in perceived stress post-intervention, (paired t-test, t ( ) = - . , p = . ; q ) (fig. ). there were no significant effects though on subjective well-being (q ), physical activity (q ) or connectedness to nature scores (q ). restricting data to a single period (aug ) when group a (after the intervention) could be compared to group b (control, i.e. no intervention) at the same time, resulted in mean perceived stress levels of . and . , respectively. anova showed this to be only significant, however at a % level, i.e. p = . ; possibly partially attributed to low replication (n = ). a difference-in-difference regression model showed that perceived stress levels overall decreased by . in the intervention group, whereas stress levels actually rose by . in the control group (fig. ) . although this result is not statistically significant (p = . ), it does suggest that the engagement with the researcher alone (control group) had no positive effect on perceived stress scores. a repeated-measures anova factoring sample day and sample time revealed no significant order effect for day or of sampling using logtransformed values (n = ). there was a significant main effect of sampling time (f = . , df = , p = . ), indicating that cortisol means varied across the day. both results suggested participant adherence to the required sampling protocol and legitimised averaging cortisol variables (dac, aucg and diurnal decline) across the two sampling days to give the most reliable measures (roe et al., ) . a paired t-test run on the residents with measures both pre-and post-intervention (n = ) showed a marginally non-significant effect, with pre-intervention concentrations ( . nmol l − ± . ) lower than post-intervention ones ( . ± . ), t( ) = . , p = . . further evaluations using simple linear regression (log-transformed values) indicated a significant relationship between the pre-/postfactor and dac (t = - . , p = . ). dac increased by % from pre-to post-intervention, and the adjusted r value showed that . % of the variation in dac can be explained by the model, (p = . ). before the intervention cortisol levels tended to be very low (≈ - mol l − ), but were higher post-intervention (≈ - mol l − ) (fig. ) . these post-intervention values were closer to reference ranges from healthy participants of similar age and socio-economic status as this sample (smyth et al., ) . a paired t-test on aucg data (n = ) showed residents significantly increased their total secretion post-intervention (aucg = . ± . ), compared to pre-intervention (aucg = . ± . ); t( ) = . , p = . . again linear regression showed a significant relationship between the pre-/post-factor and aucg (t = - . , p < . ) with % of the variation in aucg being explained by the model (p < . ). a paired t-test (n = ) conducted on the diurnal decline (difference between concentrations at and h post-awakening) indicated that declines were significantly steeper post-(- . ± . ) than preintervention (- . ± . ); t( ) = - . , p = . . linear regression though, did not show a significant relationship between the pre-/post-factor and cortisol decline (t = - . , p = . ). a two-way repeated measures anova (n = ) was also conducted to determine the effects of time (pre-or post-intervention) and sample ( or h post-awakening) on cortisol. this showed there was a significant two-way interaction between the effects of time and sample on cortisol: f( , ) = . , p = . ; suggesting values were different at h, but not necessarily at h post-awakening (fig. ) . the cortisol decline post-intervention was strongly-negatively correlated with well-being scores. this was significant (r = - . , n = , p = . ); cortisol profiles in participants with higher well-being scores showed a steeper decline in cortisol concentration and in line with what would be expected in healthy individuals. for residents providing both pre-and post-diurnal cortisol profiles (n = ), the proportion of healthy slopes rose from % pre-intervention to % post-intervention. an exact mcnemar's test showing this change to be significant, χ = . , p = . . analysing all post-intervention questionnaires (n = , i.e. pooling data across those that had and had not completed a pre-intervention questionnaire) indicated all residents ( %) felt somewhat or extremely happy with their new front garden, and % also reported that their health or well-being had improved as a result of the intervention. twenty-two residents ( %) reported that the garden helped them to feel happier, residents ( %) reported that the garden helped them to relax, and residents ( %) reported that the garden made them feel more connected to nature (fig. ). relatively few residents ( ), however, reported that the gardens directly reduced feelings of depression, worry or anxiety. moderate numbers reported an increased sense of pride ( ) and more social contacts ( ) through the questionnaire. four key themes emerged from the qualitative data analysis (interviews). introducing plants elicited feelings related to motivation, relaxation, pride and positive emotions. the intervention motivated residents to engage with their new planters, add additional plants ( residents) or garden furniture, and renovate other parts of the house/garden. one participant (male, ) fig. . salivary cortisol concentrations (mean ± standard error) pre-and postintervention (n = ). data for healthy participants from laboratory reference data and included for illustrative purposes; n = , women and men aged . ± . years (but also see smyth et al., smyth et al., , smyth et al., , . bars represent standard error (s.e.). bought a paddling pool for his dog to play in, while spending time in the front garden. a participant with paranoid schizophrenia described the importance of seeing positive change for her home: "it's the one part of the house that's nice at the moment, so it makes a difference. it definitely makes you think about the rest of the house and getting on top of things, so i'm having the back garden done next week. it's started me off; if you get a lift up, it sort of spurs you on. it definitely gets you motivated a bit more" -female, . residents also stated they were encouraged by the responsibility to care for the plants. this was especially the case for residents with chronic depression and other mental illnesses, who appreciated change in small steps. one participant described feeling "like a normal human being" when seeing the plants outside her door (female, ). the intervention influenced neighbours who had not directly participated in the research, and these purchased plants, containers and artificial grass for their own properties. one resident requested a 'plant list' so she could have a matching display for her own front garden. the majority of residents reported that it was relaxing to view the plants, come home to them, and watch them grow. "one of the big things that i've noticed, is when i come back from work and see all the daffodils, it switches me into home mode. it's like a buffer zone between work and home." -male, . one participant caring both for her ill mother and granddaughter amidst her own relationship problems, explained that sitting on her front step, next to the plants, with her morning coffee helped her cope when she did not otherwise have time for herself (female, ). the new plantings gave residents a sense of pride in their home. the interventions took place in areas with frequent fly-tipping and theft. a large proportion of participants explained that the "nice planters" would improve people's perception of the area, as well as their own. "you don't want visitors to think you live in a dump, you don't want them to pity you. […] it gives you pride, not just in your house but in the whole area. it makes it look like your area has not just been left to rot." -male, . residents noted that the colourful planters became an indicator of care, and a catalyst to pay more attention to the neighbourhood. one resident (male, ) was inspired to become a local council 'street champion' and took part in litter picks. this improved 'sense of pride' was cited as improving communication between residents and contributing to a genuine sense of community. some residents also felt an increased sense of responsibility for the plants themselves. "it is quite relaxing, but i never thought i'd say this. i'm quite attached to them now. it sounds weird because they're only plants, but they're not. they're mine. and they are living things, so you've got to look after them. it's like having a little pet." female, . all residents reported that the plants made them feel more cheerful and lifted their emotions when viewing them. they talked about better moods upon leaving/returning to the house. though experienced by all, qualitative assessment of emotional intensity during interviews suggested that this was most acutely appreciated by people struggling with poor mental health. the importance of the visual impact/flower colour was explained by several residents, and residents' home visitors also noticed the changes. "it's just nice to see the different colours. otherwise, it looks dead bare. it made me feel brighter in myself" -female, . results from the intervention support the notion that small-scale ornamental plantings improved residents' mood and self-reported health with respect to perceived stress (fig. ) . improvements in participant self-reported data were supported by aggregate measures of salivary cortisol concentrations, with a number of cortisol parameters suggesting significant improvements in cortisol patterns and traits associated with better health (q ) ( out of of our cortisol analyses showed a statistically significant difference at the % level). the significantly steeper declines in cortisol slopes observed postintervention indicate better health through more effective regulation of circadian and hormonal mechanisms, i.e. a likely consequence of reduced stress. the proportion of cortisol curves showing a healthy pattern increased significantly (by %) after plants were provided to residents. indeed, empirical values post-intervention ( % normal) were comparable to other studies for healthy individuals in similar demographic groups (ice, katz-stein, himes, & kane, ; ryan et al., ; smyth et al., ) . improvements in cortisol profiles were mirrored by significant increases in total daily cortisol secretion (aucg) after the horticultural intervention. very low values of aucg are often associated with chronically low socio-economic status and poorer health (desantis, kuzawa, & adam, ) , and increases in this parameter also suggest improvements in health status. finally, we noted an increase in the daily average concentrations (dac) of cortisol after the intervention, again to levels consistent with populations of healthy individuals. higher dac is associated with a higher cortisol awakening response, which in turn has been linked to lower perceived stress (o'connor et al., ) . overall our data suggests that for this population cortisol levels and profiles were considered 'healthy' post-intervention, but indicated poor health status pre-intervention (smyth et al., ) . indeed, the 'blunted' cortisol levels below reference ranges encountered pre-intervention are linked to depression (adam et al., ) , post-traumatic stress disorder (bechard, ) , suicide attempts (keilp et al., ) and childhood adversity (koss & gunnar, ) through the down-regulation of the hypothalamic-pituitaryadrenal (hpa) axis after prolonged exposure to chronic stress. overall, the increase in the number of cortisol curves with a healthy pattern after the intervention suggests that more residents were experiencing less hpa fatigue, stress, anxiety, sleep disturbances, or irritability. comparing the data on perceived stress in this study to others, the positive effects due to the horticultural intervention were approximately equivalent to weekly mindfulness sessions (as measured after months) (van wietmarschen, tjaden, van vliet, battjes-fries, & jong, ) . thus, the data addresses q and q , indicating the intervention reduced perceived stress levels, improved cortisol profiles and thereby had a positive effect on the residents' health status. although there was no significant increase in swemwb scores per se (q ), lower perceived stress and positive physiological responses after the planting intervention were supported by positive statements in the questionnaire. all residents reported that their health or well-being had changed for the better due to the new front gardens; the gardens were also reported to help residents feel happier ( %), more relaxed ( %) or more connected to nature ( %) (fig. ). moreover, many or the qualitative personal statements clearly articulated the positive influence the gardens had on peoples' outlook on life, with strong themes developing around more positive attitudes in general, a sense of pride and an enhanced motivation to improve the local environment, as well as the gardens being valued as a place to relax. therefore, there is some evidence the intervention provided socio-cultural benefits (q ). the intervention did not show any significant differences on either subjective well-being (swemwb) (q ), enhanced physical activity (q ) or connectedness to nature outcome measures (q ). the lack of direct relationship between the horticultural intervention and subjective wellbeing score is surprising; especially as it at odds with the data on stress, a potential precursor of certain aspects of poor mental health (toussaint, shields, dorn, & slavich, ) . this suggests that the intervention might relieve stress, but not necessarily be influencing other aspects of well-being, such as feeling loved or having increased confidence (aspects covered within the swemwb scoring). certainly, other studies on therapeutic gardens and engagement with nature have suggested that there can be misalignment between the positive effects on day to day stress management and such activities being an antidote to deeper or longer-term mental health problems (toussaint et al., ) . the lack of any enhancement in connectedness to nature score (q ) from the intervention is interesting too. this may partially due to the fact that the residents who chose to take part, already had some desire to have plants in their garden, possibly suggesting a higher nature connection level than a genuinely random control group. this skew in participants may be one reason why the nature connection measure did not change from pre-installation to post. it is also possible that an interest in gardening and nature connectedness are not exactly aligned. although on the one hand, gardening, is by definition, working and being in close proximity to nature through the medium of plants (and predominately cultivated forms of plants), it is not necessarily engagement with 'wild nature' per se. we saw no strong evidence of residents showing wider engagement with other aspects of urban wildlife, or mentioning taxa other than plants. it is possible that the horticultural intervention was inducing positive affect, as indicated by the qualitative data, but not necessarily just that associated with biophilic responses (wolf, ermgassen, balmford, white, & weinstein, ) or biodiversity (richardson, ) . gardens have been linked to an enhanced sense of self-worth through the opportunity for increased creativity, and self-expression (clayton, ) . as mentioned above, they can also be a source of pride (clayton, ) or improve a sense of place (freeman, dickinson, porter, & van heezik, ) as this study confirms. these positive aspects of gardens in sociocultural terms require further investigation using additional outcomes measures that capture these dimensions. as far as we are aware, this is the first study to evaluate the health benefits of a small-scale front garden horticultural intervention. moreover, the research was innovative in that ornamental landscape plants were used exclusively in an attempt to differentiate responses based on emotion to those of material need (i.e. food). many previous garden studies indicate food crops were grown, yet the motivations to grow food and non-food plants may be different. the focus here was purely on an aesthetic transformation to the front garden. taken in the round, these datasets indicate the horticultural intervention reduced the level of stress in residents (as captured by both selfreporting q and a physiological biomarker q ) at least in the shortmedium term (over a month period). the positive findings from this study have wider implications for urban planning. as outlined above, there is a trend in urban planning to save space by providing housing with little or even no garden space (ltd, ) . most research on salutogenic aspects of ugs have focussed on parks (wolf & wohlfart, ) , nature reserves (adjei & agyei, ) and urban forests (panagopoulos, gonzález duque, & bostenaru dan, ) , including trees close to residential properties (taylor, wheeler, white, economou, & osborne, ) and policy makers are beginning to acknowledge the value of such spaces in this respect (lee, jordan, & horsley, ) . policymakers and planners should not feel, however, that such places can necessarily directly substitute for private gardens and the health benefits they provide. private gardens are distinct from other forms of ugs in a number of important ways. they provide an opportunity for citizens to engage with the natural world in an immediately accessible manner, while also being imbued with social and cultural elements. the privacy component alone allows autonomy and opportunities to be creative or reflective in a way that would rarely be feasible in public ugs. even the social dynamics around domestic gardens may be different from that of communal gardens or allotments, despite the physical activities being very similar. they are also intrinsically linked with the domestic property and can enhance (or if poorly maintained, undermine) the sense of pride that can be aligned with homeownership. one of the principal findings from this research was the capacity for ornamental gardens to provide an immediate, accessible and easily sought place for relaxation. in effect, an important location for some 'down time' and a place to find respite from the stress and strains of urban life. the surprising element, perhaps, was how little green space was actually required to accrue these benefits. the key limitation was attrition in sample size over time; a common problem in longitudinal studies. the logistics of carrying out a longitudinal study in a deprived urban community included participants' failure to respond at specific sampling times, forgetting to take samples or meet for interviews (despite being prompted). data was tested to ensure those residents who omitted samples/missed interviews were not atypical of the population in general. for example, residents who dropped out were not correlated with more irregular cortisol profiles than those who finished the evaluation. further studies, however, should take care to ensure that later omissions are not in themselves associated with poorer health or greater stress levels. it is recommended that similar studies are conducted with larger sample sizes for higher sample power. the horticultural intervention relied on a relatively small volume of new plantings, and was facilitated by both the local housing association and the royal horticultural society. questions remain as to the impact of the number of plants used, garden style adopted, and social context (community grassroots initiatives vs. top-down local authority programmes). it should also be noted that although our data showed a positive trend between the garden intervention and i. perceived stress, ii. cortisol profiles that relate to less stress and iii. improvements in mood (trends not found in our control population), sample sizes were small, and we cannot categorically claim 'cause and effect'; other factors external to the project could also have been influencing these trends. although our groups a and b were chosen to be similar in sociodemographics, and by and large were, there was a higher proportion of homeowners in group a than b (as compared to tenants), and this may have influenced results. further research is required to note any particular influences in owning a garden as to managing one that is part of a rented property. finally, data from the connectedness to nature section of the questionnaire did not correspond well to some people's response to their own garden and this may relate to a mismatch between larger, theoretical components around nature and the more intimate feelings residents had for their familiar, small scale 'patch'. for example, residents may rarely have considered their garden when trying to address questions such as "when i think of my place on earth, i consider myself to be a top member of a hierarchy that exists in nature". perhaps a stratified or modified questionnaire is required when attempting to assess affinity to green space or urban nature per se? the data presented suggests that adding plants and containers to residents' front gardens was associated with significant reductions in perceived stress (q ) which was reflected in improved diurnal cortisol patterns (q ) post-intervention (i.e. steeper diurnal declines, increased daily average concentration and total secretions compared to 'blunted' levels pre-intervention). qualitative data also showed residents being happier, more relaxed, and having greater motivation to improve and feel a sense of pride in their living environment. we did not detect a significant improvement, however, in the subjective well-being scale -swemwb post-intervention (q ). in reality, it may be that certain components of well-being were improved but not others. data from the study also indicated that there were some socio-cultural benefits associated with the intervention (q ), for example being more 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on green space and associated mental health benefits is variety the spice of life? an experimental investigation into the effects of species richness on selfreported mental well-being walking, hiking and running in parks: a multidisciplinary assessment of health and well-being benefits. landscape and urban planning not all green space is created equal: biodiversity predicts psychological restorative benefits from urban green space the research project was compliant with uk and data protection acts ( , ) and was approved by the university's research ethics committee.funding this research was funded by the royal horticultural society, with contributions from forhousing and united utilities. the authors declare no conflict of interest. key: cord- -y vh xk authors: berger, w. r.; baggen, v.; vorselaars, v. m. m.; van der heijden, a. c.; van hout, g. p. j.; kapel, g. f. l.; woudstra, p. title: dutch cardiology residents and the covid- pandemic: every little thing counts in a crisis date: - - journal: neth heart j doi: . /s - - - sha: doc_id: cord_uid: y vh xk the covid- pandemic has overwhelmed healthcare systems worldwide, and a large part of regular cardiology care came to a quick halt. a dutch nationwide survey showed that % of cardiology residents suspended their training and worked at covid- cohort units for up to months. with tremendous flexibility, on-call schedules were altered and additional training was provided in order for residents to be directly available where needed most. these unprecedented times have taught them important lessons on crisis management. the momentum is used to incorporate novel tools for patient care. moreover, their experience of pandemic and crisis management has provided future cardiologists with unique skills. this crisis will not be wasted; however, several challenges have to be overcome in the near future including, but not limited to, a second pandemic wave, a difficult labour market due to an economic recession, and limitations in educational opportunities. is used to incorporate novel tools for patient care. moreover, their experience of pandemic and crisis management has provided future cardiologists with unique skills. this crisis will not be wasted; however, several challenges have to be overcome in the near future including, but not limited to, a second pandemic wave, a difficult labour market due to an economic recession, and limitations in educational opportunities. the covid- pandemic has hit cardiology patients hard, as they are susceptible to a severe course of their disease [ ] . due to the very rapid and unprecedented increase of covid- patients, the regular cardiology care came to a quick halt. cardiology residents all over the netherlands were reallocated to covid- cohort units. with tremendous flexibility, on-call schedules were altered and additional training was provided in order for residents to be directly available where needed most. a questionnaire of the junior board (juniorkamer) of the netherlands society of cardiology (nvvc) showed that % of cardiology residents were involved in frontline covid- care throughout the netherlands (fig. ) . the questionnaire was completed by residents from clinics in the netherlands; residents at every stage of the -year training programme from all so-called 'a-clinics' (i.e. clinics which are leading the training programme) were included. they worked at covid- cohort units for - months, while regular training programmes were suspended. when the pandemic hit hard, these young doctors felt a great responsibility to do whatever they could-within their competencies-and to do their share on the wards and intensive care units. a similar pattern was seen worldwide [ ] . the willingness of staff to enable reallocation of a large part of the residents proved to be of great support. after the first decline in the number of covid- patients in dutch hospitals, it is time to think about the lessons learned and to reshape the future. the impact of this pandemic on regular healthcare could not have been predicted. the tremendous need of resources urged nurses, physicians and supportive staff to rethink processes of daily care in order to continue acute care, to prevent spread of the coronavirus and to limit the use of scarce protection gear. residents were directly involved in crisis management. with their great day-to-day working experience in patient care, they helped to redefine the processes of emergency, clinical and outpatient care. while physicians are trained to be ready, the magnitude of this crisis could only be dealt with using real-life experience. the covid- crisis has shown the importance of teamwork in healthcare. residents have shown flexibility in both the continuation of regular healthcare for the (acute) cardiac patient and dedicated care for covid- patients. moreover, the efforts of cardiologists who were involved in tasks that are normally performed by residents increased flexibility and warranted continuation of regular (acute) care. once again, the healthcare system proves to be an efficient engine that depends on a great team effort of, but not limited to, technicians, nurses, facility services, security personnel, pharmacists and stretcher-bearers [ ] . covid- showed its many faces in the course of time. residents are continuously implementing their observations in day-to-day care, together with new knowledge, which has been shared by the many publications on this topic [ ] . they have followed crash courses in viral infections, epidemiology, advanced respiratory care, thrombosis, haemostasis, et cetera. moreover, cardiology residents have proven to be essential in the often ad hoc created multidisciplinary teams of doctors given their advanced knowledge of haemodynamics and interpretation of side effects of medications (e.g. chloroquine) on cardiac conduction and function [ , ] . ehealth solutions were readily made available to proof their value as an efficient alternative to face-toface contact. daily plenary teaching moments were replaced by on-demand virtual meetings. cardiologyspecific training, as provided by the cardiovascular teaching institute (cvoi), underwent fast and rigorous innovations in online medical education. worldwide ehealth and virtual leaning opportunities have gained an enormous momentum due to the circumstances, and we know they are here to stay [ , ] . the necessary measures to prevent further spread also changed behaviour and manners in patient care. a hand on the heart or a 'low bow' has replaced the now old-fashioned handshake to welcome a patient. family visits for admitted patients were limited to a bare minimum and communications were mainly made by phone or videophone. these included emotional and difficult conversations, such as end-of-life discussions. the covid- crisis improved our abilities as a doctor; it taught healthcare workers to be aware of their behaviour and to improve their communication skills (tab. ). the covid- pandemic showed once again our humility toward nature and rein- forced a skill that may sometimes be forgotten during medical training: compassion. at the same time, we experienced that everyday social interaction with colleagues is of great importance to cope emotionally with the heavy workload and the often grievous impressions this crisis has brought us. the experiences gained during the covid- pandemic have taught the residents many lessons, even though almost half of the cardiology residents reported a delay in their cardiology training of - months (fig. ) . to prevent gaps in training or knowledge, a personalised restructuring of the training programme is necessary for many cardiology residents. this new training scheme will be implemented in an era in which several important constraints to daily care resulting from social distancing are still valid. this could limit the exposure of residents to clinical cases and training procedures. however, we have to utilise the current circumstances to introduce new training methods, such as virtual reality education, distance learning or advanced teaching, to improve learning efficiency. residents have to work together with their mentors in teaching hospitals and to keep being creative and flexible in order to create practical solutions. the pandemic has an enormous economic impact, also on the dutch healthcare system. we hope that the (financial) uncertainties that lie ahead do not hinder the future careers of cardiology residents. these future cardiologists, who conquered covid- in the front-lines of healthcare with tremendous effort and flexibility, are well prepared for a great future in clinical care. the lessons they learned will be of great importance for a paradigm shift to a more pandemic-resistant society and a modern healthcare system with an accelerated introduction of ehealth solutions. since we are in a second wave of coronavirus infections, we need to work together with all stakeholders to be prepared for the (near) future. open access this article is licensed under a creative commons attribution . international license, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons licence, and indicate if changes were made. the images or other third party material in this article are included in the article's creative commons licence, unless indicated otherwise in a credit line to the material. if material is not included in the article's creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. to view a copy of this licence, visit http://creativecommons.org/licenses/by/ . /. cardiovascular considerations for patients, health care workers, and health systems during the covid- pandemic the impact of the covid- pandemic on cardiovascular fellows-in-training: a national survey ongoing transcatheter aortic valve implantation (tavi) practice amidst a global covid- crisis: nurse-led analgesia for transfemoral tavi cardiac function inrelationtomyocardial injury inhospitalisedpatientswith covid- the risk of qtcinterval prolongation in covid- patients treated with chloroquine chloroquine-induced qtc prolongation in covid- patients virtual learning during the covid- pandemic: a disruptive technology in graduate medical education adapting the educational environment for cardiovascular fellowsin-training during the covid- pandemic key: cord- -eeqgtk authors: kusmaul, nancy title: covid- and nursing home residents’ rights date: - - journal: j am med dir assoc doi: . /j.jamda. . . sha: doc_id: cord_uid: eeqgtk nan act included a bill of rights for residents out of recognition of the steep power imbalance between residents and staff , and the development of learned helplessness by those who live in such settings . born from a time when nursing homes residents were subject to physical restraints and sedation, these rights sought to give residents greater control over daily routines and social interactions . could covid- be sending residents rights back to this time? as soon as the story about the kirkland, washington nursing home and covid- became national news the centers for medicare and medicaid services (cms) took swift action to protect nursing home residents . their press release on march , characterized their directives as the most aggressive and decisive, and they certainly were. they immediately restricted all visitors, volunteers, and nonessential personnel from entering nursing homes and cancelled group activities and communal dining. while the covid- pandemic seemed urgent and the risks to nursing home residents were real, these directives superseded and countered residents' rights. one of the core resident's rights is the right to spend time with visitors of your choosing. "you have the… right: to spend private time with visitors. to have visitors at any time, as long as you wish to see them, as long as the visit does not interfere with the provision of care and privacy rights of other residents." the restriction of rights is concerning, even in the face of a global pandemic. nursing homes are required by federal regulations to provide maximal quality of life. as defined in the federal register, § . "quality of life is a fundamental principle that applies to all care and services provided to facility residents. each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care." how can residents maintain the highest practicable mental and psychosocial well-being when they are not able to connect with other human beings, including loved ones? cms made exceptions for "compassionate cases" which were left to the nursing homes' discretion. • consider physical barriers. the true meaning of residents' rights empowering the elderly nursing home resident: the resident rights campaign cms announces new measures to protect nursing home residents from covid your rights and protections as a nursing home resident federal register. cfr § requirements for states and long term care facilities sid=f c ab a da f f f f &mc=true&tpl=/ecfrbrowse/title / cfr _main_ .tpl. accessed treatment intervention: learning residents' rights frequently asked questions (faqs) on nursing home visitation west virginia department of health and human resources thoughts on living in a nursing facility during the pandemic key: cord- -tmk c eh authors: alhaj, ahmad kh.; al-saadi, tariq; mohammad, fadil; alabri, said title: neurosurgery residents perspective on the covid- : knowledge, readiness, and impact of this pandemic. date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: tmk c eh abstract background the novel coronavirus disease (covid- ) is a life-threatening illness, which represents a challenge to all the health-care workers. neurosurgeons around the world are being affected in different ways. objectives this is the first study regarding the readiness of neurosurgery residents towards the covid- pandemic and its impact. the aim is to identify the level of knowledge, readiness, and the impact of this virus among neurosurgery residents in different programs. methods a cross-sectional analysis in which neurosurgery residents from different centers were selected to complete a questionnaire-based survey. the questionnaire comprised of three sections and questions that ranged from knowledge to impact of the current pandemic on various features. results the median knowledge score was out of . the proportion of participants with satisfactory knowledge level was %. there was a statistically significant difference between the knowledge score and location of the program. around % of the neurosurgery residents dealt directly with covid- patients. receiving a session about personal protective equipment (ppe) was reported by . %. the neurosurgery training at the hospital was affected. about % believed that this pandemic influenced their mental health. conclusion neurosurgery residents have a relatively good knowledge about covid- . the location of the program was associated with knowledge level. most of the participants did not receive a sufficient training about ppe. almost all responders agree that their training at the hospital was affected. further studies are needed to study the impact of this pandemic on neurosurgery residents. the novel coronavirus disease (covid- ) is a respiratory tract viral infection, caused by the newly emergent, severe acute respiratory syndrome coronavirus (sars-cov- ). , it is a life-threatening viral illness, which represents a challenge to all health-care workers over the globe. the world health organization (who) reports that this viral infection confers a % to % crude mortality rate. this pandemic has affected everyone in all aspects of daily life, especially in the healthcare. the quality of residency training is negatively influenced as a result of the recent pandemic. as the number of individuals infected with this virus rapidly increases, neurosurgeons from different nations are significantly affected in multiple ways. , , , neurosurgery residents are now facing a major challenge, especially for those who work in hospitals with a high number of covid- patients. in addition, some residents are fully responsible for patients with this infection. the strategies to increase the regional intensive care unit (icu) allowance included the reduction of all surgical activities, starting with elective, to ultimately, also, include some urgent cases. currently, most of the neurosurgical centers postponed their elective surgeries due the burden of this infection. , , furthermore, several programs have reduced the number of residents by % of normal, thus keeping the remainder of the residents at home. almost all neurosurgery programs around the world have changed their academic meetings to online communication in an attempt to reduce physical contact. to our best knowledge, this is the first study regarding the readiness of neurosurgery residents towards the covid- pandemic and the impact it has on their training. the aim of this study is to identify the level of knowledge, readiness, practices, as well as the impact of this virus among neurosurgery residents in various neurosurgical programs. this cross-sectional study involves the assessment of neurosurgery residents through a questionnaire-based survey. the study was conducted during the pandemic, from the th until the th of april . the sample size "n" is represented by a total of respondents from different neurosurgical programs. they completed the survey (appendix a) on the awareness, knowledge, practices, and safety measures about covid- . the questionnaire was mainly adapted from the current interim guidance and information for healthcare workers, published by the us centers for disease control and prevention (cdc). several editorial studies published recently about the impact of the virus on neurosurgery residents was also utilized to create the questionnaire. , , the target population consists roughly of around residents, comprised of neurosurgery residents from various neurosurgical centers that we chose. a representative sample from canada, united stated of america (u.s.a.), kuwait, saudi arabia, serbia and italy were selected. we divided the regions into north america, which includes canada and u.s.a. in addition, saudi arabia and kuwait represent the programs in the arabian gulf cooperation council (gcc) countries. regarding the european programs, we reached out to residents from serbia and italy. residents from different centers where selected from three different regions, with the number of participants from each region being close to one another. moreover, we communicated with senior neurosurgeons from these regions, and they provided us with lists of residents with their contacts, which we selected randomly from. therefore, our sampling procedure comprised of random selection of the participants. in addition, each resident was reached in person via a direct phone call or a text message in order to restrict the data to our inclusion criteria, which involved only neurosurgical residents. moreover, this method of direct contact facilitated a very high response rate. all neurosurgeons who finished their training or were above the sixth year of the program were excluded from our data. an informed consent was obtained from each subject. the study objectives were explained to the residents. they were also assured regarding confidentiality of the collected information, and that they were free to decline participation in the study. one participant who refused to complete the survey was excluded. the questionnaire consisted of three sections and questions. the first section ( items) involves the baseline information: gender, age, location of the program, year of training, and current health condition. the next section ( items) contains inquiries about basic biological and microbiological knowledge of this virus , , hand hygiene, as well as personal protective equipment (ppe). additionally, we evaluated whether the subjects received any formal training in hand hygiene, ppe, and n- mask handling. the final section ( items) focuses on the impact of this pandemic on the resident in terms of neurosurgical training, studying, mental health, as well as whether their social life was affected or not. , , convenient sampling method was used for data collection, and the distribution of qualitative responses was presented as frequency and percentages. sub-groups were classified on the basis of gender, age, location of the program, and year of residency training. the statistical package for social sciences (ibm spss statistics , ibm corporation, armonk, ny, usa, ) was used for data entry and analysis. first, univariate analysis was conducted, and qualitative variables were described by frequency and percentage. the quantitative variable (total knowledge score) was calculated by adding the points for the five knowledge items (each item equals one point). this variable, with a non-normal frequency distribution, was summarized by a median and inter-quartile range. we determined that the cut-off of the satisfactory knowledge level is a total knowledge score ≥ median. also, a logistic regression model was used to identify the determinants of low knowledge level. at that point, p-value ≤ . was used as the cut-off level for statistical significance. pearson's chi-square test was utilized to assess the association between the qualitative variables. mann-whitney u test was used to compare two groups with a non-normal frequency distribution, while kruskal-wallis one-way analysis of variance test was used to compare more than two groups. we tested the association of our questions in relation to age, gender, location of the program, and year of residency training. in the present cross-sectional sample survey, neurosurgery residents attending different centers around the world were contacted directly from the six countries mentioned earlier. out of this number, participants returned a completed self-administered questionnaire, and hence, the analysis was based on this number (response rate = . %). table depicts the descriptive analysis of self-reported baseline information and the current health status of the residents with regard to covid- virus. the majority of the participants were male ( . %). concerning the age, . % were below year old, and . % were year-old or above. regarding the location of the neurosurgery program, the percentage of residents representing each country in our sample were as follow: canada . %, u.s.a. . %, kuwait . %, saudi arabia . %, and from the european countries (italy and serbia) . %. the frequency of participants from each year of the residency (r) training were: (r ) . %, (r ) . %, (r ) . %, (r ) . %, (r ) . % and (r ) . %. besides, table , also shows the current situation of residents in terms of this pandemic: . % were under stay home order by their institution or the government; however, . % are resuming their work at the hospital. in addition, according to our results, . % of the neurosurgery residents were under quarantine or isolation. from our sample, only one resident from europe tested positive for covid- . furthermore, about . % were negative, the rest, which represent the majority, . %, were not tested for the infection. almost half of the responders, . %, dealt directly with covid- patients, while the rest did not. table a shows the frequency of correct responses to the five items of the knowledge score about the virus and the safety measures in relation to the location of the program. the number of residents who answered the questions correctly were as follows: . % knew that the virus type, . % knew the main mode of transmission, and . % recognized the most common symptoms. the most accurate estimation of the incubation period of this virus was answered by only . % of participants. concerning the preferred hand hygiene method in the healthcare settings; unexpectedly, only . % knew the correct answer. the first section of the table also displays the responses according to each location of the program in details, and some of the items showed statistically significant results. in table b, we recorded the responses about the training of safety measures, the safe practices, and the strategies of infection control. as expected, receiving a formal hand hygiene training was reported by . %. in addition, receiving formal session of the correct sequence of ppe donning and doffing was stated by . %. only % of our sample knew their correct size of n- mask prior to this pandemic. likewise, only % knew how to correctly obtain a nasopharyngeal swab sample. most of the results in the previously mentioned items were significantly associated with the location of the program. the distribution of the total knowledge score was shifted to the right with left skewness (figure ). the maximum total knowledge score was five, and the median knowledge score of our participants was four out of five, representing a good knowledge level. table demonstrates the association of this score about the virus with gender, age, year of residency training, location of the neurosurgery program. the table also depicts the association between the knowledge score and whether the participant was taking care of covid- patients. the median for male residents was four, compared to three in females. there was neither a difference in medians nor statistical significant association of the knowledge score with regard to age and year of residency training. the median in each location was as follow: four, four, and three in north america, gcc countries, and europe region, respectively. the difference in medians was statistically significant between europe and north america, as well as between europe and gcc countries (p-value = . ). figure shows the boxplot of the knowledge score based on the region of the program. the cut-off of the satisfactory knowledge level was four, which is the median. in our results, . % had satisfactory knowledge about the virus, while . % had a non-satisfactory level. the impact of this pandemic among neurosurgery residents is shown in table . almost all of the residents found that their training at the hospital was affected. when asked about their opinion regarding the neurosurgical procedures during this pandemic, roughly % desired to resume their elective surgical procedures. additionally, the daily studying hours was affected by about %, while the remaining did not face a change in the studying hours per day. the social life of all residents in our sample was influenced by the current situation. shockingly, this pandemic affected the mental health of % of the participants. in table , the association of the impact on mental health of covid- and year of training revealed that the mental health of all residents in the first, third, and sixth year of training was affected. although the percentage of fifth year residents was also high ( . %), they were the lowest group in this aspect. this association was significant (p-value . ), but other confounders' effect could not be eliminated. our study is the first regarding the readiness of neurosurgery residents towards the covid- pandemic and the impact it has on their training. this pandemic is evolving rapidly worldwide, disrupting personal and professional life, including that of neurosurgeons and neurosurgical residents. most programs have seen a significant drop in elective or nonessential surgical volume, impacting the functional neurosurgery cases foremost. regarding surgeries, around . % in our study agreed that elective neurosurgical procedures should not be resumed during this pandemic ( figure -a) . in another editorial, authors stated the following "we have halted all elective cases, but will continue to schedule urgent and emergent cases, involving head and spine trauma, cauda equina syndrome, embolic stroke, ruptured aneurysms, and acute hydrocephalus are relatively noncontroversial; however, urgent cases such as malignant brain tumors and progressive cervical spondylotic myelopathy may require a more nuanced discussion." responses from our analysis disclosed that only % think that brain tumor or compressive spinal cord tumor surgeries should be postponed. in terms of skillset, a trustworthy neurosurgical team should have the ability to treat patients with infectious diseases who also require emergency operations. at the same time, in our survey, most of the residents (≈ %) will only do emergency surgery on a confirmed covid- patient if there are appropriate ppe, while a minority (≈ %) will perform it regardless the presence or absence of ppe; none of the participants refused to perform this surgery in either way ( figure -c) . access to and training on proper ppe use are critical to the safety of workers. when asked about the residents' opinion, if neurosurgical programs should involve a session about ppe every year, around % agreed that this session is essential ( figure -b) . overall, programs report a significant decrease in the volume of cases. clinic visits have transitioned to telemedicine where possible, decreasing resident exposure to outpatient encounters. similarly, all in-person conferences such as grand rounds, resident education conferences, and multidisciplinary meetings have been replaced by video teleconferences. in concordance with our expectations, almost all of the residents found that their training at the hospital was affected. certainly, once this pandemic has concluded, careful retrospective analysis of its impact on resident case volume will be necessary to ensure we are prepared for any future event. the american board of neurological surgery has postponed both primary and oral examinations. , the royal college of physicians and surgeons of canada has also decided to postpone the written exam, while the oral component will no longer be required. in our sample, the daily studying hours was affected in about %. nonetheless, the studying hours might be affected positively or negatively. a study, about involving physicians in patients' care during epidemics, advised of possible alternatives to real patient-physician interaction as to avoid placing trainees at risk. less than half of the neurosurgery residents ( . %) feel competent in taking care of covid- patient, most of those who feel capable have already dealt with covid - patients (figure ) . due to increasing number of covid- patients who require hospitalization, some radiology residents have been reassigned to internal medicine and icu as to care for the high influx of patients. similarly, almost half of the neurosurgery residents in our sample, . %, dealt directly with covid- patients in the previously mentioned settings. on the other hand, some neurosurgery residents might gain intensive care skills. in the end, working temporarily in the icu or internal medicine department will benefit any physcians in one way or another. "social distancing measures have circumvented the traditional trainee-faculty member workstation teaching, which is especially disadvantageous for residents who may be rotating on a service for the first or second time in their training." our survey revealed that . % of the sample followed social distancing in a daily manner, while only two of the participants found it difficult to stick to this practice. "work-related stress is a potential cause of concern for health professionals. it has been associated with anxiety including multiple clinical activities, depression in the face of the coexistence of countless deaths, long work shifts with the most diverse unknowns and demands in the treatment with patients with covid- ." in our data, this pandemic negatively affected the mental health of % of the participants. however, this influence is not specific, and might affect the residents mental health either positive or negative way. the median knowledge score about covid- pandemic and infection control measures was four out of five ( %) with a range from one to five. the correct answers to the knowledge questions were the following: . % knew that the virus type is an rna virus single-stranded and . % knew that the main mode of transmission is via respiratory droplets. moreover, the most common two symptoms of the virus are fever and cough , which . % got correct. the most accurate estimation of the incubation period of this virus is days , and it was answered by only . % of participants. concerning the preferred hand hygiene method in the healthcare settings, which is hand rub for at least seconds with % ethanol ; unexpectedly, only . % knew the correct answer. on the other hand, . % think that hand rub for at least seconds with soap and water is the preferred method. only % of the residents knew their correct n- mask size, as it is required to safely manage any suspected or confirmed cases. this study has some limitations. temporal association of the knowledge score with the aspects discussed above cannot be definitely established due to the nature of the cross-sectional study design. besides, the pandemic has affected the whole world in diverse degrees at different times. we have reached the neurosurgery residents in only six countries with different academic settings and resources. therefore, the ability to generalize the results of this study to all neurosurgery programs may be limited. our study suggested that neurosurgery residents have as a relatively good level of knowledge about covid- pandemic, despite that a significant number of the participants did not reach the satisfactory level of the knowledge score. the location of the program was independently and significantly associated with knowledge score after adjusting for confounding between variables. concerning the infection control, most of the neurosurgery residents received a formal hand hygiene training prior to the pandemic. however, receiving a formal training of the correct sequence of ppe donning and doffing was not sufficient. most of the responders agree that their training at the hospital was affected. larger retrospective studies that include a representative sample of neurosurgical residents with a wide range of regions is essential in order to generalize the results to the target population. it is recommended that health authorities provide infection control sessions to prepare the residents for any future events. neurosurgery program directors may consider sharing experiences with other programs to enhance education and decrease the infection rate among surgeons. regarding surgery, delay of elective procedures but proceeding with semi-elective, urgent, and emergency surgeries is advised. that being said, surgeons should also be provided with sufficient quantities of ppe so as procedures can be performed safely. due to increased stress and decrease studying hours, we urge to provide the residents with adequate time to prepare for any upcoming evaluation. according to the reviewed editorials about this pandemic, we also encourage that the academic training should be continued with social distancing measures with a minimal number of attendees, or even online communication. furthermore, ease of access of residents to mental health professional to prevent any psychological traumatic event, and provide them with stress-management sessions is also suggested. • % = column % • p-values were generated using pearson's chi-square test (≤ . is statistical significant) figure . frequency distribution of the total knowledge score among the neurosurgery residents in our sample. coronavirus disease (covid- ) situation report- the outbreak of covid- : an overview coronavirus disease (covid- ) situation report- letter: academic neurosurgery department response to covid- pandemic: the university of miami/jackson memorial hospital model neurosurgical priority setting during a pandemic: covid- neurosurgery in the storm of covid- : suggestions from the lombardy region, italy (ex malo bonum) impact of covid- on neurosurgery resident training and education response to covid- in chinese neurosurgery and beyond and chiocca ea. editorial. covid- and academic neurosurgery information for healthcare professionals coronaviruses post-sars: update on replication and pathogenesis q&a on coronaviruses (covid- ) covid- awareness among healthcare atudents and professionals in mumbai metropolitan region: a questionnairebased survey the impact of covid- on radiology trainees the american board of neurological surgery the royal college of physicians and surgeons of canada involving physicians-in-training in the care of patients during epidemics supporting the health care workforce during the covid-• gcc: arabian gulf cooperation council (gcc) countries • p-values were generated using the mann-whitney u test for comparing two groups, and *kruskal-wallis one-way analysis of variance test for comparing more than two groups & canada gcc: arabian gulf cooperation council countries (kuwait & saudi arabia). european country: data selection from italy & serbia we thank all the participants in this project for their time and effort. we also thank dr. dragan savic and dr. jacquelyn corley, for providing us the contacts of some neurosurgery residents. in addition, we would like to thank all the health-care workers in the front lines against covid- pandemic. this is the first study regarding the readiness of neurosurgery residents towards the covid- pandemic and its impact. the aim is to identify:• the level of knowledge about the novel coronavirus among neurosurgery residents in different programs. • we also studied and discussed the readiness of the neurosurgery residents.• the impact of this virus on the neurosurgery was illustrated in order to give a general picture of the effect of this pandemic on the training in the hospitals, studying, and the general well-being of the residents. • neurosurgery residents have a relatively good knowledge about covid- .• the location of the program was associated with knowledge level.• most of the participants did not receive a sufficient training about personal protective equipment (ppe).• almost all responders agree that their training at the hospital was affected.• about % believed that this pandemic influenced their mental health.• further studies are needed to study the impact of this pandemic on neurosurgery residents. key: cord- -fdxq rx authors: rakofsky, jeffrey j.; talbot, thomas b.; dunlop, boadie w. title: a virtual standardized patient–based assessment tool to evaluate psychiatric residents’ psychopharmacology proficiency date: - - journal: acad psychiatry doi: . /s - - -x sha: doc_id: cord_uid: fdxq rx objectives: a virtual standardized patient-based assessment simulator was developed to address biases and practical limitations in existing methods for evaluating residents’ proficiency in psychopharmacological knowledge and practice. methods: the simulator was designed to replicate an outpatient psychiatric clinic experience. the virtual patient reported symptoms of a treatment-resistant form of major depressive disorder (mdd), requiring the learner to use various antidepressants in order for the patient to fully remit. test scores were based on the proportion of correct responses to questions asked by the virtual patient about possible side effects, dosing, and titration decisions, which depended upon the patient’s tolerability and response to the learner’s selected medications. the validation paradigm included a novice-expert performance comparison across th year medical students, psychiatric residents from all four post-graduate year classes, and psychiatry department faculty, and a correlational analysis of simulator performance with the prite somatic treatments subscale score. post-test surveys evaluated the test takers’ subjective impressions of the simulator. results: forty-three subjects completed the online exam and survey. total mean scores on the exam differed significantly across all the learner groups in a step-wise manner from students to faculty (f = . , p = . ). total mean scores by residency class correlated with prite somatic therapies subscale scores (p < . ). the post-test survey mean likert results ranged from . ± . to . ± . , indicating neutral to favorable responses for use of the simulator. conclusions: this simulator demonstrated strong construct validity and high participant acceptability for assessing proficiency in the psychopharmacologic treatment of mdd. the last three decades of outpatient psychiatry practice have witnessed an increasing emphasis on psychopharmacology over psychotherapy [ , ] . simultaneously, the armamentarium of psychotropic medications has grown substantially, with over medications now having marketing approval for the treatment of major depressive disorder alone. illnesses previously believed to be best treated primarily by psychotherapy, such as substance use disorders [ ] and some types of eating disorders [ ] , now have pharmacological treatment options. moreover, the continuing expansion of mechanisms of action [ , ] utilized by newly approved drugs further increases the psychopharmacology knowledge requirements for psychiatric drug prescribers. theoretical education in psychopharmacology in psychiatry residency programs is delivered through didactic lectures and journal clubs, while practice-based learning occurs through inpatient and outpatient psychiatry experiences which provide opportunities to initiate medicines, monitor treatment responses, and manage emerging side effects [ ] . currently, residents' psychopharmacology proficiency is measured by their performance on the psychiatry residency in training exam (prite) and through the accreditation council for graduate medical education (acgme) psychiatry milestone assessments completed by supervisory attendings. however, these tools have significant limitations regarding their ability to assess trainees' psychopharmacologic knowledge. the prite is a question exam that psychiatric residents take annually [ ] . it assesses knowledge in a variety of areas of psychiatry, including diagnostic assessment, epidemiology, and neurology, but psychopharmacology constitutes < % of the questions. additionally, the questions are primarily presented using a short patient vignette followed by a single-question, multiple-choice format. the vignettes do not provide follow-up information or additional questions after the initial question is answered. consequently, the prite structure provides for only very limited assessment of the depths of residents' psychopharmacology knowledge and ability to use medication in a manner that reflects real-world practice. the acgme psychiatry milestones is an assessment tool that provides a framework for evaluating behaviors or qualities associated with a resident's development as a physician [ ] . attending physicians who work with residents complete the form, indicating the level of knowledge or practice skills the resident has achieved during the period of assessment. for psychopharmacologic knowledge, this tool includes a single item, "pc somatic therapies," which subsumes a number of behaviors related to "using psychopharmacologic agents in treatment." the scoring range for the item is - , which lacks adequate scale to capture the complexity of the psychopharmacologic practice. for example, behaviors listed as part of the highest level of competency, level , such as titrating dosages and managing side effects, are often demonstrated by first year residents working on inpatient units. as a result, this milestone has very limited ability to discriminate junior from senior residents and to identify specific areas of deficiency. a second milestones item, "mk . somatic therapies," requires faculty to rate the resident's medical knowledge of somatic therapies, including medicines, electroconvulsive therapy, and other emerging somatic therapies. ratings on this item are impressionistic rather than systematic, given the large number of somatic therapies that exist and the reliance on clinical discussions between resident and attending to make this determination. the milestones tool is also susceptible to the recency effect [ ] , given that the faculty member's assessment is retrospective and thus likely to overweigh recent or highly salient events or interactions. these limitations of existing assessments point to the need for more specific, indepth, content-valid assessment of residents' psychopharmacology knowledge and skills. an alternative to paper exams and faculty impressions is assessments conducted via simulators. when used for assessment purposes, simulators have the advantage of eliminating assessor biases because scoring is systematic and based on the presence or absence of specific actions. additionally, highfidelity simulators may provide realistic testing scenarios that can more fully assess skills and knowledge than a multiplechoice question-based exam. to date, simulators developed for psychiatric uses have focused on enhancing or assessing students' communication and diagnostic skills; none, as far as the authors know, have been developed to specifically assess psychiatry residents' proficiency in medication management for depression [ ] . the goal of this study was to develop an evaluative tool that could eventually replace the prite and other forms of theoretical evaluation. herein, we report on a virtual standardized patient (vsp)-based psychopharmacology simulator developed to provide a summative assessment of the learner's ability to initiate medication, adjust doses, and manage the emerging side effects in a patient with treatment-resistant major depressive disorder. exam development requires collecting validity evidence to evaluate the appropriateness of the use, interpretations, or decisions that arise from the exam results [ ] . the kane framework for testing validity arguments for educational assessments organizes the evidence into four categories: scoring, generalization, extrapolation, and implications [ ] . scoring pertains to how the test performance is translated into a score, generalization pertains to how the score reflects test performance, extrapolation pertains to how the score reflects realworld performance, and implications pertain to how the score influences decisions or actions that affect the learner (e.g., promotion, remediation). this study focused primarily on collecting extrapolation data in the form of novice-expert performance comparisons and comparison to a standardized test measuring a similar construct. these comparisons are the most common approach when validating the use of medical simulators [ ] . the emory university institution review board designated this study to be exempt from review. the virtual standardized patient software was created through the university of southern california standard patient studio platform, a freeware virtual patient community that was developed by the university of southern california with funding from the department of defense. standard patient combines virtual human avatars, artificial intelligence, and an advanced pedagogical design to create realistic, emotionally expressive interactions, including live voice communication. in addition to providing conversational interaction, the system supported live feedback to subjects and collected a myriad of performance parameters. prior research has demonstrated that standard patient has shown a high degree of performance, assessment accuracy, and utility for training [ , ] . see the patient narrative was created by one of the authors (jjr), who is a mood disorders expert and educator, with more than years of clinical experience, more than years of directing and providing supervision in a residents' psychopharmacology clinic, and with more than peer-reviewed publications on medical education, major depression, and bipolar disorder. the narrative featured a -year-old white man with major depressive disorder (mdd) who sees a psychiatrist for medication management. the story line was divided into four sequential modules, with each module featuring particular classes of medications. the four modules were generally aligned with the treatment algorithm applied in the sequenced treatment alternatives to relieve depression (star*d) study [ ] , while also incorporating newer pharmacologic options based on more recent studies. the first module included selective serotonin reuptake inhibitors and bupropion. the second module included serotonin-norepinephrine reuptake inhibitors and mirtazapine. augmentation strategies (e.g., lithium, triiodothyronine, and second-generation antipsychotics), tricyclics, and monoamine oxidase inhibitors were included in the third and fourth modules. within each module were "distractor" psychotropic medication options that most psychiatrists would not prescribe for mdd at that level of treatment resistance. the learner was prompted to select a medication in each module to target the patient's symptoms. following the selection, the virtual standardized patient would ask the learner questions about the medicine, including possible side effects and dose titration questions. food and drug administration medication package inserts and clinical trials data were used to generate the correct answers to these questions. the learner would select from a list of possible answer choices and was given immediate feedback on all of their choices and the rationale. if the virtual patient agreed to take the medicine, he would return month later (instantly for the test taker) to provide an update on the effect and tolerability of the medicine. this process continued until the learner exhausted the treatment options for the particular module and then was instructed to move on to the following module. because the virtual patient's depression was designed to be treatment-resistant, the learner was forced to move through all modules of the software. throughout the different modules, the learner was asked a variety of questions about the medicines they selected. these questions pertained to starting doses, possible side effects, relevant lab work, and dose titration decisions in the face of non-response or tolerability problems. at the least, there were questions each focusing on dosing, side effects, and dose titration decisions. the more medicines selected by the participant, the more questions they were asked. a pilot version of the exam was taken by an expert (bwd) in the psychopharmacology of mood disorders who has more than years of clinical experience, more than years of supervising residents in a psychopharmacology clinic, and over publications on the biology and treatment of mdd. the pilot exam was also taken by a chief resident in psychiatry and th year medical students completing a digital medicine elective offered by the university of southern california. they were instructed to provide feedback on the breadth of medicines included, the clarity of the virtual patient's emory university fourth year medical students (m ) participating in a psychiatry sub-internship elective, general psychiatry residents (pgy level - ), and faculty with psychopharmacology practices were recruited via institutional e-mail to participate in the testing. they were offered a $ gift card to reimburse them for their time. participants were informed that their test results were anonymous and could not be linked to them individually, so their answers could have no impact on their academic standing. learners took the exam without access to supplemental materials. multiple supervised test sessions were scheduled to occur from january-february . these sessions were held in a classroom within the residency education suite, and participants could attend the session that was most convenient for them. participants were required to bring a laptop and ear buds. at the beginning of the test session, a proctor played a pre-recorded online video that reviewed the instructions for completing the exam. the purpose of the video was to ensure consistency of instruction across study sessions. use of the closed-caption feature on the simulator was encouraged but not required. to avoid contamination, participants were instructed to avoid discussion of the test with others after completing the exam and to refrain from use of their smartphones or the internet for assistance while taking the exam. participants were then provided a handout which listed their randomly generated username, password, the weblink to the exam, and the weblink to the post-test survey. the proctor remained in the room for the duration of the exam to resolve technical problems and to hand out the gift card upon completion of the exam and post-test survey. participants were given up to min to complete the exam although everyone finished within - min. given the interest in participating but the inconvenience of the testing sessions for some, towards the end of the recruitment period, we permitted participants to take the exam in an unsupervised setting, at a time and location of their choosing. the protocol was the same as it was with the supervised testing sessions except no proctor was in the room while the participants completed the exam. the prite exam scoring report provided to residency program directors breaks down each resident's score into three different categories: global scores, psychiatry subscale scores, and milestones. a number of subscale scores are reported within each of these categories. in the milestones category, the mk : somatic therapies subscale most closely reflects the construct being measured by the virtual patient simulator. grouping the results by class and deidentifying the resident, the emory university residency program provided the mk : somatic therapies subscale standardized scores of all the psychiatry residents who participated in the virtual standardized patient assessment. because residents' simulator performance was identified only by their residency class, the correlational analyses had to be conducted by residency class mean performance rather than by individual resident performance. faculty and medical students were excluded from this analysis since they did not take the prite exam. the prite exam included mk : somatic therapies questions out of total questions. of those , nine ( %) referenced an antidepressant or nonbipolar depression in the question stem, and another five ( %) included at least one antidepressant as a possible answer response option. a ten-item survey to assess test acceptability to the learner was created. for the first eight questions, respondents were asked to use a likert scale ( = strongly disagree, = disagree, = neutral, = agree, = strongly agree) to indicate the degree to which they agreed or disagreed with statements about the simulator. the ninth question pertaining to the pacing of the test provided respondents with answer choices "too fast," "too slow," or "just right," and the tenth question was an openended inquiry for written responses to their experience of taking the test. no identifying information was solicited on the survey in order to maximize the respondent's candor. each question on the exam assessing psychopharmacology knowledge and decision-making was worth one point, and scores were calculated by dividing the number of points by the total number of questions on the exam. this total number was a function of the number of medicines each participant selected in each of the four modules. participants with incomplete data on any modules of the exam were excluded from the analysis. score means and standard deviations were calculated for each participant group (m , pgy- , pgy- , pgy- , pgy- , faculty) for each module of the exam, and for the total performance on the exam (all modules combined). anova testing was used to compare the overall scores between each participant group followed by a post hoc tukey's test to determine which groups were significantly different. percentage of questions answered correctly for items related to side effects, dosing, and titration were also reported for each participant group. means for each residency class were calculated for the prite mk : somatic therapies subscale standardized scores and then correlated with the mean total score on the simulator for each residency class using spearman's correlation coefficient. likert scores for each applicable item on the post-test survey were averaged and reported. the data were analyzed using spss statistics (ibm, armonk, new york). forty-three subjects completed the online exam and survey with % ( of ) of the training program's residents participating; exam data from three subjects were excluded due to incomplete responses. the analyzed sample included fourthyear medical students ( % of the total sample), pgy- residents ( . %), pgy- residents ( %), pgy- residents ( %), pgy- residents ( %), and faculty members ( . %). the majority of participants were male (n = , . %; female n = , . %) and completed the exam and survey in a supervised testing setting (n = , . %; unsupervised, n = , . %). the participants who completed the exam unsupervised included faculty (only with complete data), pgy- s, and medical students. as shown in fig. , total mean scores and standard deviation on the exam differed significantly among the learner groups in a step-wise manner: m student = . ± . , pgy- = . ± . , pgy- = . ± . , pgy- = . ± . , pgy- = . ± . , faculty = . ± . (f = . , p < . ). post hoc testing revealed significant mean score differences among the following groups: pgy- vs. m ( . ± . , p = . ), pgy- vs. pgy- ( . ± . , p = . ), pgy- vs. m ( . ± . , p = . ), pgy- vs. pgy- ( . ± . , p = . ), faculty vs. m ( . ± . , p = . ), and faculty vs. pgy- ( . ± . , p = . ). although faculty scored higher than senior-level residents, the differences were not statistically significant, suggesting that the senior residents had achieved an acceptably high level of psychopharmacologic knowledge. the percentages of side effect, dosing, and dose titration questions answered correctly are presented in table . there was a linear trend for greater accuracy within increasing levels of learner experience for all three types of psychopharmacology questions. prite mk : somatic therapies subscale scores were received for of the participating residents. the mean score per class and standard deviation was pgy- = . ± . , pgy- = . ± . , pgy- = . ± . , and pgy- = . ± . and correlated significantly with the mean total simulator performance by class (p < . ). see fig. . as shown in table , the post-test survey mean results ranged from . ( . ) to . ( . ), indicating overall favorable responses for most components of the simulator, and a neutral response when compared to an oral exam. none of the learners thought the test moved too quickly. sixty percent ( / ) of participants described the pacing of the test as "just right," while % ( / ) described it as "too slow." this study evaluated a novel, virtual standardized patientbased psychopharmacology assessment simulator among fig. comparison of mean total score performance among all participant groups. key = m (n = ), pgy- (n = ), pgy- (n = ), pgy- (n = ), pgy- (n = ), faculty (n = ), anova results, f = . , p = . medical students, psychiatry residents, and psychiatry attendings within an academic medical center setting. the results demonstrated that the simulator had strong construct validity using novice-expert performance comparisons and comparisons to a test measuring a similar construct and had high participant acceptability. the participant groups with greater experience prescribing psychotropic medications performed better than those with the least experience. faculty, pgy- , and pgy- residents all performed statistically significantly better than the pgy- residents and th year medical students; however, there were numeric differences between all groups with faculty scoring the highest. the step-wise improvement in scores by experience level suggests that this tool can discriminate between test takers with different levels of mastery, supporting the tool's construct validity as a measurement of proficiency in the psychopharmacological treatment of major depressive disorder. this step-wise improvement between groups was also seen when focusing on the specific areas of psychopharmacology knowledge: side effects and titration. medication dosing showed some step-wise improvement; however, the pgy- residents excelled in this category, likely owing to their recent experiences working in a psychopharmacology clinic with a high volume of mood disorder patients. the mean total score on the simulator by class correlated with the mean scores on the somatic therapies subscale of the prite, providing additional construct validity evidence for the virtual-patient simulator. although the prite is not a comprehensive measure of psychopharmacology knowledge, the somatic therapies subscale focuses on psychopharmacology. additionally, the exam itself is a widely used tool to measure overall resident competence and correlates with future performance on the american board of psychiatry and neurology part i exams [ ] . on the user experience survey, average scores for the survey items fell between the "neutral" and "strongly agree" anchor points. the lowest rated (neutral) item was for the statement, "this test is a superior way to assess clinical psychopharmacology skills compared to an oral exam". the survey comments suggest that some participants believed an oral exam would give them more latitude with answer responses as they could justify their choices. while this is true, the disadvantages to using oral exams include more opportunity for examiner bias, less standardization, and more personnel requirements. the highest rated item was the statement, "the process of moving through the test was intuitive and clear", supporting the usability of this tool and its ability to reliably engage test takers. the item, "the experience treating this areas of knowledge are the categories of psychopharmacology knowledge that clinicians must have to prescribe psychotropics safely and effectively. the participant groups include the trainees (medical students and residents) and faculty members who completed the virtual standardized patient assessment virtual standardized patient is reasonably similar to the outpatient psychiatry experience" was rated in the neutral to agree range, supporting the authenticity of the simulator. given the number of participants who likely had minimal to no outpatient psychiatric experiences up to that point (e.g., fourth year students, pgy- and pgy- residents), it is possible that this item may have been scored even more favorably had it been limited to the senior level residents and faculty. because the surveys were anonymous, this possibility could not be explored. examples of constructive survey comments included, "it would be nice to have a wider array of interview questions to choose from for the patient interview component," and "it would've been enhanced by the test taker being able to offer free text or other alternatives." a potential limitation to this study was the inclusion of only those fourth year medical students participating in psychiatry sub-internship electives. had a broader group of fourth year medical students been recruited, it is possible there would have been a greater separation in the scores between the medical students and other participant groups. another limitation was the small sample sizes per participant group, which limited power to identify statistically significant differences between each experience level. because we decided to ensure participants' anonymity to maximize candor, and due to the lack of a gold standard to measure psychopharmacology proficiency, we could not compare test performance to learners' real-world outcomes. strengths of the study include the method and simulator design features that address the different validity components within the kane framework for testing validity arguments. those features include ( ) scoring: computer-based entry of answers to accurately capture and score learner performance; the use of equally weighted scoring for each question to reduce bias among the different areas of psychopharmacology knowledge; survey data indicating that the test-taking process and the virtual patient's voice was clear; pilot phase testing to determine usability; and the use of a proctor to prevent cheating and test contamination; ( ) generalization: test question development generated from a standard treatment algorithm; questions covering the major components of psychopharmacology (dosing, side effects, titration); and pilot testing to determine adequate breadth of the questions; ( ) extrapolation: the novice-expert performance comparisons; correlation with a test measuring a similar construct; survey data indicating that the simulator experience was similar to the outpatient experience; the use of a realistic-appearing outpatient psychiatric office in the design of the software and the use of natural prosody in the virtual patient's voice to enhance the authenticity of the testing experience. addressing the implication of the simulator test results will require evaluation as a formal assessment tool within a residency program. the development and validation of this psychopharmacology summative assessment tool demonstrates the potential utility of a virtual standardized patient simulator to achieve a fair and full evaluation of residents' psychopharmacology proficiency in treating mdd. the major advantage to this kind of exam is its ability to reduce bias from the assessor and to evaluate psychopharmacology knowledge in an indepth, realistic, and dynamic way. because a computerbased simulator can scale up for wider use easily across institutions, it is conceivable that with more validity data collected over time and in larger samples, a limited suite of similar simulators, including those developed for other psychiatric disorders, could in combination yield a standardized summative assessment of psychopharmacology proficiency across residencies. this assessment could occur throughout the th year of residency as senior residents would have had a substantial number of hospital and clinic training opportunities to prepare them for such a comprehensive exam. for this vision to be achieved, virtual standardized patient simulators testing proficiency in the treatment of other psychiatric illnesses (e.g., schizophrenia, bipolar disorder) will need to be developed, and more validation studies addressing all the components of kane's framework will be required to support the use of these simulators as a standard measure of psychopharmacology knowledge and skills. finally, in the age of the covid- table post-exam survey results using a likert scale ( = strongly disagree, = strongly agree) likert score pandemic, this virtual online assessment tool and others like it can allow evaluations of residents to occur remotely without creating an increased risk of infection for residents, patients, and faculty. funding information funding for this study was provided by the american board of psychiatry and neurology "faculty innovation in education grant" awarded to jjr. national trends in psychotherapy by officebased psychiatrists national trends in the outpatient treatment of anxiety disorders comparative effectiveness of extended-release naltrexone versus buprenorphine-naloxone for opioid relapse prevention (x:bot): a multicentre, open-label, randomized controlled trial efficacy of lisdexamfetamine in adults with moderate to severe binge-eating disorder: a randomized clinical trial efficacy and safety of flexibly dosed esketamine nasal spray combined with a newly initiated oral antidepressant in treatment-resistant depression: a randomized double-blind active-controlled study trial of sage- in patients with major depressive disorder us psychiatric residents' treatment of patients with bipolar disorder the psychiatry milestone project: a joint initiative of the american council for graduate medical education and the american board of psychiatry and neurology the serial position effect of free recall simulation and mental health outcomes: a scoping review validation of educational assessments: a primer for simulation and beyond a contemporary approach to validity arguments: a practical guide to kane's framework virtual standardized patients for interaction conversational training: a grand experiment & new approach the star*d study: treating depression in the real world how well does the psychiatry residency in-training examination predict performance on the american board of psychiatry and neurology. part i. examination? publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations disclosures jjr receives research funding from takeda and national institutes of mental health.tbt owns medical mechanica llc which licenses the software used for this study.bwd receives research support from acadia, sage, takeda, and the national institutes of health, and has served as a consultant to myriad neuroscience and aptinyx, none of which have any commercial interest in this software. key: cord- - uhhqasl authors: dimitriu, mihai c.t.; pantea-stoian, anca; smaranda, alexandru c.; nica, anca a.; carap, alexandru c.; constantin, vlad d.; davitoiu, ana m.; cirstoveanu, catalin; bacalbasa, nicolae; bratu, ovidiu g.; jacota-alexe, florentina; badiu, cristinel d.; smarandache, catalin g.; socea, bogdan title: burnout syndrome in romanian medical residents in time of the covid- pandemic date: - - journal: med hypotheses doi: . /j.mehy. . sha: doc_id: cord_uid: uhhqasl burnout is a state of physical or mental collapse caused by overwork or stress. burnout during residency training has gained significant attention secondary to concerns regarding job performance and patient care. the new covid- pandemic has raised public health problems around the world and required a reorganization of health services. in this context, burnout syndrome and physical exhaustion have become even more pronounced. resident doctors, and especially those in certain specialties, seem even more exposed due to the higher workload, prolonged exposure and first contact with patients. this article is a short review of the literature and a presentation of some considerations regarding the activity of the medical residents in a non-covid emergency hospital in romania, based on the responses obtained via a questionnaire. burnout prevalence is not equal in different specialties. we studied its impact and imagine the potential steps that can be taken in order to reduce the increasing rate of burnout syndrome in the pandemics. the burnout syndrome in health care professionals has gained significant attention over the last several years. given the intense emotional demands of the work environment, clinicians are particularly susceptible to developing this syndrome more than in other jobs. residency can cause a significant degree of burnout, leading to individuals' ability to establish correct communication with the patient, solve diagnostic dilemmas, and have a good overview of the correct treatment. burnout is associated with a variety of negative consequences including depression, risk of medical errors, and negative effects on patient safety. the goal of this review is to provide an overview of the prevalence in different specialties of the burnout syndrome, even more pronounced in covid context, provide team leaders with options to minimize the risks and prevalence and recognize its potential hazards towards the medical act and its medical caregiver [ ] . although reported and discussed long before the pandemic, after its outbreak, burnout syndrome became even more pregnant [ ] . the coronavirus epidemic broke out in wuhan, china, in a metropolis of million people in december [ ] . free movement of people led to the spread of the virus in europe (italy), the united kingdom and the united states in january-february , becoming soon a pandemic that affected almost all countries [ ] . resident physicians often represent the communication interface between the attending physician and the patient, so that the time spent with the patient is often longer. in the context of the pandemic, physical fatigue is added to the mental stress associated with a possible infection. resident physicians have the most prolonged contact with patients, including in the time window from the testing moment to the arrival of the result for sars-cov- , therefore the stress is even more pronounced. some physical factors are added to the equation. prolonged wearing of personal protective equipment, excessive heat provided by them, lack of hydration, alimentation, sleep deprivation, all together accentuate fatigue and the burnout syndrome. from this point of view, the most affected doctors are from the emergency units, radiology, intensive care units, but also from the specialties that ensure surgical, obstetrical, orthopedic and neurosurgery emergencies. the modification of the shifts and of the work schedule, of the type of the current activity, the time and the technique of dressing and undressing the protective equipment, all constitute the novelty that adds an additional stress factor. last, but not the least, wearing facial protection equipment leads to a depersonalization of the activity, both in contact with patients and medical staff. the impossibility of reading facial expressions, the lack of interpersonal interactions and facial expressions decreases the possibility of socialization and mutual encouragement. in this sense, the idea related to wearing a photo of the holder on the protective suit appeared. there are studies that paradoxically indicate a higher level of stress in regular, non-covid wards of hospitals, compared to front-line ones [ ] . a possible explanation would be that better organization and a sense of control reduce the stress level of those in the front line, while the fear of being exposed when the protocols do not seem perfect is higher in non-covid wards. here, however, there is a permanent threat of a positive patient, so no one seems to be safe. some studies in china and uk have also revealed depression and anxiety due to the covid- outbreak that medical staff experienced [ , , ] . the pandemic has led to numerous cases of depression and anxiety, as well as worsening preexisting mental illnesses [ ] . the term "burnout" was described by psychologist herbert freudenberger [ ] in in an article entitled "staff burnout" in which he discussed job dissatisfaction precipitated by workrelated stress. a broadly applicable description defines burnout as a state of mental and physical exhaustion related to work or care-giving activities. a long-standing conceptual and operational definition characterized burnout as a triad of emotional exhaustion (emotional overextension and exhaustion), depersonalization (negative, callous, and detached responses to others), and reduced personal accomplishment (feelings of competence and achievement in one's work) [ ] . the maslach burnout inventory (mbi) [ ] is the most used questionnaire to measure burnout in research studies. the mbi human services survey is a self-administered, item questionnaire that was developed to measure burnout in human services workers and is the "gold standard" of measuring burnout [ ] . the mbi items are rated on a likert scale from to ( = never, = a few times per year, = once a month, = a few times per month, = once a week, = a few times per week, and = every day) and score sample items such as: "i feel emotionally drained from my work.". it is designed to assess the primary dimensions of burnout: emotional exhaustion, depersonalization, and personal accomplishment. burnout is detected using cutoff scores of high emotional exhaustion (≥ ), high depersonalization (≥ ), and low personal accomplishment (≤ ), based on normative data from medical professionals [ ] . a study in china, comparing burnout of front line workers with that of normal ward staff, in covid context, used maslach questionnaire for medical workers and the results were interesting and quite unexpected [ ] . in , martini et al [ ] did a unique study that compared burnout rates among the different specialties using the mbi. the overall burnout rate was % and ranged from % to % among different specialties. this variation among specialties was not statistically significant; however, burnout rates were as follows: % in obstetrics-gynecology followed by % in internal medicine, % in neurology, % in ophthalmology, % in dermatology, % in general surgery, % in psychiatry, and % in family medicine. however, this variation among specialties was not statistically significant. being in one's first year in residency, mood fluctuation, dissatisfaction with clinical faculty, recent family stress, and being unmarried were all associated with increased likelihood to meet burnout criteria [ ] . psychiatry residents were noted to have additional stressors including fear and exposure to patient violence and suicide [ ] [ ] [ ] [ ] [ ] in a study by fahrenkopf et al [ ] , no actual correlation was found between burnout and the number of medical errors seen in collected data. one plausible explanation may be that residents reporting symptoms of burnout may be more likely to over-report their errors. in this pandemics, there is a need for practical methods to assess medical stuff burnout. some researchers have even proposed the continuous wearing of sensors to quantify fatigue [ ] . the aim of our study was to compare the frequency of burnout syndrome between medical residents considered to work on the front line (emergency unit, radiology and intensive care unit) and those working in normal hospital wards (surgery, obstetrics and gynecology, obstetrics). our hypothesis that we wanted to prove is that there is higher prevalence of burnout syndrome in regular, non-covid wards of hospitals, compared to front-line ones. the study was conducted in a hospital with an emergency clinical profile, which is not in the frontline in the fight against coronavirus, ensuring non-covid emergencies or suspects until the result of the real time polymerase chain reaction test is obtained. during the pandemic, the teaching processes in the hospital were stopped, both for medical students and residents, opting for online teaching. students' access to the hospital was stopped by a university decision to limit the spread of the infection. the medical residents continued to carry out medical activity, restricted to the activity in this only hospital where they have an employment contract. we distributed a survey of questions to medical residents, for resident doctors in the emergency department, radiology and intensive care unit (considered first-contact with the questionnaires for first-line medical resident were distributed as follows: for residents in emergency unit, for residents in intensive care unit and for residents in radiology department (lot a). the other questionnaires were distributed in that we considered normal wards. they were allocated for residents in general surgery ( questionnaires), gynecology ( ) and orthopedics ( ) -lot b in our study. all the invited participants anonymously completed the survey and the responses were valid to be analyzed. demographics characteristics can be found in table . demographic characteristics showed that the two groups were relatively homogeneous in terms of distribution by age and gender. the extreme ages were and years, respectively, given that the target was represented by resident doctors. burnout was defined as a high level of emotional exhaustion (≥ ), and/or high level of depersonalization (≥ ), and/or low personal accomplishment (≤ ). according to our results, we obtained an average burnout for medical residents of %, about two months after the outbreak of the pandemics in our country, which is superior to studies conducted in normal periods. the global prevalence of burnout syndrome among medical residents is high, proving that the threat posed by sars-cov- is a major stressor for medical staff. the results are all the more worrying as the target group was represented by resident doctors, of young age (maximum years), who, at least theoretically, should have a better adaptability to the new condition represented by this pandemics, compared to senior doctors. the burnout was significantly more frequent in normal wards workers (lot b) (prevalence %) compared to medical residents working in places that we considered front-line departments: emergency unit, radiology, including ct/mri department and intensive care unit -lot a in our study, that showed a prevalence of burnout of only % (p< . , from chi-square statistic test) (table ). we considered emergency unit, radiology, including ct/mri department and intensive care unit as front-line departments as all the patients, at presentation time, are now considered potentially infected ones till invalidation by a negative real time polymerase chain reaction test that usually takes hours in our hospital. the prolonged time is due to the fact that this test is analyzed in an external laboratory. there can be an array of methods that can be used to fight against the burnout sydrome. in a sample of professionals, maslach [ ] showed that venting, laughing, and discussing care with colleagues decreased personal anxiety. in conditions of social distancing, even between colleagues, all these mechanisms are annulled. the place of direct socialization is partially replaced by social media groups and net socialization. there are no studies on suggested interventions for reducing the prevalence or how it works on each individual. each person is different genetically, racially, different sex and culture, different family environment and so on. with these many factors comes the problem of pinpointing the trigger factor for each individual. that is why with these many stress factors comes a multitude of anti-stress factors which can be used: from physical activity to meditation. mentoring programs in residency training can also be helpful in this regard [ , ] . the negative impact of burnout on patient care includes risk of medical errors, patient safety risks, and potential compromise of quality of care. burnout and fatigue can affect the caution of medical staff, lead to negligence on self-protection measures and increase the risk of infection. negative consequences of burnout on physicians in training include depression, suicidal tendencies, and medical illnesses. the problems of medical errors related to fatigue and burn-out syndrome seem to be more serious for the surgical specialties [ ] . effective interventions to address burnout should be developed at both the individual and institutional levels [ ] . in a previous study conducted in our hospital, in non-pandemic conditions, the conclusion was that surgeons' fatigue seems to be a more subjective self-perception of surgeons than an objective fact and that surgeons tend to attribute their mistakes to burn-out syndrome, this being more acceptable for their conscience. in normal times, the rates of complications were not statistically higher on call-days and the days immediately after, when exhaustion should be maximum [ ] . maslach [ ] summarized effective working through burnout by stating: "if all of the knowledge and advice about how to beat burnout could be summed up in word, that word would be balance-balance between giving and getting, balance between stress and calm, balance between work and home." pandemics of this magnitude have appeared in humanity about once every years [ ] . so you cannot talk about personal experience in managing a crisis like this. it is also difficult to assume that the competent centralized structures, such as governments, public health organizations, could fully manage the situation at individual level. in certain critical situations, it even turned out that local authorities, along with the population, had more competent organization and involvement (the example of hurricanes). in our opinion, the local organization at the hospital level is much more important for decreasing the stress level and the prevalence of the burnout syndrome. the existence of clear protocols for any possible situation, the practical trainings with the personnel regarding the protection measures, the adequate use of the protection equipment are all measures that ensure a state of confidence and control, which obviously decreases the stress level. this could explain the higher prevalence of burnout syndrome in staff in regular wards, compared to employees in the emergency department. medical residents in emergency unit had more training hours about the protective equipment and the wearing of the personal protection equipment was continuous, throughout the working time, that gave them the feeling of being safe, reducing the stress. all the successes of medical teams must be promoted by all means, being a source of positive emotions. the shift program must be organized in such a way as to respect the epidemiological timing (incubation period or quarantine time). periods of rest and relaxation are important and must be observed to prevent burnout, even if, often, they cannot take place in the privacy of families. the burnout-syndrome is a real phenomenon and may manifest in many forms. each resident and other higher level caregiver is susceptible to it. being aware of this, the new physician generations are shown to have an attraction towards balancing activities. all in all medical leaders and mentors should be aware of their colleagues and residents, thus allowing themselves to partake in the well-being of the team and making the work environment less stressful. the research in individual stress-factors and its many ways in which to actively fight them it is a gateway to making a whole medical environment better by concentrating upon the individual and giving a successful education to the next generation of physicians. in the context of covid- , the best way to combat burnout seems to be, in our opinion, the precise local organization within the hospital and practical training sessions on the use of personal protective equipment, source of a mental comfort feeling. mean age (standard deviation) low personal accomplishment total (burnout frequency) ( %) ( %) p= . table . characteristics of burnout syndrome elements of the two lots burnout during residency training: a literature review coronavirus disease (covid- ) and beyond: micropractices for burnout prevention and emotional wellness emergence of a novel coronavirus causing respiratory illness from wuhan the outbreak of coronavirus disease (covid- )-an emerging global health threat a comparison of burnout frequency among oncology physicians and nurses working on the frontline and usual wards during the covid- mental health care for medical staff in china during the covid- outbreak occupational risks for covid- infection covid- : give nhs staff rest spaces and free parking not thank yous, says doctor factors associated with mental health outcomes among health care workers exposed to coronavirus disease staff burnout burnout: a multidimensional perspective professional burnout: recent developments in theory and research maslach burnout inventory manual stress in health professionals: psychological and organizational causes and interventions evaluating stress: a book of resources burnout comparison among residents in different medical specialties general psychiatry in no-man's land hidden ethical dilemmas in psychiatric residency training: the psychiatry resident as a dual agent observations on burnout in family medicine and psychiatry residents burnout among dutch medical residents burnout and internal medicine resident work-hour restrictions rates of medication errors among depressed and burnt out residents: prospective cohort study continuous monitoring and detection of post-traumatic stress disorder (ptsd) triggers among veterans: a supervised machine learning approach burned out an exploratory study of resident burnout and wellness mentoring matters: mentoring and career preparation in internal medicine residency training burnout and medical errors among american surgeons surgical malpractice in relation to long calls burnout: the cost of caring the mother of all pandemics is years old (and going strong)! maria sklodowska curie carol davila sos. pantelimon, , bogdan.socea@umfcd.ro, + , kindly ask you to take in consideration our submission for your journal, having the title all authors have been read and approved the final manuscript. the study was performed according to the world medical association declaration of helsinki and according to national legislation, using a protocol approved by the local bioethics committee. all subjects have previously signed an informed written consent about future publication of data all authors have significant scientific contribution to the manuscript. all authors have been read and approved the final manuscript. the study had no funding. there are no conflicts of interest. key: cord- -arif ejj authors: barik, sitanshu; paul, souvik; kandwal, pankaj title: insight into the changing patterns in clinical and academic activities of the orthopedic residents during covid- pandemic: a cross-sectional survey date: - - journal: knee surg sports traumatol arthrosc doi: . /s - - - sha: doc_id: cord_uid: arif ejj purpose: the covid- pandemic has presented an unprecedented challenge to the orthopedic residency training programs to adapt to a form of a web-based learning process and simulation-based training. this study focusses on the viewpoint of the orthopedic residents to the paradigm shift in clinical care as well as the academic activities. methods: an anonymous questionnaire was created in an online survey generator and was sent through e-mail to orthopedic residents of seven tertiary care centres in north india. the questionnaire was divided into three sections, academic activity section, mental health section, and clinical activity section. there were a total of single answer questions with answers according to the increasing difficulty at present situation compared to a previous time before the covid- pandemic. results: a total of questionnaires were filled by junior residents ( . %) and senior residents ( . %). residents ( %) were quarantined and three became positive for covid- . although all of them knew about necessary precautions, personal protective equipment was difficult to avail at times. increased difficulty in recruiting new patients for research ( . %) and conducting prospective research ( . %) was observed. the online-based learning process was reported to be easier ( . %) by most of the residents. routine clinical work in the operating room, out-patient department, and inpatient department was found to be difficult according to the majority of the residents along with the anxiety of contracting the infection. conclusion: there are unique opportunities for improvement of residency programs during these times of uncertainty and the findings of this study can help the universities as well as program chairs to develop a robust program that can outlive this pandemic. the web-based learning process might prove to be useful and can be incorporated into the resident training program in the long term. level of evidence: level v. the covid- (coronavirus disease ) global pandemic has emerged to be the biggest threat faced by the healthcare system of india at present. since the first case reported in kerala, the epidemic has rippled through the whole country within a matter of days [ , ] . while facing a crisis of healthcare workers, all elective surgeries had been cancelled in most of the hospitals in india since april [ ] . like other specialties, orthopedic residents have been frontline soldiers in this battle against coronavirus pandemic since the beginning [ , ] . looking at the drastically falling numbers of elective orthopedic surgeries [ , , , ] , residents have been posted in covid- screening out-patient departments, intensive care departments, inpatient departments, and telemedicine centre at different centres around the world [ , ] . they have been utilized by dividing into teams, where one team will be appointed to serve covid- patients, whereas other teams will be posted in orthopedic duties or kept in quarantine [ ] . there has been a paradigm shift in the learning process of residents from problem-based learning to the virtual web-based learning process [ ] . there has been an upsurge of webinars and educational meetings conducted on different web platforms [ ] . teams of orthopedic residents have been quarantined routinely or after being exposed to some covid- -positive patients. some of the orthopedic residents have also appeared for different forms of examinations too during this period including end-term examination for junior residency. the current body of literature lacks specific studies focussing on the resident's feedback on these drastic changes in the routine clinical and academic activities. the resident's perspective can help to improve the curriculum of orthopedic residency program all over the world according to the present pandemic situation. this study aims to highlight the experience of orthopedic residents while working in current situations in orthopedic as well as non-orthopedic duties. it also aims to bring the mental status of the residents into the spotlight, while they cope with this stressful work environment which has not been explored before. the study was done in accordance with the ethical standards of our institution (aiims/iec/ / ). an online survey was conducted by emailing anonymous questionnaire to orthopedic residents of seven tertiary care centres in north india. among them, filled questionnaires were received ( . %). the questionnaire was divided into three sections, namely, the academic activity section, the mental health section, and the clinical activity section (see figs. , ). the academic activity section was divided into three subsections-online academic activities, research, and examination section. most of the residents underwent summative assessments in between this period in different centres. the cognitive domain was assessed by multiple-choice questions. whereas the affective and psychomotor domains were evaluated by objective structured clinical/practical examination (osce/ospe) and case scenarios using standardized patient. the respective sections were designed to get to know the perspective of the residents on the change of curriculum and clinical works. all participants were also required to answer general questions about their age, current affiliation, the experience of treating covid- positive patients, awareness about precautions while working in covid- designated area including steps of donning and doffing personal protective equipment (ppe), history of quarantine, or taking covid- tests and if anyone tested positive for the infection. all participants were asked to provide a single answer for all the questions if possible and skip the questions which they did not find suitable to answer. the questions had the same options for answers according to the increasing difficulty at present compared to a previous time before the covid- pandemic. all junior or senior orthopedic residents working in the present situations were included in the study. a pilot study was conducted in ten residents fulfilling the inclusion criteria for testing comprehensibility, ease of reading, and acceptability of questionnaires. each question was assessed for suitability on a likert scale of - ( : suitable to highly suitable). missing responses for each question were also assessed. data from the pilot study were not included in the main study. the aim of the study was to assess the maximum percentage of responses for each questions denoting the degree of difficulty of that work at the present time. the questionnaire was created in an online survey generator and the collected data were transferred to excel sheets (microsoft excel ) for further analysis. the percentage of response for each answer in all of the questions were noted. all quantitative variables were expressed in terms of mean and standard deviation. the statistical analysis was done in ibm spss version . . the mean age of participants was . ± . years. there were junior residents ( . %) and senior residents ( . %). all of the residents had been posted in covid- patient care areas and were aware of all the precautions for covid- patient care including steps of donning and doffing ppe. however, residents ( %) were quarantined due to contact with a covid- -positive patient. a total of residents had undergone covid- testing due to various reasons and three residents among them tested positive. the questionnaire was completely filled by residents ( . %), whereas the examination-related questions in the academic activity section were not attempted by residents ( . %), and residents ( . %) left research questions incomplete. in the pilot study, all of the questions were answered by most of the participants ( . %). the mean score according to the likert scale was . ± . . most of the residents found overall learning through web platforms ( . %) to be easier than before. however, the majority of residents felt that participating in an online case presentation ( . %) and maintaining the attention of the audience ( . %) during any online presentation were relatively difficult than offline activities. during the present situation, recruiting new patients ( . %) and conducting prospective research ( . %) posed difficulty to most of the residents. although there were difficulties in facing a complete online interface-based viva voce ( . %), multiple-choice questions (mcq) or objective structured clinical and practical examination (osce/ ospe) di not pose any problem for most of the residents ( . % and . % respectively). the responses are summarized in table . the majority of residents found spending time during quarantine ( . %), pursuing non-orthopedic hospital duties ( . %), ppe was difficult to obtain in operating room (or) ( . %), out-patient department (opd) ( . %), and inpatient department (ipd) ( . %). among clinical activities, working in or was found to be difficult in all aspects. it was also noticed that the clinical examination of patients ( . %), working at dressing and plaster room ( . %), and sending laboratory or radiological investigations in opd ( . %) are to be difficult than before. the majority of the residents ( . %, . %, and . % in ipd, or, and opd, respectively) were found to be working with anxiety about contracting covid- infection. the most important findings of the present study were that the orthopedic residents had been facing difficulties in performing routine or, opd, and ipd works during covid- pandemic. the present situation has posed a threat to the mental health of residents by increased anxiety of contracting the disease and difficulty in spending time alone without socializing with others. although residency training in orthopedics has been profoundly affected due to the present situation, it has been advocated for orthopedic surgeons to step up as role models in these times, both in clinical and medical education activities [ ] . in the absence of little or no guidance, the administrators of residency programs had to develop methods and strategies to keep imparting quality as well as feasible clinical care as well as medical education in these times. however, the literature lacks the feedback of orthopedic residents to these changes and whether they can be carried out in the long term. this study, one of the first in the literature, focusses on the viewpoint and feedback of the orthopedic residents to the paradigm shift in clinical care as well as the academic activities. crises like this are an opportune moment for educators to potentially alter the mode of resident training. the medical education in these times has transitioned into a more digital format with an increased amount of seminars and didactic lectures being conducted online with the help of video conferencing and e-learning platforms [ , ] . as overall learning through web platforms was found to be easy by the majority of residents in this study, online platforms can surpass the effectiveness of offline activities in future times. similarly, instructional videos for procedural learning with faculty intervention for answering the questions of residents are a novel way forward. in the absence of broad guidelines from universities, it has been up to the program director to devise innovative ways to conduct medical education in consultation with the academic wing of the hospitals. due to a sharp decrease in patients visiting hospitals with orthopedic complaints, residents had found it difficult to conduct a prospective research study during these times. moreover, enrolling new patients or following them up might pose a threat to the patients and also to contract the disease while a visit to the hospital. the telephonic consultation and followup might be the way forward. many countries have started including osce/ospe as the form of assessment for residents in their curriculum and use standardized patients for exams [ ] . the literature lacks any conceptual framework for framing standardized osce/ ospe questions [ ] . also, it is not clear whether the successful performance of osce/ospe can be adjudged as having sound clinical judgement [ ] . although the majority of residents found it more difficult to get used to the onlinebased exam and its resultant difficulty in interaction with examiners as well as standardized patients, it has helped the final year residents to complete their junior residency within the stipulated time period. the residents were demanded to bridge the gap in covid- healthcare while managing emergency orthopedic cases during the pandemic. it was observed in this study that most of the work related to routine clinical activity has become more difficult during this pandemic. this finding may be attributed to the fact that many healthcare workers have been diverted from their routine services towards covid- management [ ] . the exception to this finding was noted in the ability to manage the patient volume, which was rated as easy owing to the reduced orthopedic cases during this period. another factor that can be attributed to the same is that the residents were pooled into three teams. there was one team each for covid- care and emergency orthopedic cases and the third team was placed on standby in case one of the above teams is quarantined for exposure. despite the known highly contagious nature of the infection, a significant number of respondents had difficulty in obtaining ppe at their work stations (table ) . this led to the increased anxiety regarding acquiring covid- during their work routine as noted in this study. this anxiety has also got accentuated due to the frequent change of guidelines for the management and prevention of covid- . it is still unknown how long will this pandemic last and for how long will the orthopedic residents be expected to care for non-orthopedic patients, which leads to a focus on the mental well-being of the residents [ ] . the majority of residents in this study had apprehension regarding the quarantine/isolation and risk of infection during work. during these uncommon times of social distancing and less frequent face to face interaction, virtual social hours with the faculty and residents can be organised through online platforms to engage in topics apart from medical education. efforts to reduce interpersonal isolation (increase interpersonal communication) help in minimising anxiety and stress that the residents are going through [ ] . a major limitation of this study is that the findings are based on the responses of orthopedic residents from only one country, which may not be extrapolated to other countries all over the world. as other countries may have different types of health care system infrastructure and resident training programmes. moreover, this study is also limited by the rapidly evolving strategies in public health as well as medical education, it has tried to provide a glimpse of the feedback from the orthopedic residents regarding early strategies employed after the cancellation of routine clinical and medical education services. it is difficult to quantify the efficacy of current strategies with respect to previous routine protocols. as the fate of this pandemic is still unclear, some major changes need to be integrated into the residency training programmes all over the world. the findings of this study might enlighten the path in this decision -making. the emphasis must be put on web-based learning, simulation-based surgical process, and telemedicine-based patient consultations while providing the residents' maximum safety and mental support. embracing these changes will lead the way to better patient care as well. to conclude, this pandemic represents a challenge to program chairs to provide effective and feasible strategies for clinical care and medical education. there are unique opportunities for improvement of residency programs during these times of uncertainty and the findings of this study can help the universities as well as program chairs to develop a robust program that can outlive this pandemic. the webbased learning process might prove to be useful and can be incorporated into the resident training program in the long term. for all these strategies to succeed, the residents must feel protected and cared for. embracing the feedback from the residents shall help the orthopedic education community to rise to the challenges of this pandemic. funding there is no funding source. how are orthopaedic surgery residencies responding to the covid- pandemic? an assessment of resident experiences in cities of major virus outbreak novel coronavirus and orthopaedic surgery: early experiences from singapore covid- ioa guidelines ( ) indian orthopaedic association, new delhi covid- coronavirus: recommended personal protective equipment for the orthopaedic and trauma surgeon home-based management of knee osteoarthritis during covid- pandemic: literature review and evidence-based recommendations objective structured clinical examinations (osces) compared with traditional assessment methods nolte mt ( ) orthopaedic education during the covid- pandemic the validity of performance-based measures of clinical reasoning and alternative approaches orthopaedic resident management during the covid- pandemic -aiims model the immediate psychological and occupational impact of the sars outbreak in a teaching hospital covid- -esska guidelines and recommendations for resuming elective surgery repurposing orthopaedic residents amid covid- what's important: redeployment of the orthopaedic surgeon during the covid- pandemic: perspectives from the trenches assessing musculoskeletal examination skills and diagnostic reasoning of th year medical students using a novel objective structured clinical exam understanding acgme scholarly activity requirements for general surgery programs in the era of single accreditation and the next accreditation system disruption of joint arthroplasty services in europe during the covid- pandemic: an online survey within the european hip society (ehs) and the european knee associates (eka) the lancet ( ) india under covid- lockdown india's coronavirus lockdown and looming crisis the authors declare that they have no conflict of interest. informed consent informed consent was obtained from all individual participants included in the study. key: cord- -glq t p authors: sabharwal, samir; ficke, james r.; laporte, dawn m. title: how we do it: modified residency programming and adoption of remote didactic curriculum during the covid- pandemic date: - - journal: j surg educ doi: . /j.jsurg. . . sha: doc_id: cord_uid: glq t p abstract objective to describe the modified operational plan we implemented for residents and faculty in our orthopaedic surgery department to allow continuation of resident education and other core activities during the novel coronavirus (covid- ) pandemic. design description of educational augmentation and programming modifications setting the johns hopkins hospital and johns hopkins bayview medical center, baltimore, md participants residents and faculty, department of orthopaedic surgery methods in response to the covid- pandemic, we developed and implemented a modified operational schedule and remote curriculum in the orthopaedic surgery department of our health system. our plan was guided by the following principles: protecting the workforce while providing essential clinical care; maintaining continuity of education and research; and promoting social distancing while minimizing the impact on team psychosocial well-being. results the operational schedule and remote curriculum have been implemented successfully and allow resident education and other core departmental functions to continue as our health care system responds to the pandemic. conclusions we have been proactive and deliberate in implementing these operational changes, without compromise of our workforce. this experience provides residents exposure to real-life systems-based practice. we hope that our early experience will provide a framework for other surgical residency programs facing this crisis. in december , clusters of patients with pneumonia of unknown cause were linked epidemiologically to a seafood and wet animal market in wuhan, china; scientists isolated a novel coronavirus from the epithelial airway cells of these patients, naming the virus -ncov. the first case of -ncov in the united states was detected in january , in a year-old man who had returned to washington after visiting family in wuhan. our institution has been tracking cases of coronavirus disease, or covid- , in real time; as of march , , more than , cases have been confirmed globally, with more than , in the united states. the highly contagious and virulent nature of -ncov make the covid- pandemic a critical threat to the global health care system. to date, the only successful mitigation strategy has been radical reduction of social interaction. , much of the literature regarding this pandemic and prior pandemics, such as sars (severe acute respiratory syndrome) and mers (middle east respiratory syndrome) pertains to the "front lines" and critical care of patients. studies describe disease management and appropriate triage for managing surge capacity, but nothing, to our knowledge, has been published regarding adaptations that surgical subspecialty personnel must make in this new paradigm. [ ] [ ] [ ] in our academic orthopaedic surgery department, we have adopted a modified operational schedule and remote curriculum for resident education in response to the covid- pandemic. our plan was guided by the principles of protecting the workforce while providing essential clinical care; maintaining continuity of education and research; and promoting social distancing while minimizing the impact on team psychosocial well-being. [ ] [ ] [ ] by sharing our early experience with this plan, we hope to provide an operational and educational framework for other departments now and in the future. we have developed and implemented a comprehensive set of modifications to our department's operations to protect our workforce and support patient care, maintain continuity of resident education and research, and ensure social distancing while minimizing the impact on team psychosocial well-being. faculty, residents, and advanced practice providers have been divided into teams: team a and team b. residents on elective rotations have been moved from our ancillary clinical sites and consolidated into these teams to serve our hospitals that handle the largest volume of trauma cases. our interns, junior residents (pgy - ), and senior residents (pgy - ) have been evenly distributed into teams, creating teams a and b at each of our main hospitals. all orthopaedic subspecialty services have been consolidated into the team system. at each of our main hospitals, there is only orthopaedic resident team at any time. the separation of staff into teams reduces the risk of disabling the entire team if quarantine is required. teams a and b alternate clinical in-hospital duty every days. while team a works on-site, performing essential clinical activities (i.e., urgent and emergency cases and consultations, as well as continuing care of hospitalized patients), team b works remotely. the remote team has no face-to-face interaction with the clinical team. although there is built-in redundancy within each team to accommodate for house staff falling ill while on clinical duty, the remote team serves as additional reserve personnel to support the clinical team on an asneeded basis. as both a department and an institution, with consensus across all surgical specialties, we have cancelled all elective cases and decreased clinical volume, limiting in-person visits to those deemed to be urgent or emergencies. whenever possible and appropriate, telemedicine consultations supplant in-person visits. although we have eliminated resident clinic coverage to reduce in-person exposure, residents have completed the requisite training to participate in telemedicine consultations. participation in these consultations provides continuity of clinical education without additional risk. operative cases are staffed by no more than faculty and resident to limit exposure. a comprehensive hand-off between teams a and b is completed by teleconference just before switching of on-site and remote duties, and closed-loop communication is emphasized throughout this process. while the remote team may not attend to the hospital or other clinical sites in-person, they are available to assist with supportive tasks, such as answering patient calls or performing discharge summaries. in addition to performing research and completing an augmented remote curriculum, discussed in further detail below, residents working remotely maintain their availability as backup, in case of illness or quarantine of on-site staff. social distancing is an expectation during the -week remote rotation, which mirrors the time recommended for a home quarantine if indicated. daily teleconferences minimize the impact of social isolation while promoting social distancing and preventing disease spread. it is expected that the remote team will avoid contact closer than feet with anyone outside their households. in addition to maintaining educational continuity, daily teleconferences provide a sense of community and promote team well-being. we will distribute surveys at regular intervals to monitor resident and faculty mental health, using short-form measures of burnout, social isolation, and well-being. [ ] [ ] [ ] as stated above, residents working remotely complete an augmented didactic curriculum ( table ). the remote curriculum begins with a live, -hour teleconference presented by a faculty member on the remote team, covering clinical cases. this presentation is followed by a break of several hours, using the principle of spaced repetition. a chief resident on the remote team then leads a question review, also by teleconference. residents also independently complete a structured "flipped-classroom" curriculum, comprising pre-recorded webinars and assigned reading, as well as additional review questions, in preparation for the next day's faculty-led teleconference topic. in addition to this didactic curriculum, residents (and faculty) participate in teleconferences engaging multiple departments across the institution on pandemic-specific topics, including appropriate personal protective equipment use, care of the critically ill covid- patient, and ethical stewardship. from the perspective of experiential learning, these adaptations expose residents to a real-life example of systems-based practice. residents working remotely continue to pursue research and to check in with their research mentors each week by email and teleconference, to discuss the progress of ongoing projects. our department's editorial services team also continues remote operations to support the research volume produced during this period. the covid- pandemic presents many uncertainties. by proactively developing and implementing a modified operational schedule and remote curriculum, our department is striving to minimize risk to our workforce while we continue core functions. this experience exposes - - residents to a real-life example of systems-based practice. although the particular staffing constraints of individual programs may warrant modifications to the approach we describe, we hope that our early experience will provide a framework for other surgical subspecialty residency programs facing this crisis or similar events in the future. a novel coronavirus from patients with pneumonia in china first case of novel coronavirus in the united states an interactive web-based dashboard to track covid- in real time effectiveness of workplace social distancing measures in reducing influenza transmission: a systematic review isolation, quarantine, social distancing and community containment: pivotal role for old-style public health measures in the novel coronavirus ( -ncov) outbreak hospital emergency management plan during the covid- epidemic coronavirus disease in china preparing intensive care for the next pandemic influenza long-term psychological and occupational effects of providing hospital healthcare during sars outbreak a control banding framework for protecting the us workforce from aerosol transmissible infectious disease outbreaks with high public health consequences chapter . protection of patients and staff during a pandemic. recommendations and standard operating procedures for intensive care unit and hospital preparations for an influenza epidemic or mass disaster a short scale for measuring loneliness in large surveys: results from two population-based studies responsiveness of the short warwick edinburgh mental well-being scale (swemwbs): evaluation a clinical sample single item measures of emotional exhaustion and depersonalization are useful for assessing burnout in medical professionals overcoming distance: video-conferencing as a clinical and educational tool among surgeons enhancing human learning via spaced repetition optimization academic outcomes of flipped classroom learning: a meta-analysis systems-based practice: improving the safety and quality of patient care by recognizing and improving the systems in which we work key: cord- - zwt bfo authors: fero, katherine e.; weinberger, james m.; lerman, steven; bergman, jonathan title: perceived impact of urologic surgery training program modifications due to covid- in the united states date: - - journal: urology doi: . /j.urology. . . sha: doc_id: cord_uid: zwt bfo objective: significant healthcare disruption due to pandemic coronavirus disease (covid- ) has implications across all aspects of clinical care in the united states (us). in this study, we aim to assess urology residency program modifications in the context of covid- , and perceptions of the impact on urology trainees. methods: a cross-sectional survey of program leadership and residents at accredited us urology residencies was administered between april , – march , . total cohort responses are reported, and sub-analyses were preformed comparing responses between those in in high vs low covid- geographic regions, and between program leaders vs residents. results: program leaders from % of programs and residents from % of programs responded. respondents reported decreased surgical volume ( %- % varying by subspecialty), increased use of telehealth ( %), a transition to virtual educational platforms ( %) and decreased size of inpatient resident teams ( %). most residents are participating in care of covid- patients ( %) and % endorsed that urology residents have been re-deployed. % of respondents perceive a negative impact of recent events on urology surgery training and anxiety regarding competency upon completion of residency training was more pronounced among respondents in high covid- regions. conclusion: major modifications to urology training programs were implemented in response to covid- . attention must be paid to the downstream effects of the training disruption on urology residents. objective: significant healthcare disruption due to pandemic coronavirus disease (covid- ) has implications across all aspects of clinical care in the united states (us). in this study, we aim to assess urology residency program modifications in the context of covid- , and perceptions of the impact on urology trainees. methods: a cross-sectional survey of program leadership and residents at accredited us urology residencies was administered between april , -march , . total cohort responses are reported, and sub-analyses were preformed comparing responses between those in in high vs low covid- geographic regions, and between program leaders vs residents. results: program leaders from % of programs and residents from % of programs responded. respondents reported decreased surgical volume ( %- % varying by subspecialty), increased use of telehealth ( %), a transition to virtual educational platforms ( %) and decreased size of inpatient resident teams ( %). most residents are participating in care of covid- patients ( %) and % endorsed that urology residents have been redeployed. % of respondents perceive a negative impact of recent events on urology surgery training and anxiety regarding competency upon completion of residency training was more pronounced among respondents in high covid- regions. conclusion: major modifications to urology training programs were implemented in response to . attention must be paid to the downstream effects of the training disruption on urology residents. the viral pandemic disease, covid- , has abruptly disrupted urology practice and urology training. the immediate and long-term impacts remain unknown and have yet to be systematically studied. the impact of covid- on the united states (us) healthcare workforce is multi-faceted and continues to evolve. in geographic regions that have been inundated with covid- patients requiring hospital care, resources such as personnel, hospital beds, ventilators and personal protective equipment are in high demand and short supply. in such settings, hospitals are further constrained by providers contracting covid- , necessitating self-isolation as recommended by the centers for disease control (cdc). re-deployment has been implemented in these hospitals in an effort to meet patient care needs. in contrast, many hospitals in regions with lower covid- prevalence have limited their routine patient care to preserve resources, resulting in decreased clinical volume. as a surgical subspecialist, the urologist typically performs a high volume of scheduled surgeries in ambulatory surgery centers and hospital based operating rooms, in addition to clinic procedures and ambulatory clinic visits. this traditional healthcare delivery pattern has been severely disrupted by covid- . the downstream impact on the urologic trainee with respect to surgical and ambulatory volume, educational opportunities, and workforce restructuring has yet to be described. furthermore, amidst the uncertainty regarding the future of healthcare, there are likely to be varying impacts on the trainee's psyche ranging from moral injury, burnout, and fatigue to a renewed sense of purpose in medicine, improved morale and pride in one's work. in this study, we aim to assess the impact of healthcare disruption due to covid- on urology residency programs and trainees via survey of us program directors and residents. we hypothesized a priori that a reduced case volume would lead to a decreased perception of surgical preparedness, but an improved sense of morale and purpose. an anonymous online survey was administered to residents and program leadership (program directors (pds) and associate program directors (apds)) in the united states. the american urological association (aua) website was used to identify the accredited urology residency programs. pd email addresses were collected from the aua residency listing page, the aua member directory, or individual program websites. of the accredited urology residency programs, programs did not have available contact information for program leadership. the survey was sent to pds with request to complete and forward communication to their apd (if applicable), and their resident cohort for completion. the survey was distributed on april , and closed on may , . no responses were excluded. this study was deemed exempt from review by the institutional review board at the university of california, los angeles. the -question survey was designed and administered via our institutional license of the web-based qualtrics platform (qualtrics, provo, ut). prior to distribution, the survey questions were developed in an iterative fashion with input from the authors and additional faculty and residents at our institution. we collected demographic data including respondent all survey question responses were coded as binary or categorical variables. descriptive statistics of the overall cohort were performed. we defined a geographic variable to identify respondents in high-covid- regions. respondents from the ten us states or districts with the highest number of per-capita covid- infections at the time of survey closure (may , ) were considered to be in 'high covid- ' regions (new york, new jersey, massachusetts, rhode island, connecticut, washington d.c, delaware, louisiana, illinois, and maryland). we performed sub-group analysis with data stratified by high covid- vs low covid- geographic status comparing outcomes with pearson's chi-square test. for additional sub-group analysis, pd and apd responses were combined and defined as 'program leaders'. using pearson's chi-square test we then compared program leader vs resident responses to investigate any differences in perception of residency impact related to role. p values < . were considered significant. we received survey responses from program leaders representing programs ( / = %) and residents representing programs ( / = %). the geographic distribution of respondents is represented in figure ; % were located in high covid- regions. most respondents were male ( %). of the resident respondents, the majority were junior residents ( % pgys - vs % pgys - ). there were consistent reports of decreased surgical and ambulatory volume. we queried changes in specific subspecialties' surgical case volume and saw reported a decrease in volume across all subspecialties, including urologic emergency case volume ( figure ). residents continued to assist in surgical cases that were ongoing ( %). almost all ( %) respondents reported implementation of telehealth for ambulatory visits; fewer reported resident participation in telehealth encounters ( %) and continued participation in in-person clinic encounters ( %). we assessed changes to standard educational conferences including grand rounds, didactics, journal club, morbidity & mortality, and indications conferences. nearly all respondents ( %) reported discontinuation of in-person conferences with most reporting a transition to virtual platforms ( %). fifty four percent of respondents reported an increase in number of educational activities. overall, % of respondents reported a decrease in the number of residents per team managing inpatients (admitted patients and consultations). a majority ( %) reported resident participation in the care of covid- infected patients, or persons under investigation, during their duties as a urology resident. more than half of respondents reported a resident had to stay-at-home for some period of time due to exposure, personal illness or family member illness ( %). we also queried how programs were managing trainees who fall into at-risk populations due to pregnancy or immunocompromise. the majority responded that some modification has been made: % ( / ) of those who responded to this question reported pregnant residents are not providing care to covid- positive patients; % ( / ) of those who responded reported pregnant residents are not providing direct patient care at all. similar modifications were reported regarding immunocompromised residents: % of respondents reported these residents are not providing care to covid- positive patients and % reported they are not providing direct patient care. urology trainees were re-deployed ( %) in a diverse number of settings ( % intensive care unit, % wards, % emergency room, % non-urology telehealth, % general surgery team, % invasive-procedures team; more than one choice allowed). education in preparation for possible redeployment was provided in the form of in-person didactics ( . %), in-person procedural instruction ( %), virtual didactic or selfdirected learning ( %) (more than one format choice allowed). additional support services that were provided to urology trainees by either institutions or programs included childcare ( %), temporary overnight accommodations ( %) and meals ( %) (more than one response allowed). we queried perceptions of the downstream effects of modifications to urology training programs (table ) in sub-group analysis we compared responses between high covid- vs low covid- regions, as previously defined (supplemental table ). significantly more respondents from high covid- regions reported decreased emergency urologic surgical volume ( % vs %, p = . ) and cancelled educational activities ( % vs %, p < . ). a significantly larger proportion of respondents in high covid- regions reported urology trainees caring for covid- patients ( % vs %, p= . ), being re-deployed ( % vs %, p< . ), and being required to stay at home due to sickness or exposure ( % vs %, p < . ). more respondents in high covid- regions reported that pregnant residents continue to work without modification ( % vs %, p < . , supplemental table ). there was a significantly higher proportion of respondents in high covid- regions who endorsed increased anxiety about competency upon completion of residency ( % vs %, p= . ) ( table ). there was no significant difference in the proportion of respondents who agreed with statements regarding increased pride in work or improved morale between cohorts. in additional sub-group analysis, we compared responses between program leaders and residents. there was concordance in nearly every domain, with no statistically significant differences between groups in responses regarding clinical modifications, educational modifications or workforce restructuring. however, responses to two questions regarding perception of impacts differed significantly. compared to program leaders, residents were more likely to disagree with a statement that 'changes in urology services due to covid- have 'disrupted home life' ( % vs %, p = . ). compared to program leaders, residents were less likely to agree with a statement that 'changes in urology services due to covid- have increased my worries about my family's finances' ( % vs % p < . ). here, we report the first us national survey of urology residency program leadership and trainees assessing covid- -related program modifications and their impact on trainees. our results confirm the hypothesis that significant modifications have been made across all aspects of surgical training. in accordance with urologic and other surgical society guidelines recommending postponement of non-emergent surgeries, nearly all respondents reported a decrease in surgeries performed across all subspecialties. - interestingly, surgical volume decrease was also noted for emergency services, particularly in high covid- regions, which may reflect an aversion of the general public to seek any care due to fear related to the surgical volume decrease has important implications regarding experience lost to trainees. in light of this, it is not surprising that most respondents agreed with a statement that covid- related changes have negatively impacted surgical training. the accreditation council for graduate medical education (acgme) and the american board of urology (abu) maintain procedural and surgical case-based standards for accreditation and resident advancement. , because this survey was administered at a single time point, we cannot comment on duration of decreased case volume, however attention should be paid to resident-reported acgme case logs during this time-period, and into the coming months. program leaders and governing bodies should consider modifications of, or exceptions to, volume-based standards (i.e. replace or supplement with competency-based standards). for most residents in -or -year programs, a short duration of decrease in high volume subspecialties (i.e. oncology, endourology) will likely be offset by adequate volume during non-peak-pandemic times. however, many trainees have more limited exposure to subspecialties including pediatrics and reconstructive urology. residents on such a rotation during the peak-pandemic scale-back may have missed out entirely on their required case volumes and critical exposure to a potential field of interest. program leaders must consider options to compensate for such missed opportunities, including flexibility in future rotation scheduling or off-rotation experiences. worth noting is the significant proportion of respondents who endorsed increased time for self-directed learning and research efforts. the notion that value lost with decreased surgical volume may be offset by enhanced time for other educational endeavors is intriguing, given the complex cognitive machinations needed to successfully treat patients with surgical diseases. future study is needed into the relative effects of these changes. in the ambulatory setting, a similar scale-back was seen with nearly all respondents reporting decreased in-person clinic visits and implementation of telehealth encounters. while % of respondents report that residents are participating in telehealth encounters, there is certainly room for improvement in engaging residents in a meaningful way in this aspect of patient care. there has been much discussion in the literature regarding implementation of telehealth as an opportunity for clinical education; we must be sure to maximize educational value as telehealth will possibly become a fixed component of urologic patient care. [ ] [ ] [ ] in the context of cdc recommendations to employ social distancing and avoid large groups, it is not surprising that our respondents endorsed a nearly universal transition to virtual platforms for conferences and didactics serving educational purposes. while not surprising, it is important to note that respondents in high covid- regions reported a high proportion of educational sessions being cancelled outright. however, a high proportion of respondents in both high and low-covid- regions ( % and %) reported that program changes due to covid- have allowed for more time for self-directed learning. how to best capitalize on this time, and attempt to compensate for decreased operative experience, is of utmost importance. for years, medical educators have been investigating novel strategies to educate adult trainees and the covid- pandemic has forced adoption of some of these strategies. some of these novel strategies include employing a flipped classroom (learners first pre-study with a didactic lecture followed by expert-led, interactive session), and generating libraries of virtual lectures and surgical videos from thought-leaders in the field. , rapid implementation of virtual didactic series have enabled learners across the us (and internationally) access to free, highquality, educational material. , we found significant workforce restructuring occurred among urology trainees. changes included decreased size of inpatient teams, education in preparation for redeployment, and, particularly in high covid- regions, re-deployment. these findings are in line with modifications recently reported in otolaryngology, general surgery and neurosurgery. [ ] [ ] [ ] programs also had to manage resident absence due to personal illness or exposure, and protect medically vulnerable residents. our study has several limitations. as a survey study it is subject to response bias related to phrasing and question order. additionally, respondents in areas impacted by covid- may be over-represented due to interest or perceived applicability. with respect to our decision to define high covid- regions on the state level, we are aware that we fail to capture the variability of covid- infection density down to the city level. however, most residency programs are affiliated with large medical centers typically located in high population-density areas of a given state, a fact that helps overcome this limitation. finally, while overall program representation was strong (which is good for relatively objective measures such as impact on surgical and clinical volumes, education strategies and workforce restructuring) we may lose some power to detect more individualized (i.e. psychosocial) impacts of covid- on trainees by our relatively low raw resident response rate. in the months after the emergence of covid- , us urology residency programs underwent significant modifications including decreased surgical and ambulatory volume, increased use of telehealth, increased educational activities via virtual platforms and significant workforce restructuring. in the context of these changes, program leaders and trainees perceive an overall negative impact on surgical training and increased anxiety about competency. it will be important for program leaders and trainees to collaborate in developing solutions to the unique challenges faced by trainees during this time period and moving forward. european association of urology guidelines office rapid reaction group: an organisation-wide collaborative effort to adapt the european association of urology guidelines recommendations to the coronavirus disease elective surgery in the time of covid- covid- : elective case triage guidelines for surgical care. american college of surgeons reduction in st-segment elevation cardiac catheterization laboratory activations in the united states during covid- pandemic accreditation council for graduate medical education: urology residency requirements using technology to maintain the education of residents during the covid- pandemic telemedicine and econsults for hospitalized patients during covid- implementing telemedicine in response to the covid- pandemic coronavirus disease (covid- ): communities, schools, workplaces, and events practical techniques to adapt surgical resident education to the covid- era adapting urology residency training in the covid- era urology collaborative online video didactics (covid) emergency restructuring of a general surgery residency program during the coronavirus disease pandemic: the university of washington experience impact of the covid- pandemic on neurosurgical residency training in new orleans otolaryngology resident practices and perceptions in the initial phase of the u.s. covid- pandemic clinic akron general urology residency program's covid- experience college of obstetricians and gynaecologists. occupational health advice for employers and pregnant women during the covid- pandemic covid- : doctors in final trimester of pregnancy should avoid direct patient contact addressing general surgery residents' concerns in the early phase of the covid- pandemic key: cord- -puly tyv authors: pak, jamie s.; sayegh, christopher i.; smigelski, michael b.; mckiernan, james m.; cooper, kimberly l. title: a urology department's experience at the epicenter of the covid- pandemic date: - - journal: urology doi: . /j.urology. . . sha: doc_id: cord_uid: puly tyv nan since the first reported case of the novel coronavirus disease in washington state, the united states has become the global epicenter of the pandemic. with many predicting critical shortages of hospital beds, ventilators, and health care providers in new york city (nyc), the newyork-presbyterian hospital and columbia university irving medical center (cuimc) quickly implemented system-wide changes to prepare our response. as of may , , nyc itself had , cases and , deaths, the latter only surpassed by five countries outside the united states. in this correspondence, we summarize the cuimc department of urology's experience at the global epicenter of covid- to guide other departments in the response to this and future pandemics. in early march , our department held twice-weekly phone conferences to address the spread of covid- to nyc. all urology faculty, residents, and administrative personnel participated, allowing all parties to ask questions and give input regarding the frequent changes in protocols. these calls ensured immediacy, transparency, and fidelity of information during a rapidly evolving situation. the volume of covid- patients was quickly increasing and many front-line providers were being quarantined for symptoms and/or exposure. it was clear that redeployment of our staff was imminent. to increase available personnel, equipment, and physical space, all elective surgical cases at cuimc were suspended on march . on the evening of march , our chairman called an emergency phone conference. hospital leadership had declared that our emergency rooms (ers) were overrun and in need of assistanceredeployment had been activated. urology faculty and residents were asked to volunteer on an "opt-in" basis. this was in consideration of the yet unknown roles and risks of redeployment. the hope was that enough willing and able staff would volunteer to fulfill the need, while considering those who may have personal reasons to abstain unless absolutely necessary. our program leadership also emphasized that in the spirit of departmental solidarity, all volunteering urology physicians would be redeployed in pairs of one resident with one attending. this paired team model ensured that we would embark on these challenges together. ultimately, a total of residents, attendings, two nurse practitioners (nps), and three medical assistants volunteered for redeployment. half of the residents continued working in our urologic inpatient services, though they were available for activation should anyone in the redeployment pool need to quarantine (figure ). these separate resident pools were created to minimize the risk of covid- exposure within our department. initially, we were redeployed to two ers at our main university and satellite hospitals, assigned to provide -hour coverage for admitted, "non-covid" patients awaiting bed placement. on the first day of redeployment, our department encountered the overwhelming number of patients, very few of whom were "non-covid." practically every patient in the er was being ruled out for or confirmed to have covid- . our assignment immediately transformed into an undefined ancillary role to serve however needed, including assisting with chest compressions, ensuring empty oxygen tanks were replaced, placing intravenous/arterial lines and foley catheters, and constantly reassessing patients' vital signs. as the cases of suspected/confirmed covid- increased exponentially, many patients in our hospital required icu-level care in the er while awaiting inpatient transfer. our department recognized this gap in care and with the help of our medical colleagues, developed a novel -bed "emergency department-intensive care unit" (ed-icu) to care for these critically ill patients. the team per -hour shift consisted of: ) one medical intensivist or subspecialist as the supervising attending, ) one to two senior medicine icu resident(s) as the team lead(s), ) one icu pharmacist during the day shifts, ) one respiratory therapist, ) ed nurses with prior icu experience, and ) one urology attending/resident pair with or without a urology np. our attending/resident pairs were responsible for entering orders, reviewing labs and imaging, adjusting ventilator settings, contacting consultants, and speaking with patients' families. as the ed-icu gained prominence in the care pathway of covid- patients at cuimc, we also played an instrumental role in onboarding providers from other specialties to the attending/resident pair role. this involved creating an ed-icu manual with a primer on critical care specific to covid- , hosting an online orientation, and taking extra shifts in an oversight role. the volume of critically ill patients in our hospitals continued to increase to unprecedented levels. in order to further increase critical care capacity, several "pop-up" icus were created in various areas throughout the main and satellite hospitals, including many of the pre-operative areas and operating rooms (ors). our roles in these "pop-up" icus were identical to our responsibilities in the ed-icu. at our satellite hospital, with all established icu beds filled to capacity, a "pop-up" icu of six critical care beds was created in the pre-operative area. we began rotating in this new icu on april . given the residents' increasing comfort with caring for critically ill covid- patients, urology residents were redeployed to this icu without an accompanying attending. each -hour shift, the team consisted of: ) one medical intensivist as supervising attending, ) one to two medicine subspecialty fellow(s) as team lead(s), ) one respiratory therapist, ) two to three rns, and ) one urology resident with or without a urology np. at the main university hospital, several of our ors were converted to "pop-up" icus (or-icu), with each or able to accommodate four critically ill patients. on april , the volume of patients in the main hospital ed-icu subsided enough that our department was fully reassigned to the or-icus on april . each bay, consisting of three or-icus (maximum of twelve patients), was covered by one medical intensivist as supervising attending and one senior otolaryngology or anesthesiology resident as team lead. each or-icu was then covered by two rns with prior icu experience and an attending/resident pair from urology or another redeployed specialty. eventually, as the overall volume of critically ill patients with covid- began to subside, our department was informed that we were no longer needed in the or-icus on may and in the satellite hospital "pop-up" icu on may . during the swift and drastic process of redeployment, one of the many concerns was the maintenance of urologic services. residents and attendings who were not in the deployment pools worked in staggered shifts, both in the outpatient and inpatient settings. the vast majority of outpatient visits in both the resident-and faculty-run practices were transitioned to televisits via phone or video, unless an in-person visit was absolutely necessary. the suddenly vacant faculty practice space allowed us to utilize the clinic in another way. to minimize patient and urology consultant exposure to covid- in our ers, our department collaborated with our emergency medicine colleagues to create a new diversion protocol for patients presenting to the er with an acute urologic issue. once a patient was determined to meet certain inclusion and exclusion criteria there have been several sources of anxiety specific to healthcare workers during this pandemic. early on, there were justified concerns about adequate personal protective equipment, potential transmission of covid- to family and friends, and ability to provide appropriate care if redeployed to an unfamiliar setting (i.e., er, icu). as these concerns somewhat dissipated, we encountered the dark realities of critical illness and death from covid- in our patients, colleagues, family, and friends. emotions such as guilt, helplessness, and grief accompanied our anxiety. in response to such concerns, our hospital promoted active working relationships between the housestaff mental health service and our providers. two mental health experts, one who is a psychiatrist and director of mental health services for graduate medical education at cuimc, hosted weekly virtual peer support sessions via zoom, separately for urology residents and faculty. these sessions allowed us to openly express concerns, share common experiences, and discuss coping techniques with our colleagues. in addition, these meetings promoted direct relationships with the mental health staff, who encouraged us to contact them by phone or e-mail at any time. remain open at all times. another unfortunate consequence of the pandemic has been the detrimental effect on urology resident education and training. most urologic surgeries and clinic appointments were cancelled, and anecdotally, inpatient urologic consult requests decreased in number and variety. in addition, weekly multidisciplinary tumor boards and departmental educational conferences were suspended or transitioned to videoconferences. though covid- put a heavy strain on our health care system in general, the changes required to respond to the pandemic led to an overall increased amount of available time for urology residents and faculty. to address this need, our residents and faculty started several educational initiatives. the most prominent of these has been the educational multi-institutional program for instructing residents (empire) lecture series (https://nyaua.com/empire/), sponsored by the new york section of the aua. with inspiration from the "covid" series from the department of urology at the university of california, san francisco, we initiated a multi-institutional lecture series with a focus on resident mentoring, education, and the aua core curriculum given by accomplished speakers across all subspecialties of urology. the schedule of lecture topics was posted at least one week in advance on the empire website, the new york section's twitter account, and via an email listserv. every weekday morning in march and april , two one-hour lectures were given over zoom, with the first ten minutes of each lecture reserved for a q&a session focused on resident career counseling. each day, there were fifty to one-hundred fifty participants, who were encouraged to post questions for the speaker to be answered at the end of each lecture. for those who could not join the live sessions, the lectures were recorded and posted on the empire youtube page. with the empire series covering clinical practice and guidelines, resident surgical training also needed to be addressed. our department therefore initiated the surgical interactive resident curriculum (sirc) and a robotic surgery competition. sirc occurred every afternoon, with a different faculty member hosting an hour-long interactive review of pre-recorded urologic surgeries with cuimc residents and medical students over zoom. this allowed residents to explore the attendings' operative thought processes in terms of steps, techniques, and concerns while obtaining a refresher on relevant anatomy. secondly, the residents, with faculty support, utilized the down time to improve their robotic skills. in order to promote participation and a spirit of competition, a robotic surgery fantasy league was created. residents were split into teams, with an even distribution of post-graduate year experience. every two weeks, three exercises on the da vinci® skills simulator™ were designated and each team member was required to record their best scores during that time period. this approach has resulted in strong resident engagement and improved operative fundamentals, an idea supported in the education literature. a week after our department was relieved from redeployment in early may , the majority of the "pop-up" icus in the ors were vacated. this allowed the space and supporting staff for surgical departments to resume scheduling procedures again, although at limited capacity. this next stage has presented unique challenges of its own. to prioritize surgeries appropriately during decreased or capacity, our department has continued to use our "covid- urologic surgery triage algorithm" (figure ) to prioritize emergent and urgent cases. patients themselves have expressed hesitancy about undergoing surgery at our main hospital in nyc, and therefore have been rescheduled for a later date or at a satellite hospital. this slow process of rescheduling elective surgeries may prolong the detrimental effects of the covid- pandemic on both resident surgical training and patient care. leveraging the aforementioned technologies of videoconferencing and robotic simulation will help to mitigate the effects on resident education. unfortunately, the downstream effects of delay in surgical care will be much more difficult to ameliorate, particularly for patients with cancer. in regards to our outpatient practice, we have reintroduced in-person office visits for select patients, with symptom and temperature checks in the clinic lobby, mask requirements for all patients and visitors, and strict enforcement of six-foot social distancing. though we would like to ensure a "covidfree" space, we recognize that the false-negative rates of the early covid- tests and the presence of asymptomatic carriers make this nearly impossible. given the increased use of televisits during the pandemic, many patients are now more comfortable with the technology, which allows consultation with our providers in the safety and comfort of their homes. similarly to our patients being scheduled for surgeries, those who require in-person visits are being offered appointments at a later date or at a satellite hospital. we foresee that televisits will continue to be a prominent component of our outpatient practice even once the pandemic has subsided. from a big picture perspective, the long plateau of global covid- case numbers highlights the uncertainty of when, if ever, we will return to "normal." though the future remains unclear, our department's unified response to the pandemic has strengthened our sense of solidarity and purpose. our providers volunteered for redeployment, while creating innovative clinical care and educational solutions in a time of need. we have now started performing surgeries and seeing our patients in person again, albeit in much smaller numbers than we had in the pre-covid era. while the recovery first case of novel coronavirus in the united states understanding and addressing sources of anxiety among health care professionals during the covid- pandemic instituting a surgical skills competition increases technical performance of surgical clerkship students over time collateral damage: the impact on outcomes from cancer surgery of the covid- pandemic likely need for imaging (e.g., rule out testicular torsion, suspected renal colic) . likely need for procedural monitoring/sedation (e.g., priapism, abscess incision and drainage) . likely need for admission (e.g., febrile patient with gu chief complaint) key: cord- - xu g authors: zuberi, maaz k.; nizam, wasay; shah, adil; petrosyan, michael; fullum, terrance; cornwell, edward title: should i be concerned? surgical training in the time of covid date: - - journal: j surg educ doi: . /j.jsurg. . . sha: doc_id: cord_uid: xu g as the us healthcare system restructured to deal with the covid- pandemic, medical training was significantly disrupted. during the peak of the crisis, three surgical trainees in different stages of their residency shared their experiences and concerns on how this pandemic affected their training. the article is intended to generate discussion on the concerns of derailment and stagnation of surgical training and difficulties faced at all levels of surgical training to perform clinical duties and fulfill academic responsibilities during the early months of the covid pandemic. as the us healthcare system restructures to deal with the covid- pandemic, medical training is being significantly disrupted. three surgical trainees in different stages of their residency share their experiences and concerns on how this pandemic is affecting their training. howard university hospital, the home program of the authors, is a mid-sized level one trauma center in the dc metropolitan area, has significantly busy surgical and medical services, and is a designated safety net hospital for marginalized dc residents. the surgical residency program is comprised of five categorical residents in each of the five years of training, and nine preliminary junior residents. the residents not only rotate at their home institution, but also complete rotations at affiliated community hospitals in maryland. furthermore, two residents with significant academic interests are selected each year at the end of their second year to complete two additional years of research. the research residents can choose to stay at their home institution to complete research or pursue research at other facilities of their choosing. as junior surgical residents working in these unique circumstances, unlike our medical colleagues who are bearing the brunt of managing the covid outbreak, we seem to be looking at it from a distance. as resources re-route to emergency rooms and covid units, the surgical arm of the medical system seems to be regressing. understandably, all surgical associations have recommended taking all necessary precautions and cancelling or postponing elective cases during the worst phase of this pandemic. , in light of the expected decline in case volumes for the residents, the american board of surgery (abs) has responded by changing its graduation requirements for the current academic year; it has reduced required annual work weeks to from and slashed required surgical cases by %. our program adapted by merging all surgical service lines into a mega service and residents were rotating on service only on days when they were on call. we suddenly found ourselves having more free time than was ever expected during residency. most residents have been utilizing this slowdown in clinical work to learn new skills, enhance their knowledge, and finish overdue research projects. although cancellation of all elective cases means much less time in the operating room honing our surgical skills, it has given us an opportunity to focus on improving our peri-operative clinical acumen. unlike medical residency, where knowledge acquisition is the most critical component of training, operative exposure composes a significant portion of surgical training. with operating rooms expected to be on a standstill for the total duration of this outbreak, there is real fear of losing out on crucial training. in light of this, residents have adapted by spending more time in the simulation center to practice their skill; the simulation center has remained open during the outbreak and residents have been encouraged to book timeslots to use the equipment, which is decontaminated after each use. our program has also implemented additional video conferences to specifically discuss intra-operative decision making to overcome the loss of operative exposure. additionally, our weekly academic discourse, which include morbidity and mortality conferences as well as didactic sessions, have continued via virtual platforms. there is hope amongst the residents of a slow revival of elective procedures once the worst phase of the pandemic is over, and once hospitals have developed measures to screen elective patients in a safe manner. on the upside, unlike other subspecialized surgical residents, general surgery residents are adept at managing acute respiratory distress, and so we have had the pleasure of performing our part during this outbreak. we have been actively involved in the management of critically ill covid patients both in the surgical icu and the overflow pacu, once the medical icu reached capacity. even though there is a looming fear of contracting the disease, junior residents share a feeling of achievement in being able to support our medical colleagues during these tough times, and we believe that this crucial experience will not only help improve our ventilator management skills but also enable us to better understand the critically ill patient. our home institution has restructured the surgical residency to limit our interaction with covid positive patients who are not being actively taken care of by our surgical icu residents. only one resident team member visits the icu to see strictly surgical consults, and we are utilizing chart checking and telemedicine to screen surgical consults that will not require intervention. the trauma bay has also been restructured, and all trauma evaluations are now being performed while donned in personal protective equipment (ppe). the call schedule has also been restructured to reduce resident exposure, while ensuring adequate staffing is present in the setting of some of the residents contracting sars-cov- . residents staff the hospital on a rotational basis, with non-essential residents staying home. one of our community affiliate hospitals has implemented a -team format, each one on for one week at a time. with new interns soon to be inducted into the program in july, at the peak of the covid crisis, it is yet to be seen if these measures will be sustainable. sign outs are occurring over the phone or by utilizing virtual video based platforms , with individual teams maintaining no contact with each other. although all these measures have helped reduce interpersonal contact and the risk of covid transmission, it has led to individual isolation. the extended periods of free days, significantly reduced human interactions and extremely poor outcomes of the critical covid patients has taken a collective toll on the morale of the residents. our program leadership and senior residents have helped boost morale by doing virtual happy hours and weekly virtual check ins to discuss mental health concerns. we have also really appreciated the out pour of love from the community during these testing times. the current shortage and mismanagement of ppe has become a major barrier for delivering care to patients while remaining protected. in some hospitals ppe is being re-used while in some instances ppe cannot always be provided. understandably, most er and medical residencies have reduced their resident exposure by only having attendings manage covid positive patients, however this structure is not always possible for general surgery programs. , ppe shortage means we are rationing n masks and eye shields. our program has taken steps to mitigate this shortage by providing individual residents with - n s which can be used on a rotational basis, recycled every days. however not every hospital structure has the capacity to provide such ppes, and our residents rotating at community centers have had to use the same ppe on multiple patients. at our community affiliate hospitals, the residents have stepped up to play their part and are involved in invasive bedside procedures such as chest tubes, arterial and central lines and emergency airway access for covid positive patients. although the risk and fear of exposure has increased apprehension amongst the surgical trainees, our collective sense of duty has helped us overcome these apprehensions. similar to the disruption of covid- on daily clinical activities, the world of academic surgery has also been immensely affected. approximately a third of surgical trainees interested in academic careers punctuate their training with - years of dedicated research time. as the world continues to reconcile with the new realities mandated by a pandemic that currently shows no signs of slowing, academic centers and the researchers engaged in them have also adapted, embracing innovative solutions and novel processes to minimize the disruption to their scientific endeavors. unsurprisingly, the enforcement of full or partial lockdowns accompanied by aggressive social distancing measures resulted in a tangible effect on research activity. , temporarily, almost overnight, our research laboratories, devoted to studying lung cancer were shuttered, and all planned activities were placed on hold for an unknown period as the safety of both research participants and investigators was evaluated. with the exception of experiments that needed to be performed in a time sensitive manner, bench work was limited to the bare minimum necessary to sustain existing projects. similarly, anticipating the unknown, we were tasked to swiftly develop contingency plans for our ongoing clinical trials and their participants to mitigate any foreseen disruptions. as unsettling as this impact has been, the resulting unanticipated void provided a unique and fortuitous opportunity to restructure and engage in different ways. , while wet lab research was forced to halt, we shifted our research load to focus more on studying genomic databases, conducting chart reviews and analyzing the data we already had. this window of opportunity provided a somewhat welcome break to tackle the mountain of pending unwritten manuscripts that each researcher invariably grapples with. literature reviews were restructured and synthesized to produce topic reviews and book chapters. additionally, at the encouragement of our principal investigator, we have been able to explore a multitude of online educational resources. utilizing these avenues has enabled the acquisition of alternative skill sets such as those relevant to machine learning, data management and statistical analysis. daily lab meetings and brainstorming sessions were transitioned to virtual platforms to ensure that critical thinking and academic discussion continue uninterrupted. aside from academic discourse, remaining connected and engaged in this virtual manner provided us a necessary avenue for moral support, encouragement and reflection as we collectively embraced the new challenges we encountered. on a similar note, with respect to academic conferences, we are faced with new challenges. these meetings afford budding investigators a platform to display their productivity and learn of other innovative works. as these events transition to online platforms, it is exciting to consider the broadened impact and potential scope that will exist for networking and engaging with a wider audience and like-minded colleagues to explore further research ideas and avenues. , in certain regions hardest hit by the pandemic, research residents have also functioned as a unique ancillary force that hospital and institutions were able to call upon as they grappled with the need for additional healthcare workers. while our institute was not placed in such a situation, it was heartening to read stories through social media of how various residents rose to the challenge of embracing the surge faced by their co-workers and provide an additional source of manpower. undoubtedly, we should anticipate the future occurrence of further impacts and derailments as a result of these truly unprecedented times. as unpleasant and disappointing as these events may be, we should strive to refashion these situations to our benefit, focusing not on the potential downsides but rather the positive opportunity costs that we can extract and repurpose to our advantage. learning from our shared experiences will be vital in this regard as we collectively seek our common goals of advancing academic surgery and ultimately benefitting our patients. as the pandemic surges, senior residents across the country have found themselves thrusted into leadership roles with the responsibility to provide patients the best possible care in the most austere environments, while maintaining academic integrity of the training program. with austerity comes the threat of risky working conditions, that have the potential to affect all trainees. junior residents, often at the forefront of delivering patient care on hospital floors, have remained most susceptible to exposures during patient interactions. a large part of assuming leadership has been to protect all levels of trainees from exposure and to staunchly advocate for improved access to personal protective equipment. another major aspect of our new role has been to maintain the morale of the surgical residency and provide emotional support to the junior residents during these difficult times. procedures, which were previously fertile ground for teaching, are now largely overseen by senior residents and attending surgeons to reduce the risk of exposure. this has been to the detriment of junior trainees' training experience and case volumes. from the perspective of the senior residents at our program, we have seen a drastic decline in subspecialty elective procedures since the start of the covid- pandemic. our emergency general surgery services have remained strong, however the total case numbers have been reduced to a quarter or less of the usual capacity. although we believe that this momentary decline will not affect our ability to achieve the minimum index cases required to graduate, it is a welcome relief to see that the abs has reduced their required cases for graduation. hope remains that this momentary embargo on elective cases will lead to a surge in case volumes for all levels of trainees once the pandemic lessens and the restrictions are eased. interestingly, one of the biggest impacts of the nationwide quarantine has been on the interviews for fellowships for residents, and potential job opportunities for graduating fellows. the academic community has, for the first time, been forced to seriously consider and conduct interviews using virtual platforms. four of our five rising chiefs have seen their interview trail get effected due to covid, with all chiefs having nearly a quarter of their interviews via virtual video platforms. overall, the experience of virtual interviews has been positive, however most of my fellow chiefs felt that it is more difficult to judge the culture of a program during these video interviews. although this paradigm shift towards virtual interviews cannot replace an in-person interview, it is an avenue worth exploring. , this pilot test of conducting video conference interviews will bear results after the conclusion of the match process, once programs have an opportunity to evaluate their chosen applicants in the clinical setting. added fine-tuning and a move towards efficient standardization of the interview process will help alleviate the extraneous fiscal cost of the interview trail for applicants and reduce time away from training programs, as demonstrated by a recent acgme survey showing more than a week of missed work for % of applicants and an average of $ in travel related expenditure. the recent difficulties faced by the abs in conducting the virtual board examinations shows that the surgical community as a whole needs to adapt to the current times, and that this evolution will effect current trainees in more ways than expected. it is clear that safeguards need to be in place to prevent surgical residents from facing financial and educational hardship during this time. medical personnel and trainees cling to hope that once the dust settles, they will be witness to a new era in how medicine and surgery are conducted in the us. many beliefs held in dogma are now being challenged and the potential for disease spread has brought previously controversial aspects of treatment of surgical ailments to the forefront. the wealth of information and experiences that result from the pandemic should be geared towards evolving current surgical practices and molding our surgical education. the strong work of our junior colleagues who courageously rose up to the challenge of the pandemic should be commended, and the surgical leadership should make sure that their interests are safeguarded and their surgical education is not shortchanged. selfish endeavors that place allied healthcare workers at risk of exposure may have long lasting repercussions. our collective national experience should mold the ideology of inclusiveness and break down barriers for the coming generation of surgeons. there should be a higher percentage of trainee representatives in surgical board and committees to help establish this culture of inclusiveness. additionally, with the tremendous increase in use of virtual platforms, we should aim to take advantage of this resource and broaden the horizon of our surgical meetings and conferences. lastly, it is imperative that leadership across the country not lose sight of the fact that it will take a collective push to overcome this adversity. let's not lose sight of the fact that current trainees will be both leaders and colleagues in the near future. the steps we take now, will guide the essence of surgery as a field for decades to come. sages and eaes recommendations regarding surgical response to covid- crisis covid- : guidance for triage of non-emergent surgical procedures american college of surgeons modifications to training requirements -covid- update american board of surgery using technology to maintain the education of residents during the covid- pandemic emergency restructuring of a general surgery residency program during the coronavirus disease web conferencing, webinars, screen sharing a terrifying privilege": residency during the covid- outbreak pandemic: how covid- is affecting trainees about % of americans have been ordered to stay at home. this map shows which cities and states are under lockdown critical research hit as covid- forces physics labs to close covid- slows drug studies the effect of covid- on clinical trials: insights from the inside amid coronavirus, disruptions to clinical trial, drug development accelerate in conversation with: science and the response to covid- three science conferences canceled in san diego due to coronavirus covid- : medical conferences around the world are cancelled after us cases are linked to massachusetts meeting virtual interviews in the era of covid- : a primer for applicants conducting interviews during the coronavirus pandemic matching for fellowship interviews launching security investigation for virtual general surgery qe key: cord- -hgty t c authors: cai, yi; jiam, nicole t.; wai, katherine c.; shuman, elizabeth a.; roland, lauren t.; chang, jolie l. title: otolaryngology resident practices and perceptions in the initial phase of the u.s. covid‐ pandemic date: - - journal: laryngoscope doi: . /lary. sha: doc_id: cord_uid: hgty t c objective: the coronavirus (covid‐ ) pandemic has had widespread implications on clinical practice at u.s. hospitals. these changes are particularly relevant to otolaryngology–head and neck surgery (ohns) residents because reports suggest an increased risk of contracting covid‐ for otolaryngologists. the objectives of this study were to evaluate ohns residency program practice changes and characterize resident perceptions during the initial phase of the pandemic. study design: a cross‐sectional survey of u.s. ohns residents at programs was conducted between march , , and march , . results: eighty‐two residents from institutions ( % of invited programs) responded. at the time of survey, % of programs had enacted policy changes to minimize covid‐ spread. these included filtered respirator use for aerosol‐generating procedures even in covid‐ ‐negative patients ( %), decreased resident staffing of surgeries ( %), and reduced frequency of tracheotomy care ( %). the majority of residents ( %) perceived that residents were at higher risk of contracting covid‐ compared to attendings. residents were most concerned about protective equipment shortage ( %) and transmitting covid‐ to patients ( %). the majority of residents ( %) were satisfied with their department's covid‐ response. resident satisfaction correlated with comfort level in discussing concerns with attendings (r = . , p < . ) and inversely correlated with perceptions of increased risk compared to attendings (r = − . , p < . ). conclusion: u.s. ohns residency programs implemented policy changes quickly in response to the covid‐ pandemic. sources of resident anxieties demonstrate the importance of open communication and an integrated team approach to facilitate optimal patient and provider care during this unprecedented crisis. level of evidence: . laryngoscope, on january , , the united states reported its first case of the novel coronavirus disease (covid- ) . as of april , , the united states leads the world in confirmed cases with over thousand people affected, , and over states have adopted directives to keep people at home to "flatten the curve." as the number of coronavirus cases continues to climb, healthcare systems have begun to feel the strain on resources. on march , , the center for disease control and prevention recognized that different states may have varying degrees of risk but nonetheless recommended that all u.s. hospitals prepare for a surge of patients with covid- requiring acute and critical care. preparations included changing practices to prevent the spread of disease and to protect the safety of healthcare workers (hcws). in response to an evolving body of information from this early stage of the pandemic, some hospitals and professional societies modified departmental policies and physician-hospital coverage plans to minimize risk, viral exposure, and personal protective equipment (ppe) depletion. teaching hospitals face the unique responsibility of balancing current public health goals with resident education. , specific to otolaryngology-head and neck surgery (ohns), many procedures such as endoscopy; tracheotomy; and sinus, skull base, and upper airway surgery can aerosolize respiratory droplets. the high viral loads in the nasal and oropharyngeal mucosa, along with our current understanding of the route of severe acute respiratory syndrome (sars) transmission and anecdotal reports of disease transmission during aerosolizing procedures, place otolaryngologists at a higher risk for contracting covid- . along with other hcws directly treating covid- patients, ohns residents may experience considerable anxiety regarding their personal safety, transmission of the infection, and education. prior studies of hcws during the - outbreak of sars showed long-term psychosocial effects among hcws who cared for sars patients. , recent recommendations from the american academy of otolaryngology-head and neck surgery (aao-hns) and society of university otolaryngologists (suo) necessitated changes to resident clinical responsibilities, rotation schedules, and ppe guidelines during this pandemic. the aao-hns released a position statement on march , , advising otolaryngologists to limit care to time-sensitive problems and use appropriate ppe. the following day, the suo council released recommendations to reduce trainee risk of contracting covid- through minimizing unnecessary exposure to patients as well as social distancing among resident team members. with these guiding principles, varying departmental policies were created in response to covid- during march because current and projected numbers of cases and resource shortages varied broadly across the country. to our knowledge, there are no published studies examining practice patterns among residents of any specialty during the initial phase of the covid- pandemic. thus, we conducted a cross-sectional analysis to evaluate u.s. ohns residents' practice patterns and perceptions or concerns during the early stages of this pandemic. an understanding of institutional guidelines and differences may help inform programs' policies and identify areas of resident-specific concerns during the covid- pandemic. this study was approved by the institutional review board at the university of california, san francisco. an anonymous, online survey (see supporting information appendix s , available online only) was distributed to u.s. ohns residents on march , , via the qualtrics survey platform (qualtrics international, inc., provo, ut). resident contact information was gathered using publicly available e-mail addresses from aao-hns section for residents and fellows representatives and resident contacts at institutions. thus, otolaryngology programs were not contacted because no publicly available resident e-mail addresses were available. we collected basic demographic information, including postgraduate year (pgy), size of program, number of hospitals requiring resident coverage, and geographic location as defined by the u.s. census regions. residents in pgy through pgy were defined as junior residents, whereas pgy and pgy trainees were defined as senior residents. survey response collection was closed on march , . no response was excluded. respondents were asked when (if applicable) any policy changes had been enacted within their city/county, hospital, and department. departmental policy changes assessed included those affecting rotation schedules, clinical responsibilities, and aerosol-generating procedures. each study participant was queried on the specific ppe policies for various clinical scenarios. covid- status was dichotomized into covid- -positive or person under investigation (pui) versus covid- -negative or those without symptoms. lastly, participants were asked about their concerns, satisfaction with their department response, and perceived level of risk for residents and attendings for contracting covid- . these likert-scale responses were scored from to . responses were collated in microsoft excel, version . . (microsoft corp., redmond, wa) and stata (stata . college station, tx). data were analyzed by chisquared or t tests as appropriate. kaplan-meier curves were used to analyze the time to policy change for programs by high versus low numbers covid- infections in their states. the states considered to have high numbers of covid- infections were the states with the greatest numbers of covid- cases on the date the survey was released and included california, florida, georgia, illinois, louisiana, massachusetts, michigan, new jersey, new york, and washington. for data regarding institutional policy changes, if multiple participants within the same institution provided differing responses, the most common answer provided by respondents was utilized. if there was no majority, then the most conservative answer suggesting a change in policy was used for analysis. to compare dates of policy changes, we selected the earliest date any type of change related to resident staffing of operating rooms, clinics, or inpatient consults was implemented. the relationship between resident satisfaction and resident risk perception or resident comfort with discussing concerns with their department was analyzed using pearson's correlation coefficient. we evaluated the association between resident satisfaction and timeliness of enacted policy changes, which was dichotomized into early versus later responders by the average date of policy change for programs included in this study. we obtained complete survey responses from residents across of institutions contacted. this yielded a program response rate of % and represents % of all u.s. ohns residency programs ( table i ). the percentages of junior and senior resident respondents were similar ( % and %, respectively). most programs ( %) required resident coverage for at least two hospital sites. all geographic regions were represented, and % of states with an ohns residency program ( of ) were included. all programs reported policy changes for local businesses, and almost all hospital systems ( %) had postponed elective surgeries and nonurgent clinic visits. a timeline of ohns residency programs' policy changes relative to nationwide events is depicted in figure respectively). at the time aao-hns released a position statement on march , , % of programs had already implemented their own policy changes. in addition, % of programs advised decreased resident coverage in the operating room or clinic, and % limited nonurgent inpatient consultations. the specific policy changes for resident clinical responsibilities varied between programs (table ii) . over % of programs decreased the number of team members in the operating room. nineteen programs ( %) attempted to mitigate exposure by creating resident cohort groups. of these programs, created resident cohort schedules that alternated on a weekly basis. some programs incorporated or increased senior resident ( %) or attending ( %) coverage of the primary call pool. the majority of programs made changes to performance of aerosolizing procedures by halting decongestant/anesthetic spray use ( %) and restricting tracheotomy tube changes to urgent scenarios ( %). for nasolaryngoscopy, % of programs required an attending or fellow to perform the procedure, and % required attending approval before residents proceeded. ppe usage policies were also assessed (fig. ) . for asymptomatic or covid- -negative patients, the majority of residents reported use of surgical masks for history and physical exams ( %), and an n or powered airpurifying respirator (papr) for aerosol-generating procedures ( % and %, respectively). in contrast, among covid- -positive patients or puis, n or papr use was almost universal. resident perception of risk of contracting covid- was queried (fig. ) . when asked to rate the perceived risk of junior residents relative to senior residents of contracting covid- , residents responded differently based on their level of training. the majority of junior residents ( %) and a minority of senior residents ( %) rated junior residents as being at a higher risk of contracting covid- relative to senior residents. there was a significant difference between the average likert-scale scores between juniors ( . ae . ) and seniors ( . ae . ; p < . ), with % of senior residents reporting equivalent risk among residents. furthermore, the majority of residents applying pledgets in nose prior to endoscopy % ( ) nasolaryngoscopy performed by attending or fellow only % ( ) require approval by attending or senior resident % ( ) attending call/rotation changes attendings covering (or covering more) primary call % ( ) attendings covering fewer hospital sites % ( ) resident call/rotation changes senior residents now covering (or covering more) primary call % ( ) residents covering fewer hospital sites % ( ) cohorted residents* % ( ) residents alternating at hospitals weekly % ( ) *cohorting was defined as division of the residency cohort into teams that do not overlap. covid- = coronavirus . at all levels ( % of junior residents; % of senior residents) rated a higher risk of contracting covid- when asked to rate risk level between residents and attendings. only % of junior residents and % of senior residents perceived a lower risk of contracting covid- for residents compared to attendings. the likert-scale ratings for resident risk compared to attending risk did not differ between junior and senior residents (p = . ). the areas of greatest concern for residents included ppe shortage, transmitting covid- to patients, and transmitting disease to family or friends. there were extreme or moderate levels of concern about these issues in %, %, and % of survey respondents, respectively (fig. ) . the effect of covid- on resident education was a significant concern for % of respondents, whereas % of residents expressed concern about anxiety or burnout for themselves. overall, the majority of residents were satisfied with their departments' response to covid- and were comfortable expressing concerns to attendings and department leadership. seventy-three percent of residents were "extremely satisfied" or "somewhat satisfied" with their fig. . resident perceptions of risk for contracting covid- when asked to rate risk level between junior and senior residents and between residents and attendings. responses from junior (years - of training) and senior (years - of training) residents were compared. *there was a statistically significant difference in average scores between junior and senior residents when asked to rate risk level between junior and senior residents (p < . ). the majority of residents rated residents at a higher risk level than attendings for contracting covid- . covid- = coronavirus . departmental response, and % of residents felt "extremely comfortable" or "somewhat comfortable" with communicating their concerns. a minority of residents were dissatisfied with their program response ( %) and uncomfortable communicating their concerns to their department ( %). satisfaction level was strongly correlated with comfort in communicating their concerns (r = . , p < . ) and inversely correlated with resident perception of increased risk of contracting covid- relative to attendings (r = − . , p < . ). furthermore, residents at programs with departmental policy changes by march , (the average date of department policy change among programs), had higher average satisfaction scores than residents at programs that implemented changes at a later date ( . ae . vs. . ae . , p = . ). this is the first study to assess the response of ohns residency programs to a pandemic and resident perceptions of these changes. our results show timely action by ohns residency programs across the united states in efforts to both contain the spread of covid- within departments and throughout the broader healthcare system. almost all programs instituted departmental policies to either reduce resident clinical staffing or limit nonurgent inpatient consults by the time the aao-hns released their position statement on march , . most departments made changes to the call schedule, with the major themes of reducing the number of residents within the hospital and minimizing overlaps of teams. less common adjunctive measures included shared primary call burden by attendings and senior residents. the majority of residency programs also made changes to the practice of aerosol-generating procedures, such as nasolaryngoscopy, that were congruent with recommendations by the aao-hns. , a majority of programs ( %) eliminated nasal sprays prior to endoscopy. alternatively, % of programs started using pledgets to achieve topical anesthesia or decongestion for endoscopies, which may have value in curbing the sneeze reflex and subsequent aerosolization of droplets. furthermore, the vast majority of residents started using filtering respirators for aerosol-generating procedures regardless of patient covid- status or symptoms. in a minority of programs, flexible laryngoscopy was performed by only attendings or fellows. these policies are consistent with recently published anesthesiology guidelines which noted that sometimes the most appropriate airway managers are senior-level physicians. another potential practice change, not assessed in this study, involves laryngoscopy equipment options. an ohns department in china recommended using the smallest-diameter flexible laryngoscopes available. meanwhile, our institution has transitioned to disposable flexible video laryngoscopes to further minimize risk of disease transmission during transport and sterile processing of reusable endoscopes. the changes to tracheotomy care seen in this study echoed similar themes from the aao-hns position statement regarding tracheotomy recommendations during the covid- pandemic. most programs reported a reduction in the frequency of tracheotomy tube changes to prioritize the safety of hcws. in addition, for covid- positive patients, the aao-hns recommended performing tracheotomy no sooner than to weeks after intubation and utilizing heat moisture exchange devices when the patient no longer requires mechanical ventilation, regardless of covid status. we suspect specific institutional guidelines regarding tracheotomy procedures and routine care will evolve in response to this position statement. it is notable that two-thirds of the residents who were surveyed perceived their risk of contracting covid- as higher than that of their attendings, and this increased perception of risk correlated with reduced resident satisfaction. prior studies suggest that risk perceptions among hcws may have psychosocial implications. in a study of over thousand singapore hcws who worked during the sars outbreak, % perceived a great personal risk of contracting sars. hcws at sars-affected institutions expressed significantly higher levels of anxiety than their counterparts at unaffected institutions, which had ramifications on long-term psychological stress and burnout. a longer duration of perceived risk of contracting sars also correlated adversely with burnout, posttraumatic stress, and maladaptive coping mechanisms. our survey results show that, in addition to creating risk-mitigating policies, ohns programs have taken measures to manage risk with greater faculty oversight. for example, residents at some programs discussed flexible laryngoscopy with attendings before performing the procedure or attendings performed it themselves. moreover, attendings and senior residents have increased their share of the call burden at certain programs. such efforts serve as examples of increased teamwork and communication, which have been shown to reduce perceived risk in a study of hcws during the to ebola outbreak. communication within ohns hospital teams may also serve as a form of social support, which has been shown to be protective against hcw anxiety and stress during the covid- pandemic in wuhan, china. taken together, enhanced communication and a supportive network within ohns departments are vital to survive the high-stress clinical situations associated with the covid- pandemic. although concerns about personal anxiety and burnout were least prevalent in our survey, over half of survey respondents were at least moderately concerned about burnout for themselves or for coresidents. studies on resident burnout suggest that fostering a sense of meaningful work provides residents with purpose and professional satisfaction. elements that improve meaning in work include direct patient care, intellectual engagement, respect, and community. clinical practice during the present covid- pandemic presents residents with unique opportunities for meaningful and necessary work in direct patient care. strategies to enhance intellectual engagement and build community are underway to integrate ohns residency programs nationally. for instance, the creation of three daily, multi-institutional, ohns-specific, virtual teaching forums - with accessible educational opportunities during a time of social isolation. looking ahead, open communication and an integrated team approach within and between ohns departments will be essential to provide efficient and thoughtful care to patients and providers alike in the months to come. there were limitations to this cross-sectional survey study. our survey represents only % of u.s. ohns residency programs, although this correlates to a larger percentage of total u.s. ohns residents given that our survey captured over % of residency programs with more than residents and all residency programs with more than residents. thus, our survey results may be less representative of programs with fewer residents. in addition, it is possible that earlier survey responses do not reflect the most current information because policies are rapidly changing at this time, and institutions likely implemented changes in a stepwise process. this may have been further amplified if different programs implemented changes at different rates based on local covid- infection rates. we tried to minimize this limitation by capturing survey responses within a short time interval of days to reflect programs' initial planning phases for the pandemic. furthermore, selfreflective risk level comparisons are subject to bias, and the elective nature of the survey may allow for selection bias. , perceived risk may further change because clinical demands evolve with the pandemic as otolaryngologists at some institutions begin to be redeployed to other departments. further follow-up surveys of ohns residents will be essential to characterize practice patterns, perceptions, and stressors for burnout during the course of the covid- pandemic. we believe these efforts are valuable and time-sensitive, particularly as we potentially face multiple waves of the covid- pandemic. the field of ohns has been responsive to the covid- pandemic across all geographic regions in the united states. common clinical practice and procedural changes included reducing resident staffing of the operating rooms, limiting nonurgent clinics and consults, creating separate team cohorts, and reducing risks associated with aerosol-generating procedures. ohns residents are most concerned about ppe shortages and transmitting covid- to others. overall, the majority of residents were satisfied with their department's response to covid- . residents' satisfaction correlated with their level of comfort in discussing concerns with their attendings and inversely correlated with perceptions of increased risk of contracting covid- relative to their attendings. as our field moves past the initial phase of the covid- pandemic, ohns residency programs should continue to evolve practice changes in response to resource and clinical needs as well as engage residents in open communication in order to effectively address sources of anxiety related to this healthcare 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