On February 24, 2022, the full-scale Russian invasion of Ukraine began. This day dramatically changed the lives of the 44 million people living in Ukraine. Ukrainians made significant sacrifices to survive, protect their families, and help their country. One of the heaviest burdens fell on the physicians and other health care professionals. As of July 24, 2022, according to Viktor Liashko, the Minister of Health care of Ukraine, “…almost 900 health care facilities were damaged, including 127 completely destroyed hospitals…” (https://glavcom.ua/country/health/lyashko-nazvav-kilkist-medichnih-zakladiv-zruynovanih-okupantami-862764.html, https://jamanetwork.com/journals/jama/article-abstract/2790921, https://www.who.int/news/item/07-04-2022-who-records-100th-attack-on-health-care-in-ukraine, https://www.grid.news/story/global/2022/07/28/the-ukraine-war-in-data-869-attacks-on-healthcare-facilities/) The war caused radical changes in the education of residents in Ukraine (https://moz.gov.ua/uploads/7/39132-dn_1327_27_07_2022.pdf). We describe the war’s impact on the training of resident surgeons at 1 academic medical center.
The Shalimov National Institute of Surgery and Transplantology is a tertiary care academic center located in Kyiv, Ukraine. It is a referral hospital for patients throughout Ukraine and hosts the top general surgery residency program in the country. General surgery residency training in Ukraine lasts 3 years (https://ieu.edu.ua/docs/ospage/surgery.pdf). With their permission, we share the experiences and perspectives of 6 of the 75 PGY 1-3 trainees at the Shalimov Institute. Though only a few residents shared their stories, these narratives represent a broad range of experiences and perspectives that reflect the impact of the war on the training of surgical residents at our institution. Narratives were collected through interviews and edited for length and clarity.
RESIDENT NARRATIVES
On the first day of the war, N.F., PGY2, went to the hospital and waited for the wounded, who never came. After 2 days, she decided that she would better serve her country in the Territorial Defense Forces as a physician. Later, she joined the Armed Forces of Ukraine, where she continues to work as a junior lieutenant of the medical service, with 47 people under her command. N.F. is currently coordinating the procurement and delivery of medications for the division. She directs the evacuation of patients from the front lines, and she leads the organization for training young soldiers in tactical medicine. N.F. plans to continue her general surgery training after the war.
D.Z., PGY2, spent the first 2 months of the war at the Shalimov Institute. He also continued part-time work as a paramedic. Three ambulances in his fleet were shot by Russian soldiers near Kyiv. D.Z. wanted to gain experience as a military surgeon, so he joined the Volunteer Mobile Hospital on the front lines. On the second day of his service in Slavyansk (https://www.nytimes.com/2022/06/01/world/europe/ukraine-russia-losses-east.html), a Russian rocket fell 200 meters from the hospital and hit a residential building. This was the first case of mass casualty in D.Z.’s practice. He took care of a great number of trauma patients and, out of necessity, functioned autonomously above his level of training. After a month of work and many days without electricity or water in the hospital, he took what he learned regarding trauma triage, leadership, and resuscitation and returned to Kyiv to continue his residency.
O.K., PGY3, was on rotation in his hometown in the Chernihiv Oblast, 25 km from the Russian border, when the war started. He woke up to explosions of Russian bombs. On the first day of the war, the Ukrainian army blew up the bridge that connected his city with Kyiv to slow down the advances of the Russian army. A 2-month–long occupation left his hometown with no food or medications, with limited access to electricity, internet, and mobile communications. O.K. and his wife gave up meals, so their child could eat. Despite these challenges, O.K. continued working in the hospital, providing care with limited medical supplies. After 2 months, the Russian Army retreated from the city. In May 2022, O.K. returned to the Shalimov Institute in Kyiv to finish his training and successfully passed his surgical exam in June 2022. He has returned, now as an attending surgeon, to Chernihiv Oblast, to continue serving his hometown in these challenging times.
A.D., PGY3, was on vacation near Bucha when the war began and was evacuated to a small town in the Ternopil region with only a single backpack. He moved into the hospital in this rural area and served as a volunteer surgeon for 2 months. The population increased significantly as a result of the influx of refugees from Eastern Ukraine, with increased operative volume as a result. Patients included local residents, refugees, and soldiers recently evacuated from Kharkiv. Besides A.D., there were only 2 other surgeons staffing this hospital. “Because of the war, many doctors relocated, and there was a time when there were no dentists in the city. A patient came to us with a dental abscess, and we had no experience treating this pathology. I called my friend in Kyiv via video call. He gave me an advice on how to drain the abscess.” A.D. recalls. A.D. realized that in this time of need, he must prepare himself to treat pathologies outside of his standard scope of practice. His experience inspired the creation of the HealUA mobile application, which provides secure peer-to-peer consultations remotely in Ukraine.
After spending several days in the Shalimov Institute, A.R., PGY2 realized that he would be more useful in helping people who were under occupation in Irpin and Bucha. He helped evacuate wounded Ukrainians from these territories. In June 2022, A.R. went to Kramatorsk in Eastern Ukraine as part of a humanitarian group, where he helped evacuate critically wounded soldiers from the front lines to regional and tertiary care hospitals. “I worked as an intensive care nurse while I was studying in medical school. This experience helped me a lot, as 90% of the patients that I evacuated were in shock and intubated. I believe that I am needed here and plan to stay while the war is ongoing. After that, I hope to resume my surgical education.” said A.R.
G.Y., PGY3, was 9 km from the Belarusian border on rotation in her hometown in Zhytomyrska Oblast when the Russian army crossed the border in the first days of the war in preparation to take Kyiv. The city was repeatedly subjected to airstrikes. Residential buildings were damaged. A shell damaged the hemodialysis unit. Ukrainian troops transported both wounded Ukrainian and Russian soldiers to the hospital. “It was really hard for me psychologically to treat Russian soldiers, but the medical oath is sacred, so we just did our job.” G.Y. said.
Program Director and Shalimov Institute Director’s thoughts
Dr Yaroslav Voitiv, Associate Professor of Surgery and General Surgery Program Director, described many changes in surgical residency training as a result of the war: “The educational process was forced to change, and all lectures were conducted in an online format. More lectures about military medicine were added to the schedule. Questions about battlefield surgery were included in the set of questions for the oral surgery exam. Undoubtedly, the nature of surgical pathology has changed significantly since there are more wounded civilians and soldiers. Our residents who study and work in these challenging times face difficulties in education, work, losses, stress, separated families, and difficult logistics, among many other previously unencountered challenges. Difficult times require difficult decisions and shape strong personalities. In such difficult conditions, an individual’s character is inevitably revealed. In my opinion, the main task of postgraduate medical education, in addition to professional knowledge and skills, is the formation of a personality: a physician who is always ready to help.”
“In wartime, it is difficult for our entire country, but we all try to do our duties at the highest level as a soldier, doctor, volunteer, or teacher: this is the key to our victory,” said Dr Oleksandr Usenko, Professor of Surgery, an academician at the National Academy of Medical Sciences of Ukraine and Director of the Shalimov Institute. He fully supports the desire of residents to help their country. Those who wanted to work on the front lines as volunteer surgeons were allowed to go and are awaited back to finish their training.
CONCLUSION
Surgical residents had to interrupt their residency training because of the Russian invasion but found other opportunities to learn and serve their country (Fig. 1). Ukraine needs good doctors more now than ever before, therefore, providing flexible, high-quality postgraduate training, especially for surgeons, is an important part of supporting Ukrainian health care in this crucial time. Free access to online courses and hands-on training, webinars, articles, conferences, and books are small actions that can have an appreciable impact. Observership and training opportunities abroad are also needed. During these challenging times of interrupted education, under the bombs and sirens of war, the medical community worldwide must continue to support Ukrainian health care. Ukrainians feel the support of international allies and are very grateful for the assistance provided. Ukrainian physicians are gaining enormous experience in war trauma at a very high cost, lessons that they will gladly share with the global medical community. Ukrainians stand together as a unified nation to defend our independence with blood and sweat on the battlefield, at the operating table, and in the lecture hall.
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FIGURE 1: Top left: N.F. Top right: this map shows the cities where some residents worked during the war. Left below: Graduating residents. Right below: A.R. stands next to a destroyed Russian tank.
