Introduction
The novel coronavirus disease 2019 (COVID-19) pandemic has led to unprecedented and
sudden changes within our world over the past few months. Even as the Centers for
Disease Control and Prevention (CDC) advocates “shelter in place,” “social distancing”
and adherence to meticulous personal hygiene, COVID-19 has proven to be highly transmissible,
and has swiftly spread throughout our country.[1]
[2]
[3] With the rapid rise in the number of confirmed COVID-19 cases, the burden imparted
on the healthcare system has been unparalleled in the last century. This strain on
healthcare delivery has led to numerous changes in the usual day-to-day operations,
including the cancellation of all surgical cases except for those that are considered
essential, emergent, or cancer-related.[4]
[5]
[6] Clinic schedules have been severely reduced to include only urgent patients who
need to be seen in a time sensitive manner, while telemedicine has swiftly usurped
the traditional face-to-face doctor to patient encounter.
The conventional otolaryngology residency education involves a balance of surgical
training in the operating theater, patient encounters in clinic, academic time in
the form of didactic lectures and self-study. The reduction in surgical and clinical
volume has altered the residency experience, and has required novel approaches to
make up for these lost opportunities. As a residency training program, considering
the health and well-being of residents is of utmost importance. Ensuring resident
safety and limiting unnecessary exposure to COVID-19 is critical, as those who are
infected and symptomatic must be quarantined according to CDC guidelines.[7] Infected residents pose a risk to fellow residents and staff whom they work closely
with, and thus appropriate precautions must be taken to avoid propagating infection
to other members of the residency, which can have detrimental effects on the ability
of the department to deliver patient care.[7]
[8] Additionally, infected medical professionals pose a risk to patients they interact
with, thus causing further potential endangerment to those we are tasked to care for,
and worsening the dissemination of disease. Our otolaryngology residency serves downtown
Detroit and its surrounding communities, which have been particularly hard hit by
COVID-19, and thus, developing effective and reliable mechanisms to keep our residents,
staff and patients safe during this time has been paramount.[9] The present paper describes our strategies and techniques utilized to maximize resident
education as well as ensure patient and staff safety during the COVID-19 pandemic.
Methods
Residency programs across all medical and surgical specialties currently find themselves
in a complicated predicament, and are forced to maintain some level of normalcy in
a situation which could have never been truly anticipated or prepared for.[10] As our department considered contingency plans, we identified three unifying key
elements that guided our decisions. First, patient care was to remain the top priority,
and all members of the clinical team expressed that this could not be compromised,
especially under such critical circumstances. Second, resident safety and well-being
had to be preserved at all times, and clinical duties were reorganized to ensure minimization
of unnecessary exposure to COVID-19 patients. Last but not least, substantial effort
was made to ensure continuity of resident education and learning opportunities during
the pandemic despite the overall reduction of surgical and clinic volume. The present
study was deemed by the authors to be exempt from institutional review board review
at (XXX blinded for review process XXX) Wayne State University according to institutional
policy.
Results
To implement the key elements described above, our residency resorted to a five-team
approach divided among three practice sites. At our program, we cover multiple hospitals
including a tertiary referral freestanding cancer center, two American College of
Surgeon (ACS) designated Level 1 Trauma Centers, a smaller community hospital, and
a Veterans Affairs (VA) hospital. We divided up the five hospitals into three functional
groups based on geographical location and clinical volume. The 2 busiest hospital
groups were each assigned 2 different teams consisting of three residents (PGY-4/5,
PGY-2/3, PGY-1/2). The least busy group was assigned a team of two residents (PGY4,
PGY2) due to the slower clinical volume and limited call coverage needed at these
hospital sites. Each team works for 3 days at their assigned location before being
replaced by the next 3-person team at our 2 busiest sites. Resident teams are kept
completely separate from each other, so that they do not interact with the other team
covering the same site nor with those working at other sites. This not only enables
us to limit the possibility of cross infection spreading amongst a large number of
residents, but also decreases the risk of multiple residents and staff being quarantined
simultaneously.[7]
[11] Additionally, by adhering to a 3-day-on 3-day-off schedule, extra precautions can
be undertaken should an infected resident start to present COVID-19 symptoms, in which
case he/she can be kept off work duties to reduce inadvertent spread to coworkers
and patients. Each resident is paired with a backup resident who can relieve him/her
should that resident be unable to work. Should a whole team of three residents fall
ill, we have another team that can fill in seamlessly. Residents rotate call and are
given postcall days whenever possible. Residents are encouraged to go home immediately
after rounds if there are no surgical cases or clinics scheduled for the rest of the
day, to minimize their time in hospital where there may be an inherently greater risk
of contracting COVID-19. Residents are able to take home call as well, which is the
normal routine for our program.
Every resident who is not in the hospital performing clinical duties is considered
to be on “academic time,” and are expected to engage in all offered online didactics,
self-study and research. Even those residents who are tasked with clinical responsibilities
are expected to utilize any downtime, such as that in between surgical cases or clinics,
to immerse themselves in academic activities. All residents are expected to keep a
record of all academic pursuits during this crisis.
In this fashion, we have been able to continue providing around-the-clock coverage
at multiple hospital sites without any compromise on patient care or overall resident
and staff health and well-being. Our hope is that other training programs may use
this information to serve as a guide for setting up their own system within their
department. It is anticipated that residency programs which cover fewer hospital sites
may have even greater flexibility in devising this type of disaster resident coverage
for maintenance of patient care while considering resident interests and safety.
Resident Education
Surgical education has changed drastically throughout the past century. Although the
principles developed by William S. Halsted, M.D., the father of American surgical
residency training programs, are still the focus of modern-day resident education,
the development of new technologies and methodologies have led to an evolution of
surgical education. Today's surgical residents use multiple platforms to gain information,
including online textbooks, current literature in the form of journal articles, live
and recorded surgical videos, informational podcasts, and participation in multidisciplinary
rounds, just to name a few.[12] Smartphones and tablet devices in surgery have become ubiquitous, allowing rapid
communication between attendings and residents, ready access to references for clinical
decision making, and real-time management of patient data.[13] Nonetheless, hands-on training in the operating room has always been the mainstay
of surgical training.
Unfortunately, the COVID-19 pandemic has had a profound impact on otolaryngology residency
education. Otolaryngology residents have seen a dramatic decline in their in-person
academic activities and clinical case volumes. In response to the detrimental impact
of the COVID-19 pandemic experienced by otolaryngology programs nationally, faculty
from around the country have come together to develop resources to support ongoing
daily resident education.
Didactic Education
At our institution, residents usually have four hours of protected academic time every
week to ensure well-rounded scholarly development. These activities include Grand
Rounds, multidisciplinary tumor board conference, basic science lectures, trauma conference,
head & neck review series, and translational research symposium. Other scholarly activities
include mock oral boards, journal clubs and quality improvement conferences.
The COVID-19 pandemic has served as a catalyst for positive changes in the structure
of our Otolaryngology residency education. First, we implemented a videoconference
format for our weekly two-hour Grand Rounds, utilizing Zoom (Zoom Video Communications,
San Jose, CA, USA). Not only has this facilitated continuation of our scheduled didactic
curriculum, the ease of access has enabled increased participation by our diverse
faculty group, of whom some would have otherwise been unable to join weekly due to
conflict in their clinical schedules at distant hospital sites. In addition, residents
have access to remote lectures given live by world-renown faculty from numerous institutions
through three major national otolaryngology educational consortiums. Didactic lectures
are provided via the Consortium of Resident Otolaryngologic Knowledge Attainment Initiative
in Otolaryngology (led by the University of Kentucky Department of Otolaryngology
– Head and Neck Surgery), The Great Lakes Otolaryngology Consortium (led by University
Hospitals/Case Western Reserve University), and by the Collaborative Multi-Institutional
Otolaryngology Residency Education Program (led by USC Caruso Department of Otolaryngology
– Head and Neck Surgery). The staggered timing of these lectures has enabled easy
access daily by residents, creating a very robust yet flexible, disciplined learning
experience. The video lectures are also recorded so that those who missed the live
lectures due to clinical responsibilities can watch the videos on their own time in
the future.
Surgical Education
“See one, do one, teach one” has been the traditional method of teaching in surgery.
Many critics have recently argued that this method is out of date, with the main contention
being that patient safety is at risk because surgical residents are unable to safely
perform a procedure after only seeing it once.[14] Although quality care and error reduction have been a major focus of concern in
healthcare for several decades, it remains true that in surgery, learning is often
hands on. The structure of graded responsibility with each advancing year is still
featured in our current training system. While attending supervision is often mandated,
“see some, do some, teach some” continues to mold future otolaryngologists in our
program.
Subsequent to the World Health Organization (WHO) declaration that the novel coronavirus
disease 2019 (COVID-19) was a global pandemic, the United States Surgeon proclaimed
a formal advisory to cancel/postpone elective surgeries at hospitals. The American
Academy of Otolaryngology – Head and Neck Surgery recommended that all otolaryngologists
limit providing patient care activities to those individuals with time-sensitive,
urgent, and emergent medical conditions. From a compilation of information based on
personal communication with international colleagues reporting their individual experiences,
we found out that a significant number of doctors who died in China, Iran, and Italy
were otolaryngologists, possibly due to the high viral shedding from the nasal cavity.
Based on this information, Stanford University sent out their guidelines of performing
only urgent/emergent cases of endoscopic endonasal surgery. The COVID-19 pandemic
has profoundly impacted facial plastic and reconstructive surgeons, who have ceased
providing non-essential services. Many facial plastic and reconstructive surgeons
have even deployed their privately owned anesthesia machines/ventilators to hospitals
in need. In the state of Michigan, many hospitals have even cancelled/delayed surgery
for cancer patients as they were forced to allocate resources to a surge of COVID-19
patients. Our program is affiliated with the Karmanos Cancer Institute, a freestanding,
NIH-designated comprehensive cancer center, so certain cancer surgeries are still
being performed after taking into account the medical condition, social circumstances,
and needs of each individual patient. Nonetheless, over the last 6 weeks, our surgical
case volume has been nowhere near prepandemic levels. In addition, to limit the total
number of exposures and mitigate the potential for disease, our program has restructured
coverage of surgical cases such that only one resident is allowed in each operating
room.
Previous studies have shown that there is a correlation between visual-spatial ability
and surgical performance in trainees.[15] The Web Initiative for Surgical Education of Medical Doctors (WISE-MD) is a collection
of Web-based modules designed to enhance the teaching of common surgical problems
and practices to surgical residents. It was built on the theoretic framework laid
out by Richard E. Mayer, who proposed that improved learning occurs when animation
and narration occur simultaneously.[16]
[17] Ahmet et al performed a systematic review to explore the influence of videos on
surgical education and found that video-based education can provide substantial benefits
in surgical education by promoting faster acquisition of skills and accelerating the
learning curve.[18] In our program, the Division Chief of Facial Plastic and Reconstructive Surgery
reviews high-quality surgical videos with us in a group study format via an online
platform to help make up for the significant loss of time in the operating room.
Clinical Education
As with surgical volume, the resident clinical experience during these times has also
been significantly affected. Clinic schedules have been significantly reduced, with
primarily only patients undergoing active cancer treatment, postoperative patients,
and those with urgent needs being seen. Additionally, when possible, resident coverage
of attendings during clinics has been more limited in an attempt to reduce exposure
and to maintain a healthy resident workforce. To substitute for time missed in the
clinic setting, residents have been involved in telehealth visits where they can practice
and refine their history taking skills in the presence of the attending. Although
the concept of telehealth has existed for decades, it has been relatively slow to
catch on. Providers have faced an uphill battle when it came to legally treating patients
and being reimbursed for their virtual care. Social distancing and shelter-in-place
practices due to the COVID-19 pandemic have made telehealth a necessity.[19] For the first time, the government and private insurers have empowered healthcare
providers to implement telehealth visits in their practices. However, one unique challenge
of telehealth within the field of otolaryngology is the difficulty in performing a
physical exam in the remote setting. The physical exam is a crucial component of any
otolaryngology clinic visit, and a complete head and neck exam frequently relies on
specific medical equipment, such as an otoscope or flexible fiberoptic laryngoscope.
While they are often crucial components of the physical exam, these tools cannot be
utilized in the remote setting. Also, even the ability to perform essential, but basic
physical exam maneuvers, such as assessing the oral cavity and oropharynx or palpating
the neck are difficult or even impossible to perform. We have found that routine postoperative
patients, along with patients presenting with obstructive sleep apnea, in particular
those we are assessing for hypoglossal nerve stimulator placement, to be excellent
candidates for telehealth visits. As the use of telehealth in our clinics is a new
experience, we have emphasized reviewing the telehealth rules and procedures to be
critical to ensuring patient confidentiality.
Discussion
In the short term, otolaryngology resident education faces an uncertain future. These
are unprecedented times and there is no guide that those in charge of otolaryngology
residency education can use to help maneuver through this experience. Our rotating
three-person team at each hospital that our residency has utilized, as outlined above,
has allowed our program to ensure that we have residents available at all hospitals
to care for patients as needed, while also ensuring that residents are able to stay
healthy, safe, and rested during these difficult times. It also decreases the number
of residents that interact with one another, thus preventing the inadvertent spread
of COVID-19 to a large portion of the residency. Additionally, it allows us to quickly
adapt should residents become infected with COVID-19 and need to be quarantined, which
is likely to inevitably occur with increasing frequency as more people become infected.
The COVID-19 pandemic has inevitably transformed otolaryngology training and practice
and how we proceed in the future. As mentioned previously, the rise of telemedicine
during this time, and the inherent convenience and benefits it offers in certain circumstances,
will lead to its continued use as we proceed into the post-COVID-19 future. With its
continued use, further refinement and improvements to the process will follow, leading
to a more streamlined process that will make this technology more applicable to a
wide variety of patient health concerns. Our program has also found benefit in surgical
videos as a substitute for surgical experience, during these times. The opportunity
to see a surgery and hear expert commentary, while no replacement for actually performing
a surgery, has proven to be useful especially for more junior residents. Given that
certain otolaryngology surgeries are frequently difficult to observe for those not
directly involved in the surgery, these videos have been beneficial for our fellow
residents and will be something that we will look to continue even after surgeries
resume. Additionally, the opportunity to stream grand rounds remotely has proven very
popular with residents. Our residents frequently have to drive to other hospitals
prior to grand rounds, and having the option to remotely stream these conferences
reduces the driving burden. Thus, our program has considered continuing the option
of remote access to grand rounds for these residents.
Despite all the challenges during these times, the willingness of the otolaryngology
academic community to step up for the benefit of resident education as a whole has
been unprecedented. Otolaryngology residents have access to upwards of 8 hours of
live lectures per day, 5 days a week, due to the dedication of those within the field
and their commitment to resident education. Our approach has limitations. We recognize
that not all cities are geographical hot spots for COVID-19.
Conclusions
Despite the difficulty during these times, our program has found that maintaining
resident safety and well-being does not need to compromise patient care, but requires
strong leadership and unique solutions to novel challenges. We remain optimistic in
the future of our education despite these challenges, and cautiously look forward
to returning to the operating room and clinic, armed with new knowledge and experiences
developed during this time.
