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Table of Contents
Year : 2021  |  Volume : 23  |  Issue : 3  |  Page : 100-106

The COVID-19 and its impact on otolaryngology trainees' competency and their psychological well-being: A nationwide cross-sectional study

1 Department of Otorhinolaryngology, College of Medicine, Imam Abdulrahman Bin Faisal University, Al Khobar, Saudi Arabia
2 Division of Epidemiology and Biostatistics, Department of Family and Community Medicine, College of Medicine, Imam Abdulrahman Bin Faisal University, Al Khobar, Saudi Arabia

Date of Submission14-Oct-2020
Date of Decision25-Oct-2020
Date of Acceptance23-Nov-2020
Date of Web Publication05-Oct-2021

Correspondence Address:
Dr. Salma Saud AlSharhan
Department of Otorhinolaryngology, College of Medicine, Imam Abdulrahman Bin Faisal University, Al Khobar
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sjoh.sjoh_50_20

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Background: As a consequence of the COVID-19 global pandemic, otolaryngology residents are at high risk due to the nature of the specialty and long work hours. Moreover, COVID-19 could have a severe impact on residents from different frontline specialties, particularly otolaryngology. To the best of our knowledge, this is the first nationwide survey providing insights into the otolaryngology residents' prospective of view about the impact of COVID-19 on their training competency development as well as related worries and concerns. Methods: A cross-sectional questionnaire-based study was conducted among all otolaryngology training centers of Saudi Arabia to investigate the extent of the impact of COVID-19 on otolaryngology residents and the learning process. Results: A total of 152 residents were contacted to participate in the study, and 101 participants were included after successfully completing the questionnaire. The mean age of the participants was 28.12 years (standard deviation = 1.89, max = 36, min = 25). There has been a significant impact on outpatient clinics, elective operations, consultations, and working hours. Further, we evaluated the impact on academic training activities, the frequency of training activities per week, and the psychological impact of the COVID-19 pandemic on otolaryngology residents as well. Conclusion: COVID-19 has had a serious impact on residents both physically and mentally; otolaryngology residents have been hit, especially hard by this emergency pandemic period. Trainees suffered from excessive worries regarding clinical training, specifically academic concerns for different training levels. Further studies need to be done here in Saudi Arabia to evaluate this impact in greater detail and to protect the residents.

Keywords: Coronavirus infection, medical residency, otolaryngology

How to cite this article:
AlSharhan SS, Al Bar MH, AlSaied AS, ALEnazi AS, Aljubran HJ, AlKhaldi SK, Alghamdi AA. The COVID-19 and its impact on otolaryngology trainees' competency and their psychological well-being: A nationwide cross-sectional study. Saudi J Otorhinolaryngol Head Neck Surg 2021;23:100-6

How to cite this URL:
AlSharhan SS, Al Bar MH, AlSaied AS, ALEnazi AS, Aljubran HJ, AlKhaldi SK, Alghamdi AA. The COVID-19 and its impact on otolaryngology trainees' competency and their psychological well-being: A nationwide cross-sectional study. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2021 [cited 2022 Jul 2];23:100-6. Available from: https://www.sjohns.org/text.asp?2021/23/3/100/327571

  Introduction Top

Coronavirus disease (COVID-19) first appeared then spread rapidly in Wuhan City, China, and was identified on December 31, 2019, as a highly contagious disease that affects the respiratory system.[1] On January 30, 2020, the World Health Organization declared the situation a public health emergency of international concern. In Saudi Arabia, more than 76,000 reported cases and 411 deaths had been announced by May 27, 2020. This was in addition to the surge of confirmed COVID-19 cases in Saudi Arabia and a subsequent stay-at-home policy implemented in many regions, which affected many people of different demographics and professions. Notably, the COVID-19 outbreak undoubtedly interrupted residency training programs, in general, including the otolaryngology residency program. The Saudi Board program of Otolaryngology Head and Neck Surgery is a 5-year residency training program, offering a unique educational experience that provides exposure to all facets of otolaryngology. Overall, due to this pandemic emergency, many health practitioners are at high risk. However, otolaryngology residents are at even higher jeopardy, which has been classified in the very-high-risk category because of the potential of exposure to coronavirus through aerosol-generating procedures.[2] Hence, it is necessary to reduce the risk of this outbreak by minimizing residents' close contact with suspected COVID-19 patients. However, such exposure can distract residents and negatively impact their performance.[3],[4]

Because of the contagious nature of the disease, the board members of the Saudi Commission for Health Specialties (SCFHS) have discussed changes, raised national alert levels, and implemented wide-range measures to minimize the risk for trainee residents. It is worth mentioning that the impact of COVID-19 on residents extends beyond infection to possibly negatively impact residents' mental health and developmental and learning processes.

This study explores the magnitude and extent of this impact on otolaryngology residents' training competency from their prospective. Likewise, the article discusses the current challenges and offers some simple strategies to bridge the gaps in trainee residents' training and education to overcome this crisis.

  Methods Top

We conducted a cross-sectional questionnaire-based study targeting all otolaryngology residents in Saudi Arabia to evaluate the degree to which COVID-19 affected them physically and mentally utilizing competency indicators in three aspects: knowledge, skills, and attitude and to evaluate their general knowledge about the disease, having first obtained institutional board review approval (IRB-2020-01-129) from the Imam Abdulrahman bin Faisal University Ethical Review Committee. An online survey was specifically designed for this study and sent to all otolaryngology residents of the SCFHS through text messages in four regions of Saudi Arabia (Eastern, Western, Middle, and Southern) over a period of 3 weeks from May 18, 2020, to June 8, 2020, followed by reminder messages sent three times with a 5-day gap. The principal study consisted of 44 questions written in English, which comprised two thematic blocks. The first 21 questions queried the residents' sociodemographic data, including age, gender, marital status, training level (ranging from R1 to R5), center of training, region, and practice as routine involvement in a clinical practice relevant to the pandemic. The second consisted of 23 questions and comprised four sections. The first section evaluated the residents' knowledge about the COVID-19 pandemic measured using a percentage scale that ranged from 0 to 100. The evaluation of the residents' concern about the pandemic was in the second section and was measured using a numeric slider that determined the percentage of their concern (0–100). The third section screened the magnitude of anxiety using the screening tool of the Generalized Anxiety Disorder-7 (GAD-7).[5] The final section evaluated the residents' attitudes toward COVID-19 using a percentage scale ranging from 0 to 100.

The analysis were done using StataCrop (2019) software version 16. Student's t-test and one-way analysis of variance test were used to examine the difference in the items' scores among our study subgroups, as appropriate. In addition, a Chi-squared test was used to examine the differences in the distribution of the study variables among the study subgroups.

  Results Top

Included participants and their sociodemographic features

We were able to approach 152 out of 211 otolaryngology residents in Saudi Arabia. After excluding any incomplete data, 101 participants were included, giving a completion rate of 65.58%. [Table 1] summarizes the sociodemographic features of the participants and their academic indicators. The mean age of the participants was 28.12 years (standard deviation [SD] =1.89, max = 36, min = 25). In addition, the majority of the trainees who sacrificed their otolaryngology training covering frontline duties were receiving their training in secondary hospitals (56.67%, n = 17), and they were in the junior training level (63.33%, n = 19; R1 = 6, R2 = 13).
Table 1: Distribution of sociodemographic features of the study participants (n=101)

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The impact of the COVID-19 pandemic on academic activities

The majority of training activities were continued despite the presence of the pandemic (59.4%, n = 60). However, the COVID-19 pandemic was found to have a statistically significantly large impact on the number of covered outpatient clinics, elective operations, consultations, and working hours. At the same time, the COVID-19 pandemic did not statistically significantly affect the number of homes on-calls [Table 2]. Around 36.63% (n = 37) of participants went under quarantine, which lasted on average for 15.24 days (SD = 11.72, min = 1, max = 60) as 29.70% (n = 30) worked in COVID-19 pandemic frontline defense either to cover the intensive care unit (20.00%, n = 6) or by performing otolaryngology-related procedures (such as taking nasal swabs, laryngoscopy, or airway intubation; 26.67%, n = 8), assisting in the emergency room department (16.67, n = 5), as well as doing paperwork duties to support other medical specialty physicians. As an alternative to traditional clinics and face-to-face consultation, around 63.37% (n = 64) of otolaryngology residents used telemedicine either through texting applications such as WhatsApp, e-mails, or other social media applications (37.50%, n = 24), through performing video calls using applications such as Zoom, Skype, or others (9.38%, n = 6), or through using audio calls such as phone calls or other audio applications (53.13%, n = 34). However, as seen in [Table 3], other than using telemedicine for consultations, many training programs were not affected by the pandemic, as a minority of trainees were pulled out of their otolaryngology training activities to fight against the COVID-19 pandemic.
Table 2: Impact of the coronavirus disease-19 pandemic on the frequency of various training activities per week

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Table 3: Influence of the coronavirus disease-19 pandemic on academic activities in relation to level of training program

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Attitudes of residents toward their training activities during the COVID-19 pandemic

[Table 4] summarizes the central tendency statistics of trainees' attitude items' scores (0–100) toward their academic training according to their academic level. In general, R5-level residents were found to have the highest satisfaction mean scores toward their training activities. Nevertheless, regarding the training center level, participants who were trained in a tertiary hospital reported a significantly higher satisfaction toward their self-development during COVID-19 (mean = 55.16, SD = 29.23, F = 3.20, P = 0.046) compared to university hospital trainees (mean = 43.52, SD = 29.23) and secondary hospital trainees' (mean = 43.63, SD = 21.30) satisfaction levels. These results are due to the fact that tertiary hospitals tend to provide residents with a high-quality level of education experience and clinical training. Furthermore, training is aided by the expertise of physicians who are present more often in tertiary hospitals compared to other hospitals.
Table 4: Summary of central tendencies of ear, nose, and throat trainee's attitude item's scores in relation to their training level

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The psychological impact of the COVID-19 pandemic on otolaryngology residents

As shown in [Table 5], around half of the otolaryngology trainees suffered from excessive worries (54.46%, n = 55). However, these worries (in the majority) were not excessive in terms of their intensity, frequency, or ability to control them. Furthermore, there was no difference between trainees who covered the frontline service against the pandemic and trainees who remained at their duties in regard to the severity or the characteristics of these worries. In contrast, [Table 6] specifically provides insight into the academic concerns and worries in relation to the training level. As seen there, the highest level of concern was experienced in regard to the absence of a clear training rotation plan (mean = 67.02, SD = 30.99); however, there were no differences between the trainees in regard to the type of their concerns, except regarding the absence of personal experience in such a pandemic situation as R3 trainees statistically significantly showed the lowest levels of concern.
Table 5: Distribution of anxiety screening questions (generalized anxiety disorder-7 questions) in relation to shifting to performing frontline duties instead of regular ear, nose, and throat training clinical duties

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Table 6: Summary of central tendencies of training-related specific worries' items scores caused by the coronavirus disease-19 pandemic in relation to the otolaryngology residency program training level

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  Discussion Top

The COVID-19 outbreak is an unprecedented challenge with ripple impacts throughout healthcare systems globally. During this study, conducted during the peak of the pandemic in Saudi Arabia, we sought to determine how COVID-19 has disrupted the practice of otolaryngology residency training programs and affected trainee residents' learning curve and especially the competency in clinical knowledge and surgical skills. Further, we evaluated the impact on academic training activities, the frequency of training activities per week, and the psychological impact of the COVID-19 pandemic on otolaryngology residents as well.

To the best of our knowledge, this is the first nationwide survey providing insights into the impact of COVID-19 on otolaryngology residency training programs, which have been hard hit by the emergency pandemic period. In this study, participants reported a large magnitude in Cohen's d effect size in some of their training activities, such as outpatient clinics, elective operations, consultations, and their working hours. These significant deficiencies from the residents' prospective would consider implementing a strategies and solutions to ensure that the residents are given the optimum qualified training that they require.

Among physicians, otolaryngologists have been one of the most affected groups during this global pandemic. Moreover, they have been recorded as having the highest proportion of contagion spread due to the nature of their work as they have the closest contact with the upper respiratory tract mucosa where the high viral load exists.[6],[7],[8],[9] In addition, patients with COVID-19 may present with symptoms mimicking those that appear in patients who are seeking medical advice about the ear, nose, and throat region, which also puts otolaryngologists at high risk compared to other specialties.[9] Accordingly, urgent measures were implemented to minimize the transmission of COVID-19 in healthcare settings, which included reducing specialist clinics, outpatient procedures, and use of operating theaters. In response, telemedicine has been implemented in the majority of hospitals, allowing face-to-face consultations to be cancelled and replaced by telephone consultations and virtual clinics. Moreover, all nonurgent cases should have been postponed, as per the European Rhinology Society's recommendations, as should all elective surgery cases that did not require immediate intervention, with priority reserved for oncology and obstructive airway cases.[10] Likewise, outpatient procedures were stratified by urgency. Importantly, in such cases, crucial personal protective equipment (PPE), such as N95 masks, fluid-resistant gloves and gowns, and goggles/face shields must be worn. Furthermore, adequate PPE should be provided by hospitals to handle this crisis, with all trainee residents trained in the proper usage of this equipment. Taken together, these precautions will maximize the residents' protection from the COVID-19 risks, including the physical and psychological aspects.[11] At the same time, this will affect the practice of residents as well as their mental health, as elective cases have been suspended and residency examinations delayed, which will surely have a stressful impact on training residents.[12]

Despite all those issues residents were facing because of this pandemic, the training residency program continued. For this reason, Saudi board program members have discussed changes to national healthcare systems and the impact on otolaryngology residents to initiate a new plan for their residents in response to the COVID-19 pandemic to ensure their safety and provide maximum clinical practice.[13]

A slowdown of the learning curve for residents was inevitable, so residency teaching switched to online learning and attempts to maintain training were applied through online smart-learning circuits, webinars, and video calls. Based on the different central tendency statistics of trainees' attitudes' item scores, our study reported satisfaction with the residents' academic development among the different resident levels. In general, R5-level residents were found to have the highest satisfaction mean scores toward their training activities, which can be explained by their seniority and years of experience.

In addition to the activities and attitude effects, as a new disease with limited information about its characteristics, COVID-19 has had a significant impact on residents' physical and mental health.[14] Currently, few studies have been conducted on mental health among residents during this crisis. In our study, we used GAD-7 scores to measure otolaryngology residents' anxiety; we found that around half of the residents were understandably anxious. However, their anxiety was not immoderate in terms of its intensity, frequency, or ability to control it. Overall, there was no difference between trainees who covered the frontline service against the pandemic or trainees who remained in their duties with regard to the severity or the characteristics of these worries. Yet, the current pandemic and changes in work plans will no doubt contribute to residents' burnout.[15] During the crisis, it is important to offer psychological counseling for trainees to cope with the situation.[16]

Residency training programs are facing the same crisis with an overall reduction in their activities and increase in stress and concerns. It was clear from our results that the highest concern level is the absence of a clear training rotation plan because of the unexpected appearance of this pandemic. Nevertheless, there were no differences in the other types of concern, except in that of personal experience, which showed a high level in some training levels, such as R2 and R4, while R3 and R5 residents showed a low level of concern, which was controversial. Although we have dedicated our careers to otolaryngology surgery, in times of need, otolaryngologists have played a role in serving society and public health.

As with all studies involving surveys from volunteers, selection bias is hard to avoid and may not necessarily represent the majority opinions of every trainee resident around the world. To help overcome these limitations, private social media networks were utilized specifically targeting otolaryngology residents to participate in the surveys. Other drawbacks include the absence of objective indicators, for example, log books and details about surgical skills, as otolaryngology is a surgical specialty. Accordingly, further studies are needed to elucidate the effects of other variable factors.

  Conclusion Top

COVID-19 has had a serious impact on otolaryngology residents' competency and psychological well-being, which are the core elements in the residency training programs. Moreover, further studies need to be done here in Saudi Arabia to evaluate last long of this impact in greater details and among different specialties to protect residents.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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