Impact of COVID-19 on the Neurosurgical Resident Training Program

Significant global disruption in neurosurgical teaching and training has arisen from the COVID-19 pandemic. Decreased surgical exposure has negatively impacted educational provision. However, advancements in virtual technology have allowed for more affordable, accessible training especially in LMICs (lower- and/or middle-income countries). Using this, initiatives to reduce physical and mental stress experienced by trainees should be paramount 1)

A study evaluated the impact of COVID-19 pandemic restrictions during the first lockdown period in spring 2020 on the neurosurgical resident training program, and provides constructive approaches to deal with such situations.

A concurrent embedded mixed methods design was used. Qualitative data were collected through in-depth interviews from all neurosurgical residents at three university hospitals in Germany. Concurrently, quantitative data of the number of performed surgeries, outpatient visits, and the usage of telemedicine in the period from October 2019 to July 2020 were collected and analyzed accordingly.

During the period of COVID-19 pandemic restrictions in spring 2020, there was a marked reduction in the number of surgeries performed by neurosurgical residents, from an average of 41.26 (median 41) surgeries per month to 25.66 (median 24) per month, representing a decrease of 37.80%. The decrease in the operations was concerning mainly spinal and functional neurosurgery. Outpatient visits were reduced significantly, with a concurrent fivefold increase in the usage of telemedicine. General and pediatric neurosurgery outpatient clinics were the most affected. However, although surgical exposure was reduced during the lockdown phase, neurosurgical residents focused on conducting research and improving theoretical knowledge. Nevertheless, the global uncertainties caused by COVID-19 generated notable psychological stress among some residents.

The COVID-19 pandemic restrictions significantly affected the neurosurgical training program. Innovative solutions need to be developed to increase teaching and research capacities of neurosurgical residents as well as to improve surgical skills by installing surgical skill laboratories or similar constructs 2).

Romano et al. described the impact of the COVID-19 virtual match cycle and discuss approaches to optimize future cycles through applicant and neurosurgical education leadership insights. Anonymous surveys of neurosurgery program leaders (program directors and program chairs), program administrators (PAs), and 2020-2021 neurosurgery residency match applicants were distributed by the SNS, in conjunction with the Association of Resident Administrators in Neurological Surgery and AANS Young Neurosurgeons Committee. Optimizing a national strategy for the neurosurgery application process that prioritizes equity and reduces costs, while ensuring adequate exposure for applicants to gain educational opportunities and evaluate programs, is critical to maintain a successful training system. 3).

A 33-item electronic survey was sent to neurosurgery residents from Latin America from May 10 to 25, 2021. Statistical analysis was performed using SPSS version 25.

Results: A total of 111 neurosurgery residents responded to the survey. Mean age was 29.39 ± 2.37 years; 22.5% were female and 36% were training in Mexico. Residents who reported experiencing discrimination for testing positive to COVID-19 had the highest levels of depersonalization (66.7%; P = 0.043) and emotional exhaustion (75%; P = 0.023). Female respondents reported higher rates of gender discrimination (80% vs. 1.2%; P = 0.001), abuse (84% vs. 58.1%; P < 0.005), and sexual harassment (24% vs. 0%; P < 0.001) than did male respondents. Residents training in Mexico reported lower rates of emotional or verbal abuse (59.2% vs. 32.5%; P = 0.007) and bullying (P < 0.005) than did those in other countries in Latin America. Older age was a protective factor for high depersonalization scores (odds ratio [OR], 0.133; 95% confidence interval [CI], 0.035-0.500). Experiencing discrimination represented a risk factor for presenting high emotional exhaustion scores (OR, 3.019; 95% CI, 1.057-8.629). High levels of depersonalization were associated with a 7-fold increased risk of suicidal ideation (OR, 7.869; 95% CI, 1.266-48.88) 4).

4: Jain R, Carneiro RAVD, Vasilica AM, Chia WL, de Souza ALB, Wellington J, Kumar NS. The impact of the COVID-19 pandemic on global neurosurgical education: a systematic review. Neurosurg Rev. 2021 Oct 8:1–10. doi: 10.1007/s10143-021-01664-5. Epub ahead of print. PMID: 34623526; PMCID: PMC8497188.

5: Nugroho SW, Pradhana I, Gunawan K. New adaptation of neurosurgical practice and residency programs during the Covid-19 pandemic and their effects on neurosurgery resident satisfaction and welfare at the National General Hospital, Jakarta, Indonesia. Heliyon. 2021 Aug 12;7(8):e07757. doi: 10.1016/j.heliyon.2021.e07757. PMID: 34458606; PMCID: PMC8379449.

6: Almufarriji R, Elarjani T, Abdullah J, Alobaid A, Alturki AY, Aldakkan A, Ajlan A, Lary A, Al Jehani H, Algahtany M, Alqahatani S, Alsubaie F. Impact of COVID-19 on Saudi Neurosurgery Residency: Trainers' and Trainees' Perspectives. World Neurosurg. 2021 Oct;154:e547-e554. doi: 10.1016/j.wneu.2021.07.089. Epub 2021 Jul 26. PMID: 34325024; PMCID: PMC8461645.

7: Tzerefos C, Meling TR, Lafuente J, Fountas KN, Brotis AG, Demetriades AK. The Impact of the Coronavirus Pandemic on European Neurosurgery Trainees. World Neurosurg. 2021 Oct;154:e283-e291. doi: 10.1016/j.wneu.2021.07.019. Epub 2021 Jul 9. PMID: 34252632; PMCID: PMC8461641.

8: Wilson CM, Brown NJ, Detchou DKE. Letter: Impact of Sub-Internship Cancellations in Neurosurgery During COVID-19. Neurosurgery. 2021 Aug 16;89(3):E201-E202. doi: 10.1093/neuros/nyab232. PMID: 34192742; PMCID: PMC8344663.

9: Sahin B, Hanalioglu S. The Continuing Impact of Coronavirus Disease 2019 on Neurosurgical Training at the 1-Year Mark: Results of a Nationwide Survey of Neurosurgery Residents in Turkey. World Neurosurg. 2021 Jul;151:e857-e870. doi: 10.1016/j.wneu.2021.04.137. Epub 2021 May 8. PMID: 33974985.

10: Algattas H, Roy S, Agarwal N, Maroon J. COVID-19 Impact in Neurosurgery Residency: Grit During Pandemic. World Neurosurg. 2021 Jul;151:e395-e398. doi: 10.1016/j.wneu.2021.04.057. Epub 2021 Apr 21. PMID: 33894398; PMCID: PMC8059256.

11: Kilgore MD, Scullen T, Mathkour M, Dindial R, Carr C, Zeoli T, Werner C, Kahn L, Bui CJ, Keen JR, Maulucci CM, Dumont AS. Effects of the COVID-19 Pandemic on Operative Volume and Residency Training at Two Academic Neurosurgery Centers in New Orleans. World Neurosurg. 2021 Jul;151:e68-e77. doi: 10.1016/j.wneu.2021.03.122. Epub 2021 Mar 31. PMID: 33812067.

12: De la Cerda-Vargas MF, Stienen MN, Soriano-Sánchez JA, Campero Á, Borba LAB, Nettel-Rueda B, Castillo-Rangel C, Ley-Urzaiz L, Ramírez-Silva LH, Sandoval- Bonilla BA. Impact of the Coronavirus Disease 2019 Pandemic on Working and Training Conditions of Neurosurgery Residents in Latin America and Spain. World Neurosurg. 2021 Jun;150:e182-e202. doi: 10.1016/j.wneu.2021.02.137. Epub 2021 Mar 6. PMID: 33689850; PMCID: PMC7936760.

13: Singh R, Sahu A, Singh K, Prasad RS, Pandey N, Singh RC. Impact of COVID-19 Pandemic on Neurosurgical Practice in a Tertiary Care Center in India. J Neurosci Rural Pract. 2021 Jan;12(1):24-32. doi: 10.1055/s-0040-1716455. Epub 2020 Sep 4. PMID: 33531756; PMCID: PMC7846333.

14: Ashry AH, Soffar HM, Alsawy MF. Neurosurgical education during COVID-19: challenges and lessons learned in Egypt. Egypt J Neurol Psychiatr Neurosurg. 2020;56(1):110. doi: 10.1186/s41983-020-00242-8. Epub 2020 Nov 26. PMID: 33262563; PMCID: PMC7689385.

15: Suryaningtyas W, Wahyuhadi J, Turchan A, Subagio EA, Parenrengi MA, Apriawan T, Al Fauzi A, Bajamal AH. Neurosurgery at the epicenter of the COVID-19 pandemic in Indonesia: experience from a Surabaya academic tertiary hospital. Neurosurg Focus. 2020 Dec;49(6):E5. doi: 10.3171/2020.9.FOCUS20559. PMID: 33260130.

16: Dash C, Venkataram T, Goyal N, Chaturvedi J, Raheja A, Singla R, Sardhara J, Gupta R. Neurosurgery training in India during the COVID-19 pandemic: straight from the horse's mouth. Neurosurg Focus. 2020 Dec;49(6):E16. doi: 10.3171/2020.9.FOCUS20537. PMID: 33260120.

17: Atli K, Selman W, Ray A. A Comprehensive Multicomponent Neurosurgical Course with use of Virtual Reality: Modernizing the Medical Classroom. J Surg Educ. 2021 Jul-Aug;78(4):1350-1356. doi: 10.1016/j.jsurg.2020.11.003. Epub 2020 Nov 19. PMID: 33221253.

18: Cheserem JB, Esene IN, Mahmud MR, Kalangu K, Sanoussi S, Musara A, El- Ghandour NMF, Fieggen G, Qureshi M. A Continental Survey on the Impact of COVID-19 on Neurosurgical Training in Africa. World Neurosurg. 2021 Mar;147:e8-e15. doi: 10.1016/j.wneu.2020.11.008. Epub 2020 Nov 10. PMID: 33186788; PMCID: PMC7834456.

19: Khalafallah AM, Lam S, Gami A, Dornbos DL, Sivakumar W, Johnson JN, Mukherjee D. A national survey on the impact of the COVID-19 pandemic upon burnout and career satisfaction among neurosurgery residents. J Clin Neurosci. 2020 Oct;80:137-142. doi: 10.1016/j.jocn.2020.08.012. Epub 2020 Aug 19. PMID: 33099336; PMCID: PMC7438065.

20: Aljuboori ZS, Young CC, Srinivasan VM, Kellogg RT, Quon JL, Alshareef MA, Chen SH, Ivan M, Grant GA, McEvoy SD, Davanzo JR, Majid S, Durfy S, Levitt MR, Sieg EP, Ellenbogen RG, Nauta HJ. Early Effects of COVID-19 Pandemic on Neurosurgical Training in the United States: A Case Volume Analysis of 8 Programs. World Neurosurg. 2021 Jan;145:e202-e208. doi: 10.1016/j.wneu.2020.10.016. Epub 2020 Oct 13. PMID: 33065350; PMCID: PMC7550889.

21: Saad H, Alawieh A, Oyesiku N, Barrow DL, Olson J. Sheltered Neurosurgery During COVID-19: The Emory Experience. World Neurosurg. 2020 Dec;144:e204-e209. doi: 10.1016/j.wneu.2020.08.082. Epub 2020 Aug 19. PMID: 32827748; PMCID: PMC7435331.

22: Wittayanakorn N, Nga VDW, Sobana M, Bahuri NFA, Baticulon RE. Impact of COVID-19 on Neurosurgical Training in Southeast Asia. World Neurosurg. 2020 Dec;144:e164-e177. doi: 10.1016/j.wneu.2020.08.073. Epub 2020 Aug 15. PMID: 32805466; PMCID: PMC7428452.

23: Zoia C, Raffa G, Somma T, Della Pepa GM, La Rocca G, Zoli M, Bongetta D, De Divitiis O, Fontanella MM. COVID-19 and neurosurgical training and education: an Italian perspective. Acta Neurochir (Wien). 2020 Aug;162(8):1789-1794. doi: 10.1007/s00701-020-04460-0. Epub 2020 Jun 18. PMID: 32556815; PMCID: PMC7302726.

24: Pelargos PE, Chakraborty A, Zhao YD, Smith ZA, Dunn IF, Bauer AM. An Evaluation of Neurosurgical Resident Education and Sentiment During the Coronavirus Disease 2019 Pandemic: A North American Survey. World Neurosurg. 2020 Aug;140:e381-e386. doi: 10.1016/j.wneu.2020.05.263. Epub 2020 Jun 5. PMID: 32512244; PMCID: PMC7274118.

25: Khalafallah AM, Jimenez AE, Lee RP, Weingart JD, Theodore N, Cohen AR, Tamargo RJ, Huang J, Brem H, Mukherjee D. Impact of COVID-19 on an Academic Neurosurgery Department: The Johns Hopkins Experience. World Neurosurg. 2020 Jul;139:e877-e884. doi: 10.1016/j.wneu.2020.05.167. Epub 2020 May 24. PMID: 32461176; PMCID: PMC7245648.

26: Kanmounye US, Esene IN. Letter to the Editor “COVID-19 and Neurosurgical Education in Africa: Making Lemonade from Lemons”. World Neurosurg. 2020 Jul;139:732-733. doi: 10.1016/j.wneu.2020.05.126. Epub 2020 May 21. PMID: 32446982; PMCID: PMC7241362.

27: Scullen T, Mathkour M, Maulucci CM, Dumont AS, Bui CJ, Keen JR. Letter to the Editor Impact of the COVID-19 Pandemic on Neurosurgical Residency Training in New Orleans. World Neurosurg. 2020 Jul;139:718-719. doi: 10.1016/j.wneu.2020.04.208. Epub 2020 May 5. PMID: 32380334; PMCID: PMC7198391.

Jain R, Carneiro RAVD, Vasilica AM, Chia WL, de Souza ALB, Wellington J, Kumar NS. The impact of the COVID-19 pandemic on global neurosurgical education: a systematic review. Neurosurg Rev. 2021 Oct 8:1–10. doi: 10.1007/s10143-021-01664-5. Epub ahead of print. PMID: 34623526; PMCID: PMC8497188.
Omer M, Al-Afif S, Machetanz K, Bettag C, Tatagiba M, Rohde V, Krauss JK. Impact of COVID-19 on the Neurosurgical Resident Training Program: an Early Experience. J Neurol Surg A Cent Eur Neurosurg. 2022 Feb 21. doi: 10.1055/s-0042-1743108. Epub ahead of print. PMID: 35189640.
Romano R, Mukherjee D, Michael LM, Huang J, Snyder MH, Reddy VP, Guzman K, Lane P, Johnson JN, Selden NR, Wolfe SQ; Society of Neurological Surgeons. Optimizing the residency application process: insights from neurological surgery during the pandemic virtual application cycle. J Neurosurg. 2022 Jan 21:1-9. doi: 10.3171/2021.11.JNS211851. Epub ahead of print. PMID: 35061981.
De la Cerda-Vargas MF, Stienen MN, Campero A, Pérez-Castell AF, Soriano- Sánchez JA, Nettel-Rueda B, Borba LAB, Castillo-Rangel C, Navarro-Domínguez P, Muñoz-Hernández MA, Segura-López FK, Guinto-Nishimura GY, Sandoval-Bonilla BA. Burnout, Discrimination, Abuse, and Mistreatment in Latin America Neurosurgical Training During the Coronavirus Disease 2019 Pandemic. World Neurosurg. 2021 Nov 8;158:e393–415. doi: 10.1016/j.wneu.2021.10.188. Epub ahead of print. PMID: 34763105; PMCID: PMC8574080.
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