Plastic surgery training during COVID-19: Challenges and novel learning opportunities.

Dear Sir,

The COVID-19 pandemic has fundamentally changed the way we work and care for patients. We read with interest the correspondence by Armstrong et al. outlining the response of their plastic surgery department in one of the largest teaching hospitals in Europe including leadership strategies, team restructuring and altered patient pathways. However, one vitally important area not discussed is the impact on training. Furthermore, social distancing has necessitated a shift in teaching paradigms and there has been an almost-viral uptake in webinar-based learning opportunities. Notable examples include the Pulvertaft Hand Centre/PLASTA and ICOPLAST series, whilst the inaugural British Society for Surgery of the Hand “Great Debates of Hand Surgery” webinar attracted over 500 attendees. Here we consider the impact of COVID-19 on plastic surgery training and discuss the merits of webinar-based learning including how to best utilise this increasingly important teaching resource.

Impact on training

COVID-19 has significantly impacted training in plastic surgery. Reduced working hours due to illness, changes in rotas to limit exposure to the virus, a reduction in face-to-face patient assessments, an increasingly non-operative approach to common conditions, and a move to consultant-led services have limited learning opportunities for trainees in both acute and elective settings. Furthermore, examinations, educational courses and conferences have been cancelled, as have many fellowship placements. Redeployment of trainees to other specialties during the pandemic will impact training, but whether transferable skills can be obtained remains to be seen; for example, greater experience in critical care may be relevant for burns management.

Responding to the challenge

In response to these challenges the webinar has become king. Whilst widely described in the pedagogical literature, the use of webinars in plastic surgery has received limited attention. Webinars represent a synchronous virtual learning platform and confer a number of advantages. Most importantly, webinars offer geographic flexibility, which not only facilitates compliance with social distancing but also increases learning opportunities from leading experts, often across international boundaries. Many large online events are attended by participants from different healthcare settings, enriching discussions and facilitating the dissemination of information on a global scale. Furthermore, the synchronous setup allows participants to communicate directly with trainers and removes barriers caused by shyness, for example through the use of text-chat boxes. Finally, compared to traditional teaching methods, webinars also offer greater temporal flexibility through recording and storage online for revision.

Optimising training through webinars

The educational benefits of webinars are clear and methods to optimise training in plastic surgery through this novel platform should be explored. Here we present 6 key lessons from our experience:

Choose an appropriate platform: A number of different online video conferencing platforms are available including ZoomⓇ, Google MeetⓇ, Microsoft TeamsⓇ and SkypeⓇ, each with unique features (Table 1 ).

Table 1

Online video conferencing applications.

Software	Compatibility	Cost (per month)	Maximum number	Other free-version	Additional useful
			of participants	limitations	features
Google Meet	Windows, MacWeb browsers*iOS, Android	Free	100 for freeUp to 250 for G Suite subscribers	Gmail account required	Screen shareVideo recordingLive subtitlingLow-light mode Integration with other video conferencing apps
Microsoft Teams	Windows, MacWeb browsers*iOS, Android, Win	Teams - freeBasic - £3.80Standard - £9.40E3 - £17.60	250, or10′000 for live events†	8  hour limit on group chat,4  hour limit on live events†No video recordingNo hosting	Screen shareBackground blurFile-share and co-authoring documentsIntegrated apps
Skype	Windows, MacEdge, ChromeiOS, Android, Win Amazon Kindle/FireAlexa, Xbox	Free unless making international calls to phone numbers	50	4  hours/chat and 10  hours/day limit on group chats	Screen shareVideo recordingLive subtitlingCan call phone numbers not on Skype
Zoom	Windows, MacWeb browsers*iOS, Android, Win	Basic - FeePro - £11.99Business/ Enterprise - £15.99	100 freeUp to 1000 depending on plan	40  minute limit on group meetings	Screen shareVideo recordingVirtual backgroundCo-annotation

Internet explorer, Edge, Chrome, Firefox, Safari.

Live event limits extended to 20′000 attendees and 16 hours until 1st July 2020.

Decide on the size of audience desired: Local or regional webinars would typically have fewer than 20 attendees and can be held in a ‘chat-room’ format where all participants can see each other, maximising real-time interactions and discussion. On a national or international scale there are often >100 attendees in which case opportunity for in-depth discussion is limited and a formal presentation, followed by a structured Q&A may be more appropriate. Very large events can be live-streamed on YouTube to overcome participant limits on video-conferencing platforms.

Advertisement: To reach a wider audience consider advertisement through regional and national networks, and/or social media.

Security: Consider using password protection to prevent unauthorised access, and ensure all material does not risk breaching patient confidentiality.

Establish a code of conduct: Punctuality and professionalism should be maintained. Participants should be muted when not speaking to avoid background noise and distractions.

Encourage participation: Whilst many traditional pedagogical methodologies should be maintained in webinar-based teaching, novel opportunities to engage participants exist. For example, we have used the real-time co-annotation functionality on Zoom to allow trainees to demonstrate the planning of local flaps, and the polling functionality to ask questions, test learning and gather feedback. This would enable one to engage in higher levels of learning including application, analysis, synthesis and evaluation as per Bloom's hierarchy.

Conclusions

The war against coronavirus has challenged training in plastic surgery; however, we believe that in the midst of chaos, there is also opportunity. Webinar-based learning may be the norm for weeks or months to come, but also offers a fantastic platform through which educators can reach a wider audience and trainees can access expert teaching. Furthermore, reduced costs, greater flexibility and reduced carbon footprint make webinars an attractive option for the future. Further research should focus on how we can best utilise this powerful educational tool in plastic surgery training, whilst a coordinated approach from different providers could help avoid timetabling clashes and optimise attendance.

Declaration of Competing Interest

The authors declare no conflicts of interest.