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The Impact of the Global SARS-CoV-2 (COVID-19) Pandemic on Neuroanesthesiology Fellowship Programs Worldwide and the Potential Future Role for ICPNT Accreditation

Rajan, Shobana MD*; Bebawy, John MD; Avitsian, Rafi MD, FASA; Lee, Chanhung Z. MD, PhD§; Rath, Girija MD, DM; Luoma, Astri MBChB, FRCA, FFICM; Bilotta, Federico MD, PhD#; Pierce, John T. MS**; Kofke, William A. MD, MBA, FCCM, FNCS††

Author Information
Journal of Neurosurgical Anesthesiology: January 2021 - Volume 33 - Issue 1 - p 82-86
doi: 10.1097/ANA.0000000000000738

Abstract

Neuroanesthesiologists provide perioperative care for neurosurgical and neurologically impaired patients. Training in this subspecialty of anesthesiology requires clinical experience as well as an in-depth understanding of the surgical procedures and of neurophysiological and pathophysiological disturbances.1 Neuroanesthesiology fellowships should provide training in an environment where trainees are exposed to a wide range of neurosurgical procedures in adequate numbers to provide adequate experience in common and complicated scenarios.2

The coronavirus disease 2019 (COVID-19) pandemic has strained the educational and emotional well-being of physicians in training. It has also created unforeseen anxiety and fears for future practice as a subspecialist because of the impact of the pandemic on postgraduate medical education and training.3 The feeling of loss of control because of disruption of daily schedules, fears about personal protective equipment and safety, and in some cases truncated training serve to heighten these concerns.4 Neuroanesthesiology fellowship training program directors have also been affected by the many changes imposed by the pandemic. They have been obliged to channel their energies into coping with a new and rapidly expanding medical emergency and change in caseload as well as restructuring education for fellows within the limited available resources and time.

Despite reports that the COVID-19 pandemic has extensively affected training in several medical specialties,5 including anesthesiology,3 there are not data that specifically assess its impact on neuroanesthesiology training. The primary aim of this international survey was to assess the perspectives of neuroanesthesiology training program directors and fellows about the impact of the COVID-19 pandemic on training programs in terms of disruption of the curriculum, redeployment to other clinical areas, and mitigation measures for education and well-being. The secondary aim was to enquire about the response of the Neuroanesthesiology Program Relations Committee of the International Council on Perioperative Neuroscience Training (ICPNT) to the pandemic. The mission of the Neuroanesthesiology Program Relations Committee is to foster academic and professional relations and networking among participants in ICPNT accredited training programs.

METHODS

The Society for Neuroscience in Anesthesiology and Critical Care (SNACC) Trainee Engagement Committee developed 2 email-based surveys to investigate the impact of the COVID-19 pandemic on neuroanesthesiology fellowship training. Sixteen neuroanesthesiology fellowship program directors in various geographical regions that were listed on the SNACC fellowship database were chosen at random (by S.R., A.L., G.R.) and contacted by email to seek information on the impact of the COVID-19 pandemic on their training programs. The program directors were asked to disseminate the second part of the survey for completion by fellows or advanced trainees rotating through neuroanesthesia in their departments. The initial survey, inviting answers to questions about clinical training, educational concerns, and trainee well-being during the pandemic, was sent in April 2020. In July 2020, a short follow-up survey was sent to the program directors who responded to the original survey request to seek additional information.

Some of the fellowship programs chosen for inclusion in the survey were accredited by the ICPNT, and some others were considering the possibility of accreditation. We, therefore, asked the ICPNT Neuroanesthesiology Program Relations Committee to provide information about their ongoing and planned efforts to assist accredited neuroanesthesiology training programs during the pandemic.

The responses to all questions were provided as free text. The main and secondary surveys are available in the Supplementary Material (Supplementary Digital Content 1: Survey Questionnaire, https://links.lww.com/JNA/A318).

RESULTS

Sixteen program directors were contacted, and responses were received from 14 (88% response rate). Responses were received from 2 programs each in Canada (Toronto and Vancouver), India (New Delhi and Trivandrum), the UK (both in London), and the United States (Chicago and Cleveland), and 1 program each in Australia (Brisbane), China (Beijing), Iran (Tehran), Italy (Rome), Spain (Barcelona), and Qatar (Doha). Thirty-six fellows from 5 neuroanesthesiology fellowship programs (2 each in India and the United States, and 1 each in Australia, Iran, and China) completed the fellows’ section of the initial survey. Responses from >1 trainee in a single institution was summarized as a collective response for that center. The secondary survey was sent to the 14 program directors who responded to the original survey, and we received responses from 11 (71% response rate).

Program Director Responses

Program director responses are summarized in Table 1. Those in the “hardest-hit” regions (stages 2 and 3 of the Accreditation Council for Graduate Medical Education (ACGME) classification of the COVID pandemic6) reported that their fellows’ education had been affected adversely by the pandemic. Program directors in the not so “hard-hit regions” (corresponding to ACGME stage 16) found it difficult to answer yes or no to this question; maintenance of a reasonable volume of emergency and urgent cases in some of these tertiary referral centers helped to maintain the acuity of clinical training.

TABLE 1 - Program Director Responses
Clinical Training Academics and Education Personal Wellness
Australia (Brisbane) Adversely affected with fellows being deployed to ICUs. Elective cases canceled Videoconference teaching. Maximize clinical experiences for trainees who needed them based on training level Wellness program initiated. Developed a wellness area for relaxation
Canada (Toronto and Vancouver) Not too adversely affected; reasonable volume of neurosurgical cases maintained to provide training Seminars and lectures through Zoom. Fellows are given allotted time weekly to complete scholarly activities Weekly discussions with fellows, checking on their well-being and their families
China (Beijing) Clinical work continued with adequate PPE. No one redeployed or moved to the ICU Online training modules, live video problem-based learning, and journal club Fellows with fever were quarantined in the hospital, had dining arranged daily, and help with daily necessities
India (New Delhi and Trivandrum) Adversely affected. Elective cases canceled, fellows moved to the COVID-19 ICU. Fellows who were supposed to go to neighboring states for observerships could not go due to lockdown and quarantine Regular face-to-face seminars, case presentations, and journal clubs were stopped. Online classes were initiated. Exit examinations for fellowship conducted online. They got more time to learn EEG, evoked potentials, and neuroimaging Fellows are encouraged to communicate with their mentors. The psychiatry department arranged lectures/seminars on anxiety and depression
Iran (Tehran) Adversely affected. Fellows removed themselves completely from the hospital Online teaching, webinars, and virtual teaching Fellows told to stay home and social distance to avoid the stress of being in the hospital
Italy (Rome) Adversely affected; trainees redeployed to non-COVID-19 cases Web-based initiatives (PBLDs and CBLDs) Limited resources at the time of the pandemic; 24/7 call center for psychological help
UK (London) Adversely affected; trainees redeployed to ICU for 8 wk Educational videos for COVID-19 education Biweekly well-being Zoom webinars conducted by psychologists; wellness snack boxes available
Qatar (Doha) Adversely affected. Fellows seeing COVID-19 patients and pulled to the ICU Online teaching Regular communication with trainees about well-being. Resources provided for wellness
Spain (Barcelona) Adversely affected: trainees suspended from all duties. Research projects put on hold Regularly used virtual online campus for education. No disruption due to COVID-19 Nothing formal but doing everything to be as helpful to the trainees as possible by keeping in touch with them
United States (Chicago and Cleveland) Adversely affected. Elective cases canceled Switch from classroom learning to articles. Virtual online didactic series Weekly email check-ins as well as proving various resources for mental wellness, coping strategies, and financial benefits
CBLDs indicates case based learning discussion; COVID-19, coronavirus disease 2019; EEG, electroencephalogram; ICU, intensive care unit; PBLDs, problem based learning discussion; PPE, personal protective equipment.

Clinical Training

The greatest impacts on clinical training were the cancellation of elective neurosurgical procedures and other changes in work patterns as hospitals prepared to manage a surge in COVID-19 patients. In general, program directors reported that the most experienced anesthesiologist on site (most likely the attending anesthesiologist) intubated COVID patients, although in 20% of program trainees were part of the COVID intubating team. Although trainees may have performed fewer intubations during the pandemic, there was no perceived competition among them to perform these intubations. All programs had established airway protocols centered around the safety of health care providers. Overall, 80% of programs had access to intubation boxes (a clear plastic box that is placed over a patient’s head before intubation as an extra layer of safety against aerosolized virus particles) and all found it cumbersome to use. Although 80% of programs used fiberoptic intubation less frequently during the pandemic, fiberoptic intubation was performed if clinical circumstances dictated (eg, in the setting of an unstable cervical spine).

The rate of redeployment of fellows to intensive care units (ICUs) to manage critically ill COVID and non-COVID patients varied from 20% to 100%, depending on the clinical need in individual centers. To mitigate the lack of exposure to elective neurosurgical cases, program directors endeavored to match the available clinical workload to those fellows with the greatest need, for example, those requiring completion of a module of training. Some impacts of the pandemic were more substantial, including the postponement of postgraduate examinations; one program offered provisional licenses to practice independently despite the delay in examinations. There was also an extension of training by ∼3 months in 50% of the programs surveyed. In the ICPNT accredited programs, the flexibility afforded by additional research time without compromising clinical rotations prevented graduation delays. As far as financial repercussions were concerned, there were no reported trainee job losses, although in 2 programs there was a decrease in monetary compensation because of a reduction in the number of shifts undertaken by trainees.

Academics and Education

While some hospitals in several parts of the world were already using web-based modalities for some trainee teaching, many undertook this effort de novo as a result of the pandemic Most centers switched to web-based initiatives and platforms, including Zoom, Ding Talks, Microsoft Teams, to facilitate educational training. This included problem-based and case-solving discussions, journal clubs, and the development of individual literature search projects which were subsequently discussed with written and “face-to-face” (through the aforementioned web media) interactions. There was a significant focus to train fellows on safety issues related to caring for patients with COVID-19, particularly those patients who require aerosol-generating procedures. Learning and practicing proper techniques for donning and doffing personal protective equipment was a key component of safety training and was conducted via video and simulation training sessions.

Emotional Well-being of Trainees

Program directors reported several initiatives to support trainee well-being during the pandemic, including identifying departmental well-being leaders, creating task forces to manage trainee well-being, weekly newsletters with information on relevant resources (food, accommodation, parking, etc.), contact details for institution-wide wellness leaders, and resources for online psychological support. Some departments also provided enhanced physical resources for their trainees, such as revamped rest areas with sofa beds, improved lighting to allow rest, nourishment, and other useful facilities (eg, phone charging stations). Program directors made regular contact with their fellows to ensure that they were coping with the challenges they faced during the pandemic. According to program directors, feelings of isolation and despair varied from 2 to 8 (on a scale of 1 to 10) in different programs.

Fellow Responses

Fellow responses are summarized in Table 2. Fellows reported that their clinical training had been adversely affected by the COVID-19 pandemic. Specifically, there was decreased exposure to elective subspecialty cases and decreased opportunities to complete workplace-based assessments and training portfolio requirements. Cancellation of examination preparation courses and delayed examinations were cited as common sources of stress. However, trainees also reported that the pandemic provided an opportunity to learn new principles about pandemic preparedness and management and how to cope with the unique challenges of being a health care professional in a pandemic situation.

TABLE 2 - Fellow Responses
Concerns and Challenges Potential Solutions
Clinical training Elective case training disruption Logbooks to be maintained so that they can be posted in cases that they missed. Would like to be involved with the COVID-19 task force and decision making in the department which keeps them involved
Redeployment from OR sites to fever clinics and other outpatient clinics Clear lines of communication about the pandemic preparedness and COVID-19 response of the department
Postponement of examinations hindering graduation and extension of training Online testing modalities should be made available
Academic and education Social distancing leading to disruption of lectures, journal clubs Being on a common virtual platform with the rest of the world gave confidence and satisfaction and be in touch with faculty
Online modalities were not a substitute for hands-on training Video lectures for procedural skills. Neuromonitoring lectures over Zoom during the time off, which was an educational time that may otherwise have been very broken up
Personal wellness Anxiety about steering through the pandemic Adequate breaks for physical exercise, sleep, a good reading plan. Availability of PPE
Stress about the safety of their family was a concern Adequate personal time for communication with other residents and family
COVID-19 indicates coronavirus disease 2019; OR, operating room; PPE, personal protective equipment.

Although online teaching modalities were beneficial, trainees universally felt that they were no substitute for hands-on clinical training. However, collaborative online platforms and teaching material did help to instill confidence and decrease feelings of isolation. Interactions with families and colleagues, as a social support system, were very beneficial for trainees.

ICPNT Accredited Programs

Among the 14 surveyed programs, 3 were ICPNT accredited before the COVID-19 pandemic; Cleveland Clinic, US; Northwestern University, US; and University College London Hospitals, UK. Accreditation was pending for 3 other programs at the beginning of April 2020; Vancouver General Hospital, University of British Columbia, Vancouver, Canada; Princess Alexandra Hospital, Queensland, Australia; Beijing Tiantan Hospital, Capital Medical University, Beijing, China.

ICPNT accredited programs reported that an important aspect of their accreditation during the pandemic was the availability for networking with other programs; this allowed them to share problems and potential solutions and led to an overall feeling that they were not alone. Accredited programs were also able to work within the flexible framework of ICPNT guidelines, although the appropriate clinical experience was still required to ensure that fellows met criteria for independent practice. ICPNT accreditation and participation was noted to be a good point of reference to ensure that fellows were “on track” clinically, even if some of their experience was obtained away from usual clinical areas (eg, during redeployment to critical care).

The Neuroanesthesiology Program Relations Committee hosted an online webinar for all ICPNT accredited fellowship programs worldwide to discuss the impact of the COVID-19 pandemic on trainees. Topics addressed in this webinar included the effects of the COVID-19 on the nervous system and working patterns, educational challenges and wellness, and coping mechanisms during the COVID-19 pandemic.

DISCUSSION

The COVID-19 pandemic is an overwhelming international health crisis, particularly in the “hotspots” of the world. According to many neuroanesthesiology training program directors, the pandemic has led to a paradigm shift in clinical and educational endeavors. The pandemic has meant complete restructuring of clinical workflows in most medical centers worldwide and has affected the educational experience for trainees. The cancellation of elective neurosurgical procedures and the need for the redeployment of personnel to support ICUs to manage the surge of patients admitted with severe COVID-19 occurred in many neuroanesthesiology fellowship programs, and this caused disruption to curricula and to fellows’ training. The wide range of responses to our survey highlights how neuroanesthesiology fellowships are structured differently throughout the world and the variability between programs; the pandemic has only intensified this variation.

Similar to many accreditation systems, ICPNT provides clinical rotation guidelines and requirements for fellowship programs to ensure fellows’ competency to provide optimal patient care and to guide professional development. It also provides flexibility within that framework, allowing prioritization of the emergency need for critical care support of patients in a pandemic situation. The Neuroanesthesiology Program Relations Committee of the ICPNT facilitated educational networking and sharing knowledge in the setting of a pandemic through a webinar discussion. The use of a common online platform made fellows feel that they were not alone, and this might have improved their sense of well-being.

At the peak of a pandemic, trainee education may not be a high priority. Program directors faced major challenges to maintain some degree of teaching and training and had to rapidly develop alternative and innovative methods to optimize educational and academic experiences for trainees. Many programs responding to this survey utilized online platforms to deliver clinical discussions, literature reviews, and journal clubs, as well as to provide safety training modules; together, these ensured high-quality trainee education and enhanced personal safety during the pandemic. The SNACC Web site also offers excellent online resources under its Education and Trainee tabs.

As COVID-19 continues to spread globally, its psychological impact, and the well-being of health care workers have become serious concerns.7 The unforeseen stress and need for support are clearly demonstrated in the trainee responses to our survey, similar to other fellowship programs in anesthesia and other specialties.8 The particular needs of trainees highlighted by this survey include adequate breaks from clinical duties for rest and recreation and, most importantly, time to communicate with their social support systems of family and friends. Involving fellows in conversations centered around patient care and task teams also appears to be helpful in improving morale in the clinical setting.

There are some notable limitations to this survey-based report. The questions to program directors and fellows were sent via email with the capability for free text, and hence quantifiable and objective measured results were not always obtained. Furthermore, the 2 surveys were conducted relatively early in the pandemic response phase in many countries, so other objective data, such as the number of COVID-positive cases, number of cumulative ICU hours/shifts undertaken by trainees, etc. could not be reported. Certainly, such information would be useful in future attempts to gather data on the international neuroanesthesia fellowship program pandemic response and the coping strategies used.

CONCLUSIONS

As neuroanesthesiology fellowship training program directors tackled the clinical impact of the surge of COVID-19 cases, they also strived to maintain clinical training with innovative approaches to neuroanesthesia fellowship education. The well-being of trainees was also thoughtfully handled. Fellows found virtual education tools useful but did not feel that it replaced reality. The findings of this survey might be a useful basis for future assessment of how ICPNT accreditation might have a beneficial impact and what lessons can have been learned to further improve the accreditation system.

ACKNOWLEDGMENTS

The authors extend appreciation to all the program directors who responded to this survey and shared their valuable experience, specifically Drs John Bebawy, Rafi Avitsian, Alana Flexman, Lashmi Venkatraghavan, Tumul Chowdhary, Girija Rath, Val Luoma, Audrey Tan, Federico Bilotta, Ricard Valero, David Highton, Neeraj Kumar, Zahid Hussain Khan, and S. Manikandan, and also to all the trainees who completed the survey.

REFERENCES

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4. Rossi R, Socci V, Pacitti F, et al. Mental health outcomes among frontline and second-line health care workers during the coronavirus disease 2019 (COVID-19) pandemic in Italy. JAMA Netw Open. 2020;3:e203976doi: 10.1001/jamanetworkopen.2020.3976
5. Alvin M, George E, Deng F, et al. The impact of COVID-19 on radiology trainees. Radiology. 2020;296:246–248doi: 10.1148/radiol.2020201222
6. Accreditation Council for Graduate Medical Education. (Archived) Three stages of GME during the COVID-19 pandemic; 2020. Available at: www.acgme.org/COVID-19/. Accessed September 17, 2020.
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Keywords:

COVID-19; pandemic; neuroanesthesia; neuroanesthesiology; fellowship; education; training

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