key: cord-0901717-agdbwg9o authors: Upadhyaya, Gaurav Kumar; Jain, Vijay Kumar; Iyengar, Karthikeyan P.; Patralekh, Mohit Kumar; AbhishekVaish title: Impact of COVID-19 on post-graduate orthopaedic training in Delhi-NCR date: 2020-07-25 journal: J Clin Orthop Trauma DOI: 10.1016/j.jcot.2020.07.018 sha: 5bdbc987497f7f628fce8dc3ef284cfc18f0c7cf doc_id: 901717 cord_uid: agdbwg9o PURPOSE OF THE STUDY: The Coronavirus disease 2019 (COVID-19) pandemic has had profound effects on healthcare system including medical training and education in India. The study was aimed to evaluate the impact of COVID-19 on post-graduate teaching and learning amongst candidates pursuing higher qualification in orthopaedics, in the Delhi- National Capital Region in India. DESIGN: An online cross-sectional survey of 29 questions was circulated amongst post-graduate students pursuing higher orthopaedics degree to evaluate (i) Impact on PG teaching (ii) Impact on surgical training (iii) Impact on Dissertation (iv) Future implications on PG training programme (v) Mental wellbeing. RESULTS: 138 (77.5) PG trainees contributed in the survey, and 65.1% of them stated that no clinical classes are being held presently. The majority (94%) confirmed that COVID-19 has affected their surgical and clinical training. A large number (71.6%) had problems in completing their dissertations and 96% had concerns about mental health. CONCLUSION: COVID-19 pandemic has severely disrupted the education and training of the Orthopaedic PG students, in Delhi-NCR region and perhaps elsewhere similarly too. The Government and Teaching organisations should take serious consideration of the plights of PGs and devise satisfactory mechanisms to overcome their problems and provide reasonable solutions also. The World Health Organisation (WHO) declared Coronavirus disease 2019 (COVID-19) as pandemic on 11 March 2020 [1] . To contain and prevent the pandemic, Government of India announced many steps such as nationwide lockdown on 25 March 2020, promoting social distancing and infection control guidelines including the use of masks, personal protective equipment (PPE) [2, 3] .The stringent 'Lockdown' restrictions has disrupted daily life, also affecting the field of orthopaedics including orthopaedic surgeons and trainees [4, 5] . Routine out-patient department (OPD) services and elective surgeries have been cancelled which has decreased orthopaedic patient influx to hospitals. Institutes and hospitals have re-organised orthopaedic services with cancellation of face to face lectures, clinical rounds, seminars, and similar academic and teaching activities [6] . This has affected post-graduate (PG) teaching and learning in an unprecedented manner. The PG teaching in orthopaedics is going through difficult times during COVID-19 pandemic. We have conducted an online survey among currently pursuing PG students of orthopaedics in Delhi-National Capital Region (Delhi-NCR) area to find out the impact of COVID-19 on PG teaching and learning. Difficulties and problems faced by them during the pandemic in terms of the progress in dissertation, lectures, seminars, clinical case discussions, surgical training, re-deployment challenges and the effect on mental health were enquired. Study design: This cross-sectional study (online survey) was conducted from 11 June 2020 to 15 June 2020, to study the problems faced by PG students in orthopaedics in Delhi-NCR area. A questionnaire of 29 questions was created and was circulated among students Evaluation The survey focussed on following points. We have used Wilcoxon sign rank rest for pre (2019) and post COVID (2020) data in the same months for number of classes and cross tabulation and chi square tests for other variables for testing association. All results are described in percentage. A two-sided P value< 0.05 was considered as significant. Funding: No funding was received for this study. The survey was sent to the most (178) orthopaedic PG students, who could be traced in The majority (84.5%) felt that their basic skills in various common orthopaedic procedures such as cast application, skin, and skeletal traction application, local and intra articular injections, wound care and dressings are severely affected during COVID-19 pandemic. This feeling was significantly associated with feelings of overall decrease in clinical and surgical learning during PG course due to COVID 19(P<0.001) and feeling of lack of competency to work in independent practice after PG completion (P<0.001). Only 28.4% students had completed their dissertation and the majority remaining were struggling with the completion of their research and dissertation work, due to several reasons. Major reasons being follow up patients which were part of their study are not coming to the hospital (53.2%) followed by decrease in number of surgeries (48.6%), decrease in number of OPD cases (43.1%) and difficulty in recruitment of new cases (41.2%) ( Figure 2 ). Almost all the student felt the lack of clinical teaching (96%) on the ward rounds and case presentations (91%).These feelings(lack of clinical teaching and lack of case presentation) were significantly associated with feelings of COVID-19 having an overall negative effect on passing the PG final examination (P<0.001). Major difficulties faced by PG students in training were decrease in surgical exposure (88%), change in working schedule (57%), decrease in teaching time (42%) and redeployment to other places (40%)( Figure 3 ). As a PG student, major problems faced by PG students were significant decreased load in the surgical cases (92%), lesser OPD cases (83%), difficulty in clinical case presentation (78%), fear of contracting COVID-19 (68%), and cessation of seminar and journal clubs (58%), amongst others ( Figure 4 ). The vast majority of the PG students (94%) confirmed that COVID-19 pandemic has overall decreased their clinical and surgical training and this was significantly associated with (around 70% students)the feeling that it has negatively affected their chances of passing the final PG exit exam(P<0.001). Majority of the PG students (71.56%) were redeployed for other non-orthopaedic duties, related to the management of COVID-19 patients and 81% of them had come in contact with the COVID-19 patients, during their clinical duties ( Figure 5A ).10% of the trainees were also infected withCOVID-19 ( Figure 5B ). The risk of contracting COVID infection was significantly associated with redeployment for Screening in OPDs, COVID wards, ICU's, or other places in the hospital, and with history of exposure to COVID positive patients during the course of treatment(P<0.001). If the COVID-19 crisis is prolonged then the majority student (68%) were of the opinion that they should approach the government and educational bodies to help them out, by modifying the rules of their training and exit exam. 69% of the respondents are of opinion that they would like to learn surgical skills from virtual workshops. Around one-third (38%) trainees would like to ask extension in training period from institute ( Figure 6 ). 83% participants were of the view that the Medical Council of India (MCI) criteria of presenting poster and paper in conference are not possible in this time, due to COVID-19 pandemic during their PG tenure. 89% participants were confused in their choice of virtual classes and seminars with so many being conducted across the country. Significant association was seen with anxiety about difficulty in poster and paper presentations (83%) and confusion about choosing appropriate virtual seminars and classes (89%). As the number of surgeries are going down significantly in hospitals 84% feel that teaching on simulators may be helpful during COVID-19 pandemic ( Figure 7A ).More than half (55%) trainees felt that due to decreased surgical experience, their confidence in doing independent practice after completing their post-graduation was significantly reduced. Around two-thirds students were in the favour of continuing their learning by virtual teaching and workshops during the pandemic, although the majority (91%) confirmed that the virtual teaching cannot replace the face-to-face teaching ( Figure 7B ). About 3/4 respondents were still in favour of face to face examinations instead of virtual examination for PG exit exam. Association between different variables and their significance is summarised in Table 1 . In India, the PG teaching in Orthopaedics is usually offered through different courses; MS, DNB, and Diploma in Orthopaedics (D.Orth) [7, 8] . The purpose of PG course in Orthopaedics is to create professionals who can impart high quality and specialized health care services at different level of health centres.COVID-19 has caused unprecedented changes to orthopaedic training. As orthopaedic residents continue to perform necessary patient care during the COVID-19 crisis, they will unquestionably face both daily challenges to personal health and long-term questions about their training experience [9] . Our survey demonstrated that problems in the training of PG students are significantly increased due to COVID-19 pandemic. Lectures and theoretical classes have been cancelled in the teaching hospitals and institutions to prevent and contain the spread of COVID-19 [10] . Seminars and Journal clubs have also taken a hit as reported by 58% respondents. Inter-departmental academic meets such as with radiology, pathology, physiotherapy, and nursing departments to discuss important and unique cases have also been cancelled, as of now as reported by 39% participants. There are lot of webinars being hosted on various topics. This provides PG students an opportunity to learn from the best of the field. But this also creates confusion in their mind as reflected in this survey. There should be proper coordination among the various orthopaedic societies and organizers to streamline such issues. State medical councils could give accreditation to these academic activities as Continued Medical Education activities which would work favourably for PG students. Routine OPD and elective non urgent surgeries have also been suspended at most places [10] .The reduced patient load has affected the demonstration of many clinical skills such as slab and cast application, skeletal and skin traction application, local and intra-articular injections, wound care, and dressings as reflected in this survey also. Decrease in number of cases for clinical discussions could be dealt with the use of card cases and other tools such as virtual classes. In case, it is essential to examine the patient in face to face clinic the student must wear full Personal Protective Equipment (PPE), which may not be feasible in most places [13] . Video conferencing facilities could be used for demonstration of technical procedures and other small procedures if feasible. Faculty members may use instructional videos to teach PG students and discuss with them online [11] Surgery is an art and it can be learned and mastered at a place, where it is performed. While the number of elective orthopaedic surgeries such as arthroplasty, arthroscopy, spine, and other specialized surgeries has been reduced, the opportunity for PG student to observe, assist and perform the surgery has also been lost during the pandemic. This is the major difficulty faced by almost 92 % of PG students. Decrease in surgical and clinical learning was causally related to the effect of COVID-19 on basic clinical skills (P<0.001). Surgical simulation techniques are rapidly evolving field and would be powerful and important tool for teaching osteo-synthesis and arthroscopic surgeries to PG students which would provide them valuable experience and meet the surgical training demand [14, 15] . This technology can improve the surgeon's confidence. However, this is costly and requires infrastructure space which may be a concern for many hospitals. It has to be noted though only a few surgical procedures can be learnt using simulation techniques [16] . To prevent the spread of COVID-19 and following the norms of social distancing, the number of personnel in OT has to be kept to minimum and may thus influence their participation in all the surgical procedures. Similar recommendations have also been provided by other authors [11] . PG students who have a dissertation to submit are finding themselves in a difficult situation. Patients who are the part of their clinical studies have not been able to come to the hospital for follow up because of lockdown, travel restrictions and migration to home states from big cities. It is difficult to recruit new patients for those PG students who have dissertation topics related to non-urgent elective surgeries as elective surgeries and OPD have been shut down. Some patients don't want to come to the hospital for follow up because of risk of contracting COVID-19. Even for those students, whose topics are related to trauma surgeries, the number of patients has decreased considerably. Most of the operated patients are followed up by the surgical team through telemedicine or remote consultations (e.g. telephone or video consultation), so as to avoid their hospital visit and face-to-face interaction with the doctor and other hospital staff [17] . Gathering information about outcome scores and follow-up radiographs is difficult in this scenario. This has caused great inconvenience for the PG students and faculty members. significantly associated with feelings of decreased exposure to basic skills (P<0.001). The focus of the PGs has now shifted to COVID-19 due to redeployment and 40% respondents are finding it difficult. If this paradigm shift continues for too long, the orthopaedic PGs may lose skills in managing a broad range of orthopaedic surgical pathologies [18] . Social distancing norms have prevented group study and discussion among PG students. Logbooks need to be signed by faculty members as part of academic curriculum. As the patient load has been reduced and there is redeployment of PG students to non-orthopaedic work, students would find it hard to fill the details of surgical procedures performed or assisted. This problem has been reported by 28 % of respondents. The majority of PG students have come in contact with the COVID-19 patients during their clinical duties and 10% of these students have contracted COVID-19 which should be a cause of concern. Redeployment was related to the risk of contracting COVID-19 (P<0.001). It is desirable as a part of curriculum for PG students to present poster and paper at conferences and attend at least 2 conferences or workshops or continued medical education (CME) activities during their tenure. However, this is not possible now as reported by 83% of participants of this survey. Students face difficulties as academic conferences and workshops have been cancelled and it is unclear when these academic activities would restart. Connecting with experts in field of orthopaedics face-to-face is most valuable opportunities during live conferences for future research, publication and receiving expert advice in their practice. Virtual meetings do not replicate face-to-face interaction at such meetings. Thus, PG students will lose this opportunity to network with experts in their desired fields in virtual meetings. PG students who were due to appear for their final examination have faced a lot of uncertainty and anxiety. Many institutes have delayed their PG examinations and are waiting for guidelines from universities. 70 % feel that COVID-19 pandemic has negatively affected their chances of passing their exit examination and it is related to the decrease in the ward round clinical teaching (P<0.001) and decrease in the clinical case presentation (P<0.001). It is not known that how long COVID-19 pandemic is going to stay. What PG students would like to change in the current scenario if similar situation continues for another 6 months? Majority would like to approach government and higher bodies to modify rules for PG training and would like to learn from virtual workshops. As all PG courses are of fixed tenure there is loss of precious time of approximately 2-3 months for teaching and learning. It is anticipated that these residents may graduate and become specialist/consultant without achieving proficiency in essential surgical procedures [18] . Similar finding has been brought out during our survey where 55 % participants don't feel competent enough to work independently after PG completion. Orthopaedic PG students are exposed to stressful life and COVID-19 pandemic has added to it. COVID-19 pandemic has effect on mental health and wellbeing according to World health Organization (WHO) [19] . Mental well-being is often overlooked. COVID-19 has impacted the surgical training period. And there is lot of uncertainty regarding future prospects. They expose not only themselves but their family members too through them to COVID-19. Some are not able to visit their families because of lockdown measures. Saddik B et al also reported mild to severe anxiety in medical students during COVID-19 pandemic which decreased after the introduction of online teaching programmes [20] . Institutions should be aware of this fact and should be proactive in providing the necessary counselling services required for the sound mental well-being of the students. Adequate sleep and rest are essential to those who are working in COVID-19 area for long hours. The orthopaedic training for post-graduates during this phase must essentially include daily updated information on the nature of pandemic, the rationale behind the use PPE, social distancing, safe surgical skills, and other essential things to prevent them from contracting COVID-19. This can be through video lectures or through social media such as WhatsApp, Facebook, and Twitter over smartphone [21] . Possible solutions or Recommendations for PG teaching programme during COVID-19 pandemic is summarised in Table 2 . The COVID-19 pandemic has also been learning opportunity and appears to have been a catalyst for new, innovative ways delivering teaching and training [22] . In these COVID-19 times, clinicians have more time compared to the regular days. Hence, they have the opportunity to update themselves as well. This in turn is helping them impart their up to date knowledge via webinars, virtual meets and paper writing. Hence, improving the quality of learning and the participants also has a chance to ask one to one questions and clarify. The of Interest: none stated. Authors statements Author's Contributions: GU and VJ involved in Conceptualization, literature search, manuscript writing and editing. KPI and MKP in Literature search, methodology, Data curation, manuscript review and editing. RV supervised overall submission and approved final draft. All authors read and agreed the final draft submitted Funding Statement: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors Competing interests: None declared Disclosure Statement and Conflict of Interest statement: Nothing to disclose Statement of Ethics: All our clinical procedures were fully compliant with the ethical standards in accordance with the local consenting and ethics guidelines. 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