The COVID-19 pandemic has presented a global challenge to both healthcare delivery and medical education.1 As of December 2020, there had been more than 14 million confirmed COVID-19 cases and 250 thousand deaths in the United States alone.2,3 This crisis has placed an increased strain on an already-saturated care system and therefore, increased pressure on healthcare workers. As hospitals have reorganized care structures in preparation for surges in patient volumes, the resident workforce has been influenced to a particularly powerful and unprecedented extent.
Despite the specialized nature of the care they traditionally provide, orthopaedic surgery residents have not been immune to these changes. Many have been forced to stop elective procedures, halt in-person interaction, and provide direct medical care to patients with COVID-19.4–6 Furthermore, with a total of 179 Accreditation Council for Graduate Medical Education-accredited orthopaedic surgery residency programs, 3,500 resident physicians in-training, and thousands of immediately family members, these effects have been far-reaching.7
In the setting of such drastic changes, the potential for stress, emotional exhaustion, and lack of wellbeing among orthopaedic residents has been high. Moreover, given that an estimated 50% of residents meet criteria for burnout in the absence of a pandemic, efforts to maintain and/or restore orthopaedic resident wellness during these particularly stressful times are especially critical.8,9 Using the largest national survey of orthopaedic residents during COVID-19 to date, the goal of the present study was to assess the perspectives of orthopaedic surgery residents to evaluate (1) what was valued during a particularly stressful event such as a pandemic, (2) strategies that were used to help maintain resident well-being, and (3) expectations on health care delivery roles during an emergency event such as a pandemic. Given the baseline stresses associated with orthopaedic residency, in addition to the possibility of similar events in the future, our aim is to help guide policy makers, program leadership, and residents to better face these challenges moving forward by learning from the current experience.
Study Participants and Survey Distribution
A comprehensive list of publicly available contact information for orthopaedic surgery residency program directors was established through the efforts of the Collaborative Orthopaedic Education Research Group. A voluntary survey was sent to all 179 Accreditation Council for Graduate Medical Education-accredited orthopaedic surgery residency program directors to distribute to their residents. The survey was made available for completion between June 2 and July 9, 2020, to assess period of the first wave of the pandemic. Residents were asked to identify their year of residency as of June 2020, even if the survey was completed in July after the start of the new academic calendar. A reminder e-mail was sent to the program directors after four weeks to maximize participation.
Demographic factors included year of residency, home living situation, and whether their program was located in a COVID-19 hotspot. The term “hotspot” was not explicitly clarified in the survey but is used in accordance with the defining criteria from the Johns Hopkins University COVID-19 Dashboard as a region in which cases and positivity rates increased by 5% or more over the past 14 days, or a positivity rate of 10% or more over a 7-day rolling average.3 Remaining questions focused on issues that may have occurred, program's responses, and expectations of programs during the pandemic. Respondents were also asked to rate their level of concern from 1 (minimum concern) to 5 (maximum concern) regarding a number of key issues. No exclusion criteria exist based on demographics, geography, or other responses.
A priori analyses were done to determine whether responses varied based on year in training and whether the respondent was in a hotspot. For numerical variables, Student t-tests were done on the independent samples. To compare numerical variables by year in residency, a multivariate regression model was used with year as a covariate. Finally, for categorical variables, chi-square tests were used to assess for differences between groups. Statistical significance was set at P < 0.05.
In total, 507 residents completed the survey, of which 75 (14.8%) were women and 432 (85.21%) were men. Respondents were fairly evenly distributed regarding their year of residency training (Table 1). In addition, a near-equal distribution of residents was noted in COVID-19 hotspots (N = 210) and those not in hotspots (N = 228) at the time of survey completion. Finally, 289 (57.0%) respondents reported living with a spouse or child at the time of the pandemic (Table 2).
Table 1 -
Number of Respondents by Level of Training
Table 2 -
Respondent Home Living Situation
|Spouse with children
|Separated with children
Clinical Duties and Personal Protective Equipment
Overall, 85.6% (N = 434) of respondents reported being in a platoon system, meaning some residents worked in the hospital, whereas others remained quarantined at home. In total, 10.85% (N = 55) of respondents reported being deployed to do nonorthopaedic medical care. Junior residents (P < 0.001) and residents in hotspots (P < 0.001) were more likely to be redeployed to provide nonorthopaedic care. Sixty percent (N = 33) of redeployed residents reported that they felt that it was within their job requirements to cover services that put them at risk of contracting the virus so long as adequate personal protective equipment (PPE) was available (Table 3). This response did not differ by class (P = 0.347). Despite this attitude, 27.8% (N = 15) reported feeling unsafe and/or not having an adequate supply of PPE while doing these duties. Regarding hospital availability of PPE for orthopaedic residents, 80.1% reported having enough PPE but that it was rationed, 9.1% (N = 46) reported an abundance of PPE without rationing, and 10.1% (N = 51) reported having not enough PPE. Furthermore, respondents in hotspots were more likely to report an inadequacy of PPE availability (P < 0.001).
Table 3 -
Respondent Attitudes Toward Nonorthopaedic Deployment
|Deployment is part of my job
|Deployment should be voluntary
|Deployment is not part of my job
Resident Wellness and Concerns
In total, 76.0% (N = 407) of respondents reported that their program director and Graduate Medical Education leadership considered resident well-being to be “important” or “very important” (Table 4). The distribution of this response did not vary by class (P = 0.346) or whether the respondent was in a COVID-19 hotspot (P = 0.957). Overall, 44.5% (N = 182) reported that time away from coresidents had a negative effect on overall resident cohesiveness, with junior residents more likely to report this relative to senior residents (P = 0.0015). Regarding social support, 41.6% reported that their program held nonacademic events to maintain connectivity to other residents. Regarding communication from program directors, most respondents reported weekly (N = 324, 64.2%) or daily (N = 139, 27.5%) communications, and residents in hotspots were likely to receive more frequent communication (P = 0.025) (Table 5).
Table 4 -
Perceived Level of Importance of Resident Well-being to Program Leadership
Table 5 -
Frequency of Communication From Program Director
The greatest concern for respondents was the possibility of getting family members sick (mean = 3.89, on scale of 1-5), followed by personally contracting the illness (mean = 3.38), uncertainty of daily schedule (mean = 3.00), being asked to work outside the scope of orthopaedic surgery (mean = 2.98), changing safety protocols (mean = 2.76), and finally not having an adequate supply of PPE (mean = 2.74) (Figure 1).
The COVID-19 pandemic has influenced the orthopaedic surgery resident workforce to an unanticipated and unprecedented extent. In this study, the largest national survey of orthopaedic residents working during the pandemic, we shed light on resident roles, thoughts regarding non-orthopaedic duties, efforts to maintain wellness, and attitudes toward key areas of concern. Key themes observed in our findings included a change in daily roles for most residents, both in COVID hotspots and nonhotspots, a general willingness to provide nonorthopaedic care, and an overarching concern regarding the possibility of spreading pathogens in the home environment.
Throughout the pandemic a perception of widespread resident duty changes and reassignment to the direct care of patients with COVID-19 has been noted.10–12 Our findings suggest that for orthopaedic residents, these changes occurred primarily in the form of reassignment to platoon systems. This practice was endorsed and publicized early as a viable and safe method of distributing resident labor for orthopaedic programs.1,4,5 Interestingly, a relative minority of orthopaedic residents, in both COVID hotspots and nonhotspots, reported being called to participate in nonorthopaedic care. This is in contrast to residency programs in other specialties, where the incidence of nonspecialty care has been reported as high as 75%.13–15 Of those who were called to participate in nonorthopaedic care in the present study, 60% felt that it was their responsibility to do so.
Since the start of the pandemic, a number of resources have been aimed to provide guidance with potential ethical, legal, and contractual dilemmas such as reassignment of clinical duties.16–18 The Hastings Center—a nonpartisan, nonprofit organization that produces publicly available guidelines on issues in health, science, and technology—stated that health care institutions that employ trainees must first and foremost recognize these workers as a vulnerable cohort.18 Furthermore, all efforts should be taken to support and protect these workers. Similarly, concern has been raised that healthcare workers may be subject to undue legal pressures and/or litigation because of caring for a patient cohort outside their area of traditional expertise.19,20 Although broad protections exist to safeguard providers who act reasonably during this difficult time, a reliance on up-to-date guidelines and treatment protocols is critical to ensure that the best possible care is being provided.20 Clarity in the types of roles the residents were asked to serve (ie, managing ventilators, serving in the role of an intern for a care team, being a part of the proning teams, etc.) might help institutions to better understand whether the concerns of those unwilling to provide nonorthopaedic care were because of lack of comfort or more philosophical reasons. We encourage frequent discussion between residents and leadership to truly grasp the concerns of this vulnerable cohort, set expectations, and modify plans when change is necessary.
The effect of these changes in clinical duties and daily routines on mental well-being cannot be overstated. As many as 90% of residents have reported that the COVID-19 pandemic has had an adverse effect on their mental health.21 Those involved in the direct care of patients with COVID-19 may be even more adversely affected. In a survey of 393 physicians in training across multiple specialties at a single care system, Kannampallil et al22 found that residents who were directly involved in the care of COVID-19 patients had a significantly higher likelihood of meeting burnout criteria compared with those who were not directly involved (odds ratio 1.31 [95% confidence interval, 1.21-1.41] vs odds ratio 1.07 [95% confidence interval, 0.96-1.19]; P = 0.002). The findings of our study suggest that this care burden can fall disproportionately on the junior resident cohort. This is likely because of the greater expertise of the senior residents being put to use in their chosen field providing care that junior residents would not be yet competent to provide. Strategies for minimizing stress are paramount for these junior residents who are likely to experience uncertainty in clinical duties and daily schedules in response to major events in the future. In fact, Dzau et al warn that these efforts are critical to prevent a “parallel pandemic” within the cohort of residents, characterized by a high potential for loneliness, distress, substance abuse, and the possibility of adverse chronic medical conditions.23,24
Given the possibility of future events similar degree of emergency planning and reorganization, the timely anticipation of barriers to resident well-being is critical. Although most respondents in the present study reported feeling that their wellness was “important” or “very important” in the eyes of their program leadership, this survey and those mentioned above highlight potential opportunities for improvement. For resident physicians, anticipated challenges may include basic physiological needs (ie, nutrition, exercise, and sleep), adequate supply of PPE, and psychosocial and mental health support. Resources for mental health are particularly important, but unfortunately have been underutilized by this vulnerable cohort over the years.25,26 De Brier et al27 completed a recent systematic review of factors affecting mental health of physicians-in-training during epidemics such as COVID-19, finding that organizational support, clear concise communication, and development of a sense of control were the most meaningful protective factors in avoiding adverse mental health outcomes. Allowing residents to be involved in decisions that affect them, even if the result is not the desired one may give them some feeling of control and at a minimum allow for an understanding of the situation(s) that require decisions to be made. Most respondents in the present study reported having regular daily or weekly communication with their program leadership. The use of regular, but efficient and concise notifications is critical to effectively communicate while simultaneously avoiding message fatigue. Finally, feelings of emotional distress must be normalized, the stigma of mental health support must be diminished through discussion of common stressors, and the utilization of this support must be encouraged.
Similar lessons can be drawn from the 2003 outbreak of severe acute respiratory syndrome in the greater Toronto area.28 Over a several-month period, 74 cases of the deadly condition were reported to the city, 29 of which (39%) were healthcare workers. Retrospective investigation has found that a one in three workers reported a high degree of distress and that efforts to promote psychological support and efficient communication early in the outbreak were particularly critical in this distress not growing further out of control.29,30 Successful practical interventions included streamlining the hospital scrubs exchange process and ensuring availability of PPE in the highest-demand physical locations throughout the hospital.30
Among key issues regularly voiced publicly, respondents to our survey shared the highest concern regarding the possibility of bringing the pathogen to the home environment and getting family members sick. Over half of respondents reported having a spouse or child at home, and a considerable number likely had other roommates such as friends or nonimmediate family members who were not captured by our analysis. This concern regarding sharing a potentially harmful pathogen with family and loved ones has been echoed across a number of subspecialties.31 Avoidance of this dreaded complication begins with successful strategies to limit exposure for healthcare workers and intrahospital spread of the disease.32 To better assess risk factors for intrahospital spread, Wang et al33 comprehensively analyzed 92 medical staff at a single institution for demographic, habitual, and social interaction variables related to the presence or absence of COVID-19. They found the most important factor in preventing spread was consistent use of a surgical mask, whereas constant touching of the cheek, nose, or mouth while working was the most meaningful risk of personal infection. Importantly, however, zero patients in the infected group and one (1.6%) in the noninfected group experienced known spread of the disease to family members. Therefore, although efforts to minimize the likelihood of pathogen spread to family remain important, it may be more fruitful to focus efforts on minimizing occupational exposure and intrahospital spread. Nonetheless, the fear of the possibility of home transmission should not be underestimated by departmental and program leadership.
Finally, although these findings may lead some to think that the absence of family in the home environment may be somewhat protective against stress during the pandemic, the value of social support is important. Kannampallil et al22 found that residents who were unmarried were at notably higher risk of becoming depressed during the COVID-19 pandemic compared with their married colleagues. Thus, support of both residents with families at home and those who lack immediate family, remains equally critical.
The present study has important limitations to consider. Although the survey was administered to a comprehensive list of orthopaedic residency program leadership, it is unknown how many program directors forwarded the study to their residents, and a true response rate therefore cannot be calculated. Potential exists for a sampling bias if programs with a particularly meaningful experience (positive or negative) to COVID-19 were more strongly represented. Although the survey did analyze key areas of stress, it did not capture other related factors such as sleep and emotional pressures. Finally, this survey was completed during the first wave of COVID-19 for most major US metropolitan areas. It is possible that, since that time, a greater percentage of residents have been asked to change daily duties and provide nonorthopaedic care and that our findings may be slightly different.
COVID-19 is the first pandemic in the United States that has strongly influenced the resident work force, a group that contributes a substantial portion of the physician labor at academic hospitals. The pandemic has led to numerous changes and novel sources of adversity for orthopaedic surgery residents. Leadership for most programs have placed a high value on resident wellness but opportunities for improvement remain. Over half the residents asked to participate in nonorthopaedic care were comfortable with this proposition. The possibility of bringing a pathogen to the home environment and infecting family members seems to be an overarching concern, and ensuring safety should be a key focus for residency leadership. These findings may help guide programs to ensure resident wellness in the event of similar events that call for redefining resident roles.
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