Letter to the Editor: Changes in Neurosurgery Resident Education During the COVID-19 Pandemic: An Institutional Experience from a Global Epicenter.

Letter:

The first case of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and its associated 2019 novel coronavirus disease (COVID-19) in New York State was diagnosed on March 1, 2020. COVID-19 was subsequently declared a global pandemic by the World Health Organization on March 11, 2020. As it rapidly spread across New York City, the city's major teaching hospitals underwent unprecedented changes to reorganize resources, make space for the massive surge in COVID-19–positive patients who would require hospitalization and ventilatory support, and redeploy physicians of all specialties to aid in the effort. Given that New York City is leading the United States in the number of patients with a diagnosis of COVID-19 (277,606 cases as of April 25, 2020), coupled with the cancellation of all elective surgeries, the comprehensive redeployment of attending neurosurgeons and residents to assist in covering a COVID-19 intensive care unit (ICU) became a necessity. Here we present our detailed institutional experience from the heart of the pandemic, from a 1141-bed tertiary care academic center and 6 other affiliate hospitals of the Mount Sinai Health System in New York City, on how the reorganization efforts changed our neurosurgical graduate medical education program.

On March 23, 2020, the Department of Neurosurgery at Mount Sinai issued its first version of changes to resident practice. The inciting event for this was the conversion of the new neurosurgical ICU (NSICU) into a dedicated 35-bed COVID-19 ICU, requiring full-time staffing from all 4 of our faculty neurointensivist physicians. At this juncture, neurosurgery departmental leadership redeployed residents and attending physicians to provide 24/7 neurocritical care coverage, and midlevel providers were assigned to coverage in the emergency department and COVID-19 ICU. The old NSICU was reactivated, and all neurosurgical patients were transferred there. One of the first changes made was expanded resident coverage to staff this older NSICU with junior residents responsible for call every 3rd night. The 4 chief residents (7th postgraduate year and 6th postgraduate year) rotated on a weekly basis between the NSICU, the standard ICU, and 2 neurosurgery operating rooms (ORs). The NSICU chief supervised the neurosurgical service, neurosurgery floor patients, and NSICU patients; oversaw neurosurgery consultations; and attended rounds with the ICU team in the morning to build expertise in critical care. They were also responsible for preparing the biweekly radiology conference. The ICU chief neurosurgery resident worked closely with the ICU physician and attended rounds on all patients in the ICU, supervised day-to-day ICU management, and was in-house during the day with home call at night. The first OR chief had primary OR responsibility, and the second OR chief was to remain home unless the second OR was running. Both 5th postgraduate year residents were exclusively assigned to the cerebrovascular neurosurgery service and functioned at the fellow level. This change was in response to the 7-fold increase in stroke admissions related to COVID-19 seen at Mount Sinai within recent weeks. All junior residents were reassigned to a minimum of 6 weeks of neurocritical care and 6 weeks of neurosurgery. The neurocritical care junior residents were scheduled for 24-hour in-house call every 3rd day. The juniors assigned to the neurosurgery service were scheduled for 24-hour call every 4th day. Their responsibilities include preparing patients for the OR, preparing the radiology list, and covering the surgical cases. One other junior resident was considered backup for covering cases and otherwise was to stay at home. Interns were assigned to the NSICU through July 2020. The same principles applied to the residents covering the other Mount Sinai affiliate hospitals. All resident weekly teaching conferences and grand rounds were held virtually via video conferencing. On April 6, 2020, changes were made to this aforementioned version of the department staffing by introducing a dedicated senior and junior resident to staffing the COVID-19 ICU owing to increased need. The chiefs were also reassigned to four 1-week rotations consisting of the NSICU, the ICU, the OR, and the hospital floor/neurosurgical consultations. The reason for this change was that the low volume of surgical cases did not require a second chief resident and that physician staffing was better used in other areas of the hospital dedicated to COVID-19.

The changes to neurosurgery resident education at Mount Sinai were borne out of a necessity for redeployment of our physicians to assist in the fight against COVID-19, given the sheer abundance of COVID-19–positive patients in New York City. The Emory University Department of Neurosurgery reported similar changes for residents covering their neurosurgical service, and each resident is to spend 1 week during the month of April caring for patients with COVID-19. A number of programs have reported reducing resident staffing by 50% with teams rotating 1 week at a time, while the rest of the residents remain at home. Cases that ultimately go to the OR are typically limited to a single resident both to reduce exposure and to preserve personal protective equipment. The Massachusetts General Hospital/Brigham and Women's programs has redeployed attending physicians and residents on a voluntary basis. The shutting down of research facilities for residents completing their research years has also led to delays in scientific productivity for those involved in wet bench research. Emory University, along with many other programs, has similarly used videoconferencing for live-streaming grand rounds, educational didactic sessions, and case conferences. Resources created by the Congress of Neurological Surgeons (CNS) via their complementary online education program, the American Association of Neurological Surgeons (AANS) resident courses, the Cohen-Gadol Neurosurgical Atlas, and the Rhoton Collection have been instrumental in furthering resident education during this time.

The COVID-19 pandemic has dramatically transformed the clinical neurosurgery residency training program at Mount Sinai owing to the need to treat the unprecedented high numbers of >1600 COVID-19–positive patients currently admitted to our hospital. The COVID-19 pandemic has required our department to change resident education to an exceptional degree, but we are continuing neurosurgical learning in innovative ways while heeding the call to care for the city's sickest patients.