COVID-19 Impact on residency, Fellowships: Adaptation, flexibility smooth a bumpy road of change and confusion

The first presumptive cases of COVID-19 were diagnosed in the United States and Canada, respectively, on Jan. 21 and Jan. 25. Since the declaration of a national emergency in the United States on March 13 – and with many jurisdictions in Canada declaring equivalent states of emergency – circumstances have evolved rapidly. At Plastic Surgery Resident press time, approximately 9.2 million cases have been documented worldwide, with more than 477,000 deaths; approximately one-quarter of the cases and deaths have occurred in the United States.

Responding to the burden of COVID-19 on the healthcare system and ICUs, governments instituted social distancing measures that included the closure of schools, daycare centers and non-essential businesses. The Centers for Disease Control and Prevention (CDC) and the American College of Surgeons (ACS) likewise published guidelines with the aim of preserving healthcare resources for a potential surge in patients requiring hospitalization and critical care. The ACS published the following for managing elective surgical procedures:

• "Each hospital, health system and surgeon should thoughtfully review all scheduled elective procedures with a plan to minimize, postpone, or cancel electively scheduled operations... until we have passed the predicted inflection point."

• "Immediately minimize use of essential items needed to care for patients, including... ICU beds, personal protective equipment, terminal cleaning supplies, and ventilators."

These guidelines, supported by ASPS President Lynn Jeffers, MD, MBA, recommend that all plastic surgeons cease providing any elective or non-essential services. Given the elective to non-urgent nature of much of plastic and reconstructive surgery, case volumes decreased significantly in March and April. While the reopening of several states allowed clinical volumes to rise slightly, those reopenings have led to record numbers of new cases; it remains unknown when clinical volumes will return to pre-pandemic levels.

While a debate on the impact of these guidelines on patient care is outside the scope of this article, decreased clinical volumes and postponement of elective surgery in some centers is already having an impact on resident surgical education. The University of Washington Plastic Surgery Residency Program recently published its experience, estimating a decline of nearly 100 percent in clinical volumes at the VA Medical Center and of approximately 75 percent at Harborview Medical Center.

Whether or not one believes the "10,000-Hour Rule" popularized by Malcolm Gladwell in Outliers, we can all agree that exposure and practice are necessary components of resident education. Decreased exposure may limit progression along the learning curve – unless programs and residents adapt and accelerate their learning by maximizing educational opportunities outside and inside the O.R.

Decreased exposure, delayed skill

Resident education is multifaceted; it includes independent learning, interactive lectures, operative experiences and reflection. While little can be done about the reduction in elective surgery caseloads, we are fortunate to train in a specialty with creative and dedicated mentors who've pivoted to maximize our didactic learning opportunities. International experts within our field have organized interactive educational events through multimedia platforms. ASPS, ASAPS, ASSH, AAHS and several other international societies, hospitals and companies created lecture series that residents can work through interactively or independently. While lectures are not a replacement for clinical and surgical exposure, understanding the literature is a necessary step for application in clinical settings.

The impact of reduced case volumes on residency will declare itself with time. A better understanding of anatomy and the literature learned outside the O.R. can translate into improved understanding and proficiency inside the O.R., thus accelerating the learning curve and allowing residents to maximize their surgical opportunities when elective surgical case loads return to a more typical level.

The secondary concern with decreased operative experience is whether residents will meet criteria for graduation upon completion of their program. The American Board of Medical Specialties (ABMS) published a statement regarding the need to provide flexibility, with some subspecialty boards already having made programmatic adaptations. The American Board of Surgery (ABS) outlined that for chief residents completing training in 2020, non-voluntary, off-site time used for education can be included as clinical time; 44 weeks of clinical time would be acceptable; and the ABS would accept a 10 percent decrease in total operative case numbers. Inability to meet these metrics would result in program directors petitioning the ABS using information gathered from their respective Clinical Competency committees.

Instructions have been released by the American Board of Plastic Surgery (ABPS) to Written and Oral Board Examination candidates, with the date of the written examination pushed back and the required caseload for the oral examination reduced. Requirements for Continuous Certification (until recently, Maintenance of Certification) have also been adjusted. ACGME guidelines can be referenced for residents. As outlined by the group from the University of Washington, graduation from residency is multifactorial and ultimately based on the program's assessment of the trainee's competence, with case minimums impacting accreditation and not program completion. In Canada, residency program directors and the Royal College of Physicians and Surgeons agreed to be as judicious as possible in determining whether residents have sufficiently achieved competencies in their respective programs, understanding that the pandemic has created unique training circumstances.

Residents in their graduating year may be concerned with the impact of delays in licensure and board examination. The current pandemic has resulted in delays in both U.S. and Canadian examinations, with the ABPS Written Examination postponed to Oct. 26, and the Royal College examination postponed to the Fall 2020 (with the makeup date yet determined). New scheduling permits have to be assigned for residents writing the ABPS exam; however, closures of Prometric sites through May 31 will result in a backlog of exams to be written, and residents may have to be more flexible with location when scheduling the examination.

Board examination and licensure differs significantly from the United States and Canada. In the United States, successful completion of residency is sufficient to obtain licensure – and the ABPS examination is necessary to become board-certified. In Canada, completion of residency is necessary to become eligible to write the Royal College examination, which is a two-step process: a two-day written exam followed by a two-day oral exam. Without successful completion of the Royal College exam, Canadian residents are ineligible for an independent practice license. This created confusion regarding the eligibility of graduating residents to practice starting in July. While the guidelines differ between provincial jurisdictions, the College of Physicians and Surgeons of Ontario (CPSO) may issue provisional licenses to residents who are exam eligible, although these will be limited licenses that require supervision.

The uncertainty in Fellowships

For residents in their final years looking beyond residency, the impact of COVID-19 on the availability of Fellowship and faculty positions remains unknown, especially for those hoping to train abroad. COVID-19 is unlikely to have a long-term impact on the need for surgical Fellows and surgeons, but the more immediate impact over the next year is difficult to predict. For those currently in a Fellowship or entering one this summer, any shutdown of elective surgeries is likely to have a more significant impact on the quality of education. Over a 12-month fellowship, decreased clinical volumes for a two- to three-month period could represent a significant portion of the educational opportunities. For those applying to Fellowship, interviews in 2020-2021 will likely take a different form than in past years.

Some programs held interviews virtually, while the microsurgery match was delayed until the fall. Many residents abroad who are looking to travel to the United States and Canada for residency and Fellowship have yet to receive their credentials, and licensure is delayed.

On April 22, President Trump issued an Executive Order temporarily suspending the issuance of immigrant visas. Fortunately, the J-1 non-immigrant visa currently is exempt, allowing residents from foreign countries with Fellowships planned in the United States to proceed.

At the other end of the residency, new plastic surgery residents in the 2020-2021 year will have a novel and possibly limited experience. While some jurisdictions across the United States and Canada began the slow return to pre-pandemic operative loads as early as May, some regions opted to delay until July or later. The first year of residency is critical in rapidly developing new skills; if surgical loads and inpatient populations remain limited, this foundational period may not be enough to prepare new residents for the remainder of residency.

Additionally, institutions are grappling with potential periods of quarantine following the arrival of incoming residents and Fellows, as well as how to handle orientation training while getting much needed residents efficiently and safely on the wards. The ACAPS/ASPS Boot Camp Joint Committee recently announced the cancellation of the 2020 Boot Camp and is exploring alternative options for providing education content to new trainees.

Resident safety in the training setting remains a significant concern. Residency exposure may be more limited in certain subspecialty areas, such as facial trauma, which poses a unique risk of exposure to COVID-19, both by nature of being in or near the oronasophyarnx and by the risk of aerosolization. While new guidelines released by the AO CMF may assist in risk reduction, PPE limitations and the nature of these procedures have led some institutions to limit resident exposure to facial trauma cases.

Dilemma of medical students

The COVID-19 crisis has also had a significant impact on medical students. Most medical schools suspended operations to help preserve PPE and reduce students' exposure. Some schools transitioned to online educational courses while others have modified requirements for graduating medical students. Current fourth-year medical students saw their Match Day events as well as graduation cancelled, which precluded them from celebrating these momentous occasions representing years of hard work. Many medical students found ways to contribute to the pandemic response by helping with telemedicine, as well as by providing childcare and other essential services to healthcare workers. Medical students in some cities – including New York, Boston and Providence, R.I. – have even been allowed to graduate medical school early in order to join frontline efforts against the coronavirus.

Rising fourth-year medical students also face significant uncertainty as they prepare to embark on the residency application and interview process. As one of the most competitive specialties, the plastic surgery match is daunting even under normal conditions. Current applicants who have been pulled from clinical rotations must now juggle roles and demands – making up their clinical requirements while navigating an already complex visiting rotation, application and interview process. Studies show that 91 percent of applicants believed an away rotation made them more competitive for matching to a program, and program directors noted that a strong performance on an away rotation was the most important criteria for a successful match. In fact, up to 71 percent of medical students match at their home program or a program where they did an away rotation.

Given the current pandemic, no programs are currently offering positions for visiting students during the summer, while a small number have begun to process applications for the fall. Medical students are told of the importance of letters of recommendation from away rotations, which they may be unable to obtain prior to the ERAS application deadline in September. Additionally, programs will not have one of their strongest recruitment and applicant evaluation tools available to them. The current ACAPS guidelines note that individual medical schools will determine policies regulating visiting sub-internships, but these also recommend waiting until the AAMC makes a recommendation on medical student interactions with patients and ACAPS develops a coordinated approach from all institutions.

Even if these governing bodies allow for visiting medical students, many hospital systems may not be able to offer positions due to the lack of PPE and burden of COVID care. As such, medical students and residency programs will need to find new ways to ensure a successful match – and guidance will be needed from ACAPS to ensure an equitable process for all.

A rise in research?

The plastic surgery community has done an exemplary job anticipating and reacting to the potential impact of COVID-19 on resident education. Strong leadership from societies such as ASPS, ASSH and CSPS, in addition to leadership from individual institutions, is invaluable in overcoming the limited clinical exposure for residents during COVID-19. With the additional time and resources, residents have a unique opportunity to read, reflect and contribute to research. This may be an opportunity to write grants, submit research ethics board approvals, or start new projects that require time to organize.

PRS Editor-in-Chief Rod Rohrich, MD, recently reported in the ASPS Virtual Grand Rounds series that PRS has seen a significant increase in article submissions, as a direct result of the research time newly available to plastic surgeons. In addition to virtual lectures, programs can further explore the utility of surgical simulation and models in plastic surgery education. The University of Toronto has explored the use of surgical simulation for procedures that are traditionally more difficult to teach intraoperatively because of confined space, limited visualization and delicate tissue handling. High-fidelity surgical simulators that replicate delicate, intraoperative tissue handling required may provide an opportunity for residents to maintain their surgical skills during times of decreased clinical load.

Using this time to fulfill the other facets of residency will hopefully allow for residents to be better prepared and educated when clinical volumes return to pre-pandemic levels. Unfortunately, only time will reveal how these changes have impacted resident competency for independent practice. The hope is that while adaptations have changed education during this tumultuous period, residents will be no less-prepared at the completion of residency. Furthermore, the online resources created for education during this time may enhance resident education for the future.

Dr. Catapano is PGY5 in the University of Toronto Division of Plastic Surgery; Dr. Cho is PGY5 in the University of Washington Division of Plastic Surgery; and Dr. Akhavan is PGY4 in the University of North Carolina Division of Plastic Surgery.

The first presumptive cases of COVID-19 were diagnosed in the United States and Canada, respectively, on Jan. 21 and Jan. 25. Since the declaration of a national emergency in the United States on March 13 – and with many jurisdictions in Canada declaring equivalent states of emergency – circumstances have evolved rapidly. At Plastic Surgery Resident press time, approximately 9.2 million cases have been documented worldwide, with more than 477,000 deaths; approximately one-quarter of the cases and deaths have occurred in the United States.

Responding to the burden of COVID-19 on the healthcare system and ICUs, governments instituted social distancing measures that included the closure of schools, daycare centers and non-essential businesses. The Centers for Disease Control and Prevention (CDC) and the American College of Surgeons (ACS) likewise published guidelines with the aim of preserving healthcare resources for a potential surge in patients requiring hospitalization and critical care. The ACS published the following for managing elective surgical procedures:

• "Each hospital, health system and surgeon should thoughtfully review all scheduled elective procedures with a plan to minimize, postpone, or cancel electively scheduled operations… until we have passed the predicted inflection point."
• "Immediately minimize use of essential items needed to care for patients, including... ICU beds, personal protective equipment, terminal cleaning supplies, and ventilators."

These guidelines, supported by ASPS President Lynn Jeffers, MD, MBA, recommend that all plastic surgeons cease providing any elective or non-essential services. Given the elective to non-urgent nature of much of plastic and reconstructive surgery, case volumes decreased significantly in March and April. While the reopening of several states allowed clinical volumes to rise slightly, those reopenings have led to record numbers of new cases; it remains unknown when clinical volumes will return to pre-pandemic levels.

While a debate on the impact of these guidelines on patient care is outside the scope of this article, decreased clinical volumes and postponement of elective surgery in some centers is already having an impact on resident surgical education. The University of Washington Plastic Surgery Residency Program recently published its experience, estimating a decline of nearly 100 percent in clinical volumes at the VA Medical Center and of approximately 75 percent at Harborview Medical Center.

Whether or not one believes the "10,000-Hour Rule" popularized by Malcolm Gladwell in Outliers, we can all agree that exposure and practice are necessary components of resident education. Decreased exposure may limit progression along the learning curve – unless programs and residents adapt and accelerate their learning by maximizing educational opportunities outside and inside the O.R.

Decreased exposure, delayed skill

Resident education is multifaceted; it includes independent learning, interactive lectures, operative experiences and reflection. While little can be done about the reduction in elective surgery caseloads, we are fortunate to train in a specialty with creative and dedicated mentors who've pivoted to maximize our didactic learning opportunities. International experts within our field have organized interactive educational events through multimedia platforms. ASPS, ASAPS, ASSH, AAHS and several other international societies, hospitals and companies created lecture series that residents can work through interactively or independently. While lectures are not a replacement for clinical and surgical exposure, understanding the literature is a necessary step for application in clinical settings.

The impact of reduced case volumes on residency will declare itself with time. A better understanding of anatomy and the literature learned outside the O.R. can translate into improved understanding and proficiency inside the O.R., thus accelerating the learning curve and allowing residents to maximize their surgical opportunities when elective surgical case loads return to a more typical level.

The secondary concern with decreased operative experience is whether residents will meet criteria for graduation upon completion of their program. The American Board of Medical Specialties (ABMS) published a statement regarding the need to provide flexibility, with some subspecialty boards already having made programmatic adaptations. The American Board of Surgery (ABS) outlined that for chief residents completing training in 2020, non-voluntary, off-site time used for education can be included as clinical time; 44 weeks of clinical time would be acceptable; and the ABS would accept a 10 percent decrease in total operative case numbers. Inability to meet these metrics would result in program directors petitioning the ABS using information gathered from their respective Clinical Competency committees.

Instructions have been released by the American Board of Plastic Surgery (ABPS) to Written and Oral Board Examination candidates, with the date of the written examination pushed back and the required caseload for the oral examination reduced. Requirements for Continuous Certification (until recently, Maintenance of Certification) have also been adjusted. ACGME guidelines can be referenced for residents. As outlined by the group from the University of Washington, graduation from residency is multifactorial and ultimately based on the program's assessment of the trainee's competence, with case minimums impacting accreditation and not program completion. In Canada, residency program directors and the Royal College of Physicians and Surgeons agreed to be as judicious as possible in determining whether residents have sufficiently achieved competencies in their respective programs, understanding that the pandemic has created unique training circumstances.

Residents in their graduating year may be concerned with the impact of delays in licensure and board examination. The current pandemic has resulted in delays in both U.S. and Canadian examinations, with the ABPS Written Examination postponed to Oct. 26, and the Royal College examination postponed to the Fall 2020 (with the makeup date yet determined). New scheduling permits have to be assigned for residents writing the ABPS exam; however, closures of Prometric sites through May 31 will result in a backlog of exams to be written, and residents may have to be more flexible with location when scheduling the examination.

Board examination and licensure differs significantly from the United States and Canada. In the United States, successful completion of residency is sufficient to obtain licensure – and the ABPS examination is necessary to become board-certified. In Canada, completion of residency is necessary to become eligible to write the Royal College examination, which is a two-step process: a two-day written exam followed by a two-day oral exam. Without successful completion of the Royal College exam, Canadian residents are ineligible for an independent practice license. This created confusion regarding the eligibility of graduating residents to practice starting in July. While the guidelines differ between provincial jurisdictions, the College of Physicians and Surgeons of Ontario (CPSO) may issue provisional licenses to residents who are exam eligible, although these will be limited licenses that require supervision.

The uncertainty in Fellowships

For residents in their final years looking beyond residency, the impact of COVID-19 on the availability of Fellowship and faculty positions remains unknown, especially for those hoping to train abroad. COVID-19 is unlikely to have a long-term impact on the need for surgical Fellows and surgeons, but the more immediate impact over the next year is difficult to predict. For those currently in a Fellowship or entering one this summer, any shutdown of elective surgeries is likely to have a more significant impact on the quality of education. Over a 12-month fellowship, decreased clinical volumes for a two- to three-month period could represent a significant portion of the educational opportunities. For those applying to Fellowship, interviews in 2020-2021 will likely take a different form than in past years.

Some programs held interviews virtually, while the microsurgery match was delayed until the fall. Many residents abroad who are looking to travel to the United States and Canada for residency and Fellowship have yet to receive their credentials, and licensure is delayed.

On April 22, President Trump issued an Executive Order temporarily suspending the issuance of immigrant visas. Fortunately, the J-1 non-immigrant visa currently is exempt, allowing residents from foreign countries with Fellowships planned in the United States to proceed.

At the other end of the residency, new plastic surgery residents in the 2020-2021 year will have a novel and possibly limited experience. While some jurisdictions across the United States and Canada began the slow return to pre-pandemic operative loads as early as May, some regions opted to delay until July or later. The first year of residency is critical in rapidly developing new skills; if surgical loads and inpatient populations remain limited, this foundational period may not be enough to prepare new residents for the remainder of residency.

Additionally, institutions are grappling with potential periods of quarantine following the arrival of incoming residents and Fellows, as well as how to handle orientation training while getting much needed residents efficiently and safely on the wards. The ACAPS/ASPS Boot Camp Joint Committee recently announced the cancellation of the 2020 Boot Camp and is exploring alternative options for providing education content to new trainees.

Resident safety in the training setting remains a significant concern. Residency exposure may be more limited in certain subspecialty areas, such as facial trauma, which poses a unique risk of exposure to COVID-19, both by nature of being in or near the oronasophyarnx and by the risk of aerosolization. While new guidelines released by the AO CMF may assist in risk reduction, PPE limitations and the nature of these procedures have led some institutions to limit resident exposure to facial trauma cases.

Dilemma of medical students

The COVID-19 crisis has also had a significant impact on medical students. Most medical schools suspended operations to help preserve PPE and reduce students' exposure. Some schools transitioned to online educational courses while others have modified requirements for graduating medical students. Current fourth-year medical students saw their Match Day events as well as graduation cancelled, which precluded them from celebrating these momentous occasions representing years of hard work. Many medical students found ways to contribute to the pandemic response by helping with telemedicine, as well as by providing childcare and other essential services to healthcare workers. Medical students in some cities – including New York, Boston and Providence, R.I. – have even been allowed to graduate medical school early in order to join frontline efforts against the coronavirus.

Rising fourth-year medical students also face significant uncertainty as they prepare to embark on the residency application and interview process. As one of the most competitive specialties, the plastic surgery match is daunting even under normal conditions. Current applicants who have been pulled from clinical rotations must now juggle roles and demands – making up their clinical requirements while navigating an already complex visiting rotation, application and interview process. Studies show that 91 percent of applicants believed an away rotation made them more competitive for matching to a program, and program directors noted that a strong performance on an away rotation was the most important criteria for a successful match. In fact, up to 71 percent of medical students match at their home program or a program where they did an away rotation.

Given the current pandemic, no programs are currently offering positions for visiting students during the summer, while a small number have begun to process applications for the fall. Medical students are told of the importance of letters of recommendation from away rotations, which they may be unable to obtain prior to the ERAS application deadline in September. Additionally, programs will not have one of their strongest recruitment and applicant evaluation tools available to them. The current ACAPS guidelines note that individual medical schools will determine policies regulating visiting sub-internships, but these also recommend waiting until the AAMC makes a recommendation on medical student interactions with patients and ACAPS develops a coordinated approach from all institutions.

Even if these governing bodies allow for visiting medical students, many hospital systems may not be able to offer positions due to the lack of PPE and burden of COVID care. As such, medical students and residency programs will need to find new ways to ensure a successful match – and guidance will be needed from ACAPS to ensure an equitable process for all.

A rise in research?

The plastic surgery community has done an exemplary job anticipating and reacting to the potential impact of COVID-19 on resident education. Strong leadership from societies such as ASPS, ASSH and CSPS, in addition to leadership from individual institutions, is invaluable in overcoming the limited clinical exposure for residents during COVID-19. With the additional time and resources, residents have a unique opportunity to read, reflect and contribute to research. This may be an opportunity to write grants, submit research ethics board approvals, or start new projects that require time to organize.

PRS Editor-in-Chief Rod Rohrich, MD, recently reported in the ASPS Virtual Grand Rounds series that PRS has seen a significant increase in article submissions, as a direct result of the research time newly available to plastic surgeons. In addition to virtual lectures, programs can further explore the utility of surgical simulation and models in plastic surgery education. The University of Toronto has explored the use of surgical simulation for procedures that are traditionally more difficult to teach intraoperatively because of confined space, limited visualization and delicate tissue handling. High-fidelity surgical simulators that replicate delicate, intraoperative tissue handling required may provide an opportunity for residents to maintain their surgical skills during times of decreased clinical load.

Using this time to fulfill the other facets of residency will hopefully allow for residents to be better prepared and educated when clinical volumes return to pre-pandemic levels. Unfortunately, only time will reveal how these changes have impacted resident competency for independent practice. The hope is that while adaptations have changed education during this tumultuous period, residents will be no less-prepared at the completion of residency. Furthermore, the online resources created for education during this time may enhance resident education for the future.

Dr. Catapano is PGY5 in the University of Toronto Division of Plastic Surgery; Dr. Cho is PGY5 in the University of Washington Division of Plastic Surgery; and Dr. Akhavan is PGY4 in the University of North Carolina Division of Plastic Surgery.