|Year : 2022 | Volume
| Issue : 1 | Page : 6-11
Impact of the COVID-19 pandemic on otolaryngology – Head-and-neck surgery residency training
Abdulaziz Saad Alhammad1, Dhaifallah S Mulafikh2, Saad A Alsaleh3
1 College of Medicine, King Saud University, Riyadh, Saudi Arabia
2 Department of Otorhinolaryngology, Head and Neck Surgery, King Fahad Medical City, Riyadh, Saudi Arabia
3 Department of Otolaryngology-Head and Neck Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
|Date of Submission||17-Nov-2021|
|Date of Acceptance||23-Dec-2021|
|Date of Web Publication||02-Mar-2022|
Dr. Saad A Alsaleh
Department of Otolaryngology-Head and Neck Surgery, College of Medicine, King Saud University, Riyadh 11411
Source of Support: None, Conflict of Interest: None
Context: The novel coronavirus disease (COVID-19) has swept globally, leading to a crisis that affects all aspects of human life. Aims: This study aimed to investigate the impact of COVID-19 on otolaryngology-head-and-neck surgery (ORL-HNS) residency training in Saudi Arabia and assess the study habits of residents during the pandemic and the impact of COVID-19 on training. Settings and Design: This was a cross-sectional quantitative study that utilized a 36-item questionnaire, investigating demographic data, study habits during the pandemic, clinical involvement in various training domains before and during the pandemic, and COVID-19-related exposure and training. Subjects and Methods: The questionnaire was sent to all ORL-HNS residents in Saudi Arabia via email, except those in their first year of residency. Statistical Analysis Used: A Wilcoxon signed-rank test was performed to assess the difference in clinical involvement before and during the pandemic. Results: A total of 165 residents participated in this study (response rate = 72.7%). A statistically significant decrease in clinical involvement from before to during the pandemic was noted in all training domains, including the average number of emergency consultations during on-call duty, outpatient clinics, in-office diagnostic procedures, and operative procedures for oto-neurotology, rhinology and skull base, head and neck, pediatric and airway, and facial plastic. However, an increase in the consultation via telemedicine was apparent during the pandemic in comparison to before. Conclusion: The COVID-19 pandemic has affected ORL-HNS residency training considerably. We recommend implementing alternative didactic strategies to mitigate the decreased exposure of residents to ORL-HNS clinical training.
Keywords: Coronavirus disease-19, otolaryngology, pandemic, residency, Saudi Arabia, training
|How to cite this article:|
Alhammad AS, Mulafikh DS, Alsaleh SA. Impact of the COVID-19 pandemic on otolaryngology – Head-and-neck surgery residency training. Saudi J Otorhinolaryngol Head Neck Surg 2022;24:6-11
|How to cite this URL:|
Alhammad AS, Mulafikh DS, Alsaleh SA. Impact of the COVID-19 pandemic on otolaryngology – Head-and-neck surgery residency training. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2022 [cited 2022 Jul 2];24:6-11. Available from: https://www.sjohns.org/text.asp?2022/24/1/6/338983
| Introduction|| |
The novel coronavirus disease (COVID-19) has spread rapidly from the city of Wuhan in China, leading to a humanitarian and economic crisis worldwide. On March 11, 2020, the World Health Organization (WHO) announced the classification of COVID-19 as a pandemic. On March 2, 2020, Saudi Arabia announced the first case of COVID-19.
Many countries worldwide have taken measures to contain the spread of disease and minimize the impact on the health-care system. In Saudi Arabia, these measures included reducing transmission through the suspension of teaching at schools and universities and the suspension of all sports competitions. Preventative measures included the postponing of all elective surgeries and decreasing the number of personnel in the hospital setting in order to optimize resources and minimize further transmission of the infection. The adverse impact on residency training was a notable consequence.
A study conducted in Italy, one of the countries severely affected by the disease, has concluded that there was an overall decrease in residents' exposure to training activities from both a clinical and surgical perspective. Reduced exposure was not only noted within surgical specialties, but even radiology residents have suffered a significant impact on various domains of their training program. Although some procedures performed by otolaryngologists are emergent, many procedures are not time sensitive. Moreover, concerns surrounding viral transition during procedures that involve head-and-neck mucosa potentially contribute to further decreases in surgical opportunities for trainees.
Due to the unfortunate consequences of COVID-19 on residency training, strategies were implemented to mitigate these adverse effects. For instance, online conference platforms for educational webinars were made available, and research programs were conducted. Despite adverse consequences, an increase in the available time for self-study and research work is considered one of the potential advantages for residents.
The extent of compromised involvement in clinical and surgical activities in the otolaryngology-head-and-neck surgery (ORL-HNS) residency program in Saudi Arabia is unknown. In this study, we aimed to measure the impact of the COVID-19 pandemic on residency training in the ORL-HNS program in Saudi Arabia.
| Subjects and Methods|| |
This was a cross-sectional quantitative study. This study obtained approval from the Institutional Review Board at King Saud University (Project No. E-20-5133) on July 20, 2020. Informed consent was obtained from all participants. A web-based, anonymous, 36-item questionnaire was designed using Google Forms® and sent to all ORL-HNS residents in Saudi Arabia. Exclusion criteria included uncompleted surveys and residents in their 1st year of residency as they did not have any clinical rotations in ORL-HNS. Responses were collected during the first wave of the pandemic, starting from the 20th of July in a 20-day period.
The areas of investigation included demographic data, study habits during the pandemic, clinical involvement in various training domains before and during the pandemic, and COVID-19-related exposure and training. Demographic data included age, gender, region of the training center, and level of training.
To assess the study habits of residents during the pandemic, we used a 5-point Likert scale, and residents were asked if they had more reading since the start of the pandemic if teaching activities, and e-learning resources provided by their programs were valuable, and how satisfied they were with them. Residents were also asked if they used any new resources during the pandemic.
To assess clinical involvement in different domains before and during the pandemic, we used a 4-point Likert scale where 4, 3, 2, and 1 meant optimally involved, moderately involved, minimally involved, and no involvement at all, respectively. Domains included outpatient clinics, in-office diagnostic procedures, and oto-neurotology, rhinology and skull base, head and neck, pediatric and airway, and facial plastic operative procedures. Moreover, residents were asked to estimate the average number of emergency consultations they encountered during on-call duty before and during the pandemic. In addition to the domains above, residents were asked about their use of telemedicine before and during the pandemic.
To assess COVID-19-related exposure and training, we measured the number of residents who had received training on the use of personal protective equipment (PPE) and the management of COVID-19 patients. Furthermore, residents were asked if they had been involved in the management of COVID-19 cases that were not related to ORL-HNS. Moreover, we measured the prevalence of COVID-19 among residents and investigated the number of residents who were diagnosed, how many times residents were tested, and whether or not they were quarantined following exposure to the disease. Of the residents who were quarantined, the duration and number of quarantine episodes were assessed. Finally, residents were asked about their choice of strategies to mitigate the decreased exposure to ORL-HNS clinical training during the pandemic.
Data were checked for completeness. Demographic data, assessment of study habits during the pandemic, and assessment of COVID-19-related exposure and training were presented as frequencies and percentages. The Wilcoxon signed-rank test was used to measure the difference in clinical involvement before and during the pandemic. The analysis was performed, and a 95% confidence interval was obtained using the Statistical Package for the Social Science, version 24.0 (IBM, Armonk, NY, USA).
| Results|| |
A total of 165 participants took part in this study, with a response rate of 72.7%. Participants' ages ranged from 26 to 38 years, with a mean and standard deviation of 28.55 ± 1.856. Of all the participants, 55.2% were men. Most participants were in their 4th year of residency, representing 29.7% (n = 49) of participants, followed by 3rd year residents, 5th year residents, and 2nd year residents, representing 27.3% (n = 45), 21.8% (n = 36), and 21.2% (n = 35) of participation, respectively. The central region had the highest number of participants at 50.3% (n = 83), followed by the western, eastern, and southern regions representing 25.5% (n = 42), 13.9% (n = 23), and 10.3% (n = 17) of participation, respectively.
As presented in [Table 1], 60% of participants chose “Strongly agree” and “Agree” when asked if they had more reading time during the pandemic in comparison to before. Moreover, 77% of participants found the teaching activities and e-learning resources provided by their program to be valuable, and, overall, 62.4% of participants were satisfied with the e-learning teaching activity provided. Of all participants, 58.8% (n = 97) did not use any new resources to study during the pandemic. Further information regarding the use of study resources is summarized in [Table 2].
|Table 2: The use of any new resources to study ear, nose, and throat during the pandemic|
Click here to view
As shown in [Table 3], the Wilcoxon signed-rank test indicated that a statistically significant decrease was detected in the average number of emergency consultations encountered by residents during on-call duty. In addition, a decrease was noted in the extent of resident exposure to outpatient clinics, in-office diagnostic procedures, operative oto-neurotology procedures, operative rhinology and skull base procedures, operative head-and-neck procedures, operative pediatric and airway procedures, and operative facial plastic procedures. However, a substantial increase in telemedicine consultations during the pandemic was noted. Moreover, the highest mean score before the pandemic was found in in-office diagnostic procedures (3.62), followed by involvement in outpatient clinics (3.58), head-and-neck operative procedures (3.04), rhinology and skull base operative procedures (2.79), pediatric and airway operative procedures (2.65), oto-neurotology operative procedures (2.5), average number of emergency (ER) consultations during (2.11), on-call duty, patients' consultations via telemedicine (2.06) and facial plastic operative procedures (1.9). However, the highest mean score during the pandemic was found in patients' consultations via telemedicine (3.75), followed by involvement in outpatient clinics (2.53), in-office diagnostic procedures (2.27), head-and-neck operative procedures (2.24), pediatric and airway operative procedures (1.76), average number of ER consultations during on-call duty (1.55), rhinology and skull base operative procedures (1.44), oto-neurotology operative procedures (1.3), and facial plastic operative procedures (1.13).
|Table 3: Data analysis of clinical involvement before and during the pandemic using Wilcoxon Signed-Rank test|
Click here to view
A total of 75.8% (n = 125) of participants were involved in training on correct PPE usage. However, only 49.7% (n = 82) were involved in training on the correct management of COVID-19 patients. In order for residents to learn more about COVID-19 management, resources from the Ministry of Health were used most often (42.4%, n = 70), followed by use of the WHO resources (11.5%, n = 19), otolaryngology scientific society resources (6.7%, n = 11), the Saudi Commission for Health Specialties' COVID-19 management course (6.1%, n = 10), and Centers for Disease Control and Prevention resources (5.5%, n = 9). Furthermore, 27.9% (n = 46) of participants did not use any additional resources to learn more about COVID-19 management.
Of all participants, 47.3% (n = 78) were involved in the management of COVID-19 patients and only 8.5% (n = 14) of residents in total were diagnosed with COVID-19. Of all participants, 35.2% (n = 58) had never been tested for COVID-19, whereas 34.5% (n = 57) had been tested only once, 15.8% (n = 26) had been tested twice and 14.5% (n = 24) had been tested three times or more. Of all residents, 46.7% (n = 77) were quarantined due to COVID-19 exposure. Of the quarantined residents, 68.8% (n = 53) had been quarantined for less than 2 weeks, whereas 23.4% (n = 18) had been quarantined for 2–4 weeks and 7.8% (n = 6) had been quarantined for >4 weeks. Moreover, of the quarantined residents, 74% (n = 57) had been quarantined once, whereas 20.8% (n = 16) had been quarantined twice and 5.2% (n = 4) had been quarantined three times or more.
When the residents were asked about strategies to mitigate the decreased exposure to ORL-HNS clinical training during the pandemic, most participants (52.1%, n = 86) chose online learning tools, whereas 34.5% (n = 57) chose extension or repetition of the clinical rotation affected during the pandemic. Moreover, 12.1% (n = 20) felt that no strategy needed to be implemented, whereas 1.2% (n = 2) thought that maximizing surgical exposure with consideration of the required precautions would be a suitable option.
| Discussion|| |
Despite the decrease in the rate of new cases during the writing of this manuscript, the pandemic is far from over. The response rate in our study was higher than that in previous similar research., Around half of the participants in this study were trained in the central region, which may be because this region has the highest number of residents.
Even though some operations in ORL-HNS are considered emergencies, most are not time-sensitive. To minimize the spread of infection and optimize resources, Saudi Arabia has postponed all elective surgeries and non-emergency hospital visits. As a result of those necessary measures, otolaryngology residents' education was drastically affected., Similarly, we found a substantial reduction in all aspects of clinical involvement among residents. Since most physician–patient interactions in ORL-HNS occur in outpatient clinics, we found that the highest mean score of clinical involvement before the pandemic was from in-office diagnostic procedures followed by outpatient clinics. On the contrary, the lowest mean score of clinical involvement before the pandemic was from facial plastic operative procedures. Similarly, O'Brien et al. concluded that rhinoplasty lags behind other key indicator cases. Despite the recommended measures to decrease COVID-19 transmission, management of most head-and-neck cancers cannot be delayed. As a result, clinical involvement in the head-and-neck operative procedures had one of the lowest declines in mean score since the start of the pandemic. A notable increase was present in the percentage of patients benefiting from telemedicine. Although many patients require in-office diagnostic procedures, this may be a wake-up call to optimize the utilization of telemedicine in certain subsets of patients. Rimmer et al. concluded that, with appropriate patient selection and technological support, telemedicine can be an effective means of safely delivering patient care in multiple settings.
As a result of halting all elective surgeries and only performing emergency surgeries, most residents reported an increase in available reading time during the pandemic in comparison to before, similar to what was reported in the literature. Most residents found teaching activities and e-learning resources valuable and were satisfied with their quality and availability. This reflects a shift from the conventional didactic method to easily accessible alternatives. A study on ORL-HNS residents found that the second most important activity during the pandemic was online journal/webinars. However, certain skills, especially in a surgical specialty, require hands-on experience. When asked about strategies to mitigate the decreased exposure to ORL-HNS clinical training, more than a quarter of the residents chose repetition or extension of the affected clinical rotation. This emphasizes the importance of implementing alternative strategies to mitigate the decreased exposure to ORL-HNS clinical training. For instance, dissection laboratories could be used as an alternative to learn surgical techniques and anatomy. A study has found that dissection is the best way to maintain the learning curve of surgical skills, as reported by the residents. Another option is the use of simulation surgical kits, but consistent accessibility is still questionable., Moreover, online videos of surgical procedures may play an essential in maintaining the learning curve. Luu et al. concluded that online videos represent an appropriate resource for residents in learning otolaryngology surgical cases.
Health-care workers, in general, are typically at a high risk of developing COVID-19, and otolaryngologists have an even higher risk of developing the disease due to high viral shedding in the nasal and oropharyngeal cavities. Despite this, only a small percentage of residents in our study were diagnosed with COVID-19. This can be explained by the number of residents who received training on correct PPE usage, which is considered a pivotal part in minimizing the spread of infection and shortage of such equipment is considered a great concern among residents.,
It is estimated that the pandemic will surge to such an extent that demand for medical care may exceed the capacity of both general wards and intensive care units, ten-fold. Given these circumstances and the enormous burden of this disease on the health-care system, training residents in surgical specialties on the basics of critical care might become essential in the management of the pandemic. However, in our study, approximately half of the participants had not been involved in any sort of training on how to manage COVID-19 patients. As mentioned in our study, decreased exposure differs from one specialty to another. As a result of that, rescheduling of the residents' program may be essential to minimize the damage. For instance, residents will rotate in specialties that still have clinical exposure to maintain their surgical education and avoid unnecessary exposure to infection. Adherence to principles of flexibility and transparency was found to be important to adapt to the current situation.
We recommend implementing alternative strategies to mitigate the decreased exposure of residents to ORL-HNS clinical training during the pandemic. This can be done by online webinars, live stream surgeries, and simulation technologies. Moreover, training all surgical residents on how to manage COVID-19 patients is recommended to increase the capacity of health-care workers and appropriately manage the pandemic.
Our results may be limited by the fact that this is a cross-sectional study and is subjected to possible recall bias. Nevertheless, variable clinical exposures in different centers should be taken into account.
| Conclusion|| |
We conclude that the residency training of ORL-HNS in Saudi Arabia has been greatly affected during the pandemic. Online learning tools and compensating for the affected clinical rotations are the most desirable strategies to mitigate the decreased exposure to ORL-HNS clinical training, according to residents.
The authors would like to thank the College of Medicine Research Center (CMRC) Deanship for Scientific Research, King Saud University, for supporting this work.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Yezli S, Khan A. COVID-19 social distancing in the Kingdom of Saudi Arabia: Bold measures in the face of political, economic, social and religious challenges. Travel Med Infect Dis 2020;21:101692.
Amparore D, Claps F, Cacciamani GE, Esperto F, Fiori C, Liguori G, et al
. Impact of the COVID-19 pandemic on urology residency training in Italy. Minerva Urol Nefrol 2020;72:505-9.
Odedra D, Chahal BS, Patlas MN. Impact of COVID-19 on Canadian radiology residency training programs. Can Assoc Radiol J 2020;71:482-9.
Patel ZM, Fernandez-Miranda J, Hwang PH, Nayak JV, Dodd R, Sajjadi H, et al
. Letter: Precautions for endoscopic transnasal skull base surgery during the COVID-19 pandemic. Neurosurgery 2020;87:E66-7.
Crosby DL, Sharma A. Insights on otolaryngology residency training during the COVID-19 pandemic. Otolaryngol Head Neck Surg 2020;163:38-41.
Osama M, Zaheer F, Saeed H, Anees K, Jawed Q, Syed SH, et al
. Impact of COVID-19 on surgical residency programs in Pakistan; A residents' perspective. Do programs need formal restructuring to adjust with the “new normal”? A cross-sectional survey study. Int J Surg 2020;79:252-6.
Comer BT, Gupta N, Mowry SE, Malekzadeh S. Otolaryngology education in the setting of COVID-19: Current and future implications. Otolaryngol Head Neck Surg 2020;163:70-4.
Guo T, Kiong KL, Yao CMKL, Windon M, Zebda D, Hanna EY. Impact of the COVID-19 pandemic on Otolaryngology trainee education. Head Neck 2020;42:2782-90. doi: 10.1002/hed.26368. Epub 2020 Jul 15. PMID: 32666664; PMCID: PMC7405272.
O'Brien DC, Kellermeyer B, Chung J, Carr MM. Experience with key indicator cases among otolaryngology residents. Laryngoscope Investig Otolaryngol 2019;4:387-92.
Şahin M, Cebeci S, Duzlu M, Karamert R, Ceylan A. The effects of COVID-19 pandemic in otolaryngology practice: A review of the literature. Gazi Med J 2020;31:278-82.
Rimmer RA, Christopher V, Falck A, de Azevedo Pribitkin E, Curry JM, Luginbuhl AJ, et al
. Telemedicine in otolaryngology outpatient setting-single center head and neck surgery experience. Laryngoscope 2018;128:2072-5.
Bandi F, Karligkiotis A, Mellia J, Gallo S, Turri-Zanoni M, Battaglia P, et al
. Strategies to overcome limitations in otolaryngology residency training during the COVID-19 pandemic. Eur Arch Otorhinolaryngol 2020;277:3503-6.
Okland TS, Pepper JP, Valdez TA. How do we teach surgical residents in the COVID-19 era? J Surg Educ 2020;77:1005-7.
Munjal T, Kavanagh KR, Ezzibdeh RM, Valdez TA. The impact of COVID-19 on global disparities in surgical training in pediatric otolaryngology. Int J Pediatr Otorhinolaryngol 2020;138:110267.
Luu NN, Yver CM, Douglas JE, Tasche KK, Thakkar PG, Rajasekaran K. Assessment of YouTube as an educational tool in teaching key indicator cases in otolaryngology during the COVID-19 pandemic and beyond: Neck dissection. J Surg Educ 2021;78:214-231.
Xu K, Lai X, Liu Z. Suggestions on the prevention of COVID-19 for health care workers in department of otorhinolaryngology head and neck surgery. World J Otorhinolaryngol Head Neck Surg 2020;6 Suppl 1:S2-5.
Cai Y, Jiam NT, Wai KC, Shuman EA, Roland LT, Chang JL. Otolaryngology resident practices and perceptions in the initial phase of the U.S. COVID-19 pandemic. Laryngoscope 2020;130:2550-7.
Juprasert JM, Gray KD, Moore MD, Obeid L, Peters AW, Fehling D, et al
. Restructuring of a general surgery residency program in an epicenter of the coronavirus disease 2019 pandemic: Lessons from New York city. JAMA Surg 2020;155:870-5.
[Table 1], [Table 2], [Table 3]