key: cord-325290-hbzbyqi4
authors: Payne, Anna; Rahman, Rafid; Bullingham, Roberta; Vamadeva, Sarita; Alfa-Wali, Maryam
title: Redeployment of surgical trainees to intensive care during the COVID-19 pandemic: evaluation of the impact on training and wellbeing
date: 2020-09-14
journal: J Surg Educ
DOI: 10.1016/j.jsurg.2020.09.009
sha: 
doc_id: 325290
cord_uid: hbzbyqi4

OBJECTIVE: : The aim of this study was to evaluate the impact of redeployment of surgical trainees to intensive care units (ICUs) during the COVID-19 pandemic- in terms of transferrable technical and non-technical skills and wellbeing. DESIGN: : This was a survey study consisting of a 23-point questionnaire. SETTING: : The study involved surgical trainees that had been redeployed to the (ICU) across all hospitals in London during the COVID-19 pandemic. PARTICIPANTS: : The survey was sent to 90 surgical trainees who were between postgraduate years two to four. Trainees in speciality training programs (>5 years after graduation) were not included. Thirty-two trainees responded to the questionnaire and were included in the study results. RESULTS: : All respondents spent between 4 and 8 weeks working in ICU. Prior to redeployment, 78% of participants had previous experience of ICU or an affiliated specialty, and >90% had attended at least one educational course with relevance to ICU. There were statistically significant increases in confidence performing central venous cannulation and peripheral arterial catheterisation (p<0.05). With regards to clinical skills, respondents reported feeling more confident managing ventilated patients, patients on non-invasive ventilation, dialysis and circulatory failure patients after working in ICU. Respondents (97%) felt that the experience would be beneficial to their future careers but 53% felt the redeployment had a negative impact on their mental health. CONCLUSIONS: : Redeployment of surgical trainees to ICU led to increased confidence in a number of technical and non-technical skills. However, proactive interventions are needed for training surgeons with regard to their psychological wellbeing in these extraordinary circumstances and to improve workforce planning for future pandemics.

The World Health Organisation declared the coronavirus disease 2019 (COVID-19) a pandemic on 12 March 2020. 1 The demand for ventilatory support in COVID-19 patients necessitated an expansion of intensive care capacity within weeks. Between early March and mid-April 2020, London"s existing hospitals expanded their combined intensive care capacity from 770 to 1550 beds. 2 The ICU is a challenging working environment, managing complicated medical and surgical patients whilst also preventing further physiological dysfunction. 3 The ICU is often only visited fleetingly by surgeons during a ward round or postoperatively, but with the COVID-19 pandemic it became the new working environment for the redeployed. A pandemic like COVID-19 disrupts the sense of routine and control, making working environments stressful.

This stress is amplified when the lives of the clinicians caring for patients are at risk.

Learning how to manage a patient who is critically ill is beneficial to surgeons in training and forms part of the curriculum of core surgical training. 4 Completion of The Royal College of Surgeons of England Care of the Critically Ill Surgical Patient (CCRISP) course is mandatory prior to specialist training in the UK. The membership examinations (MRCS) which are also a prerequisite for starting specialist surgical training test the candidate on critical care. 4 The aim of this study was to evaluate the impact of the redeployment of surgical trainees to critical care units during the COVID-19 pandemic in terms of transferrable skills, wellbeing and career development. The three core competences assessed in this paper, as per the Accreditation Council for Graduate Medical Education (ACGME), are practice-based learning and improvement, systems-based practice and professionalism. 5 The results may provide insights into how to improve redeployment for future pandemics.

This was a survey study conducted using a questionnaire to explore the research aims.

Participants were recruited from London hospitals.

Doctors working at postgraduate years two to four who were redeployed from surgical specialties to ICU during the COVID-19 pandemic were included. This encompassed core surgical trainees, foundation year 2 doctors and junior clinical fellows. All surgical specialties, and those redeployed for greater than 4 weeks between the months of March and May 2020 were included. Exclusion criteria included those already in specialty training (postgraduate year 5+) and those working at registrar (senior clinical fellow) level.

All participants received training in both technical and non-technical skills, arranged by the intensive care department, prior to redeployment. The technical skills training included patient proning, insertion of central venous catheters and insertion of peripheral arterial lines in a simulated session. Teaching in non-technical skills included breaking bad news and discussion of resuscitation and ceilings of care with patients and relatives.

A novel 23-point survey questionnaire was devised to evaluate trainee experience, clinical skills, procedural skills and non-technical skills (Supplement 1). Practical skill competency was self-assessed by trainees evaluated using an arbitrary scale from 0 -6 (0 being never observed the skill before and 6 being able to perform the skill independently). Pre-and postredeployment skills were evaluated by trainees, who were asked to reflect on their skills prior to redeployment as compared to post redeployment. A 5-point Likert scale 6 was utilised to evaluate mental health and wellbeing. The questionnaire was distributed through online and paper format to 90 doctors redeployed to ICU in London hospitals as part of the COVID-19

pandemic.

Normal continuous data are summarised as mean and standard deviation (SD). Categorical data are presented as numbers and percentage (%). Continuous data were compared between pre-and post-deployment groups using Mann-Whitney U tests. A p-value of <0.05 was considered statistically significant. Statistical analysis was performed using SPSS V.20 (SPSS Inc, 2012, Chicago, Illinois, USA).

With the recent guidance from the Governance arrangements for research ethics committees (GafREC), 6 the study involves a survey of staff of the services who are recruited by virtue of their professional role, no formal ethical approval is required by the research ethics committee (REC). Completion of the questionnaire was taken as implied consent to participate in the study.

The response rate was 36% (n = 32). This included 19 males (59%) and 13 females (41%), of whom two were foundation year doctors (FY2), nine were clinical fellows and 21 were core trainees both first and second year (CT1 and CT2). The surgical specialities of the trainees are shown in Figure 1 , including general surgery (41%), orthopaedic surgery (18%), plastic surgery (12%) and trauma (6%). The other surgical specialties made up the remaining 23%.

The duration of redeployment varied from four to eight weeks. Ninety-four per cent (n=30) of the respondents were aiming for a career in a surgical speciality. Of the remaining six per cent (n=2) one was undecided and the other wanted to pursue a career in general practice. 

Although the majority of participants felt confident breaking bad news and discussing do not resuscitate (DNAR) orders before their redeployment, there was a small overall increase in confidence after working in ICU. Increased confidence was also reported for receiving critical care handover after working in ICU. Additionally, over 50% of the respondents felt the redeployment had a negative impact on their mental health (Figure 4) . The main themes of the areas causing a negative impact on mental health are detailed in Figure 5 . The majority (84%) of participants did not feel that they were more likely to pursue ICU as their specialty of choice after their redeployment.

One participant reported wanting to change from surgery to intensive care medicine and four would consider a career in intensive care medicine as a result of their ICU redeployment. Surgeons should receive appropriate training and support when working in non-surgical areas. 11 Dewey et al 13 recognised "a supportive work culture is vital to maintaining resilience" during stressful times. The perceived lack of support reported by our respondents may have contributed to the negative impact on mental health. This is in addition to the emotional toll of the high mortality witnessed working in COVID-19 units. Education was perhaps placed on the back burner as the service needs were the main emphasis, but learning did come from redeployment as shown in this study.

Support of the wellbeing of trainees is of crucial importance and cannot be overstated. 14 15 There is significant variation in the delivery of wellbeing support throughout the NHS, even between departments within the same hospital. Studies have suggested the introduction of a definition of wellbeing, with tangible outcome measures, may be useful in enabling staff to make better use of the wellbeing resources available to them. 16 17 The prevalence of psychological morbidity is growing among doctors in the UK 18 , and the report of burnout among doctors before the COVID-19 crisis was between 50-80%. 16 Among the surgical workforce poor mental health conditions has been reported to be approximately 30% 19 but this is possibly an underestimation. Burnout is associated with being undervalued and may become more apparent following the pandemic. 20 It is important to assess and address the issues of burnout to mitigate against the potential sequalae of anxiety, depression, substance misuse, poor patient care and clinician suicide. 13 21 The symptoms of burnout which can become evident are emotional exhaustion and reduced sense of accomplishment. 22 These symptoms should be assessed at regular intervals in surgical trainees during and after the pandemic. Surgeons should be encouraged to express their feelings of stress and not supress them in the false perception that it will provide both individual and team benefit. Prevention of burnout and mental health sequelae after the pandemic will require leadership from the top down. Surgeons need to be more transparent about their psychological needs, and senior leaders should be encouraging and supportive of this. 14 Structured leadership programmes should be incorporated into surgical training curricula, 23 rather than courses that trainees are expected to attend of their own accord. Shared responsibility to support colleagues and encourage them not to continue working in the face of personal risk as self-less acts is essential.

The limitations of this study include the small number of participants resulting in the low response rate. Despite this, important aspects of the redeployment of surgical trainees to critical care have been elucidated. The reasons for the non-participation are multifactorial and may be due to fatigue, exhaustion, time constraints or a general decrease in participation. 24 Wellbeing has not been extensively explored in this study but highlights areas of concern among surgical trainees. Another potential limitation is response bias, particularly in the context of reported improvement in technical and non-technical skills. The Dunning-Kruger effect may play a role with some respondents whereby there is cognitive miscalibration with individuals overestimating their abilities and reporting more confidence in the presence of less experience. 25 The evaluation of resuscitation skills was difficult to perform in this study as trainees had high levels of supervision and most decisions on clinical management were made by consultant-grade doctors. However, increased understanding of the acute presentations of COVID-19 and the management of its complications were reported.

A pandemic with a novel disease, such as COVID-19, introduces many challenges to healthcare professionals and shifts focus from patient-centred to population-centred care.

This includes the redistribution of health care workers in alignment with public health needs.

Both the technical and non-technical skills developed from the redeployment of surgical trainees to ICU will form part of their professional armamentarium for the future. Proactive rather than reactive wellbeing interventions are essential for surgeons in training with regards to their psychological health. The long-term impact of COVID-19 pandemic on surgical education is yet to be fully evaluated and more research will be required in the long-term.

Close monitoring of trainees" surgical development and mental health will be essential in alleviating the effects of this pandemic and improving our response in the future.

Contributions: AP -Conceptualisation, methodology, writing, review and editing, RR -Methodology, data collection and analysis, editing, RB -Methodology, data collection, editing, SV-Conceptualisation, review and editing, MAW -Conceptualisation, methodology, writing, supervision

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