The coronavirus disease 2019 (COVID-19) was first reported in Wuhan, China in late 2019. On March 11, 2020, the World Health Organization (WHO) characterized COVID-19 as a pandemic. The first confirmed case of COVID-19 in Algeria was reported on February 25, 2020. Algiers, the capital, is the most severely affected city by this crisis. The COVID-19 pandemic has placed an important strain on the Algerian health care system1,2. Like most specialties, orthopedic surgery activity has been largely affected. Different measures have been taken. Elective, nonurgent surgical cases have been postponed or cancelled. In addition, many orthopedic departments have redeployed their staff to intensive care units3.
The rapid evolution of this global crisis has disrupted personal and professional life of health workers, including that of orthopedic surgery residents4.
Medical education has been negatively impacted. While students were taken out of clinical rotations to protect them from the risk of exposure to COVID-19, residents, who play a major role in providing health care in Algerian’s university hospitals, have had to continue working. In addition to their effective participation in maintaining the continuity of health care and ensuring the protection of medical staff and patients, some orthopedic departments have redeployed residents to assist in caring for COVID-positive patients in intensive care units.
From an educational standpoint, teaching conferences for residents have been suspended. Grand rounds and in-person meetings have also been cancelled to comply with social distancing recommendations3. Those of us at teaching hospitals had to balance priorities and demands between patient care and resident education.
The aim of this study is to assess the impact of the COVID-19 pandemic on the orthopedic surgery residents education, clinical practice, and well-being.
Materials and methods
We developed an online, anonymous web-based survey. A 22-question cross-sectional survey (Table 1) was shared with residents in orthopedic surgery of 6 teaching hospitals in Algiers (Algeria), through multiple social media groups and platforms. The questionnaire was designed to assess the impact of the COVID-19 pandemic on the activities and education of Algerian residents in orthopedic surgery.
The study was conducted between July 13th, 2020 and July 20th, 2020 (7 d).
We shared the online questionnaire and collected relevant data. Clicking on the link and submitting the survey responses implied consent to participate. Results were exported to Microsoft Excel version 2010 for analysis. This work has been reported in line with the standards for reporting qualitative research5.
The survey included different sections. The first one included demographic factors (age and sex) and year of residency. Then, we asked residents about their experience of care for COVID-19 positive patients and their motivation to work in COVID-19 units. They were also interrogated if they had reported symptoms or had suspected a COVID-19 infection and what were the measures taken about that. They were also asked to report the level of personal protection at work. The respondents were required to report the impact of the pandemic on their theoretical and practical training and education. Finally, the respondents were asked about the impact of this global crisis on their well-being and mental health.
Fifty-eight from the 236 (24,57%) postgraduate residents in orthopedic surgery practicing at the 6 teaching hospitals of the city of Algiers (Algeria) participated to the study. The mean age was 29.9 years (range: 26–38 y).
In all, 44 (76%) were male and 14 (24%) were female. The proportion of respondents in each year of residency ranged from 17% to 34% (Fig. 1)6. Fifty-one of the residents asked (88%) declared have been in contact with and 23 (40%) have operated on a COVID-19-positive patient, respectively (Fig. 2).
We reported that 32 (54%) of the residents asked had been posted on COVID units for screening and patients care. Twenty-seven of trainees asked felt they are competent to take responsibility for the care of the COVID-19 patients. Seventy-one percent of them declared their willingness to work and help in intensive care units if needed.
From our study, only 1 resident tested positive for COVID-19. Furthermore, about 26% were negative, and the remaining 72%, who represent the majority, were not tested for the infection (Fig. 3). The resident who had a positive COVID-19 polymerase chain reaction (PCR) test have undergone a self-isolation.
When asked if the personal protective equipment (PPE) provided by their hospitals were adequate, 51 (88%) confirmed that it was not adequate. In addition, 90% of the participants referred a lack of training regarding the use of PPE and 74% indicated that the orthopedic surgery training program should include a session about PPE every year (Fig. 4)7,8.
Almost all residents found that their orthopedic surgery education at the hospital was affected. The trainees were asked if the actual crisis had a negative impact on their theoretical and surgical training; a large majority (95% and 97%, respectively) agreed (Fig. 5). Thus, 26 (45%) residents had more time for research work and study.
This pandemic affected the mental health of 93% of the participants (Fig. 6). As regards the feeling about infectious risks, 41% of participants referred to be afraid of getting infected, whereas the fear of infecting their family members was higher (90%) (Fig. 7).
The aim of this study is to evaluate the impact of the COVID-19 outbreak on the current activities and education of Algerian orthopedic surgery residents. All the residency years were represented, ranging from 17% to 34%6. As their counterparts in other specialties, orthopedic surgery residents are on the frontlines of COVID-19 patients’ care during this pandemic1. The majority of participants have already dealt and treated on patients COVID-19 positive. As a consequence of the increase in the number of COVID-19 positive or suspected patients, many orthopedic residents have been redeployed and posted on intensive care and COVID-19 units2,4,7. Even if the redeployment of residents was mandatory, a high number of them expressed their responsibility and willingness to work outside their specialty and provide support in intensive care and COVID-19 units. It is necessary for medical attendings and hospital administrators be keep in touch with residents and inquire what resources are needed to help them to accomplish their hard work in the best conditions. A special attention should also be paid to their food subsidy, transport and special lodging for self-quarantine. Keeping this sense of support will encourage our valorous residents and will make redeployment feeling more voluntary than mandatory2. In addition, Working temporarily in the ICU will provide residents with additional practical experience that will benefit residents4.
Half of participants have reported symptoms suspecting a COVID-19 infection. Only 1 trainee declared have been tested positive for COVID-19 and was self-isolated. Although, this must be interpreted in the special context of difficulty to access and limited availability of testing. In our study, more than two-thirds of the respondents were not tested. There is a real need for a periodic screening of health workers in our health institutions8.
Another crucial concern for residents is availability of PPE9.
Alarmingly, the majority of trainees asked, felt that the PPE provided by their institution was inadequate and deplored the lack of training on the use of the PPE7.
We know that the availability of PPE is crucial to protect health workers during this global crisis8. With the increasing number of COVID-19 cases, it is essential that appropriate PPE should be easily available for all medical staff.
Our study was carried out 5 months after the declaration of the first positive COVID-19 case in Algeria. Our results show an inadequate adaptation to this pandemic. Access to and training on proper PPE use must be a priority for administrators of all the health institutions of the country. In the future, residency programs should involve a session about the use of PPE every year4.
Medical education has been negatively impacted during this crisis. All teaching conferences for residents have been suspended. In-person didactics have also been cancelled. As a part of teaching hospitals, we must balance priorities between patient care and resident education. The education program should be quickly adopted7,9.
Teaching conferences, unit-based educational activities, and surgical hands-on training are key components of resident education7. Orthopedic surgery institutions and societies must propose news ways and methods to adapt training programs for residents10. It is evident that the significant decrease in elective surgeries have negative effects on residency surgical education11. As a consequence, most orthopedic residents will not be able to perform the number of surgeries per year required for their program. The impact will obviously be greatest for residents in their final or penultimate years of training7. Extending the training period can be a solution to address the training gap8.
The extent of this health crisis provides us an opportune time to consider the use of new technological methods for teaching residents. This includes the adoption of teleconferencing solutions to allow residents to be transitioned from an in-person program to a videoconferencing system3,11–13. During this crisis period, a high number of webinars were organized across the world. Algerian residents have benefited from the high quality of this new learning method to keep in touch with medical education. Such initiatives are appreciated and compensate a little bit the incomprehensive lack of conferences and webinars organized by the medicine faculties and also by the Algerian society of orthopedic surgery. However, we would like to report the excellent initiative of the Algerian Orthopedic Club (AOC), a group of young Algerian orthopedic surgeons who have organized high level webinars during this pandemic period. These webinars dealing with various pathologies in the field of orthopedic surgery were given by international world-renowned speakers, who responded favorably to the invitation of the AOC. These webinars organized weekly and hosted on the GoToMeeting (LogMeIn, Boston, MA) online platform, were very beneficial for the Algerian orthopedic community and really appreciated by the residents. This initiative is to be encouraged but remains insufficient. We hope that the faculties of medicine and orthopedic societies will get involved and proposed a new resident training program using the new technological methods (webinars, videoconferences), easily accessible permitting to keep in touch without compromising the safety of teachers and trainees. The creation of an online library that can be accessed anytime can also be benefit in this time of crisis7. The advantage with surgical activity decreasing is that most residents got enough time to devote to study and research projects9.
Once this crisis is over, a careful analysis of the impact of this pandemic on residents’ education will be necessary to adapt and prepare for any new crisis in the future4.
The mental health of the majority of residents asked has been affected during the COVID-19 pandemic.
This survey highlights the fear of trainees to be infected or to infect family members and relatives9. This significant risk is mainly related to the lack of EPP14. This unprecedented situation has generated anxiety and higher stress levels among health care workers7. Measures to reduce the psychological impact of this crisis on residents and health care workers must be rapidly instituted8. It is important to maintain communication between the residents and institution to enquire about all the needed resources especially concerning the PPE15. It is important for the morale of the residents to feel surrounded and helped by their elders and by their institutions. They must be considered as an important part of the greater medical community.
Our study has several strengths: to our knowledge it is the first report describing the impact of the COVID-19 pandemic on orthopedic surgery residents in Africa.
Second, we emphasized the negative impact on the theoretical and surgical training of residents and the need to find quick solutions to this issue. We hope that the findings of our study will be considered by medical faculties and the national society of orthopedic surgery in order to find solutions to this unprecedented challenge8.
Furthermore, our study provides a timely prospective, as it was conducted during a critical period of the pandemic in Algeria2.
On the other hand, this study has a number of limitations. First, a higher response rate to the questionnaire would have certainly benefited the study. Second, the survey questions are not standardized and due to the changes and unpredictable evolution of this, it was not possible for us to use validated questionnaires or to use questions with prevalidated scales8. Third, regarding residency program, it is difficult to quantify the training gap and it is impossible to predict how long this crisis may last1. In addition, the data collected are subjective and represent perceptions of orthopedic surgery residents asked. Furthermore, results potentially related to COVID-19 testing should be interpreted with caution.
The COVID-19 crisis led to a significant training gap due to the reduced volume of orthopedic activities and deployment of residents in intensive care and COVID-19 units.
Given the unpredictable evolution of this pandemic, urgent measures must be taken to face this unprecedented challenge and ensure the continuity of training for our residents.
History will remember that these residents were not only trained as orthopedic surgeons but have been brave doctors who contributed effectively in the fight against this global pandemic.
Sources of funding
The authors received no external funding for this research.
N.M.: participated in research design, data collection, data analysis or interpretation, drafting and writing the paper. M.D., R.N., R.B., S.B., and Z.K.: participated in the performance of the research.
Conflicts of interest disclosure
The authors declare that they have no financial conflict of interest with regard to the content of this report.
Research registration unique identifying number (UIN)
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