Adaptations to Clinical Teaching
COVID-19 had a significant impact on how we teach clinical skills to residents and fellows. One of the earliest transitions during the pandemic was the adaptation of clinical meetings (such as didactics, M&M conferences, journal clubs, tumor boards, and preoperative conferences) to virtual and/or hybrid formats to comply with social distancing recommendations. These meetings were adaptable because of their discussion-based format. These changes, however, had advantages and disadvantages with respect to convenience, content, and culture. Benefits associated with this restructuring included increased options for meeting times and methods of attendance.4 Providers could access meetings from any location and interact with individuals from other departments and institutions, leading to improved interdisciplinary collaboration. However, virtual/hybrid platforms also led to a dramatic increase in the number of meetings and, as the pandemic continued, reports of overscheduling, conflicts, and meeting fatigue curtailed the benefits of increased accessibility.5
This transformation illustrates the maxim “quantity does not always equal quality.” The increase in offerings highlighted the importance of content quality, as well as concerns about active participation of learners in these virtual environments. Particularly for residents, issues arose regarding the ability to attend educational meetings while simultaneously meeting other clinical demands.4 Because it is far easier to multitask—answer pages, write notes, see a consult, discuss patient care with another provider—when on a computer in a remote space without oversight during a virtual meeting than while convening in-person, residents perceived this change as leading to a decrease in protected educational time.4 Junior residents shouldered much of this burden, as their initial introduction to direct patient care has been overshadowed by the COVID-19 pandemic.4
On a global scale, the pandemic revealed gaps in our healthcare system that led to the development of new curricula emphasizing health equity and access.6 Globally, there was a 48% increase in the use of video conferencing before the COVID-19 pandemic, but the medical field experienced an even more rapid transition after the pandemic struck.7 The benefits of flexibility and access to meetings were critically empowering for surgeons with busy schedules and in rural settings who previously were isolated from broad collaboration. The lack of training and discussion around appropriate use of virtual/hybrid platforms, nonetheless, led to a shift in etiquette. Meetings such as didactics and M&Ms, which previously maintained a culture of formality—attire, engagement, and protected time—are now less formal engagements. Attendees can take meetings outside the workplace such as in their car, outdoors, in public spaces, or at home.7 Although some studies tout the benefits of this flexibility on personal wellness, only time will tell how the informality affects educational outcomes.8
The RAS Education Committee proposes to combat the barriers to learning using methods that include instructor training for effective virtual teaching, agenda setting and meeting management, troubleshooting technology, and using novel tools on virtual platforms to improve interactivity.
Adaptations to Teaching Technical Skills
The pandemic has resulted in a significant reduction in operative opportunities for surgical trainees.9 Nationally, elective operations were suspended or delayed for several months at a time as rates of infection increased. Time away from operative practice took away the fundamental principle of surgical training, namely the daily practice of surgery.
A study comparing average general surgery monthly case logs from March to June 2020 revealed a 33.5% reduction in major operative cases compared with the same period in 2019, before the COVID-19 outbreak.10 The RAS survey of young surgeons showed that COVID-19-related reduction in surgical caseload was the primary concern of respondents (29.6%). This reduction also affected trainees in fellowships, which carries a significant impact given the short duration of subspecialized training. Thus, surgical educators must compensate for reduced operative volume with innovative approaches through surgical simulation. Growing evidence shows that simulation-based training for skin lesion excision and small bowel anastomosis on porcine tissue translate to decreased time to completion and increased proficiency in the operating room,11 demonstrating the positive role of simulation in reducing operative time, improving outcomes, and increasing resident autonomy. These adjuncts to technical teaching become critically important in the setting of decreased operative volumes or trainees.
One example of the novel approaches to using simulation as a tool to progress surgical technical skills despite lack of access to direct operative experience comes from the University of Toronto, ON.12 This institution has developed a lung transplant model for the surgical skills bootcamp in thoracic surgery, which contained equipment and supplies that were delivered to fellows’ homes. Senior trainees were provided instructions on how to use a vascular anastomosis model pertaining to lung transplantation operation. Trainees were required to practice at home and perform the anastomosis with timed testing. A video recording was made of an attempt. The fellows in this study self-reported improved surgical efficiency over time.12
To protect trainees from exposure to COVID-19 at the height of the pandemic, virtual surgical rotations also were implemented broadly, particularly in undergraduate medical education (UME). Virtual surgical rotations consisted of interactive, live-streamed operations, outpatient telehealth visits, and virtual small groups.1 One novel approach for surgical residents in the Netherlands involved the development of a national livestreamed surgical educational series.3 In this model, one training center conducted and livestreamed common surgical procedures on cadaveric models. Additional online resources were available for self-study before the livestream. Trainees found this hybrid model to be highly educational for technical learning and a plausible alternative given the absence of clinical rotations.3
As we move forward from the pandemic with a slow transition back to prepandemic operative volumes, programs should continue to capitalize on our collective experience with technical surgical education. With established virtual education resources and subsequent comparable outcomes in resident learning, these resources should be maintained as an adjunct to in-person didactic lectures. Many regions still experience periods of reduced surgical volume because of spikes in COVID-19 cases. Continued effort is necessary to establish standardized simulation-based modules to prepare trainees for operative technique early in residency and to increase preparedness for operative autonomy when the opportunity is presented.
Adaptations to the Certification Process
Along with multiple adaptations in both clinical and technical surgical education, shifts in certification also occurred in both UME and graduate medical education. In the US Medical Licensing Examination (USMLE), the major change in board certification was cancelation of Step 2 Clinical Skills.13 For surgical trainees, modifications were seen in training requirements for 2020 graduates, including nonvoluntary offsite time toward graduation requirements, a 10% decrease in required time spent in clinical training for surgical residents, a decrease in the total case numbers required for graduation, and entrustment of program directors to “make a decision about the readiness of the resident for independent practice” even if they failed to meet the decreased time and case requirements.14 In addition to these shifts, the American Board of Surgery (ABS) General Surgery Qualifying Exam (QE) and Certifying Exam (CE) went virtual in 2020.14
These changes brought both successes and failures. The virtual administration of the 2020 General Surgery QE was intended to be safer and more convenient for trainees, but the use of a remote proctoring service resulted in delays and interruptions, as well as security concerns that resulted in the complete cancelation of the July 2020 exam.14 Many of these early challenges were surmounted during the administration of the 2021 exam.
In contrast, the virtual administration of the General Surgery CE has been largely successful, with 78% of candidates preferring the virtual exam when surveyed following the first administration.15 Passing rates also were comparable to previous in-person CE.15 Additional advantages to the virtual CE include the benefit of testing in familiar surroundings—reducing the stress of taking a high-stakes exam in a unfamiliar environment—and the alleviation of travel-related stress and expense.15 Cited disadvantages to the virtual CE included exam security concerns, and the loss of camaraderie and social support before and after the exam for both candidates and faculty.15 Overall, however, most candidates surveyed agreed that the disadvantages of the virtual format of the exam did not seem to outweigh the numerous advantages,15 and it would appear that the virtual CE may be here to stay.
Other changes, including the cancelation of Step 2 CS and changes in residency graduation requirements, appear to be a preview of the transition of the future of medical education to a competency-based model. With the elimination of Step 2 CS, the responsibility of assessing clinical skills readiness falls on medical schools, emphasizing the need to advance competency-based education.13 Similarly, changes in the surgical learning environment created by the COVID-19 pandemic have accelerated the need for improved metrics to determine whether graduating surgical residents are ready for practice.
The limitations resulting from the pandemic on classic surrogates of competency—time spent in training and number of cases completed—has necessarily accelerated the shift to direct evaluation of competency. The concept of competency-based medical education is at the core of entrustable professional activities (EPAs). EPAs are observable and measurable units of work focused on actual healthcare delivery.16 Initially piloted in UME and pediatrics, EPAs now have been developed and piloted in general surgery, and are set to be adopted broadly by the ABS in July 2023.16,17
The aim of the ABS EPA project is to develop a full suite of approximately 19 EPAs representative of the core elements of general surgical practice with the goal of creating microassessments that can be used for improvement-oriented performance feedback.17 Although EPAs will not replace standardized assessments or case requirements, they do demonstrate a shift in the culture of surgical education, where learner outcomes and feedback, rather than case numbers, are emphasized.16 The pandemic accelerated the discussion around trainee competency and, as EPAs are implemented, will continue to be the focus of surgical education for years to come.
Changes to Education for Early Career Surgeons
Surgical residents were not the only ones affected by COVID-19-related shutdowns and changes. Early career surgeons faced the challenge of transitioning to independence in a time of unparalleled change. Important technological innovations that were brought about by the COVID-19 pandemic, as well as the more widespread use and comfort with e-learning and virtual meeting platforms, have had a meaningful impact on maintenance of certification and lifelong learning.
Many publicly available asynchronous resources created by surgical societies or residency programs allow self-paced viewing for the busy surgeon.4 Audio-only formats such as podcasts also are increasingly popular.18 Meanwhile, group viewing of operations from a surgical society video library, especially when expert commentary is available, offers a more interactive approach to recordings and has some evidence of improving technical proficiency outside the operating room.2,19
Like virtual or hybrid resident didactics, the concept of webinars and virtual conferences for CME and maintaining certification is attractive. E-learning is especially appealing to rural and international surgeons as a less costly option that is welcoming of a wider audience.5,19 Unfortunately, these formats have similar limitations to those previously discussed, including reduced engagement and loss of the socialization many appreciate when attending an in-person meeting.1,5 Moving forward, just as with residency education, it is likely that a hybrid model of conferences will predominate, one that incorporates the strengths of both virtual and in-person formats based on individual learner needs.
Finally, telementoring is a promising means not only of maintaining certification, but also gaining new skills by leveraging resources and expertise remotely. The pandemic has accelerated the expansion of existing technologies, including teleconferencing and development of novel telementoring methods, including telestration and augmented reality.20 During a time with limited travel or restrictions on personnel in the OR for trainees and staff alike, alternative approaches to carrying training forward are essential. Beyond the COVID-19 pandemic, these technologies carry great promise for the future of advanced surgical training.
Conclusion and Recommendations
The pandemic has irrefutably changed the face of surgical education. Adaptations to allow for resource scarcity, allocation of workforce, and social distancing accelerated the pace of development of virtual and e-learning technologies. As a result, access to educational content has increased exponentially. It has become increasingly convenient to access educational content and collaborations. Advances in surgical simulation have increased access to technical skills training. Opportunities for local, national, and global collaboration have expanded, and new opportunities for networking, professional development, and mentoring have arisen. The process of board certification has changed in response to pandemic-related restrictions, which have also highlighted the need for true competency-based assessment methods. The wealth of resources now available and the ease of access these novel platforms allow has led to changes in expectations and etiquette. As we move forward as a community of surgeons and educators, it is important to continue to examine the progress we have made and continue to make advances for the future.
