Commentary: Caution: Falling case volumes.

Frederick A. Tibayan, MD

Adequate training during the COVID-19 pandemic requires early identification of obstacles. To meet minimum requirements, residents will need innovative educational strategies and directed mentorship.

See Article page 1126.

The response of our health care systems to manage the coronavirus 2019 (COVID-19) pandemic has necessitated a dramatic decrease in elective clinical activity, and consequently, cardiothoracic surgery case volumes. On top of this, as reported in a worldwide survey of cardiothoracic surgery training programs, many resident physicians are either directed to stay home or relocate to wards or intensive care units on the front line of an outbreak. This combination of factors drives concerns about some cardiothoracic surgery residents meeting minimum case volumes required for graduation as well as reaching the expected levels of autonomy and expertise for starting their careers. Residents, surgery programs, and employers would all benefit from early identification and intervention in scenarios where COVID-19 may significantly influence the training experience. Boskovski and colleagues present a theoretical framework for recognizing which residents are most negatively affected in terms of readiness for graduation. The authors include the overall influence of COVID-19 on the institution, baseline case volume, seniority of the trainee, concordance of the trainee's rotations and career track during the outbreak, and nonoperative components. Such a schema may prove useful for not only this pandemic, but also the inevitable outbreaks of the future, and will be informative for those both training and hiring young surgeons. For these at-risk residents, Boskovski and colleagues propose excellent strategies in use at their own institutions, such as critical review of operative videos, case-based discussions using online meeting tools, double-scrubbing with junior residents, and increased mentorship from surgical educators and senior partners.

Simple predictive models such as this have demonstrated great potential for robustness and broad applicability. However, the framework and solutions as described are most relevant for an outbreak of relatively limited duration. In regions where the burden of the pandemic is steady or increasing for extended and uncertain time periods, long-term curriculum changes for both junior and senior trainees may be required. The authors' noting of the effects of the COVID-19 pandemic on the health and family life of trainees who may have to care for sick parents or facilitate remote learning for school-aged children deserves special mention. These factors represent important aspects of the physical and emotional well-being of trainees as well as their ability to learn effectively. Everything may seem different during the pandemic, but cardiothoracic surgeons in training need flexible, compassionate education, and dedicated mentorship. That will always be a constant in our field.