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Analysis of the impact of the pandemic on surgical residency programs during the first wave in Argentina: A cross – sectional study

Introduction COVID – 19 emerged as a global pandemic in 2020 and affected the teaching methods at all levels. Surgical education has also been significantly affected by this pandemic, but the effect remains unknown. We developed a survey in order to obtain more information on how this pandemic affected the training and education of surgical residency programs. Material and methods Cross-sectional study. We surveyed 195 residents of various surgical programs, from August 20th to September 30th, 2020, in Córdoba, Argentina. The effect of the COVID – 19 pandemic was analyzed on surgical training, on the academic program, and professional burnout. Results The volume of surgical cases performed during the pandemic decreased dramatically, affecting mainly residents of lower years. Comparing the number of cases (>7) that residents carried out per week (Pre pandemic vs pandemic), we found that PGY – 1: 47% vs 9%; p = 0.01 and PGY – 2: 46% vs 8%; p = 0.03. 83.2% reported that the impact of the pandemic affected their surgical training negatively and 45% were not adequately trained to carry out their surgical activity in the residency program. On the other hand, 71.3% affirmed that this health emergency allowed them to dedicate more time to the development of their academic training. Conclusion This is the first cross – sectional survey study that shows the impact of the pandemic on surgical residences during the first wave in Argentina. Surgical training performed by residents had a negative impact.


Introduction
In 2020, the coronavirus disease (COVID -19) has affected 222 countries, areas, or territories, registering more than 79.2 million cases and more than 1.7 million deaths worldwide since the beginning of the pandemic [1]. The first reported case in Argentina was on March 3rd; four days later, the first fatality was registered in the country and in Latin America [2]. On March 6th, the first case of COVID -19 was confirmed in Córdoba, the second most populated province, out of a total of 23 provinces that make up the Argentine Republic [3]. Until December 31st, 2020, the Ministry of Health of the Province of Córdoba registered a total of 126.893 cases and 2.496 deaths from COVID -19 [4].
The current health crisis produced by the coronavirus pandemic and defined as an unprecedented situation led us to raise doubts, controversies, and dilemmas in health care in general, and in surgery in particular, understanding that the residents are probably as vulnerable or maybe more than all professionals [5].
In this scenario, the Association of Residents and Attendees of General Surgery of Córdoba (ARCCC), which represents a non-profit civil association, founded in 1989, with the purpose of promoting scientific activity among resident doctors, prepared a survey with the aim of obtaining more information on how the COVID -19 pandemic affected the training and education of surgical residency programs in Córdoba, Argentina.

Study population
A crosssectional study was carried out, supported by a digital survey tool (Google Forms). The survey presented 24 compulsory multiple-choice questions and was distributed through social networks such as WhatsApp, Facebook and Instagram, from August 20th to September 30th, 2020. All surgical residency programs were invited to participate in Córdoba, Argentina.
Before distribution, the survey was tested for internal validation until completed and reviewed by 10 ARCCC members. Only residents of surgical programs in the region were included in the analysis. Postresidency fellows were excluded.
All respondents participated voluntarily in this study and were advised that the information provided is confidential, and will not be used to identify individual responses. The survey is available in Appendix A1.
Ethical approval was not required as all data collected was anonymized. The study was reported according to the STROCSS criteria [6] and registered at ClinicalTrials.gov (NCT 04703400) which can be found via the following link: https://clinicaltrials.gov/show/NCT04703400.

Study of variables
The survey asked the demographic characteristics of the residents, the type of hospital where they carried out their surgical training (public/private/Armed Forces), the adherence of the training center to the resolution of the Ministry of Health 718/2020 (extension of the graduation and promotion of the academic year of the residents until September 30th, 2020 within the health services, to attend the health and social emergency produced by COVID-19) [7], the type and the year (Considering the National Decree 718/2020) of the training program, the work modality, the number of days of attendance at their institution and surgical practices, before and during the pandemic. Residents were asked whether these changes would affect their surgical training and overall preparation for their next professional step. The effects of the pandemic were also evaluated on the wellbeing and burnout of residents.

Statistical analysis
We entered the collected data into Microsoft Excel with a double--entry method to avoid errors during the process and SPSS 26 software  was used for statistical analysis. For descriptive analysis, variables were presented with frequencies, percentages, and pie charts. A Chi-square test was used to compare categorical variables. A value of p < 0.05 was considered significant.

Information about residents
A total of 195 resident physicians participated in this survey. 59.4% (n = 116) were men and the age of 66.7% (n = 130) ranged between 26 and 30 years old. Most of them belonged to public hospitals (48.2%; n = 94) followed by private ones (44.1%; n = 86), while 7.7% (n = 15) belonged to Armed Forces hospitals. The distribution of the type of surgical residency program can be seen in Table 1. 67.7% (n = 132) mentioned that the hospitals where they carried out their academic and surgical training adhered to National Decree 718/ 2020; concerning this, 24% (n = 47) and 20% (n = 39) were first and second clinical postgraduate year (PGY -1 and PGY -2), respectively. On the other hand, 56% (n = 109) belonged to the upper years (PGY -3 and PGY -4). 22.5% (n = 44) planned to finish the residency program or seek a training scholarship later.

Analysis of surgical training and academic activity
Considering the changes in the protocols concerning operating rooms, recommended by different national and international scientific surgical societies more recognized as the American College of Surgeons (ACS), the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and the Argentine Society of Infectiology (SADI) [8][9][10], 52% (n = 101) did not participate in scheduled surgeries and/or emergencies of COVID-19 patients and 7.2% (n = 14) were not authorized to enter the operating room.
Regarding the number of surgical procedures performed by residents per week, before and during the pandemic, we found a significant decrease (Fig. 1) (see Fig. 2).
83.2% (n = 164) reported that the impact of the COVID-19 pandemic negatively affected their surgical training and 45% (n = 87) stated that they were not adequately trained to carry out their surgical activity in the residency program.
Most of the residents (55%; n = 107) mentioned that academic activity increased by 25-75% during the pandemic, in terms of weekly classes and athenaeums, through virtual platforms. 71.3% (n = 139) affirmed that this health emergency allowed them to dedicate more time to developing their academic training and 33% (n = 64) suggested that their training should be extended after graduation of the academic year.

Working hours and professional burnout
In the pre -COVID -19 era, 52% (n = 101) attended their hospital between 4 and 6 days a week. During the pandemic, 55% (n = 107) stated that work teams were organized, with an alternate regime to avoid contact between health personnel, with a subsequent period of isolation; consequently, 65% (n = 127) did not attend their working hours for 5 days or more per month. Despite having more free time, 52.3% (n = 102) reported feeling more exhausted than usual. 34% (n = 66) were reorganized to assist patients in areas other than their surgical program. Most of the residents (70.3%; n = 137) reported concern about the possible transmission of COVID -19 to family and friends, while 39% (n = 76) about contracting COVID -19 themselves. Finally, 49% (n = 96) increased stress at work, due to a greater number of patients, sick people, and consequently more responsibility.

Discussion
In Argentina, the Health Residence is a postgraduate educational system for the recently graduated doctor, which aims to complement the comprehensive training of the professional, exercising in the responsible, efficient and ethical performance of the corresponding disciplines, through the adjudication and personal supervised execution of complexity acts and progressive responsibility [11]. In this system, surgical education is intended to provide resident physicians with a base of surgical knowledge, technical competence, and clinical judgment for the management of surgical patients [12].
Understanding the concern of residents of surgical programs, the ARCCC conducted this survey in order to evaluate the effects of the COVID -19 pandemic on surgical training (volume of surgical cases performed by residents before and during the pandemic), academic program and professional burnout.
During the pandemic, different societies and government agencies around the world made recommendations for surgical procedures based on the experience of other coronavirus epidemics [13] or according to the epidemiological context in their country of origin, with little scientific evidence [8,10]. In Argentina, the basic principles of prevention and infection control, and the standard precautions recommended by the World Health Organization [9,14] were applied. In this context, teaching methods have been modified at practically all levels. Facetoface classes were suspended, and virtual learning was implemented instead, as well as the reduction of the number of attendant residents in the same shift to reduce the exposure of health personnel [15].
Consequently, we found that the elective surgical activity performed by the residents was drastically reduced or absent during the pandemic. Likewise, the surgical demand in the emergency room decreased and conservative treatments were chosen in several situations. Considering the National Decree 718/2020 (extension on the graduation of the residents of the last year of the educational program) and the recommendation that the evaluations of cases and surgeries should be left in the hands of the professionals with more experience, the exposure of the residents in the operating room was limited, generating a reduction in surgical experience, mainly in residents of lower years (PGY -1 and PGY -2). These results are similar to other studies [16][17][18][19]. However, before the current global pandemic, surgical education has had to respond with new technologies, treatments and procedures to the dynamic changes in the knowledge of surgical disease, the demand in the supervision of resident doctors, and the demands for the patient safety [20].
In our study, the impact of COVID -19 on the educational program was positive, even though all facetoface academic activities, external and internal rotations were suspended. 71.3% mentioned that this health emergency allowed them to dedicate more time to the development of their academic training, through scheduled virtual meetings (classes and conferences) on widely disseminated platforms. On the other hand, as the backlog of surgical procedures begins to be tackled, surgical research is unlikely to be at the forefront of healthcare system providers' minds. However, if we are to avoid a drought in scientific discovery and advancement, academic surgical authorities should encourage the restart of clinical research, perhaps via modified protocols and processes to ensure safe, efficient, and effective studies [21].
Another important discovery in this analysis was regarding the wellbeing and burnout of residents of surgical programs during the pandemic. The depletion rate was higher than the traditional rates reported in the literature [16,22,23]. A national survey of general surgery residents in the United States reported a burnout rate of 33.1% [16]. However, in our study 52.1% of the survey respondents reported greater exhaustion than usual during the COVID -19 pandemic. This suggests that burnout is not only associated with work hours, longer patient lists, sicker patients, increased responsibility, but also the stress of contracting the virus and taking it home with friends and family.
A peculiarity that occurred in the territory of the Argentine Republic was the period of social, preventive and mandatory isolation, with an approximate duration of seven months (March 20th to November 8th, 2020), being considered as "one of the longest quarantines all over the world". Consequently, the peak of greatest contagion of this first wave occurred in October and this would explain why in Argentina the effects of the pandemic in surgical residences occurred later, compared to other Latin American countries such as Bolivia, Brazil, Chile, Colombia, Mexico, Peru (Fig. 3). On the other hand, many countries in Asia, Oceania, and Europe have already faced the phenomenon of the second wave of COVID -19 cases.
Our study is limited by selection bias, wherein residents who have been most affected by the pandemic may not have had time to answer our survey and by the implementation of this study in a single province (Córdoba, Argentina) that was moderately affected by the COVID -19. Policies in hospitals on permitted operations are dynamic and we have presented data for only a specific period. Future research might consider developing and evaluating contingency plans for graduate medical education in all surgical residency programs in order to maximize education when the next wave arrives.

Conclusion
This is the first crosssectional survey study that shows the impact of the pandemic on surgical residences during the first wave in Argentina. The effect on training residents with surgical programs remains unknown. We can estimate that it will have long-term effects, both positive and negative, and it is important to value a more innovative approach in the training of our professionals through virtual tools and complement each other in the fields of research and academic productivity.

Funding
No source to be stated.

Informed consent
Not applicable.

Provenance and peer review
Not commissioned, externally peer-reviewed.

Declaration of competing interest
The authors declare that they have no conflict of interest.