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Canadian ophthalmology resident experience during the COVID-19 pandemic

Published:October 26, 2020DOI:https://doi.org/10.1016/j.jcjo.2020.10.015
      The ongoing worldwide pandemic of coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has greatly affected our lives. At the time of writing this report, there have been 18 166 298 confirmed cases and 690 953 deaths worldwide owing to SARS-CoV-2, with 118 966 cases and 8995 deaths in Canada.

      COVID-19 Dashboard by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University (JHU). https://coronavirus.jhu.edu/map.html. Published 2020. [Accessed August 3, 2020].

      During the height of the pandemic in Canada, from March to June 2020, the federal government initiated policies and procedures to limit the spread of SARS-CoV-2, such as restricting travel, encouraging the use of face masks in public areas, and providing financial benefits for those unable to work.

      Vogel L. COVID-19: A timeline of Canada's first-wave response. https://cmajnews.com/2020/06/12/coronavirus-1095847/. Published 2020. Accessed [August 3, 2020].

      Only persons providing essential services (i.e., health care workers, police, firefighters) continued to actively work in the field, often in challenging conditions, and at risk to themselves and their families.
      Resident physicians specializing in ophthalmology were among the health care workers on the front lines, but with a shift in practice patterns owing to a reduction in ambulatory clinics, the shutdown of elective surgeries, and the transitioning from in-person group teaching to online formats. To our knowledge, there has not been a formal assessment of the impact of the pandemic on ophthalmology residents. The purpose of this study was to provide an overview of this impact on ophthalmology residents across Canada, from the resident perspective.
      A cross-sectional survey study was conducted. All ophthalmology residents in Canada (N = 217) were emailed a short, anonymous survey (Google Forms), from May 6 to June 13, 2020.
      The survey was created to assess the ophthalmology resident experience during the COVID-19 pandemic. Themes included the availability/use of personal protective equipment (PPE), testing for the SARS-CoV-2 virus among residents, status of medical and surgical rotations, stressors related to the pandemic, coping strategies, and attitudes of residents regarding COVD-19. This survey was reviewed by 2 academic ophthalmologists and 2 senior ophthalmology residents. In our literature review, there were no similar, validated studies on this subject matter.
      Survey data were exported to Microsoft Excel 2013 (Redmond, WA). All descriptive statistics were performed using Microsoft Excel.
      Of 217 residents, 102 (47.0%) responded to the survey, representing residents from all 15 residency programs in Canada. Residents from all 5 years of training were equally represented. There was a greater proportion of residents from larger programs (>20 residents) who responded (>20 residents 37.3%, 11–15 residents 28.4%). Table 1 summarizes the survey findings.
      Table 1Survey results of the resident experience during the COVID-19 pandemic in Canadian ophthalmology residency programs
      QuestionResidents, n%
      1. Which postgraduate year are you enrolled in? (n = 102)
      • PGY11817.6
      • PGY22625.5
      • PGY31615.7
      • PGY42726.5
      • PGY51514.7
      2. How do you identify your gender? (n = 102)
      • Male5150.0
      • Female5049.0
      • Prefer not to answer11.0
      3. How many residents are in your residency program? (n = 102)
      • 5 or less1312.7
      • 6–101716.7
      • 11–152928.4
      • 16–2054.9
      • More than 203837.3
      4. Was there an outbreak of SARS-CoV-2 in your ophthalmology department? (i.e., confirmed positive case among staff/patient that resulted in other positive cases or preventative quarantines) (n = 102)
      • Yes2726.5
      • No7573.5
      5. Have you been tested for SARS-CoV-2 in the past 4 months? (n = 102)
      • Yes3231.4
      • No7068.6
      6. If you answered yes to the above question, did you test positive? (n = 32)
      • Yes13.1
      • No3196.9
      7. Is there an adequate supply of PPE in your ophthalmology department for staff? (n = 102)
      • Yes9593.1
      • No76.9
      8. Are all patients wearing masks in clinic? (n = 102)
      • Yes6866.7
      • No3433.3
      9. What PPE do you use to examine asymptomatic patients? (n = 101)
      • Gloves + face-shield/goggles + surgical mask3534.3
      • Face-shield/goggles + surgical mask2524.5
      • Gloves + surgical mask1817.6
      • Gloves + gown + face-shield/goggles + surgical mask1211.8
      • Surgical mask only1110.8
      10. What PPE do you use to examine symptomatic patients? (n = 99)
      • Gloves + gown + face-shield/goggles + N95 or equivalent filtering system4241.2
      • Gloves + gown + face-shield/goggles + surgical mask4241.2
      • Gloves + face-shield/goggles + surgical mask65.9
      • Face-shield/goggles + surgical mask32.9
      • Have not examined symptomatic patients43.9
      • Gloves + surgical mask11.0
      • Surgical mask only11.0
      11. Have you examined a patient who was confirmed positive for SARS-CoV-2? (n = 102)
      • Yes2019.6
      • No8280.4
      12. For residents on surgical rotations, have you operated in the past 2 weeks? (n = 81)
      • Yes2834.6
      • No5365.4
      13. For residents on clinical rotations, what is the current status of clinical rotations at your hospital? (n = 96)
      • Residents returned to subspecialty clinic/scheduled rotation, reduced volume5251.0
      • All residents emergency care only (red eye clinic), working in shifts (i.e., 1 week on, 1 week off)2928.4
      • All residents on emergency care only (red eye clinic), working full time87.8
      • Residents returned to subspecialty clinic/scheduled rotation, full volume54.9
      • Residents are not seeing patients22.0
      14. Have you worked in a COVID unit in the past 2 months? (n = 102)
      • Yes54.9
      • No9795.1
      15. I am worried about catching SARS-CoV-2. (n = 102)
      • Strongly agree98.8
      • Agree4948.0
      • Neutral2726.5
      • Disagree1514.7
      • Strongly disagree22.0
      16. I am worried about spreading SARS-CoV-2 to my family/friends. (n = 102)
      • Strongly agree4342.2
      • Agree4544.1
      • Neutral76.9
      • Disagree43.9
      • Strongly disagree32.9
      17. I am worried about spreading SARS-CoV-2 to my patients. (n = 102)
      • Strongly agree2827.5
      • Agree4847.1
      • Neutral1514.7
      • Disagree87.8
      • Strongly disagree32.9
      18. I feel isolated owing to social distancing measures. (n = 102)
      • Strongly agree1413.7
      • Agree4039.2
      • Neutral2827.5
      • Disagree1514.7
      • Strongly disagree54.9
      19. My level of anxiety has been higher during the past 2 months (owing to changes related to COVID-19) compared with before the pandemic. (n = 102)
      • Strongly agree54.9
      • Agree5352.0
      • Neutral87.8
      • Disagree1817.6
      • Strongly disagree1817.6
      20. I have done the following to cope with stress owing to the pandemic. (Please check all that apply)
      • No change109.8
      • Speak regularly with family and close friends6967.6
      • Cook6664.7
      • Exercise regularly6159.8
      • Spend time outside5553.9
      • Attend “Zoom parties”3938.2
      • Increase alcohol intake1514.7
      • Speak to a therapist/counsellor98.8
      • Use sleeping aids54.9
      • Speak to a religious figure22.0
      • Start prescription medications or modify existing medications11.0
      • Other: Using phone less (n = 1), spending time with dog (n = 1), recreational activities (n = 1), spending time with kids (n = 1), regular Zoom teaching webinars (n = 1), substance use (n = 1)
      21. How are you keeping up your clinical skills? (Check all that apply)
      • Reading American Academy of Ophthalmology Basic and Clinical Science Course Manuals7977.5
      • Seeing patients in clinic7775.5
      • Webinars7270.6
      • Journal articles/research4948.0
      • None of the above00.0
      22. How are you keeping up your surgical skills?
      • I have not had access to any of the above5251.0
      • Actual cases in the operating room2120.6
      • Surgical simulator (Eyesi)2019.6
      • Practice in wet lab1918.6
      • Other: Does not apply to me (n = 2), YouTube videos (n = 1), not doing anything (n = 1)
      23. I worry that my clinical skills will deteriorate owing to the shutdown.
      • Strongly agree22.0
      • Agree3231.4
      • Neutral2827.5
      • Disagree2827.5
      • Strongly disagree1211.8
      24. I worry that my surgical skills will deteriorate owing to the shutdown.
      • Strongly agree2423.5
      • Agree3433.3
      • Neutral1918.6
      • Disagree98.8
      • Strongly disagree00.0
      • Not applicable1615.7
      25. For senior residents: I am worried about finding a job/fellowship owing to COVID-related shutdowns.
      • Strongly agree1834.6
      • Agree1426.9
      • Neutral1223.1
      • Disagree815.4
      • Strongly disagree00.0
      26. I will get sufficient training to become a competent ophthalmologist by the end of my residency.
      • Strongly agree2827.5
      • Agree5654.9
      • Neutral1211.8
      • Disagree32.9
      • Strongly disagree32.9
      27. I am concerned that I will have to repeat rotations owing to lost time during the pandemic.
      • Strongly agree54.9
      • Agree2726.5
      • Neutral2524.5
      • Disagree3736.3
      • Strongly disagree76.9
      28. I expect that clinical and surgical volumes will be significantly increased by the end of summer, to the point where lack of exposure will not affect my training.
      • Strongly agree109.8
      • Agree3433.3
      • Neutral2423.5
      • Disagree2726.5
      • Strongly disagree76.9
      PPE, personal protective equipment.
      There were 32 residents (31.4%) who were tested for SARS-CoV-2 during the 4 months of the study, of whom only 1 tested positive (1.0%). There were 20 residents (19.6%) who examined patients confirmed positive for SARS-CoV-2. Outbreaks of SARS-CoV-2 that resulted in other positive cases or preventative quarantines were present in the departments of 27 residents (26.5%). A small proportion of residents (4.9%) were assigned to work in a COVID unit for up to 1 month.
      Most residents (93.0%) felt that they had adequate access to PPE. When examining symptomatic patients, residents either used gloves, gown, eye protection, and a surgical mask (42.2%) or used gloves, gown, eye protection, and an N95 mask (42.2%).
      As of June 2020, most residents (51.0%) returned to their scheduled rotations, working at reduced volumes. At the time of survey completion, 65% of residents on surgical rotations had not operated in the previous 2 weeks.
      The majority of residents were worried about being infected by SARS-CoV-2 (58% agree/strongly agree). Residents were also concerned about spreading the virus to patients (74% agree/strongly agree), or family and friends (86% agree/strongly agree). Residents felt isolated owing to social distancing measures (53% agree/strongly agree). Most residents had increased anxiety compared with before the pandemic (70% agree/strongly agree).
      Furthermore, residents were concerned about their surgical skills deteriorating owing to the shutdowns (55% agree/strongly agree) but were less worried about losing clinical skills (43% agree/strongly agree). Most residents (51%) stated that they did not have access to a surgical simulator or wet lab to maintain their skills in the operating room. Senior residents were concerned about finding jobs and fellowships owing to COVID-19 (62% agree/strongly agree).
      The majority of residents felt that they would receive sufficient training to become a competent ophthalmologist by the end of their residency (83% agree/strongly agree).
      Residents had mostly positive coping strategies for their stress during the pandemic, including speaking regularly with family and close friends (69%), cooking (65%), exercising (60%), and spending time outside (54%). Negative coping strategies included increased alcohol intake (15%), use of sleeping aids (5%), and use of other substances (1%).
      This survey revealed that a small proportion of residents were physically affected by SARS-CoV-2. A small proportion of residents were tested (31%), and only 1% of residents surveyed were confirmed positive for COVID-19. Reasons for this may be related to adequate availability/use of PPE as well as a low rate of examining COVID-19 positive/symptomatic patients. Despite the low prevalence of infection among residents, levels of anxiety were higher compared with before the pandemic. This is likely multifactorial and included anxiety related to contracting the virus, spreading it to family/friends, isolation owing to social distancing, and increased burden of working with PPE. Senior residents were the most affected by the pandemic, owing to reduction in surgical exposure caused by shutdowns in elective surgery, the travel restrictions for international fellowships, job stress, and the postponed Royal College examinations. Importantly, most residents stated that they did not have adequate availability of surgical simulation or access to a wet lab to maintain their surgical skills. We recommend that this should be rapidly explored further by individual programs and rectified given the indeterminate timeline of the pandemic.
      Thankfully, despite the added stressors and changes brought by the pandemic, there was guarded optimism among residents, with the feeling that they would have adequate training and be competent ophthalmologists by the end of their residency.
      The 47.0% response rate, although high for national resident surveys,
      • Tran E.M.
      • Scott I.U.
      • Clark M.A.
      • Greenberg P.B.
      Resident wellness in US ophthalmic graduate medical education the resident perspective.
      ,
      • Shah M.
      • Johns M.
      • Statham M.
      • Klein A.
      Assessment of phonomicrosurgical training in otolaryngology residencies: a resident survey.
      represents half of all residents, which limits generalizability of the results. As with most survey studies, information is subject to recall bias. There was more representation from larger programs in cities that had a larger prevalence of COVID-19.

      Footnotes and Disclosure

      We thank Dr. Majd Mustafa and Dr. Irfan Kherani for their help with survey review and distribution.
      The authors have no proprietary or commercial interest in any materials discussed in this article.

      References

      1. COVID-19 Dashboard by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University (JHU). https://coronavirus.jhu.edu/map.html. Published 2020. [Accessed August 3, 2020].

      2. Vogel L. COVID-19: A timeline of Canada's first-wave response. https://cmajnews.com/2020/06/12/coronavirus-1095847/. Published 2020. Accessed [August 3, 2020].

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