Since 2020, there has been characterized by apprehension and challenges due to the
global outbreak of the severe acute respiratory syndrome coronavirus 2 (coronavirus
disease 2019 [COVID-19]) and subsequent pandemic, with more than 25.1 million COVID-19
cases worldwide and more than 6 million cases in the United States (U.S.) by the end
of August 2020.[1] This pandemic has led to significant changes in U.S. ophthalmology residency clinical
training, including redeployment of ophthalmology residents to work on the frontlines
in non-ophthalmology fields, implementation of practices to protect asymptomatic patients
and providers, and adoption of social distancing methods for teaching and patient
care such as virtual didactics and teleophthalmology.[2]
[3]
[4] Moreover, clinical and surgical volumes have been impacted, as many hospitals throughout
the United States responded to the pandemic by reducing nonessential clinical visits,
procedures, and surgeries.[4]
[5] While this anecdotally has significantly affected the ophthalmology clinical and
surgical experience in residency programs, no studies have yet assessed the experience
of ophthalmology residents in the United States to better quantify these changes.
Additionally, COVID-19 has also likely impacted residents not only due to professional
concerns, including maintaining education, changes in essential examination scheduling,
and employment worries, but also due to increased personal stressors, including potential
redeployment and its associated challenges, financial and professional concerns, risk
of infection during patient care, or loved ones suffering from COVID-19 complications.[2]
[6]
[7] Surgical residency training has been demonstrated to be associated with burnout
in the absence of a pandemic[8]
[9]
[10]; therefore identification of personal stressors during the pandemic is critical
to avoid exacerbation of burnout, which is important due to moral, ethical, and professional
implications including maintaining patient safety and quality of care.[11]
[12]
[13]
[14]
[15]
[16]
Assessing the impact of the pandemic on ophthalmology residents is essential; outbreaks
of the new variants of the virus threaten to result in persistence of the pandemic,
and the effects of the pandemic will likely endure throughout the eventual recovery
process and ultimate establishment of a “new normal.” Moreover, insights obtained
from this pandemic may be applicable to potential similar situations in the future.
Therefore, this study aims to evaluate the effect of COVID-19 on the perceived experience
of ophthalmology residents throughout the United States.
Methods
This study was a cross-sectional, nonvalidated survey study conducted at Bascom Palmer
Eye Institute. Institutional Review Board (IRB) approval was obtained, and the study
adhered to the Declarations of Helsinki. An online, anonymous survey was distributed
to ophthalmology trainees who previously applied for residency at Bascom Palmer during
the 2016 to 2017, 2017 to 2018, and 2018 to 2019 application cycles (those in their
post-graduate year [PGY] 1–3 in the 2019 to 2020 academic year), and for fellowship
at Bascom Palmer during the 2019 to 2020 application cycle (those in their PGY4 in
2019–2020). Respondents who did not successfully match to any ophthalmology residency,
as well as those who were not part of an “integrated” PGY-1 year that included formal
ophthalmology training, were excluded. This allowed for the evaluation of the experience
of trainees participating in ophthalmology residency training, regardless of whether
they matched at Bascom Palmer or were participating in other residency programs throughout
the United States, in March 2020, during the first U.S. COVID-19 surge, through August
2020. Data were collected from August 22, 2020 to August 31st, 2020. Survey creation, distribution, and data collection were similar to a prior
study conducted by our group.[17] Participation was voluntary, and no compensation was provided. Informed consent
was obtained, and participants were allowed to opt out at any time during the survey.
Data collected included participant demographics, including age, sex, and location
of residency program. Location was categorized into regions as per the U.S. Census
guidelines including Northeast, Southern, Midwest, and Western U.S. Additional collected
data included resident perception of didactic, clinical, surgical, and overall experience
and volume at the time in which residents felt their training was most affected and
at the time of survey administration, number of expected and actual cataract and noncataract
surgeries performed between March 1st, 2020 and the date of survey administration, research output, redeployment to clinical
responsibilities outside of ophthalmology training, overall satisfaction with the
residency program, and nonvalidated assessment of the effect on resident personal
life.
Association between categorical variables was assessed using Chi-squared test for
categorical variables or Student's t-test for quantitative variables. p <0.05 was considered statistically significant.
Results
The survey invitation was sent to 1,559 separate email addresses. Fifty-nine messages
were returned due to inactive email accounts. The survey invitation email was opened
by 449 (28.8%) of those invited, and responses were initiated by 357 (22.8%), with
69 incomplete responses. For the remaining 288 complete responses, 24 respondents
were excluded due to failure to match into an ophthalmology residency, 60 were excluded
due to completion of a PGY-1 year that was not classified as an integrated ophthalmology
residency during the specified time frame, and 11 were excluded due to being a nonresident
during the 2019 to 2020 academic year.
Complete responses were received from 193 (12.4%) respondents and were included in
the study. Most respondents were males (N = 114; 59.1%) between 30 and 34 years of age (N = 106; 54.9%) located in the Northeast (N = 69; 35.8%) or Southern United States (N = 55; 28.5%, [Table 1]). The geographic distribution of respondents was statistically similar to geographic
distribution of all ophthalmology residency positions (X
[2] = 2.21; p = 0.53).
Table 1
Respondent demographics
|
Gender (N = 193)
|
|
|
Male
|
114 (59.1%)
|
|
Female
|
77 (39.9%)
|
|
Prefer not to say
|
2 (1.9%)
|
|
Age (years, N = 193)
|
|
|
< 25
|
1 (0.5%)
|
|
25–29
|
69 (35.8%)
|
|
30–34
|
106 (54.9%)
|
|
35–39
|
14 (7.3%)
|
|
> 39
|
3 (1.6%)
|
Most respondents felt that COVID-19 “worsened” their overall training experience (N = 145; 75.1%), with no significant differences among geographic locations (p = 0.30, [Table 2]). Regarding the effect of COVID-19 on various aspects of training, the most common
response was in-office/clinical (N = 103; 53.4%) and surgical training (N = 87; 45.1%) was “slightly worsened,” but many (N = 85; 44.0%) felt surgical training was “significantly worsened” and didactic training
“neither improved nor worsened” (N = 57; 29.5%) or “slightly improved” (N = 51; 26.4%). These perceptions did not differ among locations (p >0.05 for all) but did significantly differ for overall effect on in-office/clinical
(p = 0.0003) and surgical (p = 0.03) training based on PGY year, with a higher percentage of PGY3 and PGY4 participants
reporting slightly or significantly worse effects on their experiences due to COVID-19
([Table 3]). Respondents reported completing an average of 44.6% of their expected number of
cataract surgeries (SD = 80.9%%; range = 0–1,000%) and 49.6% of their expected number
of noncataract surgeries (SD = 31.9%; range = 0–167%); these differences in expected
and actual cataract and noncataract surgeries did not differ among regions (p = 0.74, p = 0.74, respectively). At the time of survey completion, most participants felt that
in-office/clinical volume was at 75 to 99% (N = 96; 49.7%), surgical volume at 50 to 74% (N = 66; 34.2%), and research volume at 100 to 124% (54; 28.0%) compared with pre-COVID-19
volumes.
Table 2
Impact of COVID-19 on residency training experiences based on location
|
Location
|
All (N = 193)
|
Midwest U.S.
(N = 40, 20.7%)
|
Northeast U.S.
(N = 69, 35.8%)
|
Southern U.S.
(N = 55, 28.5%)
|
Western U.S.
(N = 29, 15.0%)
|
p-Value
|
|
Impact on didactic training
|
Peak impact
|
Current impact
|
Peak impact
|
Current impact
|
Peak impact
|
Current impact
|
Peak impact
|
Current impact
|
Peak impact
|
Current impact
|
|
|
Cancelled
|
28 (14.5%)
|
3
(1.9%)
|
0
(0%)
|
0
(0%)
|
9 (13.0%)
|
0 (0%)
|
9 (16.4%)
|
1 (2.2%)
|
3 (10.3%)
|
0 (0%)
|
|
|
Less frequent
|
31 (11.8%)
|
11 (7.1%)
|
0
(0%)
|
0
(0%)
|
15 (21.7%)
|
2 (3.7%)
|
11 (20.0%)
|
5 (11.1%)
|
3 (10.3%)
|
2 (8.7%)
|
|
|
Same frequency but modified
|
127 (48.5%)
|
129 (83.2%)
|
6 (100%)
|
6 (100%)
|
44 (63.8%)
|
49 (90.7%)
|
33 (60.0%)
|
35 (77.8%)
|
21 (72.4%)
|
18 (78.3%)
|
|
|
Unchanged
|
7
(2.7%)
|
12 (7.7%)
|
0
(0%)
|
0
(0%)
|
1 (1.4)
|
3 (5.6%)
|
2 (3.6%)
|
4 (8.9%)
|
2 (6.9%)
|
3 (13.0%)
|
|
|
Overall impact on didactic training
|
|
Significantly worsened
|
17 (8.8%)
|
3 (7.5%)
|
5 (7.2%)
|
7 (12.7%)
|
2 (6.9%)
|
p = 0.43
|
|
Slightly worsened
|
49 (25.4%)
|
14 (35.0%)
|
15 (21.7%)
|
13 (23.6%)
|
7 (24.1%)
|
|
Neither improved nor worsened
|
57 (29.5%)
|
10 (25.0%)
|
19 (27.5%)
|
17 (30.9%)
|
11 (37.9%)
|
|
Slightly improved
|
51 (26.4%)
|
10 (25.0%)
|
21 (30.4%)
|
14 (25.5%)
|
6 (20.7%)
|
|
Significantly improved
|
19 (9.8%)
|
3 (7.5%)
|
9 (13.0%)
|
4 (7.3%)
|
3 (10.3%)
|
|
Impact on in-office/clinical training
|
Peak impact
|
Current impact
|
Peak impact
|
Current impact
|
Peak impact
|
Current impact
|
Peak impact
|
Current impact
|
Peak impact
|
Current impact
|
|
|
Cancelled
|
60 (31.1%)
|
0 (0%)
|
11 (27.5%)
|
0 (0%)
|
27 (39.1%)
|
0 (0%)
|
15 (27.3%)
|
0 (0%)
|
7 (24.1%)
|
0 (0%)
|
|
|
Less frequent
|
128 (66.3%)
|
90 (58.1%)
|
29 (72.5%)
|
17 (50.0%)
|
37 (53.6%)
|
30 (56.6%)
|
40 (72.7%)
|
29 (65.9%)
|
22 (75.9%)
|
14 (58.3%)
|
|
|
Same frequency but modified
|
4 (2.1%)
|
22 (14.2%)
|
0 (0%)
|
7 (20.6%)
|
4 (5.8%)
|
8 (15.1%)
|
0 (0%)
|
4 (9.1%)
|
0 (0%)
|
3 (12.5%)
|
|
|
Unchanged
|
1 (0.5%)
|
43 (27.7%)
|
0 (0%)
|
10 (29.4%)
|
1 (1.4%)
|
15 (28.3%)
|
0 (0%)
|
11 (25.0%)
|
0 (0%)
|
7 (29.2%)
|
|
|
Overall impact on in-office/clinical training
|
|
Significantly worsened
|
35 (18.1%)
|
6 (15.0%)
|
13 (18.8%)
|
14 (25.5%)
|
2 (6.9%)
|
p = 0.23
|
|
Slightly worsened
|
103 (53.4%)
|
23 (57.5%)
|
29 (42.0%)
|
30 (54.5%)
|
21 (72.4%)
|
|
Neither improved nor worsened
|
45 (23.3%)
|
11 (27.5%)
|
22 (31.9%)
|
8 (14.5%)
|
4 (13.8%)
|
|
Slightly improved
|
8 (4.1%)
|
0 (0%)
|
4 (5.8%)
|
3 (5.5%)
|
1 (3.4%)
|
|
Significantly improved
|
2 (1.0%)
|
0 (0%)
|
1 (1.4%)
|
0 (0%)
|
1 (3.4%)
|
|
Impact on surgical training
|
Peak impact
|
Current impact
|
Peak impact
|
Current impact
|
Peak impact
|
Current impact
|
Peak impact
|
Current impact
|
Peak impact
|
Current impact
|
|
|
Cancelled
|
0 (0%)
|
5 (1.9%)
|
0 (0%)
|
0 (0%)
|
0 (0%)
|
0 (0%)
|
0 (0%)
|
3 (6.5%)
|
0 (0%)
|
2 (8.3%)
|
|
|
Less frequent
|
135 (70.3%)
|
107 (40.8%)
|
32 (80.0%)
|
25 (67.6%)
|
48 (70.6%)
|
32 (57.1%)
|
39 (70.9%)
|
33 (71.7%)
|
16 (55.2%
|
14 (70.8%)
|
|
|
Same frequency but modified
|
53 (27.6%)
|
28 (10.7%)
|
7 (17.5%)
|
5 (13.5%)
|
18 (26.5%)
|
14 (25.0%)
|
16 (29.1%)
|
7 (15.2%)
|
12 (41.4%)
|
2 (8.3%)
|
|
|
Unchanged
|
4 (2.1%)
|
23 (8.8%)
|
1 (2.5%)
|
7 (18.9%)
|
2 (2.9%)
|
10 (17.9%)
|
0 (0%)
|
3 (6.5%)
|
1 (3.4%)
|
3 (12.5%)
|
|
|
Overall impact on surgical training (N = 193)
|
|
Significantly worsened
|
85 (44.0%)
|
15 (37.5%)
|
31 (44.9%)
|
23 (41.8%)
|
16 (55.2%)
|
p = 0.27
|
|
Slightly worsened
|
87 (45.1%)
|
20 (50.0%)
|
26 (37.7%)
|
29 (52.7%)
|
12 (41.4%)
|
|
Neither improved nor worsened
|
18 (9.3%)
|
5 (12.5%)
|
9 (13.0%)
|
3 (5.5%)
|
1 (3.4%)
|
|
Slightly improved
|
3 (1.6%)
|
0 (0%)
|
3 (4.3%)
|
0 (0%)
|
0 (0%)
|
|
Significantly improved
|
0 (0%)
|
0 (0%)
|
0 (0%)
|
0 (0%)
|
0 (0%)
|
|
Current in-office/clinical volume (n = 193)
|
|
< 25%
|
5 (2.6%)
|
0 (0%)
|
2 (2.9%)
|
3 (5.5%)
|
0 (0%)
|
p
= 0.02
|
|
25–49%
|
18 (9.3%)
|
1 (2.5%)
|
9 (13.0%)
|
7 (12.7%)
|
1 (3.4%)
|
|
50–74%
|
60 (31.1%)
|
8 (20.0%)
|
21 (30.4%)
|
19 (34.5%)
|
12 (41.4%)
|
|
75–99%
|
96 (49.7%)
|
28 (70.0%)
|
31 (44.9%)
|
24 (43.6%)
|
13 (44.8%)
|
|
100–124%
|
13 (6.7%)
|
3 (7.5%)
|
6 (8.7%)
|
1 (1.8%)
|
3 (10.3%)
|
|
> 124%
|
1 (0.5%)
|
0 (0%)
|
0 (0%)
|
1 (1.8%)
|
0 (0%)
|
|
Current surgical volume (n = 193)
|
|
< 25%
|
24 (12.4%)
|
3 (7.5%)
|
7 (10.1%)
|
11 (20.0%)
|
3 (10.3%)
|
p
= 0.03
|
|
25–49%
|
33 (17.1%)
|
4 (10.0%)
|
11 (15.9%)
|
10 (18.2%)
|
8 (27.6%)
|
|
50–74%
|
66 (34.2%)
|
13 (32.5%)
|
25 (36.2%)
|
16 (29.1%)
|
12 (41.4%)
|
|
75–99%
|
58 (30.1%)
|
17 (42.5%)
|
18 (26.1%)
|
18 (32.7%)
|
5 (17.2%)
|
|
100–124%
|
12 (6.2%)
|
3 (7.5%)
|
8 (11.6%)
|
0 (0%)
|
1 (3.4%)
|
|
> 124%
|
0 (0%)
|
0 (0%)
|
0 (0%)
|
0 (0%)
|
0 (0%)
|
|
Current research output (n = 193)
|
|
< 25%
|
32 (16.6%)
|
7 (17.5%)
|
16 (23.2%)
|
8 (14.5%)
|
1 (3.4%)
|
p = 0.87
|
|
25–49%
|
15 (7.8%)
|
4 (10.0%)
|
3 (4.3%)
|
5 (9.1%)
|
3 (10.3%)
|
|
50–74%
|
19 (9.8%)
|
1 (2.5%)
|
5 (7.2%)
|
7 (12.7%)
|
6 (20.7%)
|
|
75–99%
|
46 (23.8%)
|
9 (22.5%)
|
15 (21.7%)
|
13 (23.6%)
|
9 (31.0%)
|
|
100–124%
|
54 (28.0%)
|
15 (37.5%)
|
19 (27.5%)
|
16 (29.1%)
|
4 (13.8%)
|
|
> 124%
|
27 (14.0%)
|
4 (10.0%)
|
11 (15.9%)
|
6 (10.9%)
|
6 (20.7%)
|
|
Difference between actual versus expected:
|
|
Cataract surgeries (N = 163)
|
−36.9 (30.2; −170.0 to 18.0)
|
−34.5 (25.4; −100.0 to 3.0)
|
−34.9 (26.8; −120.0 to 17.0)
|
−38.5 (34.8; −170.0 to 18.0)
|
−41.4 (34.1; −145.0 to 0)
|
p = 0.79
|
|
Non-cataract surgeries (N = 175)
|
−14.3 (13.4; −85.0–10.0)
|
−13.5 (9.6; −34.0–0)
|
−14.8 (16.1; −85.0 to 10.0)
|
−14.1 (14.4; −85.0 to 10.0)
|
−14.6 (8.7; −35.0 to 0)
|
p = 0.97
|
|
Redeployment
|
|
Possible
|
159 (82.4%)
|
36 (90.0%)
|
56 (81.2%)
|
44 (80.0%)
|
23 (79.3%)
|
p = 0.56
|
|
Actual
|
33 (17.1%)
|
3 (7.5%)
|
26 (37.7%)
|
2 (3.6%)
|
2 (6.9%)
|
p
<0.0001
|
Bold values are statistically significant (p<0.05)
Table 3
Impact of COVID-19 on residency training experiences based on post-graduate year (PGY)
|
Year
|
All (N = 193)
|
PGY-1
(N = 16, 6.3%)
|
PGY-2
(N = 76, 30.2%)
|
PGY-3
(N = 82, 32.5%)
|
PGY-4
(N = 78, 31.0%)
|
p-Value
|
|
Impact on didactic training
|
Peak impact (
N
= 193)
|
Current impact (
N
= 155)
|
Peak impact (
N
= 6)
|
Current impact (
N
= 6)
|
Peak impact (
N
= 54)
|
Current impact (
N
= 54)
|
Peak impact (
N
= 67)
|
Current impact (
N
= 67)
|
Peak impact (
N
= 66)
|
Current impact (
N
= 28)
|
|
|
Cancelled
|
28 (14.5%)
|
3 (1.9%)
|
0 (0%)
|
0 (0%)
|
6 (11.1%)
|
1 (1.9%)
|
12 (17.9%)
|
1 (1.5%)
|
10 (15.2%)
|
1 (3.6%)
|
|
|
Less frequent
|
31 (11.8%)
|
11 (7.1%)
|
0 (0%)
|
0 (0%)
|
10 (18.5%)
|
3 (5.6%)
|
12 (17.9%)
|
2 (3.0%)
|
9 (13.6%)
|
6 (21.4%)
|
|
|
Same frequency but modified
|
127 (48.5%)
|
129 (83.2%)
|
6 (100%)
|
6 (100%)
|
35 (64.8%)
|
47 (87.0%)
|
40 (59.7%)
|
58 (70.7%)
|
46 (69.7%)
|
18 (64.3%)
|
|
|
Unchanged
|
7 (2.7%)
|
12 (7.7%)
|
0 (0%)
|
0 (0%)
|
3 (5.6%)
|
3 (5.6%)
|
3 (4.5%)
|
6 (7.3%)
|
1 (1.5%)
|
3 (10.7%)
|
|
|
Overall impact on didactic training
|
|
Significantly worsened
|
17 (8.8%)
|
1 (16.7%)
|
3 (5.6%)
|
7 (10.4%)
|
6 (9.1%)
|
p = 0.83
|
|
Slightly worsened
|
49 (25.4%)
|
3 (50.0%)
|
17 (31.5%)
|
18 (26.9%)
|
14 (21.2%)
|
|
Neither improved nor worsened
|
57 (29.5%)
|
0 (0%)
|
18 (33.3%)
|
16 (23.9%)
|
20 (30.3%)
|
|
Slightly improved
|
51 (26.4%)
|
2 (33.3%)
|
13 (24.1%)
|
18 (26.9%)
|
18 (27.3%)
|
|
Significantly improved
|
19 (9.8%)
|
0 (0%)
|
3 (5.6%)
|
8 (11.9%)
|
8 (12.1%)
|
|
Impact on in-office/clinical training
|
Peak impact (
N
= 193)
|
Current impact (
N
= 155)
|
Peak impact (
N
= 6)
|
Current impact (
N
= 6)
|
Peak impact (
N
= 54)
|
Current impact (
N
= 54)
|
Peak impact (
N
= 67)
|
Current impact (
N
= 67)
|
Peak impact (
N
= 66)
|
Current impact (
N
= 28)
|
|
|
Cancelled
|
60 (31.1%)
|
0 (0%)
|
0 (0%)
|
0 (0%)
|
11 (20.4%)
|
0 (0%)
|
25 (37.3%)
|
0 (0%)
|
24 (36.4%)
|
0 (0%)
|
|
|
Less frequent
|
128 (66.3%)
|
90 (58.1%)
|
6 (100%)
|
3 (50.0%)
|
41 (75.9%)
|
23 (42.6%)
|
41 (61.2%)
|
46 (68.7%)
|
40 (60.6%)
|
18 (64.3%)
|
|
|
Same frequency but modified
|
4 (2.1%)
|
22 (14.2%)
|
0 (0%)
|
2 (33.3%)
|
1 (1.9%)
|
9 (16.7%)
|
1 (1.5%)
|
9 (13.4%)
|
2 (3.0%)
|
2 (7.1%)
|
|
|
Unchanged
|
1 (0.5%)
|
43 (27.7%)
|
0 (0%)
|
1 (16.7%)
|
1 (1.9%)
|
22 (40.7%)
|
0 (0%)
|
12 (17.9%)
|
0 (0%)
|
8 (28.6%)
|
|
|
Overall Impact on in-office/clinical training
|
|
Significantly worsened
|
35 (18.1%)
|
0 (0%)
|
4 (7.4%)
|
17 (25.4%)
|
14 (21.2%)
|
p
= 0.003
|
|
Slightly worsened
|
103 (53.4%)
|
3 (50.0%)
|
27 (50.0%)
|
35 (52.2%)
|
38 (57.6%)
|
|
Neither improved nor worsened
|
45 (23.3%)
|
3 (50.0%)
|
17 (31.5%)
|
13 (19.4%)
|
12 (18.2%)
|
|
Slightly improved
|
8 (4.1%)
|
0 (0%)
|
5 (9.3%)
|
1 (1.5%)
|
2 (3.0%)
|
|
Significantly improved
|
2 (1.0%)
|
0 (0%)
|
1 (1.9%)
|
1 (1.5%)
|
0 (0%)
|
|
Impact on surgical training
|
Peak impact (
N
= 192)
|
Current impact (
N
= 163)
|
Peak impact (
N
= 6)
|
Current impact (
N
= 6)
|
Peak impact (
N
= 54)
|
Current impact (
N
= 54)
|
Peak impact (
N
= 67)
|
Current impact (
N
= 67)
|
Peak impact (
N
= 66)
|
Current impact (
N
= 36)
|
|
|
Cancelled
|
0 (0%)
|
5 (1.9%)
|
0 (0%)
|
0 (0%)
|
0 (0%)
|
1 (1.9%)
|
0 (0%)
|
3 (4.5%)
|
0 (0%)
|
1 (2.8%)
|
|
|
Less frequent
|
135 (70.3%)
|
107 (40.8%)
|
2 (33.3%)
|
5 (83.3%)
|
34 (63.0%)
|
34 (63.0%)
|
51 (77.3%)
|
47 (70.1%)
|
48 (72.7%)
|
21 (58.3%)
|
|
|
Same frequency but modified
|
53 (27.6%)
|
28 (10.7%)
|
4 (66.7%)
|
1 (16.7%)
|
16 (29.6%)
|
10 (18.5%)
|
15 (22.7%)
|
11 (16.4%)
|
18 (27.3%)
|
6 (16.7%)
|
|
|
Unchanged
|
4 (2.1%)
|
23 (8.8%)
|
0 (0%)
|
0 (0%)
|
4 (7.4%)
|
9 (16.7%)
|
0 (0%)
|
6 (9.0%)
|
0 (0%)
|
8 (22.2%)
|
|
|
Overall impact on surgical training (N = 193)
|
|
Significantly worsened
|
85 (44.0%)
|
1 (16.7%)
|
16 (29.6%)
|
38 (56.7%)
|
30 (45.5%)
|
p
= 0.03
|
|
Slightly worsened
|
87 (45.1%)
|
5 (83.3%)
|
29 (53.7%)
|
23 (34.3%)
|
30 (45.5%)
|
|
Neither improved nor worsened
|
18 (9.3%)
|
0 (0%)
|
7 (13.0%)
|
5 (7.5%)
|
6 (9.1%)
|
|
Slightly improved
|
3 (1.6%)
|
0 (0%)
|
2 (3.7%)
|
1 (1.5%)
|
0 (0%)
|
|
Significantly improved
|
0 (0%)
|
0 (0%)
|
0 (0%)
|
0 (0%)
|
0 (0%)
|
Bold values are statistically significant (p<0.05)
Most respondents (N = 159; 82.4%) were informed that they may be required to “redeploy” into work in
a non-ophthalmology specialty with 33 trainees (17.1%) reporting actual redeployment.
While the possibility of redeployment did not differ based on location (p = 0.56), the likelihood of actual deployment did differ (p <0.0001) with the highest chance occurring in the Northeast (N = 26; 37.7%) and the lowest in the Southern United States residencies (N = 2; 3.6%). Most residents were either “satisfied” or “very satisfied” with residency
program policies regarding COVID-19-related changes (N = 122; 63.2%), communication (N = 133; 68.9%), personal protective equipment policies (121; 62.7%), and COVID-19
testing of patients (N = 116; 60.1%), but less so regarding COVID-19 testing of residents (N = 82; 42.5%, [Table 4]).
Table 4
Resident satisfaction with program COVID-19 policies
|
Satisfaction with (N = 193):
|
Changes
|
Communication
|
PPE policies
|
Patient testing
|
Resident testing
|
|
Very dissatisfied
|
8 (4.2%)
|
3 (1.6%)
|
9 (4.7%)
|
9 (4.7%)
|
20 (10.4%)
|
|
Dissatisfied
|
25 (13.0%)
|
24 (12.4%)
|
27 (14.0%)
|
22 (11.4%)
|
41 (21.2%)
|
|
Neither satisfied nor dissatisfied
|
38 (19.7%)
|
33 (17.1%)
|
36 (18.7%)
|
46 (23.8%)
|
50 (25.9%)
|
|
Satisfied
|
87 (45.1%)
|
74 (38.3%)
|
72 (37.3%)
|
78 (40.4%)
|
53 (27.5%)
|
|
Very satisfied
|
35 (18.1%)
|
59 (30.6%%)
|
49 (25.4%)
|
38 (19.7%)
|
29 (15.0%)
|
The effect of COVID-19 on residents' personal lives varied but was mostly negative,
including time spent away from family due to quarantine (N = 104; 54.5%), increased expenses (N = 26; 13.6%), and worsened relationships with co-residents (N = 57; 29.8%) ([Table 5]); write-in responses for this question highlighted difficulties regarding childcare,
as well as concerns for dichotomy in surgical volume based on whether surgery-heavy
rotations were scheduled before or during the pandemic.
Table 5
Effect of COVID-19 on respondent personal life
|
Respondent (N = 193):
|
|
|
Time spent away from family
|
104 (53.9%)
|
|
Increased time to spend with family
|
79 (40.9%)
|
|
“Forced” changes in living situation
|
29 (15.0%)
|
|
Increased expenses
|
26 (13.5%)
|
|
Improved friendships with co-residents
|
38 (19.7%)
|
|
Worsened friendships with co-residents
|
57 (29.5%)
|
Discussion
Residency training has been substantially affected by the COVID-19 pandemic throughout
the United States and internationally. This is the first study to quantitatively assess
the perception of the impact of this pandemic on U.S. ophthalmology resident experiences
as well as contribution of the pandemic to personal stressors.
Overall, most trainees reported a negative perception of their clinical and surgical
experience during this time (“slightly worsened” or “significantly worsened”). The
reduced number of cataract and non-cataract cases, which likely occurred due to cancellation
of nonessential surgeries, substantiate this negative perception of surgical experience.
Currently, graduation from U.S. ophthalmology residency requires completion of 86
cataract surgeries.[18] While the present survey is unable to identify whether residents continued to meet
required case numbers, respondents reported an average of only 44.6% of their expected
number of cataract cases between March 2020 and the time of survey completion; one
can presume that surgical training was adversely affected, especially for residents
who scheduled surgery-heavy rotations during these affected months and those participating
in programs in which surgical training occurs primarily during the PGY4 year. While
in-office/clinical volume was perceived as returning to 75 to 99% at the time of the
survey compared with prepandemic, 63.7% of respondents perceived surgical volume as
less than 75% of pre-pandemic volumes, with only 12.2% of respondents reporting return
of volume to 100 to 124% of pre-pandemic volume. This suggests that the surgical experience
is particularly susceptible to the impact of the pandemic without appropriate compensatory
return of volume; therefore, one important area of focus for training programs is
augmentation of the resident surgical experience.
Interestingly, the perceived impact of COVID-19 pandemic on didactic, clinical, and
surgical training did not vary among regions despite the temporal differences in the
COVID-19 case volume surge by region, as the first COVID-19 surge occurred sooner
in the Northeast compared with the Midwest, South, and Western regions.[19] This may be due to the design of the study, which allowed participants to define
what they considered as the peak. Additionally, patients and hospitals may have modified
their behavior, including cancellation of elective surgeries or fewer patients presenting
for nonessential visits, due to concern about the pandemic even if they were located
in regions with relatively fewer COVID-19 cases. Regardless of region, most ophthalmology
trainees nationwide deemed their overall clinical and surgical experience to have
been negatively impacted by the pandemic suggesting that trainees in programs in all
locations, even those with relatively fewer COVID-19 cases, may require dedicated
efforts to enhance their residency experience.
Other studies have investigated the impact of the pandemic on other subspecialties;
notably, there have been reports of the impact of the pandemic on urology, otolaryngology,
and plastic surgery training, which may yield useful insights as these are relevant
surgical subspecialties with numerous nonemergent procedures similar to ophthalmology.[20]
[21]
[22]
[23]
[24] Multiple other fields have also reported effects on the residency experience, including
reduction in training and surgical volume, anxiety about professional future, and
indelible compromise on their training.[20]
[21]
[22]
[25]
[26]
[27] These impacts are reported among different specialties both internationally[25]
[28]
[29]
[30] and within the United States[20]
[26]
[27] despite international differences in residency structure, suggesting that insights
regarding the effect of the pandemic on the training experience may transcend geographical
borders and specialties.
International studies assessing the effect of the pandemic on ophthalmologists and
ophthalmology trainees have reported significant negative impact of the pandemic on
the overall experience with reductions in clinical and surgical volume.[31]
[32]
[33]
[34] These findings parallel the results from our study including the effect on clinical
and surgical training. Within the United States, ophthalmology program directors in
New York City (NYC) offered perspective on modifications to residency programs, including
telemedicine, virtual lectures, and residency support meetings.[4] Bakshi et al similarly provides commentary on suggested modifications to the residency
experience without directly sharing the trainee perspective.[2] Other proposed modifications include surgical videos and simulation exercises such
as a remote cornea wet laboratory and oculoplastics virtual curriculum, which may
help address the decreased volume and worsened surgical experience reported by respondents
in our study.[35]
[36]
[37] Two publications involve firsthand accounts of ophthalmology resident experiences
in Iowa and NYC,[7]
[38] in which both redeployed and nondeployed residents discuss the influence of the
pandemic on their residency experience. These perspectives echo many of the findings
in our study, including clinical, surgical, and didactic modifications, changes in
social support and loneliness experienced by trainees, and alterations in approach
to patient care, with additional anxiety and stress resulting from fear of possible
redeployment from ophthalmology to taking care of COVID-19 patients and the enormous
emotional, mental, and physical tolls associated with redeployment.
Our study also assesses the effect of the pandemic on personal lives of ophthalmology
trainees. More respondents reported increased time spent away from family (53.9%)
compared with those reporting increased time to spend with family (40.9%). Co-resident
interpersonal relationships were also affected, with 29.5% reporting worsened friendships
with co-residents compared with 19.7% reporting improved friendships during this time.
This decreased time with family and co-residents is important to identify as loneliness
may be associated with burnout despite reduced work hours.[39] Studies have investigated the psychological impact of COVID-19 on mental health
outcomes including depression, anxiety, and insomnia of practicing ophthalmologists
and trainees; 32.6 to 50% of ophthalmologists reported symptoms of depression, 46.7%
reported anxiety symptoms, and 15% reported insomnia.[31]
[40]
[41] While the baseline mental health status of ophthalmologists prepandemic is unknown,
possible stressors include pervasive uncertainty inherent in the pandemic, concern
for patient, personal, and family risks of infection, loved ones suffering from complications
of COVID-19 including hospitalization and death, stigmatization targeting health care
professionals by mainstream media, and effects on career due to reduced patient volume.[40] As the pandemic continues, it is imperative to consider implementing support for
the emotional and mental health of ophthalmology trainees to facilitate trainee well-being
and maintain quality of patient care.[4]
The pandemic has resulted in a multifaceted influence on the ophthalmology trainee
experience, with short-term and long-term effects on clinical and surgical training
as well as personal stressors that may lead to reduced well-being. It is essential
to develop and implement strategies to address these factors to maximize the residency
experience, as the impact of the pandemic may extend well into the future especially
with the continual increase in COVID-19 cases.
Online didactics appear to be an effective method of addressing the challenges of
teaching while maintaining appropriate social distance.[31] Additional advantages of these online didactics include the possibility of recording
lectures for future availability, ability to adjust lecture time and location convenient
to the attendees and lecturer, and expansion of didactics to those who may not have
had access previously. Prior studies reported that transition to online and virtual
lectures and conferences was considered valuable.[31] The implementation of these resources may result in the perceived lack of effect
of the pandemic on the didactic experience reported by U.S. ophthalmology residency
trainees in this study.
Augmentation of clinical experiences may include virtual clinics, telemedicine, and
telephone consultations, which may lead to a shift toward routine use of virtual clinics
and novel technology in the future.[42]
[43] Despite the decrease in in-person volume, patients still present with vision and
possible life-threatening pathology, with one study demonstrating that patients with
conditions leading to vision changes, pain and photophobia, ocular malignancies, ocular
trauma, and retinal pathology resulting in vision loss or requiring intravitreal injections
continued to present for in-person evaluation during the COVID-19 pandemic.[44] Additionally, patients may present with pathology as a direct or indirect effect
of COVID-19; ophthalmic manifestations of COVID-19 include follicular conjunctivitis,
anterior uveitis, retinal changes including microhemorrhages and cotton wool spots,
optic neuritis, and cranial nerve palsies,[45] and additional cases reported include rhino-orbital mucormycosis in a patient with
COVID-19, orbital emphysema due to intubation for COVID-19 pneumonia, and UV keratopathy
due to increased consumer purchase and exposure to commercial UV light disinfectants
during the pandemic.[46]
[47]
[48]
[49] Thus, although methods to increase clinical volume should be implemented, the potential
for high-quality patient encounters and experiences with interesting pathology persists
despite decreased volume. Of note, although patients continued to present with emergent
and urgent ophthalmic pathology, the pandemic may have resulted in the avoidance or
delay in care for some individuals who may eventually present with more severe stages
of their ophthalmic condition; further studies are required to evaluate this in detail.
The pandemic has especially affected resident surgical experience due to cancellation
of elective cases and decreased volume. While not a direct substitute for operating,
surgical videos may be an alternative to observation of cases that may develop surgical
and nontechnical skills including decision-making and surgical planning.[50] Interestingly, acquisition of both motor and cognitive skills may be achieved through
observation.[51] This suggests that recording and publishing surgical videos online may be useful
to facilitate learning; moreover, this may promote an online forum for discussion
of different techniques to collaboratively share knowledge and ideas beyond what may
have occurred with a single in-person, unrecorded operating room observation. However,
while observation and surgical videos are important, muscle memory is also essential
to develop fine motor skills and techniques for ophthalmologic surgery. Simulation-based
tools may be key to develop techniques to maintain and augment surgical skills; surgical
simulation has been shown to positively impact ophthalmology resident surgical skills,
including shorter phacoemulsification times, less phacoemulsification power, and lower
complication rates.[52]
[53] Although data are equivocal regarding whether simulation-based training, including
model simulation, is superior to standard surgical training,[54]
[55] simulation-based training may allow for development of skills that may be transferable
to the operating room after surgical volume returns to normal.[56] Of note, simulation-based training should not replace surgical training but rather
may serve as a temporizing measure to maintain surgical skills in the setting of unavoidable
transiently decreased volume.
While this study provides insight into the experience of ophthalmology residents during
the pandemic, it has several limitations. Participants were included based on applications
to the Bascom Palmer residency and fellowship programs, which may not capture all
ophthalmology residents impacted by the pandemic. Since there are limited published
demographics regarding the overall population of ophthalmology residents, it is difficult
to compare our respondents to nonrespondents and to the population. However, the geographic
distribution of respondents did not differ significantly from the geographic distribution
of ophthalmology residency positions, suggesting that respondents may be representative,
at least geographically, of the overall resident population. Recall bias and response
bias are also inherent limitations of survey studies. Not all invited participants
opened or completed the survey, which may be an additional source of participation
bias, although 22.8% of those who opened the email with the survey invitation completed
the survey. Our study attempts to provide both qualitative and quantitative data regarding
perceived experiences in residency, which may lead to subjectivity. Our study also
aimed to evaluate the resident experience at the perceived worst time of COVID and
the present time, which may have flaws including geographic bias due to the variation
in the time course of COVID-19 impact on the health care system within each region,
although there was no statistically significant difference in perceived impact among
different regions. Moreover, we included the perceived experience of PGY4 trainees
at the time of the survey, which may involve their first year of practice in either
fellowship or as an attending following graduation from residency and therefore may
not reflect the true residency trainee experience.
COVID-19 has substantially impacted the clinical and surgical experience of ophthalmology
residents throughout the United States. This impact is likely to persist as the pandemic
continues and a “new normal” is ultimately established. It is important to identify
gaps in training to create novel learning methods and creatively apply emerging technologies
to augment the training experience and provide a new foundation for the didactic,
clinical, and surgical experience that will endure the challenges of this pandemic.
Moreover, insights from this pandemic may be applicable in optimizing resident experience
and allocation of resources in potential additional surges of COVID-19 and future
pandemics. Connections and collaboration are essential for enhancing the training
experience as well as providing mutual support and solidarity among colleagues as
we face the adversity of this time, serving patients and navigating this pandemic
together.
