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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 4  |  Issue : 4  |  Page : 116-122

A study on the influence of COVID-19 on cardiovascular and thoracic surgery training in india and future prospective


1 Institute of Cardiac and Aortic Disorders, SRM Institutes for Medical Science, Chennai, India
2 Clinical Associate, Heart and Vascular Institute, Cleveland Clinic, USA
3 Department of CTVS, SCTIMST, Thiruvanathapuram, Kerala, India
4 Department of Cardiac Surgery, Command Hospital Air Force, Bengaluru, India
5 Department of Cardiacvascular and Thoracic Surgery, Kokilaben Dhirubhai Ambani Hospital and Medical Research Center, Mumbai, India
6 Department of CVTS, UNMICRC, Ahmedabad, Gujarat, India

Date of Submission20-Oct-2020
Date of Acceptance23-Nov-2020
Date of Web Publication24-Dec-2020

Correspondence Address:
Dr. Mohammed Idhrees
Cardio Thoracic and Vascular Surgeon, Institute of Cardiac and Aortic Disorders, SRM Institutes for Medical Science (SIMS Hospitals), Chennai - 600 026
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/hm.hm_37_20

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  Abstract 

Purpose: COVID-19 has destabilized the routine across the members of cardiac surgery including the postgraduates. In view of this, we conducted a survey among the residents to capture their thoughts on the impact of COVID-19. Methods: An electronic questionnaire was constructed and sent to the residents on May 17, 2020. Participation was voluntary and anonymized. The survey ended on May 27, 2020. Results: A total of 91 postgraduates across the country participated in the survey. A strong majority was attributed when more than 50% of the postgraduates agreed on an opinion, and a moderate majority was attributed when 40%–50% of postgraduates agreed on an opinion. Among the specialties, thoracic surgery and peripheral posting were severely affected, and it was the surgical skill which was severely affected compared to their lectures and thesis work. Multi-institutional collaboration teaching programs were useful in understanding the protocols of different units across the country. Conclusion: Virtual lectures have to continue integrating different institutions for the benefit of students. The students' involvements in the discussion are essential. A national forum for postgraduates has to be formed, promoting their participation and publications.

Keywords: Cardiac surgery residents, cardiothoracic residents, coronavirus, COVID-19, postgraduates, trainees


How to cite this article:
Idhrees M, Ashok Kumar C J, Radhakrishnan BK, Baruah SD, Kalmath MV, Kundan S, Ananthanarayanan C. A study on the influence of COVID-19 on cardiovascular and thoracic surgery training in india and future prospective. Heart Mind 2020;4:116-22

How to cite this URL:
Idhrees M, Ashok Kumar C J, Radhakrishnan BK, Baruah SD, Kalmath MV, Kundan S, Ananthanarayanan C. A study on the influence of COVID-19 on cardiovascular and thoracic surgery training in india and future prospective. Heart Mind [serial online] 2020 [cited 2022 Dec 4];4:116-22. Available from: http://www.heartmindjournal.org/text.asp?2020/4/4/116/304807


  Introduction Top


Lockdown, quarantine, self-isolation, personal protection equipment, and social distancing have become words of daily usage during this unprecedented time. Although the focus is on the patients and the community at large to treat and prevent the spread of the COVID-19 disease, it has undoubtedly rattled the educational and training program of the residents, especially the surgical specialty. COVID-19 has destabilized the routine across the members of cardiac surgery fraternity, with restriction of elective surgeries. The need to prepare the future cardiothoracic surgeons is not being focused in the present setting of emergency. Several adaptations and modifications have been implemented to help these residents and this may change the training forever in future. In view of this, we conducted an online survey to explore the minds and thoughts of cardiothoracic residents of our country.


  Methods Top


Aim of the study

The aim of the survey was to assess the following aspects with surgeons undergoing cardiothoracic training (i) effects on COVID-19 on surgical skill; (ii) impact on COVID-19 on lectures and thesis; (iii) usefulness of the virtual lectures; and (iv) the effect of multi-institutional collaboration (MIC) in education and future need.

Study design and sampling

This is an observational cross-sectional survey that included the cardiothoracic residents of India. An electronic survey was prepared with 22 questions using Google Forms. The head of the department of cardiothoracic units in various institutes and consultants working in different cardiothoracic units were personally contacted. Depending on the familiarity, each of the authors took responsibility for a particular zone in the country. The consultants were given the questionnaire and were asked to circulate among their cardiothoracic residents. For better reach, social media such as WhatsApp were also used to reach out to students. Participation was voluntary and anonymized. We started to circulate the survey on May 17, 2020, and in view of the current climate and the need for a timely outcome, we ended the survey on May 27, 2020, for further processes and analysis.

Study population/responders

The study population comprised surgeons who are undergoing cardiothoracic training in India (Magister Chirurgiae/Diplomate of National Board [MCh/DNB] Program).

Inclusion and exclusion criteria

Inclusion criteria

  1. Surgeons undergoing cardiothoracic training in India (MCh and DNB)
  2. All the survey questionnaires which were completed were taken into consideration for analysis.


Exclusion criteria

  1. Indian origin cardiothoracic residents undergoing training outside the country
  2. Surgeons who completed their training program.


Primary end point

Impact of the pandemic in cardiothoracic training with regard to surgical skills, lectures, and thesis.

Secondary end point

Effectiveness of virtual training program and MIC.

Statistical analysis

Data were collected from Google Forms entered in an excel sheet. Data collected were analyzed using SPSS (Statistical Package for the Social Sciences) [IBM Corp. Released 2016. IBM SPSS Statistics for Windows, Version 24.0. Armonk, NY: IBM Corp].

Ethical statement

This is an electronic survey which involves the cardiovascular and thoracic surgeons of India. There is no human or animal experiment which is involved. The identity of the surgeons was anonymized in the survey. An expedited clearance was obtained from the institutional review board.

Definition

Depending on the nature of the questions, the answers were graded as (i) not affected, mildly affected, moderately affected, severely affected, or very severely affected; (ii) extremely poor, poor, average, good or extremely good; (iii) strongly disagree, disagree, neutral, agree, and strongly agree; (iv) was not useful, very little useful, useful, and extremely useful. The participants had the option to choose only one of the clusters as the questions dictate. The consensus of responses was predefined as follows: (i) an absolute majority was considered when more than 50% of the residents agree on an opinion (orange), (ii) a moderate majority was attributed when 40%–50% of residents agree on an opinion (yellow), and (iii) an equivocal response when 30%–40% of residents agree on an opinion (green).


  Results Top


A total of 91 responses were obtained from the residents undergoing training in cardiothoracic surgery. The participants included 3-year MCh residents (n = 65, 71.4%) and 6-year DNB residents (n = 26, 28.6%). The questionnaire and the result of the survey are represented in [Table 1]. It included residents from all the states across the country. Two-third (n = 68, 74.72%) of residents who responded are undergoing training in centers with a high volume caseload (>750 cases/year). Further, 66 (72.5%) responded that elective cardiac surgeries were withheld in their training center during the period of lockdown.
Table 1: The survey questions and the responses

Click here to view


Following are the opinions of the residents

  1. A moderate majority of the residents felt that the thoracic surgery and peripheral rotations were severely affected because of the lockdown
  2. A moderate majority opined that it was the surgical skill which was very severely affected because of the pandemic
  3. An absolute majority of the students thought that the virtual lectures were good. They all agreed with an absolute majority that the narrative PowerPoint presentation, surgical video during virtual lectures, panel discussion, and case-based discussion were useful
  4. An absolute majority agreed that MIC teaching programs were useful in knowing the protocol of different institutions. This helped them understand the concepts better
  5. All of them strongly disagree to discontinue the virtual lecture after lockdown
  6. A moderate majority agreed that this MIC should be conducted either every fortnight or once in a month. They believed that, in future, the classes can be conducted between 6 pm and 9 pm on weekdays or Saturday
  7. They all agreed with a moderate majority that resident participation is required in virtual classes involving journal clubs, case presentations, and symposiums
  8. Though a bulk of students (n = 65, 72.2%) agreed that lectures were increased by more than 60% during the lockdown, there was an equivocal response with regard to the quality of lectures.


The major disadvantage of the virtual lecture was the overlapping of lectures during the lockdown and lack of personal interaction. Just over a third of the students (n = 36, 39.6%) were involved in some form of manuscript writing during the lockdown period. Twenty-eight (30.8%) residents opted for additional training/support in compensation for lockdown by at least 2 or 3 months.


  Discussion Top


During the lockdown period, the surgical work went down drastically across the country. Many of the intensive care units and operating rooms were converted to COVID wards in many centers. This brought down the surgical workload to a considerable amount affecting the surgeons in training drastically. With ongoing development of vaccines and successful treatment for COVID-19, social distancing and hand hygiene are still considered to be the most effective preventative strategy. These precluded residents in training to be involved in closed group teaching sessions, journal club presentations, or clinical case presentations. The pandemic may take several weeks/months to stabilize. However, the residents have a stipulated training time limit before they appear for their certification exams. The alternative to this would be a virtual continued training session to help them compensate for the loss during this pandemic.

Medical education is an area of increasing complexity, considering the education goals of health professionals for the 21st century. Although there are no work hour limitations in the residency programs in our country, learning the wide spectrum of cardiothoracic knowledge while training in a 3-year traditional or 6-year integrated programs will be limited to the practices and policies based on one specific institution'. The availability of alternate sources of knowledge online in the form of multimedia journals and videos do play a significant role in enhancing practical knowledge among the residents and new graduates.

MIC teaching is not a new concept. With the current COVID-19 pandemic throwing every academic program into a spin, the value of alternate learning modalities such as web-based MIC seminars is proving its worth. MIC teaching provides a unique opportunity to the trainees in understanding the pathophysiology, concept, and surgical aspects of any particular disease from a different perspective. It offers them alternate practical solutions based on shared knowledge among the diverse surgeons in different hospitals or institutions. The concept of approaching a problem from different viewpoints along with critical discussions during or after MIC teaching sessions may set trends and ideas in motion for new innovations in the advancement of our field. These MIC sessions provide additional interaction with contemporaries and faculty surgeons across the world and also lay a platform for long-term relationships which might result in future multi-institutional collaborative conferences and research opportunities. MIC on the other hand should not induce conflicting thought processes in understanding the difference of protocols and concepts for the residents. The trainees should be prudent enough to adhere to their parent program protocols in the management of the surgical patients while in their training and should not get confused with alternate policies that are being practiced in other academic programs.

Simulation within surgical training and practice is defined as any activity that aims to imitate an environment to inform, modify, or assess skills and behaviors.[1] This would allow for an interactive performance replicating a real-world clinical scenario, though not identical. Furthermore, this will also ensure patient safety apart from developing surgical skills. Surgical simulation will encompass both low- and high-fidelity models – dedicated wet or dry simulation labs, simulation within working theaters, simulated – patient role play, computer-based simulators, box-trainers, and basic suturing models.[2] A survey from the UK and Ireland pointed out that 98.9% of the trainees considered simulation training programs important and more than half of them (55%) felt that it is still inadequate.

Pandemic lessons: Future prospective

  1. The lockdown has opened the options of virtual lectures and MIC, paving and easy way for students to interact with the faculty of different institutes across the country. The future MIC can be planned exclusively for the residents every fortnight in the early evening, preferably between 6 p.m. and 9 p.m. during Saturdays. This can be planned exclusively for the PGs every fortnight
  2. The major disadvantages of virtual lectures and MIC are the lack of face-to-face interaction and personal interaction. The exclusive resident's lectures with the involvement of them will address the issues to a significant extent. The students can be asked to present a clinical case for discussion or present a journal in the journal club
  3. Formation of Postgraduate Forum by the Indian Association of Cardiovascular-Thoracic Surgeons (IACTS). This team is headed by the two senior executive committee members of the IACTS and would also comprise two young surgeons who have completed the training (within 5 years after graduation). This team will be involved in the following (a) collecting the e-mails of all the residents of the country, (b) coordination with the Editorial Board of Indian Journal of Thoracic and Cardiovascular Surgery and motivating the students to get involved in manuscript writing, and (c) help in organizing the future virtual lectures and MIC
  4. When a resident enrolls himself/herself for the training program, they will also register with the IACTS's Postgraduate Forum. The IACTS can provide a free temporary membership valid till their training program is completed. In this way, they are in constant touch with the IACTS, and the association also has contact details of the residents by which the students are served in a better way in this digital era
  5. An integrated simulation program across the country, which can be virtual training or small group training. A simulation center can be set up in each zones of the country where students can be given training on a regular basis
  6. The students felt that their surgical skills were severely affected by the COVID-19 lockdown. According to the survey, one-third of the students were seeking an extension of 2–3 months of their training program. Given the present fluidity of the pandemic crisis, they may have difficulty finding a new job after their graduation. In view of these, the student can be retained in their training institute after their stipulated time helping them to compensate for the missed training.


Concerns of online training

A recent concluded study from Italy among 122 medical students showed that only 7% preferred formal training[3]. Further, 92% of the participants mentioned the new training experience met or was superior to their expectations. Many despite having little experience on simulators, found this new simulation experience as realistic and useful, meeting their expectations. They recommended for the future generations of medical students as well. Another analysis from Japan reported that these virtual simulations can help even without lecturer supervision[4]. Though this reflects the student's perspective, the reflection of the teachers has not been mirrored. Though the 'new-normal' wherein e-learning has become part of training aspects, certain aspects cannot be replaced by the same. For instance, the biggest concern for surgical trainees would be cancellation of elective cases. This coupled with them being deployed for non-surgical work during their stipulated time of training adds a concern. There are guidelines published by UK in regards to medical training for assessment format and requirements[5], but these still cause a lot of anxiety among students. A randomized study would be needed in future to assess the value of this virtual training, evaluating the knowledge and skills using this modality as compared to the traditional training.

The authors feel, though the virtual training can constitute a major portion, it cannot replace the traditional training in the following aspects

  1. The teacher – student bonding. Technology use for remote learning can whittle away at the human connection that exists in brick-and-mortar classrooms
  2. Technology Issues: A disconnection of the Internet by the host during a teaching process will warrant everyone to login again. This may disrupt the flow of teaching
  3. If there is disruption of internet for any student, he may miss the lecture. When reconnected, he may even miss the flow of the subject.
  4. Lack of peer interaction: Interaction with peer and socialization is part of learning and skill enhancement. This would be compensated in online training.


Limitations of the study

The aim of the present survey was to understand the impact of cardiothoracic surgery on residents during this pandemic era in India. Our results may be biased if the impact and preferences of the remaining cohort who did not participate vary significantly. Since we have approached the head of the units or the consultants through personal basis, it is difficult to say the exact number of residents who were contacted for the survey. Further, as it was contacted through personal basis, we tend to have more responded from southern India and less from the eastern part of the country. The investigators had no way of validating the responses from the respondents did indeed correspond to the actual practice patterns.


  Conclusion Top


Virtual training and MIC should become an integral part of every academic training program in our country, enhancing surgical core knowledge and the best quality of practice in our field. This also serves as an outreach for the residents who seek valuable career guidance from the mentors across the world. The involvement of residents with active interactions during these new remote educational sessions will benefit them. A National Forum for the residents has to be formed, promoting their participation and publications.

Consent of participation and publication

The following statement was mentioned during the survey. The response shall be pooled for analysis and academic presentations. On completion of the analysis, it will be submitted to any international Journal for consideration for publication. By taking this survey, you agree that the pooled data could be used by the survey team for academic/research purposes.

Ethical statement

This is an electronic survey which involves the cardiovascular and thoracic surgeons of India. There was no involvement of human or animal experiment. The identity of the surgeons was anonymized in the survey. An expedited clearance was obtained from the Institutional Review Board.

Human and animal rights statements

There was no involvement of human or animal experiment in the present study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Milburn JA, Khera G, Hornby ST, Malone PS, Fitzgerald JE. Introduction, availability and role of simulation in surgical education and training: Review of current evidence and recommendations from the Association of Surgeons in Training. Int J Surg 2012;10:393-8.  Back to cited text no. 1
    
2.
Nicholas R, Humm G, MacLeod KE, Bathla S, Horgan A, Nally DM. Simulation in surgical training: Prospective cohort study of access, attitudes and experiences of surgical trainees in the UK and Ireland. Int J Surg 2019;67:94-100.  Back to cited text no. 2
    
3.
De Ponti R, Marazzato J, Maresca AM, Rovera F, Ferrario MM. Pre-graduation medical training including virtual reality during COVID-19 pandemic: a report on students' perception. BMC Med Educ 2020;20:332.  Back to cited text no. 3
    
4.
Watari T, Tokuda Y, Owada M, Onigata K. The utility of virtual patient simulations for clinical reasoning education. Int J Environ Res Public Health 2020;17:1-9.  Back to cited text no. 4
    
5.
Joint Committee on Surgical Training. COVID-19 and trainee progression in 2020 (update I) – 1 April 2020. 2020.  Back to cited text no. 5
    



 
 
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