Full
length
article
Being
an
obstetrics
and
gynaecology
resident
during
the
COVID-19:
Impact
of
the
pandemic
on
the
residency
training
program
Giovanna
Bitonti
a,
Anna
Rita
Palumbo
a,*
,
Cinzia
Gallo
a,
Erika
Rania
a,
Gabriele
Saccone
b,
Valentino
De
Vivo
b,
Fulvio
Zullo
a,b,
Costantino
Di
Carlo
a,
Roberta
Venturella
aa
DepartmentofClinicalandExperimentalMedicine,UnitofObstetricsandGynecology,MagnaGraeciaUniversityofCatanzaro,Catanzaro,Italy
b
DepartmentofNeuroscience,ReproductiveSciencesandDentistry,SchoolofMedicine,UniversityofNaplesFedericoII,Naples,Italy
ARTICLE INFO Articlehistory: Received18May2020
Receivedinrevisedform27July2020 Accepted29July2020 Availableonlinexxx Keywords: Coronavirus Training European Impact Obstetrics Gynecology ABSTRACT
Objective:toevaluatetheimpactoftheCOVID-19pandemicontheobstetricsandgynecologyresidency
trainingprograminItaly.
Studydesign: Thiswas across-sectionalsurveystudyaimed toassesstheimpactof theCOVID-19
pandemicontheobstetricsandgynecologyresidencytrainingprograminItaly.Anonlinesurveywith45
questionswassentandcompletedanonymouslybyresidentsafteracceptinganinformedconsent.The
invitationtotheonlinesurveywassenttoalltheItalianresidentsinobstetricsandgynecology.Thoseon
maternityleaveatthetimeofthestudywereexcluded.Residentswereaskedabouttheirroutinely
activitybeforetheCOVID-19pandemic,andtoreportthereductionintheirclinicalpractice.Theywere
alsoaskedaboutpsychologicalimpactofCOVID-19ontheirclinicalpractice.
Results:933Italianresidentsinobstetricsandgynecology,wereinvitedforthissurveystudy.
Four-hundredandseventy-six(51%)completedthesurveyandwereincludedinthestudy.Three-hundredand
eighty-seven(81.3%)werefemale,and89(18.7%)weremale.Residentsagerangedfrom25to42.In71,8
%(342/476)ofthecasesresidentsworkinaCOVID-19referenceHospitals.One-hundredandeighty-four
outof76residents(38.6%)weretestedonRT-PCRassayofnasalandpharyngealswabspecimens,andof
them12/184(6.5%)werepositivetoSARS COV-2.Regardingtheuseofpersonalprotectiveequipment
(PPE),267(56.1%)reportedtoreceiveadequatedevice,and379(79.6%)felttobewellinformedabout
preventionandmanagementprotocols.Three-hundredandthirty-oneresidents(69.5%)reportedto
havemanagedCOVID-19positivepatients.For54,7%ofrespondentresidents,trainingactivityingeneral
decreasedsignificantlyduringtheCOVID-19epidemic.Aone-thirdreductionwasreportedin31,4%of
thecases,whereasatotalsuspensionofthetrainingin9,9%ofthecases.In89,3%ofcasesthereduction
wascausedbythereorganizationofwork.Anxietyabouttheprofessionalfuturewasreportedin84%of
theresidents,and59%ofthemhadtheperceptionthattheirtrainingwasirreversiblycompromised.
Conclusions:AmongItalianresidentsinobstetricsandgynecology,COVID-19pandemicwasassociated
withasignificanttrainingimpairment.
©2020ElsevierB.V.Allrightsreserved.
Introduction
The novel Coronavirus 2019, or Severe Acute Respiratory SyndromeCoronavirus2(SARS-CoV-2),isanewlyemergingvirus responsible for COVID-19 [1]. COVID-19 is associated with detrimental health, socio-economic, and psychologic
consequences[2–4].Amongallthecountries,Italywas dramati-callyaffected,with,asofearlyMay,morethan220,000cases,and more than 30,000 deaths. As result of theimposed lockdown, publicassemblyhasbeenbanned,andmosttravelrestricted.The Healthcare System has also been reorganized, with elective surgical procedures and most of the outpatient appointments beingpostponed.Manypatientswillexperiencelong-termeffects of theCOVID-19measures,withexpectedincreased numberof missed diagnosis, complications of conditions due to delayed treatment, and increased level of anxiety. Moreover, residency
*Correspondingauthorat:vialePioX,88100,Catanzaro,Italy. E-mailaddress:a.palumbo34@gmail.com(A.R.Palumbo).
https://doi.org/10.1016/j.ejogrb.2020.07.057
0301-2115/©2020ElsevierB.V.Allrightsreserved.
EuropeanJournalofObstetrics&GynecologyandReproductiveBiology253(2020)48–51
ContentslistsavailableatScienceDirect
European
Journal
of
Obstetrics
&
Gynecology
and
Reproductive
Biology
trainingprogramsmaybeimpactedbytheCOVID-19epidemic, althoughlimiteddatahavebeenpublishedsofar[5].
Objective
Theaimofthisstudywastoevaluatetheimpactofthe COVID-19pandemicontheobstetricsandgynecologyresidencytraining programinItaly
Materialsandmethods Studydesign
Thiswas a cross-sectional surveystudy aimedtoassess the impact of the COVID-19 pandemic on the obstetrics and gynecologyresidencytrainingprograminItaly.
Anonlinesurveywith45questionswassentusinganonline platformthroughtheItalianNetworkofTraineeinObstetricand Gynecologyandwascompletedanonymouslybyresidents after accept-inganinformedconsent.ThelocalIRBexemptedthestudy fromtheethicalreview.
TheinvitationtotheonlinesurveywassentonApril28,2020to alltheItalianresidentsinobstetricsandgynecology,regardlessof thegender.InItaly,thedurationoftheobstetricsandgynecology residencytrainingprogramisoffiveyears.Residentsfromthefirst tothefifthyearofthetrainingprogramwereinvitedtothesurvey. Thoseonmaternityleaveatthetimeofthestudywereexcluded. Thequestionnaire
Theonlinesurveyincludedthreedifferentpart.Inthefirstpart, demographicdatasuchasgender,age,andresidency’syearwere collected.Residentswerealsoaskedabouttheirroutinelyactivity beforetheCOVID-19pandemic.Specifically,theywereaskedabout numberofelectiveprocedurespermonth,withmajorandminor surgicaloperations,andoutpatientrotation.Inthesecondpartofthe survey,residentswereaskedtoreportthereductionintheirclinical practice(0=nothing,1/3;2/3;3/3=totalpracticesuspension),and teachingactivity.Inthelastpartofthesurvey,residentswereasked aboutpsychologicalimpactofCOVID-19ontheirclinicalapproachto the patients, and on their idea about the professional future. Data were collectedanonymouslyfromApril28,2020toMay08,2020. Statisticalanalysis
StatisticalanalysiswasperformedusingStatisticalPackagefor SocialSciences(SPSS)v.19.0(IBMInc).Dataareshownasmeans withstandarddeviation,orasnumber(percentage).Descriptive statistics were calculated for sociodemographic characteristics. Questionnairesscoreswerealsoanalyzedaccordingtoresidents’ gender, year of residency, COVID-19 positivity, and number of residentsinthecenterbyusinglogisticregressionanalysis.
Univariate comparisons of dichotomous datawere performed with theuseofthechi-squarewithcontinuitycorrection.Comparisons betweengroupstotestgroupmeanswithstandarddeviationwere performedwiththeuseoftheT-testbyassumingequalwithin-group variancesorwiththeuseoftheOne-wayANOVA.
A2-sidedPvaluelessthan.05wasconsideredsignificant. Results
Studypopulation
Nine-hundredand thirty-threeItalian residentsin obstetrics and gynecology, from all the 39 Italian residency training
programs,wereinvitedbyemail.Outofthe933invitedresidents, 476(51.0%)completedthesurvey.
Three-hundredandeighty-sixoftherespondents(81.4%)were female,and88(18.6%)weremale.Residentsagerangedfrom25to 42 withanaverage of29 years.In 72 %(344/476)of thecases residents worked in a COVID-19 reference Hospitals. One-hundred-eighty-fourresidents(38.6%)weretestedonreal-time reverse-transcriptase-polymerase-chain-reaction (RT-PCR) assay ofnasalandpharyngealswabspecimens,andofthem12/184(6.5 %)werepositivetoSARS-COV-2.One-hundredandninety-fiveout 476residents(41.1%)weretestedforantibodyagainstSARS-COV-2 witheither chemiluminescenceimmunoassayanalysis, or rapid IgM-IgGcombinedantibodytest.
Regardingtheuseofpersonalprotectiveequipment(PPE),267 (56.1%)reportedtohavereceivedadequatedevice,and379(79.6 %) felt tobewellinformed aboutprevention and management protocols. Three-hundred and thirty-one residents (69.6 %) reportedtohavemanagedCOVID-19positivepatients.
Surveyresults
For 54.7 % of the respondents, training activity in general decreased significantly (2/3 reduction) during the COVID-19 epidemic. Although 19 out 476 (3.9 %) responded declared no reduction in their training activity, a one-third reduction was reportedin31.4%ofthecases,whereasatotalsuspensionofthe trainingin9.9%ofthecases.In89.3%ofcasesthereductionwas causedbythereorganizationofworkshifts,while8.2%and2.5% have reduced theiractivity because of medical prescription or mandatoryquarantine,respectively.
Theareasmostinvolvedfromthisreductionhavebeenthose relatedtoelectivesurgicalprocedures,witha39.7%and40.4%of Residentsreportingtotalsuspensionofmajorandminorsurgical activities,respectively(Fig.1).Ontheopposite,laboranddelivery training and prenataldiagnosis wereless reduced,with a total suspensionofthetrainingin8.2%and23.1%ofcases,respectively. Laboranddeliveryactivitywerenotreducedatallfor43.3%of cases,whilea1/3reductionwasobservedin29.6%ofrespondents. Prenataldiagnosisactivitywasnotreducedatallfor40.8%ofcases, while a 1/3 reduction was observed in 17.9 % of respondents. Invasiveprenataldiagnosiswastotallysuspendedin29.6%ofcases while 242 out 476 respondents(50.8 %) declared that in their centerstheseprocedurescontinuedtobeperformedunchanged duringthepandemic.
Benign gynecology procedures, infertility treatments, and urogynecology related activities, on the opposite, underwent a verysignificantreduction,withareportedtotalsuspensionin55%, 54%and60%ofthecases,respectively(Fig.1).
Anunexpectedreductionwasobservedinoncologicalclinical activities.Indeed,20%ofrespondentsreducedtheirpracticeby twothirds,and36%totallysuspendedthisact.
Oncologic screening clinic and colposcopy were totally suspendedin41.8%ofcases,reducedby2/3in19.3%andreduced by1/3in10.7%,while28.1%ofResidentsdidnotreducedthis activityatall.
Logisticregression showed thatdegreeof training reduction was not associated with residents’ gender (p=0.48), year of residency(p=0.37),COVID-19positivity(p=0.54),ornumberof residentsinthecenter(p=0.63).
Residentsreportedareductioninteachingactivityin51.2%of cases, although at the same time the time dedicated to their individualstudyhasincreasedin68.1%ofrespondents.Research activity continued unchanged in 39.9 % of cases during the pandemic,wasreducedin23.7%andincreasedin36.3%ofcases, respectively.
EffectofCOVID-19onresidents’approachtothepatients,was reported as unchanged in 8.8 % of respondents, considerably changedin43.1%ofthecases,alittlebitchangedin43.7%and totallychangedin4%ofcases.
MorethanhalfoftheResidentsreportedanxietyrelatedtofear ofcontagion,duringinvasiveandnon-invasiveprocedure.Almost all the residents (457/476, 96 %), reported that COVID-19 had negativepsychological impactin terms of changes inmood, of which10%hadtheirmoodtotallyimpactedand58%considerably impactedbythepandemic(Fig.2a).
Fearabouttheprofessionalfuturewasreportedin84%ofthe residents,and59%ofthemhadtheperceptionthattheirtraining wasirreversiblycompromised(Fig.2b).
Logisticregression showed thatdegreeof moodimpairment was not associated with residents’ gender (p=0.56), year of residency(p=0.90),COVID-19positivity(p=0.59)orpresenceof infectedamong colleagues(p=0.75).Atthesametime, beinga ResidentinaCOVIDcenterdidnothaveanyeffectontheanxiety perceptionofrespondents(p=0.87),althoughthepercentageof Residentinfectedwassignificantlyhigherinthoseworkingina referencecenter (84.1 % vs15.9 %infected Residentsin COVID centerandinnot-COVIDcenter,respectively;p<0.001)(Fig.3). Discussion
Mainfindings
Thiscross-sectionalsurveystudyaimedtoevaluatetheimpact of the COVID-19 pandemic on the obstetrics and gynecology residencytrainingprograminItaly.Tothebestofourknowledge,
thismaybethefirststudyevaluatingtheimpactofCOVID-19on residentstraininginobstetricsandgynecology.Findingsfromthe survey showed that among Italian residents in obstetrics and gynecology,COVID-19pandemicwasassociatedwithasignificant trainingimpairment.Thisstudywaslimitedbythecross-sectional studydesign. WeincludedonlyItalianresidents, thereforedata fromthisstudymaynotbeapplicabletoothercountries. Implications
SinceDecember2019,theoutbreakofCOVID-19hasbecomea majorepidemicworldwide[3].COVID-19dramaticallyimpacted patient care [6] and had far-reaching effects on training in surgical programs [7–10]. Prior studies showed that COVID-19 epidemic is associated with significant reduction in residents training and reduction in medical education in different specialties[7,8].Theimpairmentmaybemoresevereinsurgical specialties, where hands-on training cannot be replaced by distanceeducation[8].AsurveyamongItalianurologyresidents, showedaseverereductionorcompletetrainingsuppressionin upto80%oftheresidents[5].
Our studyalsoshowed that morethan halfof theresidents experiencedsomedegreeofanxietyrelatedtofearofcontagion. PriorstudieshavebeenshownthatCOVID-19outbreakhadsevere phycologicalimpact ondifferent population, including patients andhealthcareproviders[4,11,12].
Theyearsspentduringmedicaltrainingprogramshaveacrucial roleinHealthcareprofessionalgrowth.AccordingtotheEuropean Congress of Obstetrics and Gynaecology (EBCOG), an optimal training,shouldensureanactiveparticipationinclinicalpractice,
Fig.1.Reductioninclinicalactivityasreportedbytheresidents.
Fig.2.a.PandemicimpactonResidents’moodandanxietyperception,evaluatedbyyearofresidency;2bResidents’perceptionoftrainingimpairmentduetothelockdown, evaluatedbyyearofresidency.
layingthefoundationsfortheachievementofspecificskillsanda minimumnumberofprocedurestobeperformed[13].
During the SARS-CoV-2 public health emergency, several medicalserviceshavebeenreduced,exceptforthoseconsidered urgentandnotdeferrable,suchaslaboranddeliveryandoncologic procedures.Consequently,althoughwithdifferentdegreesinthe specialties, doctors in training have also decreased their daily activities.Thisisinevitablyleadingtoaslowdownintraining.
Obstetricsandgynecologyresidencytrainingprogramhasone of thelargestand most heterogeneousprograms,in which the acquisitionofclinical,surgicalandemergencymanagementskills ismandatory.Dailypractice,togetherwithanadequatetheoretical preparation,playsa fundamentalroleinachievingautonomyin carryingouttheclinicalactivities.
Conclusions
Insummary,amongItalianresidentsCOVID-19pandemichada considerable negative impact on obstetrics and gynecology residencytrainingprogram.Ourfindingscanbeusedtoformulate newsolutiontolimittheimpactoftheCOVID-19onthequalityof residency training programs.New organizational strategies are necessarytominimizetrainingdeficiencies.Althoughnot compa-rable to practical activity, there may be different innovative solutionsavailable,asonlinepracticequestions,teleconferencing, involvingresidentsintelemedicineclinics,useofsimulators,and theuseofsurgicalvideos.
Financialsupport
Nofinancialsupportwasreceivedforthisstudy DeclarationofCompetingInterest
None.
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