Impact of COVID-19: a surgical trainee perspective
The COVID-19 pandemic has brought unprecedented challenges worldwide. The status quo has particularly been offset for those in the remit of healthcare training and surgical trainees are no exception.
As for any other healthcare professional, the risks of COVID-19 are real. Donning and doffing off multiple sets of personal protective equipment became routine when seeing surgical patients, until COVID-19 swabs returned negative. However, swab results provided little reassurance, as the false negative rate was as high as 29%1. Patients subsequently testing positive proved problematic as entire cohort bays were closed, exacerbating bed shortages.
A trainee’s nightmare
COVID-19 brought great distress to surgical trainees in many aspects, aside from personal risk from the disease. In preparation for the massive influx of COVID-19 patients, emergency rotas were implemented throughout multiple UK hospital trusts to boost staffing levels.This was facilitated by the British Medical Association relaxation of the 2016 Terms and Conditions of Service2. This was not without a price, as out-of-hours work and shift durations increased. Surgical staffing levels suffered further, due to redeployment of junior doctors to medical specialities. Although some reserve shifts were initially implemented to improve rest and reduce unnecessary exposure, many trainees inevitably covered additional shifts for absent colleagues who were ill, self-isolating or shielding. For many, child-care options were practically reduced to nil, with school and nursery closures3. Cancellation and postponement of annual leave also did no favours.
Impact on education and training
As attention was diverted towards keeping hospitals afloat during the tsunami of problems washed in with the COVID-19 pandemic, education and training suffered greatly. Departmental/deanery teaching, courses and conferences were cancelled. Uncertainties about fellowships, training progression, annual review of competency progression (ARCP) outcomes and exams are still a concern.
Face-to-face outpatient clinics became consultant-led telephone appointments, with its own constraints in fully assessing patients and providing education and training. More worrying, was the cancellation of elective theatre lists, although understandably done to increase HDU and ITU capacity for COVID-19 patients. Refining one’s surgical skills, like any other art, requires constant practice. There was a pervading fear amongst trainees of becoming deskilled. Admitted patients were preferentially managed conservatively and where surgical procedures were necessary, they were mostly performed by consultants, further reducing training opportunities.
Impact on patients
Patient care has inevitably been impacted. With rising cases and deaths, patients were urged to stay at home unless absolutely required. This was a double-edged sword as whilst this prevented services from being overwhelmed, it also meant late presentation of conditions which may have been better managed in its earlier stages with reduced morbidity and mortality risks. Those that presented during the peak received what care could be provided from the COVID-19-limited armamentarium. It was an interesting experience to be confined to the conservative management of acute conditions like appendicitis, all to avoid the COVID-19 exposure risks in operating theatres, through aerosol-generating procedures like laparoscopy and intubation4.
The knock-on effects extend beyond acute presentations. Much frustration comes from thinking of patients with chronic disease such as colorectal carcinoma left undiagnosed due to cancellation and slow resumption of backlogged endoscopy lists. They may now be condemned to further undue punishment from future acute bowel obstruction or worse prognosis. Somewhat draconian decisions were reluctantly made at cancer multi-disciplinary team meetings. COVID-19 has been unforgiving to say the least.
De-escalation and the future
Three months on from the initial UK-wide lockdown, there is some light at the end of the tunnel. Educational bodies have given the green light for resumption of teaching. Elective cases and endoscopy lists have slowly restarted with measures such as 14-day self isolation, swabbing 72 hours pre-admission and designated ‘clean’ wards 5. Some COVID-19 wards have been de-escalated to surgical wards, especially given recent surges in admissions since the easing of lockdown measures.
Despite the difficulties, the National Health Service (NHS) has received tremendous appreciation. “Clap for carers” has been a way for many across Great Britain to show support. Amazing people like Captain Tom Moore and many more have raised money for the NHS, and we have been gifted countless items from various organisations and individuals. Online communication platforms have revolutionised delivery of training, possibly for the better. Through the ups and downs, we have supported each other and appreciate family now more than ever.
Still, amongst the glimmer of hope, there is the looming shadow that COVID-19 will possibly and even likely return once again. There already is a race to catch up on the backlog of elective work which will undoubtedly put even more strain on services than normal. Surgical trainees have been exhausted by the impact of the first wave of the pandemic and the threat of a second wave is daunting for us all.
References
- Arevalo-Rodriguez I, Buitrago-Garcia D, Simancas-Racines D, et al. False-negative results of initial RT-PCR assays for covid-19: a systematic review. medRxiv 20066787. 2020 doi:10.1101/2020.04.16.20066787%J
- Terms and Conditions of Service for NHS Doctors and Dentists in Training (England) 2016 -Joint Statement on the Application of Contractual Protections during the Pandemic.; 2020. https://www.nhsemployers.org/-/media/Employers/Documents/Pay-and-reward/Junior-Doctors/Joint-statement-on-managing-rotas-NHS-Employers-and-BMA.pdf?la=en&hash=A91E5E8C448CEE795862F54877F20B7B2E587B4E.
- Bma.org.uk. https://www.bma.org.uk/media/2446/bma-briefing-on-covid-19-and-childcare-may.pdf. Published 2020. Accessed June 30, 2020.
- Updated General Surgery Guidance on COVID-19, 2nd Revision, 7th April 2020 | The Royal College of Surgeons of Edinburgh. The Royal College of Surgeons of Edinburgh. https://www.rcsed.ac.uk/news-public-affairs/news/2020/april/updated-general-surgery-guidance-on-covid-19-2nd-revision-7th-april-2020. Published 2020. Accessed June 30, 2020.
- Developing Safe Surgical Services (DSSS) for the Covid19 Era Contents. https://www.asgbi.org.uk/userfiles/file/covid19/developing-safe-surgical-services-dsss-for-the-covid19-era_may2020.pdf. Accessed June 27, 2020.
Dr Emily Durity, Surgical FY2
Miss Tabitha Gana, ST6 Surgical Registrar
Department of General Surgery, Chesterfield Royal Hospital, Calow, Chesterfield, S44 5BL