Surgical training during the COVID-19 pandemic- an underestimated hazard; Results from a national survey

Original Article

Hell J Surg. 2024 Oct-Dec;94(4):183–193
doi: 10.59869/24046

Maria Papadoliopoulou1, Ioannis Margaris1, Maximos Frountzas2, Francesk Mulita3, Theodoros A Sidiropoulos1, Alexandros Chamzin2, Spyridon Christodoulou1, Konstantinos G Toutouzas2, Nikolaos Arkadopoulos1, Nikolaos V. Michalopoulos1,2

1Department of Surgery, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
2First Propaedeutic Department of Surgery, Hippocration General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
3Department of Surgery, University Hospital of Patras, Patras, Greece

Correspondence: Maria Papadoliopoulou, Department of Surgery, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, 1 Rimini Street, Chaidari, 12462 Athens, Greece, e-mail: mpapadoliop@outlook.com

ABSTRACT

Introduction: Covid-19 pandemic has changed the delivery of healthcare services and organization of health systems globally. Purpose of the current study was to assess the impact on the level of training and education of surgical residents during the COVID 19 pandemic.

Methods: An online form was designed and communicated via email between January and February 2023. Participants were surgical trainees in public hospitals across Greece. Responses were anonymously collected and analysed. Primary outcomes were the participants’ perceptions on level of training, educational and research activities during the pandemic.

Results: Seventy-six residents from a wide spectrum of surgical specialties submitted their answers. The number of operating rooms per week was significantly diminished during the pandemic (median 1.00, IQR 0.50-2.00, p<0.001). Ninety-six percent of the participants stated that the level of their surgical residency training worsened during the pandemic. Approximately 82% of the respondents reported a greater than 20% decrease in cases performed. The majority (56%) felt mentoring process by senior surgeons was significantly affected. A detrimental effect on departmental educational and research activities has shown, according to 65% and 54% of the trainees respectively.

Conclusions: Our results indicate that the pandemic had a substantially negative impact on training of surgical residents in Greece.

Key Words: COVID-19, surgical education, surgical training, surgical trainees, redeployment, medical education

Submission: 02.04.2025, Acceptance: 02.07.2025

INTRODUCTION

The COVID-19 pandemic has severely affected healthcare systems of most countries, as well as healthcare personnel in various ways. Since 2020, the global scientific community has moved towards a worldwide effort to manage and possibly eliminate the disease. To accomplish that, management of other common diseases changed, prevention programs were diminished, elective surgeries were widely postponed and staff was redeployed to COVID-19 units. Furthermore, significant delays were reported in the management of a wide range of medical or surgical emergencies [1-4]. Budget and grants were used to develop vaccines, new drugs and employ personnel to assist in COVID hospital wards [5]. There are quite a few published studies that indicate COVID-19 has been associated with reduced surgical education [6-7]. Research opportunities were also far fewer during the pandemic, an occurrence that has been considered a significant hindrance towards further development of surgical practice. Moreover, a series of hands-on seminars, scientific congresses and courses were cancelled [8-10]. Within the UK, studies have shown that two particular trainee subpopulations were mostly affected by the pandemic; early-stage trainees, and those approaching the end of their training, both for different reasons; the former, were seen as prominent emergency personnel, redeployed to tackle the great national emergency, while a reported 12% of final year trainees were marked as “delayed due to COVID” [11]. Apart from the lack of surgical cases, often attributed to patient factors, including fear of hospitalization, in many countries there was a significant loss of working hours for surgical trainees, either due to sick-related absence, or due to restructuring of programs to avoid crowding of on-shift personnel [7,12]. Furthermore, the above-mentioned radical changes had a detrimental effect on mental health disorders and anxiety among medical practitioners [13].

Due to the limited opportunities for education in theatre, alternative solutions were invented to outweigh the need for training.  Virtual handovers, ward rounds, case-based discussions, multi-disciplinary team meetings and even patient appointments have been greatly popularized, and means to access them are now deemed necessary for every surgical department [11,14]. Furthermore, the ongoing social distancing recommendations led to changes in conventional educational methods, in favour of distance learning via interactive online platforms.

Our national challenges, while similar to most of the surgical training programs, hold some particularities. For instance, redeployment of specialized personnel or, in some cases, complete suspension of surgical departments were more frequent than in other countries [6]. In an attempt to assess the impact of pandemic on surgical training and education, we designed and conducted an online survey, sharing the thoughts of surgical residents in Greece. The primary aim of this study was to quantify and assess the self-assessed impact that the COVID-19 pandemic had on the quality of surgical training for residents in Greece. The secondary aim of the study was to offer further insight and assist in guiding additional improvements in all aspects of surgical training in Greece, starting by tackling the disparities caused by this recent pandemic.

MATERIALS AND METHODS

Study design and methodology

A cross-sectional study was conducted on surgical residents. An online survey form was designed, using the Google forms (Google LLC, Mountain View, CA, USA). Twenty-nine questions were conceived and carefully formulated, after consideration of the existing literature concerning the global impacts of Covid-19 pandemic on surgical education, which has been previously validated and proved to be internally consistent [15] (Supplementary material S1). Questions were put together by a team of accredited surgical educators, working within teaching hospitals, with expertise in surgical education. Τhe survey was anonymously piloted among surgical residents from the authors’ participating institutions. Face and content validity were assessed by means of focused discussions among experts and participating trainees. The survey was divided into two parts; the first part included baseline characteristics of surgical trainees, that was used to compare our cohort’s composition with those of prior studies, and also to stratify results wherever needed. The second part, was the assessment of measures of surgical training and education, looking into critical areas of forming capable future surgeons. Questions included assessment of the perceived reduction in several areas of surgical training, including elective surgical cases, emergency department attendance, senior mentorship and guidance, departmental educational and research activities. Responses were either limited to a yes or no answer (binomial scale), included a free text, or they were scaled from negative (or less) to positive (or more) in 3 to 7-point Likert scales.

The study questionnaire was accompanied by a cover letter informing participants of the process after the completion of the questionnaire. This page also enclosed confidentiality agreements, and safe data handling declarations. In both sections of the survey, there was no recording of participant-identifiable characteristics, and all survey responses were automatically anonymized by Google Forms, with no capacity for de-anonymization.

The study form was built in accordance with the latest guidance on conducting survey-based research [16]. The sample size was determined by Fisher’s formula, using a standard normal variate at 5% type I error and a precision of 0.1[17]. The proportion of surgical residents who have experienced a negative impact on their training, due to the pandemic, is not established; however, based on previous studies and the pilot study of our own survey, we used a prevalence rate of 75%. Therefore, the calculated minimum sample size was 72 participants.

Participants and survey distribution

The survey was communicated via email and the form remained accessible to participants from 06.01.2023 to 09.02.2023. Participants were selected on a voluntary basis, from current records of the Hellenic Surgical Society, as well as contact records from all deaneries. Eligibility criteria included: surgical trainees of all grades in all major surgical specialties and subspecialties in Greek public hospitals. Medical students and consultant grades were excluded from the survey.

Definitions and outcomes measured

Pandemic period in Greece was defined as the timeframe between March 2020 and June 2022, corresponding to the restrictions imposed. The main outcome measures were variations in perceived surgical, educational and research training during the pandemic. Secondary outcomes included hospital policies, reallocation of surgical residents, days off received and participants’ thoughts on future career planning.

Statistical analysis

Statistical analysis was performed using SPSS version 27.0 software for Macintosh (SPSS Inc., Chicago, IL, USA). Normality of distribution was examined using the Kolmogorov-Smirnov test. Continuous variables not following the normal distribution were presented as median (interquartile range) and compared using the Wilcoxon signed rank test. On the other hand, categorical variables were presented as counts and frequency with percentages, and were analysed using Pearson’s chi-square test and Fisher’s exact test when individual cell counts were less than 5. The significance level was set at a value of p<0.05.

Ethical considerations

Ethical approval has been received for this study by the Committee for Bioethics and Ethics of the University General Hospital Attikon of the National and Kapodistrian University of Athens (approval number DXEIR/EBD22/14.01.2022). The study was con-ducted in accordance with the Declaration of Helsinki ethical principles for medical research.

RESULTS

Baseline characteristics

Participants’ demographics, as well as data on COVID infection, training institutions and training programs are summarized in Table 1.

A total of 76 residents from 15 academic and non-academic Greek public hospitals completed the online survey and submitted their answers. From the available sources, a total number of 302 individuals were notified via e-mail calling for participation in the study. Hence, our response rate was 25% (76/302). From the respondents, 57% were male and 41% were female. Two of them did not wish to disclose their sex. The majority (57%) were between the ages of 29-33 years old. Most of the surgical residents (91%) were infected at some point by Covid-19. However, only 7% of the participants experienced complications stemming from the infection itself, meaning either need for hospitalization or long-Covid symptoms.

Just 82% of the participants resided in a large urban area. Fifty-four percent of the trainees were employed by university teaching hospitals, the vast majority of which were large institutions with a capacity of more than 500 beds. Half the residents (50%) worked in a surgical department with a capacity of more than 30 beds. General surgery interns accounted for the majority of respondents (72%), followed by other surgical subspecialties, Obstetrics and Gynaecology being the second most prevalent. Interestingly, 17% of the residents answering the survey belonged to a large training program, including at least 15 trainees. Participants were scattered across all years of training programs. Third-year residents formed the largest group (20%), nevertheless almost equal proportions of junior and senior residents completed the survey.

Adaptation to the pandemic, redeployment and surgical operations

Details on the effect of pandemic on hospital policies, surgical beds, operating rooms and residents’ personal exposure to infected patients are presented in Table 2.

The emergence of COVID-19 as a global pandemic required medical wards to rapidly adapt, in an effort to deliver health care services to infected patients. From our study, 90% of the participants’ institutions had to create dedicated COVID-only wards, while 7% of the participants’ hospitals had to become COVID-only hospitals. Only three residents answered that their training hospital remained largely unaffected or implemented solely isolation and room-entry policies for infected individuals in common medical wards during the pandemic. Particularly for the wards allocated to surgical patients, 61% of the respondents estimated that they lost at least half the surgical beds or, in some cases, entire surgical wards were closed for some time, the latter being the case according to 30% of the respondents.

Almost a third (25/76) of the trainees answering the survey, reported that during their residency they have been redeployed to assist in COVID-only wards. On the other end of the spectrum, 21% answered that they were not involved in management of Covid-19 patients.

Ninety-six percent of the residents reported a significant reduction in access to operating rooms, compared to pre-pandemic levels. According to our results, the median (IQR) number of theatres operating per specialty in each hospital before the pandemic was 5.00 (3.00-6.00) weekly, compared to 1.00 (0.50-2.00) during the pandemic and 4.00 (2.00-4.75) after the pandemic (p<0.001) (as shown in Figure 1). Sixty-six percent of the participants reported that the observed reduction in operating rooms has not been replenished, and their hospital is still functioning with less operating theatres, compared to pre-pandemic levels, as presented in Table 2.

Figure 1. Boxplot of theatres operating weekly before, during and after the pandemic.

Workload and days off

According to our study, the level of workload for most surgical residents decreased during the pandemic. Sixty-five percent reported that they had to work the same hours or less during the above-mentioned period. Moreover, 87% of the respondents felt that emergency department attendance was markedly reduced.

It seems that the pandemic did not have a negative impact on days off received by residents. In fact, at the time this survey was conducted, 36 out of the total number of 76 trainees (i.e.,47%) were receiving at least one day off monthly. On the contrary, only 27 out of 76 residents, corresponding to 36%, were receiving days off before the pandemic. Yet, the vast majority of surgical residents is not offered days off work, irrespective of the pandemic.

Impact on surgical training, education and research

The respective results are presented in Table 3 and the associations between participants’ characteristics, redeployment and surgical training parameters are reported in Table 4.

Ninety-six percent of the participants stated that the level of their surgical training and education worsened during the pandemic. In total, 56 residents were able to compare the level of their personal operative exposure before and during the pandemic. From the available data, 82% of the respondents reported a significant decrease of more than 20% in cases performed. Furthermore, 84% thought they might be insufficiently trained by the time they graduate from their program.

Fifty-five residents gave their perspective on mentorship by senior surgeons. Most of them (56%) felt the pandemic significantly disrupted the mentoring process. Consultant mentorship was maintained or increased for surgical residents above the 4th year of residency, whereas it was decreased for surgical residents below the 4th year, compared to pre-pandemic levels (p<0.001). A greater than 30% decrease in operations performed during the pandemic resulted in significantly diminished consultant mentorship (p<0.001).

Seventy-two trainees reported on educational activity trends in their department. According to 65% of them, educational activities were adversely affected during the pandemic. Notably, when asked about hours currently spent in educational activities (corresponding to the post-pandemic period), including seminars, lectures and journal clubs, a staggering 84% reported that less than two hours are spent on a weekly basis in their department for such purposes. Departments with a high Covid-19 workload were associated with a significant deterioration of educational standards (p=0.033).

Research activities were diminished, according to 54% of the respondents. Another 40% of them, felt academic work remained at the same level, while only 11% of the residents reported an increase in scientific activities. However, residency in academic surgical departments was associated with a significantly higher research activity com-pared to non-academic departments (p=0.006). Furthermore, working in a department with heavy workload related to COVID-19 infected patients was associated with a lower research activity (p=0.038).

Extension of training and career pathway

Fifty-one out of seventy-six participants (i.e., 67%) would be interested in a possible lengthening of their surgical training program. In particular, surgical residents working in tertiary urban hospitals seemed to be more likely to choose an extension of their training interval than residents working in rural hospitals (89% vs 64%, p=0.024).

As far as their future career is concerned, the majority (63%) would still choose to work in a public hospital setting. On the other hand, 37% of the respondents would be eager to explore an alternative pathway, including private practice. Work in a department with COVID-19 infected patients seemed to affect surgical residents’ preferences about future career planning; only 54% of surgical residents that worked in heavily burdened departments by COVID-19 would choose to follow a public hospital future employment pathway, in comparison to 77% of surgical residents that worked in COVID-19 departments with light workload (p=0.049). In addition, assigned medical duties related to COVID-19 patients affected future career perspectives. 79% of surgical residents that were not allocated to dedicated COVID wards or provided their services to infected surgical patients only, would choose a hospital career, whereas only 50% of surgical residents that treated COVID-19 infected patients would choose the same pathway (p=0.015).

DISCUSSION

Since the outbreak of COVID-19 pandemic in spring 2020, major alterations in hospitals’ working schedules were introduced, in an effort to meet the increasing demands for hospitalization of infected patients [5]. Rising prevalence rates of the disease had a significant impact on residents of all specialties, changing their routine practices and curricula. Medical trainees were the ones that primarily carried the burden of caring for COVID patients. Yet, surgical trainees, experienced a different effect on their specialty training. Stringent government policies, including restriction of elective surgeries among others, left surgical trainees with less clinical duties and scarce educational opportunities [9-10,18]. Instead, the unexploited surgical personnel were called to con-tribute to the pandemic setting in various ways, depending on local and hospital needs, in many cases being redeployed in COVID wards as primary care physicians [19-23]. Sixty-one percent of our participants, estimated that their departments lost at least half of the available beds due to the pandemic, and almost a third of respondents were redeployed to work in COVID-only wards. This is one of the highest recorded re-deployment rates in surgical trainees, when compared to similar studies, indicating a strong correlation with the reportedly high percentages of loss of surgical training, as reported by 96% of the responders [24-26]. As a result, theoretical knowledge as well as practical skills, stemming from hands-on experience, were severely and negatively affected.

The rising tide of Covid-19 pandemic required the implementation of significant changes in hospitals’ workflow. Dedicated isolation wards or even dedicated Covid hospitals were created; surgical bed occupancy and operating rooms for elective cases were greatly reduced [9,18,20,27]. From our survey, the number of theatres operating weekly was significantly reduced during the pandemic, and remains significantly reduced compared to the pre-pandemic levels. This indicates that policy-driven changes made in the public healthcare system seem to have left a lasting effect in surgical practice, reducing the number of available theatres by 20% on average. However, it is possible that expedited recruitment did not include operating theatre staff roles and, in fact, staff shortages may have led to inefficiently working operating rooms or even shut-downs [9-10,18]. Therefore, we can conclude that policy changes are not sufficient by themselves, and proper follow-up must be part of any changes made, even in the face of a pandemic.

Doctors from all specialties were required to undertake duties related to infected patients. Thirty-three percent of our study participants were allocated to dedicated Covid-only wards. Others, were sporadically exposed to infected surgical patients and 8% of the respondents rotated in vaccination centres alone. In a recent narrative review, referring to Urology trainees, 80% of the residents were reassigned to cover emergency departments and intensive care units among others. Airway management and basic and advanced life support courses had been offered to most of them, before reallocation [23]. One could possibly argue that this would constitute beneficial extra training. However, this form of training can be highly irrelevant to their chosen specialty, especially when talking about senior trainees that are about to take the next step in their careers. Loss of invaluable surgical training time and the resultant inability to achieve defined competencies may have an impact on future surgeons’ skilfulness, as well as on patient safety [11].

The majority of residents reported a reduced workload during the pandemic, which likely reflects a significant reduction in operating rooms, as well as a decline in emergency department attendance. It is now a well-established phenomenon from multiple previous studies, that the public avoided emergency departments during the pandemic, likely owing both to mandated restrictions, and an indwelling fear [28-29]. This led to an increase in acute conditions being mismanaged, including acute surgical conditions such as appendicitis [30-31]. The previous is also supported by other studies measuring the decreased attendance of surgical trainees in theatre, during the pandemic [8]. Moreover, based on our study results, days off were not adversely affected by the pandemic. Thankfully, it seems that among surgical trainees in Greece, days off were still protected, but that cannot be said for all medical colleagues. In fact, most of the surgical doctors in training reported zero days off received after an on-call, indicating that measures need to be taken in order to improve health and safety.

We herein asserted the grave implications of the pandemic on surgical residents’ training, education and research activities. The vast majority of respondents reported a significant reduction in operative cases performed and the related detrimental effects on consultant mentorship. Junior residents were more severely affected. A possible explanation to this may be the fact that during the pandemic all elective cases for benign surgical pathologies were indefinitely postponed. As such, junior residents were likely depleted from hands-on experience and related senior guidance. On the other hand, senior trainees or chief residents involved in malignant or emergency cases performed during the pandemic, may have maintained their level of experience and practice, as such cases were still performed. The above-mentioned results are further supported by other researchers, emphasizing on the noteworthy reduction in residents’ participation in operations [9,20,32-33]. A systematic review by Hope et al [34], included studies where trainees or program directors were expressing their point of view on surgical training during the pandemic. The total number of operative cases performed by trainees was reportedly significantly reduced (p=0.033). Research activities were similarly diminished during the pandemic. The effect was further magnified in non-academic institutions and departments.

However, it is worth mentioning that the pandemic served as an opportunity for innovation in the field of education, bringing forth the necessity to adopt cutting edge technological solutions [34-38]. Resource libraries, podcasts, surgical videos, mobile ap-plications, surgical simulation programs and online webinars were generated to replace the traditional educational means and democratize knowledge, making it even more accessible and efficient for all trainees [39-40]. Furthermore, despite concerns about possible health and safety issues, reallocation of surgical doctors to medical wards during the pandemic provided invaluable assistance towards management of the crisis and may have facilitated collaboration between specialties [32,41-44].

Sixty-seven percent of the participants in our study would opt for a lengthening of their surgical training period, indicating that surgical trainees are facing their future with anxiety rather than anticipation. In our study, residents in large tertiary urban hospitals were more likely to choose such an extension. In a recent study by Oropeza-Aguilar et al [20], 95% of the respondents reported that their practical skill learning and theoretical learning was completely or partially affected. Seventy-seven percent of them were in favour of an extension of their residency program.

Finally, even though the majority of our study participants would still choose a future public hospital career, their preferences were related to their personal exposure to Covid-19 and their hospital adaptation to the global pandemic. Heavily burdened departments by Covid-19 and systematically treating infected patients led respondents towards an alternative career planning and pathway.

Certain limitations apply to our presented study. This was an online survey including a relatively small number of participants and a low response rate. Given those, our results could be influenced and carried a selection bias. However, the study was communicated freely and without selection planning and participants answered anonymously and uninterrupted. The sample was heterogeneous, representing a variety of surgical specialties, unequal levels of training and different institutions. Hence, it is possible that results cannot be widely generalized. Confounding bias need to be considered, due to the fact that participation in the study was voluntary. Furthermore, residents’ perspectives or personal thoughts and concerns might have affected their decision to complete or not the survey and also led to a potential response bias. There is a degree of self-reporting bias, that is inherent to all survey-based studies. The majority of the participants were general surgery residents, so there was an uneven distribution across different specialties. However, results of our study might be useful to draw conclusions and possibly guide future improvements in education and training of surgical residents.

CONCLUSIONS

COVID-19 represents a major healthcare crisis, but it has also been related to a significant impairment in surgical training and education, raising additional concerns on future ability of trainees to safely and adequately manage surgical patients. According to our study, most of the surgical trainees in Greece reported an insufficient level of training during the pandemic and would most likely choose an extension of their residency program. Certain actions should be taken, in order to improve existing residency programs, ensuring that a high-quality training is being delivered and our patients are offered the best possible care.

FUNDING

This research received no external funding

INSTITUTIONAL REVIEW BOARD STATEMENT

The study was conducted in accordance with the Declaration of Helsinki, and approved by the Committee for Bioethics and Ethics of the University General Hospital Attikon of the National and Kapodistrian University of Athens (approval number DXEIR/EBD22/14.01.2022).

Informed Consent Statement: Informed consent was obtained from all subjects involved in the study

ACKNOWLEDGMENTS

None.

CONFLICTS OF INTEREST

The authors declare no conflict of interest.

DATA AVAILABILITY STATEMENT

Data are accessible upon request to the corresponding author.

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