Medical Residency in Gynecology and Obstetrics in Times of COVID-19: Recommendations of the National Specialized Commission on Medical Residency of FEBRASGO^[*]

Introduction

The COVID-19 pandemic (Coronavirus Disease 2019) has affected residencies training around the world. In the light of responses to the pandemic, many medical residencies are being forced to reorganize their rotations. These changes include a reduction in the operating room and outpatient care training, and the cancellation of some activities such as visits to the wards, simulation sessions, among others.[1]

According to recommendations of the American College of Surgeons (ACS),[1] elective surgeries should be postponed during the pandemic. The major aspects that support this position include difficulties with mobilizing human resources, materials, and personal protective equipment (PPE) needed for these procedures, the high risk of contagion of the team and of postoperative complications in patients with COVID-19. Although it is not a consensus yet, the proposal was to consider postponing elective procedures and surgeries for up to 3 months, provided that no harm was caused to the clinical condition of the patients. More recently, the International Federation of Gynecology and Obstetrics (FIGO) has published a FIGO Statement about guidance for resuming elective surgeries at the current point of the COVID-19 health crisis.[2] The American College of Obstetrics and Gynecology (ACOG) has also drawn up recommendations on how the program directors can support obstetrics and gynecology residents during the COVID-19 pandemic.[3]

In Brazil, on 8 May, 2020, the National Medical Residency Commission (CNRM, in the Portuguese acronym), linked to the Ministry of Education, released a Technical Note Draft with recommendations for medical residency programs during the pandemic.[4] Such recommendations derived from guidelines established for medical residencies by CNRM Resolution number 2/2006 and the Competency Framework of each specialty for the redefinition of the rotations and distribution of the workload among activities. The guideline also includes the “Manifestation of the Federal Council of Medicine in relation to the COVID-19 pandemic”, published on 25 March 2020. Its recommendation is that Brazilian physicians remain in their jobs, because “in this position, they will be able to exercise their most relevant role as guardians of life.” The Federal Council of Medicine also deems necessary the provision of PPE for physicians and other health professionals by the government and health authorities, so these professionals can perform their work safely.

According to this document, medical residency programs should make its curriculum more flexible to suit the pandemic context. The legislation in force establishes the maximum workload of 60 hours per week per resident, with between 10 and 20% destined to classes and between 80 and 90% to practical activities, already including a maximum of 24 hours on duty. Besides, it provides the resident with a weekly day off. The National Medical Residency Commission recommends the development of the classes within the maximum allowed limit (20% of the total workload) of 12 hours per week. Face-to-face classes must be suspended and developed through virtual meetings using videoconferencing tools. Classes should address themes related to each medical specialty, and issues related to the pandemic. Such topics include the detection, management, and flow for the care of patients with COVID-19, its complications, and individual and collective protection strategies. Also, training for donning and removal of PPE, and orotracheal intubation techniques should be included in the syllabus of medical residencies.

The National Medical Residency Commission establishes that in clinical training, the relocation of medical residents during the pandemic should be based on an Incidence Coefficient (number of new cases/million inhabitants) and the classification by the epidemiological complexity level of the Municipality and Health Region of the medical residency program. [Table 1] shows the main recommendations for the workload of the residents in fighting the pandemic according to the incidence of COVID-19 and the epidemiological complexity of the region.

Table 1 Recommendations of the National Medical Residency Commission for the relocation of medical residents in the fight against the pandemic

Level	Epidemiological complexity	Incidence coefficient	Workload in pandemic activities	% of the practical workload
1	Emergency	50% above national incidence	Up to 24h a week	Up to 50%
2	Attention	between 50% above and national incidence	Up to 20h a week	Up to 40%
3	Alert	Below national incidence	Up to 12h a week	Up to 25%

Source: Adapted from the Ministry of Education.[4]

For medical specialties related to the care of patients with COVID-19, the entire residency clinical workload can be used with care activities to combat the pandemic.

Clinical training in medical residency programs must be redistributed according to the clinical experience of the residents. The resident must practice under supervision, ensuring the maximum use of the training and preserving the patient safe. The reorganization of rotations must consider the availability and learning opportunities in clinical settings of the host institution and of institutions associated with the medical residency program, prioritizing the performance in hospital care and emergency rooms, and always respecting the maximum workload of the residents. After returning to normality, the replacement of the residency program activities that were not developed during the pandemic will be subject to analysis and to a subsequent decision by the National Medical Residency Commission.

Medical residents included in the risk group according to criteria established by the Ministry of Health, as well as pregnant women, must communicate their condition to the medical residency program supervisor and the respective Medical Residency Committee (COREME, in the Portuguese acronym) of the hospital. These individuals will be relocated according to the risk of infection or take a leave from clinical settings through sick leave, in which case the relevant medical report should be presented. In case of leave by suspicion or confirmation of COVID-19, regulations established by the Ministry of Health and health services in the states and municipalities must be followed and the resident must comply with the recommended isolation. The COREME must report the absence of the resident as “on sick leave” to the National Medical Residency Commission System (SISCNRM, in the Portuguese acronym) and notify the scholarship manager for the suspension of regular payment. Residents on sick leave must follow the procedure with the National Social Security Institute (Brazilian INSS). Other situations of leave of absence provided for in paragraphs 2, 3, 4 of Art. 4 of law number 12.514/2011 include paternity leave of 5 days and maternity leave of 120 days, extendable for another 60 days in agreement with the institution responsible for the medical residency program. The time required to complete the program must be extended by a period equivalent to the duration of the leave period of the resident.

In situations when patient care services and surgical procedures of a medical residency program have been fully suspended, part of the activities should be relocated to other services. If this is not possible, the decision regarding the continuity of the program must be taken in common agreement between the COREME and local health managers. The same recommendation applies to situations in which medical residents have been called upon to act to face the pandemic in other municipalities.

The SISCNRM also foresees the probability of interrupting the activities of a medical residency program because services are inadequate or for lack of safety for performing professionals in the face of the pandemic. In such cases, the flow should be:

• Record the reasons for interrupting the medical residency program.

• Issue an official information note on the suspension of the medical residency program to residents, preceptors, and managers of the health service.

• Move medical residents to other public or private services so they can complete their training in the specialty or transfer their activities to in-hospital care, assisting in the care of inpatients or management activities.

• Allow the anticipation of the vacation period of the residents.

Having exhausted all the possibilities for maintaining the medical residency program, the situation must be communicated to the State Medical Residency Commission (CEREM, in the Portuguese acronym) and the SISCNRM so that the medical residency program authorization act is reviewed following the consequences provided for in the legislation in force.

^* Text prepared by the members of the National Specialized Commission on Medical Residency and endorsed by the Scientific Board and Presidency of the Brazilian Federation of Gynecology and Obstetrics Associations (FEBRASGO).

• References

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• 2 International Federation of Gynecology and Obstetrics (FIGO). COVID-19–Restarting Elective Surgery [Internet]. 2020 [cited 2020 Jun 01]. Available from: https://www.figo.org/covid-19-restarting-elective-surgery
• 3 American College of Obstetricians and Gynecologists (ACOG). How program directors can support obstetrics and gynecology residents during the COVID-19 pandemic [Internet]. 2020 [cited 2020 May 25]. Available from: https://www.acog.org/news/news-articles/2020/05/how-program-directors-can-support-ob-gyn-residents-during-covid-19
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• 6 UNFPA, Avenir Health, Johns Hopkins University, Victoria University. Impact of the COVID-19 pandemic on family planning and ending gender-based violence, female genital mutilation and child marriage [Internet]. 2020 [cited 2020 Jun 01]. Available from: https://www.unfpa.org/sites/default/files/resource-pdf/COVID-19_impact_brief_for_UNFPA_24_April_2020_1.pdf
• 7 Inter-Agency Working Group on Reproductive Health in Crises (IAWG). Emergencies: COVID-19 [Internet]. 2020 [cited 2020 May 25]. Available from: https://iawg.net/emergencies/covid-19
• 8 Daniel SJ. Education and the COVID-19 pandemic. Prospects (Paris) 2020; •••: 1-6 . Doi: 10.1007/s11125-020-09464-3
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