How COVID-19 inspired surgical residents to rethink educational programs.

The coronavirus disease 2019 (COVID-19) pandemic has caused significant disruptions to education for surgical residents across the country. Residents have experienced reduced operative exposure, decreased time caring for hospitalized patients, and altered rotation schedules. A number of studies have been published since the start of the COVID-19 pandemic regarding the effect of the crisis on residents and resident education across fields including internal medicine, emergency medicine, otolaryngology, orthopedic surgery, and general surgery.2, 3, 4, 5, 6, 7 These studies have described approaches taken by programs to mitigate the pandemic’s effect on education using alternative methods of clinical and structured learning.

Surgical residents have a unique perspective on the educational value of experiences on their development. Given the significant changes during the pandemic, we sought to determine surgical residents’ perceptions of education during this time and of possible changes to enhance residents’ educational experience and competency in the future. To do so, we conducted six virtual focus groups with 25 surgical residents at the University of California, San Francisco (UCSF). Focus group methodology was chosen to provide participants the opportunity to explore their experiences during the pandemic and compare those experiences with peers in an open-ended fashion. The focus groups were held in a region with an active shelter-in-place order. However, none of the affiliated hospitals became resource-constrained based on COVID-19 admissions.

Focus group transcripts were independently reviewed by two investigators (RB and PO’S) and codes were identified using qualitative content analysis. This method allowed for interpretation of comments in the evolving context of the COVID-19 pandemic. The investigators developed a codebook and applied codes to the six transcripts. Excerpts from transcripts were reviewed again by code to identify broader themes. Themes were discussed by investigators to reach consensus. Three major themes of discussion were identified: competency-based education, changes in teaching, and relationships.

The first identified theme was competency-based education and the tension residents experienced between obtaining a certain number of cases to meet requirements and wondering if case number was the right way to determine competency. Residents of all levels were concerned about their decreased operative exposure, with one summarizing “my biggest qualm is the cases” (R3). Others pointed out that to become a surgeon requires a certain operative proficiency, regardless of the actual number of logged cases. One resident said, “our program is still five years and so it just makes me nervous that we’ll have to grow more rapidly” (R1) while another thought that “every single month of our five clinical years of training is probably not indispensable to graduate as a good surgeon” (RR).

The second identified theme was changes in teaching. Residents discovered the creation of various new and useful video-based didactics, from a service-specific level up to a national level. Virtual didactics afforded new flexibility, as one resident noted, “you can have these amazing lectures recorded or technical skills recorded and available to you” (R2). Additionally, residents in clinical years benefited from new journal clubs, skills sessions, and dedicated didactic sessions by expert attendings as well as technical practice, operative debriefing, and quizzing with peers. Furthermore, the residents found they had time to learn about each case more thoroughly than before. One resident stated, “I do like how you get a little more time to debrief on what you’ve done” (R3).

The final identified theme was relationships between surgical residents and their patients, patients’ families, and faculty. First, new social distancing and personal protective equipment (PPE) guidelines affected patient relationships. One resident remarked, “wearing the mask all the time is such a problem in terms of being able to convey empathy … because they [patients] can’t see your face” (R1). Second, changes affected relationships with families and some residents recognized that virtual stand-ins for family presence were unsatisfactory. A resident noted of this that “having multiple people conferenced in just doesn’t work well for talking” (RR). Third, the pandemic affected relationships between residents and faculty. Some residents questioned the differential exposure to COVID-19 among residents and faculty members, with one resident stating “there was never any plan to reduce resident exposure by using faculty more than usual” (R5). However, others valued the deliberate approach taken by a number of faculty members during the crisis particularly in giving lectures and taking extra time for thoughtful teaching, with one resident commenting, “there’s a strong community” (RR).

This study demonstrated the varied ways in which surgical training was affected by the COVID-19 pandemic at one institution. Suggestions have already been made with regard to post-COVID resumption of residency education in the setting of concerns that the efficiency required to perform the backlog of cases may limit resident experiences. Indeed, Hall and colleagues propose greater awareness of the perspective of various stakeholders and further empowerment of residents to help set priorities. Our findings can help by providing resident voices.

Overall, our surgical residents experienced many educational changes due to the COVID-19 pandemic. By applying what we have learned from residents’ insights, we hope that we can refine surgical training and education moving forward. We can imagine greater attention to competency-based surgical education. We also envision further emphasis on communication skills ranging from nonverbal communication to family conversations to telemedicine. Importantly, time that residents and faculty spend together should increase. This will both improve education and foster the strong relationships critical to the training of quality surgeons.

Declaration of competing interest

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. We have no declarations of interest.