The effect of COVID-19 on higher plastic surgery training in the UK: A national survey of impact and damage limitation.

Dear Sir,

The long-term manifestation of COVID-19 is unlikely to be fully appreciated for years to come as global healthcare systems have been uniformly crippled during the peak of the pandemic and in the subsequent recovery. Despite the NHS rapidly restructuring service provision, the disruption to emergency and elective surgery is well recognised. Professional development, training opportunities and progression have also suffered. The implementation of innovative solutions by some institutions and governing bodies has been an attempt to mitigate long term impact. The Joint Committee on Surgical Training (JCST) have dubbed this a “training emergency” in their #NoTrainingTodayNoSurgeonsTomorrow Twitter campaign. We sought to establish a national consensus on the state of plastic surgery higher surgical training (HST) in the UK and strategies adopted to minimise disruption.

Method

A 25-item questionnaire (Figure 2) was distributed via Google Forms to all Training Programme Directors as outlined by the JCST, for distribution to all Specialist Registrars (SpR) in the UK. The survey was opened in November 2020 for a period of one month, SpRs were requested to respond based on their experiences from the start of the COVID-19 pandemic. No financial remuneration was offered for completion and only a single submission was considered per registrar.

Figure 2

Questionnaire.

Results

A total of 56 responses was obtained, 89% of which held a National Training Number (NTN), with a spread of deaneries excluding Scotland and Ireland which returned no responses (Figure 1 ). 89% of responding registrars were in full time training and the remaining, less than full-time. A spread of training grades responded, with ST3 being the most representative group (20%). 84% of the sampled registrars felt that their training had been negatively affected by the COVID-19 pandemic despite only 21% being re-deployed to other specialities. 96% reported less surgical experience during this period and 93% reported a subsequent negative impact on their indicative surgical logbook numbers secondary to increased consultant led operating (51%). 64% expressed concerns regarding meeting the minimum threshold for elective operating as stipulated by the JCST for Certificate of Completion of Training (CCT). This concern was less pronounced for emergency operating (45%). Indicative elective procedures which trainees did not gain exposure to included Dupuytren's surgery (86%), aesthetic procedures (82%) and breast reconstruction (80%). Emergency procedures which trainees felt they lacked exposure to during the time period included microvascular anastomosis (53%), hand fracture fixation (50%) and lower limb trauma (42%). If given the opportunity to extend training, 46% would opt for this, with a further 36% considering it as a viable option. If an extension was taken, 35% would opt for 6 months and 20% either 3 or 12 months. In terms of mitigating the negative effects on training, 75% of SpRs indicated that webinars were the main source of training opportunity, with 18% reporting no in-house contingency. Very few units utilised simulation (1.8%), private sector operating (1.8%) or cadaveric training (3.6%) as viable training opportunities. 8.9% reported a negative impact on their fellowship, and 26% expressed that recent events had affected their decision to take exit examinations.

Figure 1

Distribution of Survey Results.

Discussion

Providing care to our patients and supporting colleagues who are under significant pressure remains paramount, however, we must ensure that we maintain surgical training standards. Our survey highlights a decline in training opportunities with subsequent knock-on effects on elective and trauma indicative numbers, preparation for exit examinations, and fellowships. The limitations of this study include a 16% response rate amongst NTN trainees, this is more challenging to quantify amongst the non-NTN trainees as the exact number is unknown. However, we believe the results to be representative as there is good spread across registrar grade and geography, with concordance across responses.

Despite the implementation of a vaccination programme, the effects of COVID-19 on plastic surgery HST are likely to be long standing as elective operating recovers. Implementation of webinars, although a useful modality, provided as a standalone strategy is likely to suffer from fatigue. A multi-pronged strategy is required to ensure that training is provided despite the challenging circumstances. The JCST published guidance outlining methods to mitigate impact, ranging from greater use of independent sector training opportunities, testing of personnel in green zone operating areas and therefore permitting greater trainee operating, the use of remote observation and actively capitalising on learning opportunities.

Our survey highlights that to date, the less traditional methods of training have yet to be implemented and further development (Figure 3 ) is required to prevent trainees becoming disillusioned. These findings are not limited to the first wave, and therefore long-term strategies are required to future proof for the unknown duration of the pandemic.

Figure 3

Methods to mitigate impact adapted from JCST recommendations.

We must ensure we invest in the training of future plastic surgeons. Building on the findings of the UK Plastic Surgery Trainees Association (PLASTA) national plastic survey, workforce planning is critical as key sub-specialities in the post COVID-19 recovery period become increasingly evident.

Declaration of Competing Interest

Nil.