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ORIGINAL ARTICLE Table of Contents  
Ahead of print publication
Impact of severe acute respiratory syndrome-coronavirus-2 pandemic on postgraduate medical education in armed forces medical services institutions: A students' perspective


1 Department of Ophthalmology, 7 Air Force Hospital, Nathu Singh Road, Kanpur Cantonment, Kanpur, Uttar Pradesh, India
2 Department of Ophthalmology, Command Hospital Air Force, Old Airport Road, Agram Post Bangalore, Karnataka, India
3 Department of Nephrology, Command Hospital Air Force, Old Airport Road, Agram Post Bangalore, Karnataka, India
4 Department of Medicine, 7 Air Force Hospital, Nathu Singh Road, Kanpur Cantonment, Kanpur, Uttar Pradesh, India

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Date of Submission22-May-2022
Date of Decision21-Jul-2022
Date of Acceptance28-Aug-2022
Date of Web Publication31-Oct-2022
 

  Abstract 


Introduction: The Severe acute respiratory syndrome coronavirus 2 pandemic situation brings us the opportunity to test the strength and limitations of our health delivery system. Residents being the backbone of quality-health-delivery of any institute have taken the brunt. Materials and Methods: A cross-sectional self-administered questionnaire-based survey was used to assess the effect on medical training and stress of postgraduate residents in clinical specialties of armed forces institutions. Results: 266 valid responses were analyzed. Eighty-seven percent of residents felt their surgical/procedure-related training was affected. Bedside/clinical training was found to be affected by 92% and theoretical learning by 78%. A significant difference was found between residents in medical and allied specialties and residents in surgery and allied specialties (81% vs. 96.3%) with regard to the negative effect of the COVID-19 pandemic on surgical/procedural skills training (P < 0.05). There was a significant difference in the likelihood of being posted for COVID duties based on gender (P = 0.01) and year of the course (P = 0.004). Posting on COVID duties did not significantly affect surgical, clinical, or theoretical training. Of the respondents, 37%, 49%, and 14% had a mild, moderate, and severe increase in stress, respectively. 18%, 52%, and 30% experienced mild, moderate, and severe increased stress among family members. Gender, age, category, year of residency, or subject of specialization did not have any significant effect on the level of personal or family stress. Conclusion: This survey attempts to bring forth the effect of the pandemic on medical training schedules and stress among residents. Such surveys would enhance understanding and bring solutions to the problem that the pandemic has brought.

Keywords: COVID-19, medical education, pandemic, postgraduate, residents, survey


How to cite this URL:
Nair N, Khan MA, Jha VK, Mahapatra D. Impact of severe acute respiratory syndrome-coronavirus-2 pandemic on postgraduate medical education in armed forces medical services institutions: A students' perspective. Indian J Med Spec [Epub ahead of print] [cited 2022 Dec 5]. Available from: http://www.ijms.in/preprintarticle.asp?id=360047





  Introduction Top


The unprecedented scale of the COVID-19 pandemic with the ensuing lockdowns and new norms of social distancing has put to test the conventional ways of life. Hospitals started disaster mitigation efforts by stopping all nonemergency consultations and getting the infrastructure ready for receiving the increasing number of COVID-19 cases. This resulted in medical training taking a back seat, as critical resources were utilized toward efforts to combat the present outbreak. Interactive sessions and directly supervised skill transfers that have been the cornerstones of medical training and teaching have now been substituted by virtual lectures, presentations, and webinars by eminent professionals. It is important to know to what extent they have filled the gaps in training so as to evolve more innovative methods of distance learning.

Armed forces hospitals across India have been at the forefront in the management of the COVID-19 pandemic since its onset. The resident training situation is peculiar in the armed forces because the service requirements do not give them the freedom to take additional time after graduation to get further training on their own accord. Catering to the particular scenario of armed forces institutes, we conducted this survey to assess the effect of the COVID-19 pandemic on the postgraduate training and stress levels as perceived by the postgraduate residents, undergoing training in clinical specialties at various armed forces postgraduate training institutes.


  Materials and Methods Top


Study design

A cross-sectional survey using a self-administered questionnaire was used to assess the perceived effect on medical training and stress of postgraduate residents of armed forces institutions during the COVID-19 pandemic. An online survey curated to armed forces institutions was designed on Google forms and circulated among the residents of clinical specialties in all the armed forces postgraduate institutions in India. The questionnaire was validated by two independent experts. A pilot test was run by circulating it among 10 subjects. The participants were contacted through “WhatsApp” and “e-mail.” They were encouraged to participate anonymously. Answers to queries regarding the effect on training were obtained in affirmative or negative. Answer to queries regarding the level of stress was obtained as mild, moderate, or severe, as per individual perception, and was not “score” based.

Data collection

The sample for the survey consisted of postgraduate residents of clinical specialties in the institutions of the armed forces across India. It included all categories of students, currently serving defense personnel, ex-servicemen, and civilians undergoing training in general medicine, general surgery, obstetrics and gynecology, pediatrics, ophthalmology, otorhinolaryngology, dermatology, orthopedics, anesthesiology, and psychiatry. A self-administered questionnaire was sent through “Google Forms” to all respondents. The Google Form recorded demographic details such as gender, age, category, specialty, and also involvement in COVID duties.

Statistical analysis

The data were analyzed using the IBM SPSS Statistics 23 for windows (Version 23.0., IBM Corp., NY, USA). Chi-square test was used to study the association between baseline variables such as age, gender, and specialty and perceived effect on training and stress levels. A P < 0.05 was considered to be statistically significant.

Ethical considerations

Ethical clearance was obtained from the institutional ethics committee.


  Results Top


We received a total of 275 responses. Out of these, 09 were removed due to incomplete responses and 266 were analyzed. Demographic characteristics are given in [Table 1]. One hundred and ninety (71%) participants responded that they had been posted for COVID duties. Among the participants, 208 were male (78%) and 58 were female (22%). Maximum (176) participants were in the 28–35 years of age group (66.2%), 82 participants in the > 35-year age group (30.8%), and 8 participants in the 23–28-year age group (3%). Of the total participants, 210 (79%) were serving candidates and 56 (21%) were ex-servicemen/civilian candidates. 134 (50%) of the participants were in the 3rd year of residency, 94 (35%) were in the 2nd year, and 38 (15%) were in the 1st year. 158 (59%) participants were doing a residency in medicine and allied subjects, and 108 (41%) were in surgery and allied subjects.
Table 1: Demographic profile of study participants who responded to survey questionnaire

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A large proportion of participants across all variables agreed that their surgical/procedure-related training, bedside/clinical training, and theoretical training were affected in view of the COVID-19 scenario [Table 2]. 87% of residents felt that their surgical/procedure-related training was affected. Bedside/clinical training was found to be affected by 92% of residents and theoretical learning was perceived to be affected by 78%. The training was perceived to be affected irrespective of posting on COVID duties; 89.5% of those not posted on COVID duties versus 86.3% of those posted on COVID duties perceived that their surgical training was affected (P = 0.622); similarly, 89.5% of those not posted on COVID duties versus 93.7% of those posted on COVID duties perceived that their clinical/bedside training was affected (P = 0.405) and 73.7% of those not posted on COVID duties versus 80% of those posted on COVID duties perceived that their theoretical training was affected (P = 0.426).
Table 2: Descriptive variables and their association with effect of COVID-19 pandemic on postgraduate training

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When gender, age group of the participant, and category of participant (i.e., serving vs. ex-servicemen and civilian residents) were considered, the responses were not significantly different between the groups. A statistically significant difference was found in the proportion of residents in medical and allied specialties, as compared to residents in surgery and allied specialties (81% vs. 96.3%) with regard to the negative effect of the COVID-19 pandemic on surgical/procedural skills training (P = 0.01). Analysis of the data did not reveal any significant difference in the likelihood of being posted for COVID duties based on age, category, or, specialty but there was a significant difference based on gender (P = 0.01) and year of the course (P = 0.004) [Table 3].
Table 3: Demographic variables and their association with likelihood of being posted on COVID duties

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Of the respondents 37% said that they experienced only mildly increased stress levels, 49% had moderately increased stress levels and 14% had severely increased stress levels [Table 4]. Similarly, to the query about family's stress during the COVID-19 pandemic 18% responded that the level of stress was mild, 52% responded as the stress was moderate, and 30% responded it was severe. Gender, age, category, year of residency, or subject of specialization did not have any significant effect on the level of personal or family stress. 25.6% were in an unhappy state of mind, 36.1% were happy, and 38.3% were not sure but 70% of participants felt that the pandemic caused a significant effect on their routine. 87% responded that Personal Protective Equipment supply was adequate and 13% responded negatively. Although overall stress levels were independent of being posted or not on COVID duties, higher severe stress levels were found among those who were posted for these duties.
Table 4: Descriptive variables and their association with effect of COVID-19 pandemic on stress levels of postgraduate trainees and their families

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On inquiry about the utility of webinars, 24.1% found them to be very useful, 65.4% found them moderately useful, and 10.5% thought it was a waste of time. Respondents' break up of time spent on daily activities is depicted in [Figure 1]. 75% responded that they had been using the internet effectively for studies.
Figure 1: Time spent on daily activities, X-axis - Type of activity, Y- axis – Number of respondents

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  Discussion Top


This study was carried out using self-administered questionnaires on postgraduate trainee doctors undergoing training in various clinical specialties in all the armed forces institutions. This study brings forth the likely deficiency in essential skill development resulting from a lack of opportunities for patient interactions as well as face-to-face interaction with teachers. It also highlights stress experienced during the situation which could be a combined effect of the fear of the disease itself as well as the cost it is exacting out of the precious training time. In our study, we found that nearly 80% of the trainees felt that the COVID-19 lockdown had negatively impacted their surgical training. Ninety-two percent of respondents felt that their bedside training was affected and 78% felt the classroom teaching also suffered. In an online survey[1] on trainee ophthalmologists across India, similar results were encountered where they found that nearly 80.7% were dissatisfied with their surgical training, but only 47% felt that their theoretical learning was compromised as opposed to 78% in our study. In our study, we found that 71% of responders had been posted for COVID duties whereas in the survey on trainee ophthalmologists,[1] it was found that only about 24.6% of the trainees had been deployed on “COVID-19 screening'” duties. This could be the reason for a higher percentage of dissatisfaction in theoretical learning in our survey as being posted on COVID duties means missing out on many class activities.

Similar experiences were encountered in the severe acute respiratory syndrome (SARS) outbreak of 2003 as well. In March 2003, the SARS outbreak led to the suspension of clinical teaching in the medical colleges in Hong Kong[2] and a month later in Toronto.[3] On March 17, 2020, the Association of American Medical Colleges issued an advisory to temporarily suspend clinical rotations due to the COVID-19 pandemic.[4]

Prolonged conflict or instability also leads to a breakdown in civic activity leading to delay and disturbances in education. These issues have been reported in several conflicted regions including Croatia[5],[6] and Liberia.[7] In a survey on students and medical institutions in Iraq, Ashton Barnett-Vanes found that 50% of medical schools felt the quality of training medical schools could offer had been impaired or significantly impaired due to conflict and 62% of medical students responded they felt their safety had been threatened due to violent insecurity.[8] However, solutions need to be brought like in conflict-ridden Syria, to tide over the crisis. Syrian Board of Medical Specialties was set up in mid-2015 with the aim of providing certification for the completion of specialty training after a review of applicants' experience and success at standardized examinations.[9]

Medical education has always been imparted through face-to-face interaction with patients and faculty. However, opportunity being sparse for such interactions does not mean compromising the educational experience. Implementation of teleconsultation would allow for many meaningful clinical interactions. Virtual patients may also have potential in that they help improve communication skills. Real cases should be assessed with help of pictures and video-conferencing. Video demonstration, webinars, virtual CME programs, podcasts, and E-mail-based clinical vignettes can go a long way in bridging the gaps and they have been proven to be at least noninferior to face-to-face interaction.[10] Although a multitude of webinars became available with the onset of lockdown, it was found very useful by only 24.1% of respondents in our study. The reason could be that these talks were on a variety of topics that are not structured or based on any university syllabus as required by the trainees. There is a need for centralized syllabus-based online teaching and demonstration programs for better training.

Simulation-based surgical training can be made available in all training institutions. Various simulators are available for most of the specialties such as laparoscopy trainers, bronchoscopy/endoscopy trainers, cataract surgery simulators, and airway and laryngoscopy simulators, and many institutions have been using these to continue training in the present situation but their utilization is not being done to the optimum level. These simulators can be of great help in the present situation where patient interaction is limited. In fact, the surgical simulator-based training should be continued even after the pandemic is over and should ideally be made mandatory before attempting procedures on patients. It will not only help in reducing complications but also build up the confidence of trainee doctors.

With uncertainties ahead, stress and resultant psychosocial problems are expected. In our survey among resident doctors, the majority perceived a moderate increase in the level of stress during the present pandemic and it did not correlate with any other variables such as age, year of residency, gender, category of respondents, specialty subject, but severely increased stress levels were higher in those posted for COVID duties. The increase in the level of family stress also showed a similar orientation. It is possible that the responses regarding family stress may not have been in consultation with family members and hence not a true representation of the level of stress. In their survey among armed forces doctors for the prevalence of anxiety and depressive symptoms, Gupta et al. found anxiety and depressive symptoms were seen in 35.2% and 28.2% of the doctors, respectively. In doctors with depressive symptoms, significant associations were observed with age, and duration of service. In doctors with anxiety symptoms, significant associations were observed with age, gender, and duration of service.[11] This pandemic situation and resultant stress call for a support system, in which residents should be encouraged to speak up and a faculty with social skills be appointed as a mentor. The “social support group” should be made a mandatory requirement in all institutions.

The limitation of this survey is that it is a cross-sectional survey among residents of armed forces institutes only and the responses may not be a true representation of all populations. The varied requirements and expectations among specialties cannot be equated; the survey did not analyze the differences.


  Conclusion Top


This survey brings out the dissatisfaction faced by the trainees in various aspects of their training. We as educators need to evolve more innovative methods of distant learning which could possibly come as close as possible to actual teaching sessions while we tide over the situation and also have a plan in place to fill in the gaps in clinical and surgical training as soon as the situation is under control. We should learn from the present experience and formulate a strong and reliable contingency plan for any such occurrences in the future.

Financial support and sponsorship

None.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Mishra D, Nair AG, Gandhi RA, Gogate PJ, Mathur S, Bhushan P, et al. The impact of COVID-19 related lockdown on ophthalmology training programs in India – Outcomes of a survey. Indian J Ophthalmol 2020;68:999-1004.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Patil NG, Chan Y, Yan H. SARS and its effect on medical education in Hong Kong. Med Educ 2003;37:1127-8.  Back to cited text no. 2
    
3.
Clark J. Fear of SARS thwarts medical education in Toronto. BMJ 2003;326:784.  Back to cited text no. 3
    
4.
Important Guidance for Medical Students on Clinical Rotations During the Coronavirus (COVID-19) Outbreak AAMC. Available from: https://www.aamc.org/news-insights/pressreleases/important-guidance-medical-students-clinicalrotations-during-coronavirus-covid-19-outbreak. [Last accessed on 2020 May 13].  Back to cited text no. 4
    
5.
Marusic M. War and medical education in Croatia. Acad Med 1994;69:111-3.  Back to cited text no. 5
    
6.
Marusic A, Marusic M. Clinical teaching in a time of war. Clin Teach 2004;1:19-22.  Back to cited text no. 6
    
7.
Challoner KR, Forget N. Effect of civil war on medical education in Liberia. Int J Emerg Med 2011;4:6.  Back to cited text no. 7
    
8.
Barnett-Vanes A, Hassounah S, Shawki M, Ismail OA, Fung C, Kedia T, et al. Impact of conflict on medical education: A cross-sectional survey of students and institutions in Iraq. BMJ Open 2016;6:e010460.  Back to cited text no. 8
    
9.
Bdaiwi Y, Rayes D, Sabouni A, Murad L, Fouad F, Zakaria W, et al. Challenges of providing healthcare worker education and training in protracted conflict: A focus on non-government controlled areas in north west Syria. Confl Health 2020;14:42.  Back to cited text no. 9
    
10.
Chipps J, Brysiewicz P, Mars M. A systematic review of the effectiveness of videoconference-based tele-education for medical and nursing education. Worldviews Evid Based Nurs 2012;9:78-87.  Back to cited text no. 10
    
11.
Gupta S, Kohli K, Padmakumari P, Dixit PK, Prasad AS, Chakravarthy BS, et al. Psychological health among armed forces doctors during COVID-19 pandemic in India. Indian J Psychol Med 2020;42:374-8.  Back to cited text no. 11
    

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Correspondence Address:
Debasish Mahapatra,
7 Air Force Hospital, Kanpur, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/injms.injms_64_22



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