ASRA Pain Medicine Update

Cite as: Entz R. The impact of the COVID-19 pandemic on the training and research experience of the Canadian anesthesia residents. ASRA News. 2021;46. https://doi.org/10.52211/asra050121.039.

The COVID-19 pandemic has greatly impacted healthcare systems throughout the world. Resilience and adaptability of resident physicians have been challenged during this unprecedented time. The prioritization of service and safety has disrupted traditional educational frameworks for the training of anesthesia residents. There are widespread reports of the effect of COVID-19 on learners,¹ and this article serves to improve understanding of the impact on training, exposure, research, and general wellbeing that Canadian anesthesia residents have experienced at the University of Alberta.

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As a skills-based specialty, anesthesia residents’ training may be suffering disproportionately compared to other services.

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In late March 2020 during the first wave of the pandemic, Alberta Health Services, Alberta’s province-wide health system, announced the postponement of all elective surgeries. Rooms available for resident training were drastically decreased. At some academic centers, regular resident scheduling was no longer feasible and was changed to on-call-only slating. This disproportionately affected subspecialty rotations. This persisted until early May 2020 when scheduled procedures were resumed. Scheduled surgeries were once again reduced in October 2020 during the second wave, and in December 2020 procedures requiring subsequent admission were reduced by 60% because of reduced hospital capacity secondary to a surge in hospital/intensive care unit admissions with COVID-19. These changes have limited residents to an increased number of elective ambulatory surgeries - meaning healthier ASA I or II patients - while opportunities to care for sicker patients have been fewer during regular daily hours. During on-call hours, we still take care of patients on the other end of the spectrum, some of which are even moribund secondary to late presentation.

As a skills-based specialty, anesthesia residents’ training may be suffering disproportionately compared to other services.² Senior staff have more routinely performed some procedures to spare resident exposure. Endotracheal intubation is well-established as an aerosol generating medical procedure and is thought to pose increased risk for nosocomial transmission of COVID-19 to clinicians. Although the absolute risk of transmission associated with intubation in the context of COVID-19 remains unclear,^3-5 many institutions and clinicians have adjusted their approach. Residents are performing considerably fewer bag-mask-ventilations or intubations using direct laryngoscopy and are more often using videolaryngoscopy to limit attempts and exposure. This impairs development of a fundamental skill for anesthesia residents. This decreased exposure also has extended to extubations, and learners may have missed opportunities dealing with post-extubation airway complications. These attempts to limit learner risk also have affected anesthesia residents on off-service rotations who missed out on many emergency department presentations involving shortness of breath and useful scoping procedures during rotations such as emergency medicine and otolaryngology, respectively. Some of these opportunities are unique to residency and are unlikely to be remediated.

Research opportunities for residents also have been affected. Perhaps the biggest obstacle is in relation to data gathering. Given the postponement of elective surgeries, data have the potential to be skewed to urgent/emergent populations or patients coming for day procedures. Most of the clinical research, unless COVID-19 related, has been postponed or cancelled due to university restrictions to mitigate virus transmission. Some residents have chosen to pursue quality improvement projects to avoid these challenges. More funding opportunities have been available for projects related to COVID-19, and this has produced some unique projects. For instance, one resident was involved in a project evaluating the potential of a plexiglass intubation box to act as a barrier during potentially aerosolizing intubations.⁶ The opportunities for in-person presentations on our annual Research Day also have been changed to virtual presentations limited to the residents in their final year. 

Testing and licensing for residents has been postponed. Junior residents are expected to complete part two of a licensing examination required by the Medical Council of Canada (MCC) to be fully licensed and eligible to extend. Extending is a process where licensed residents can provide coverage overnight for other services for increased pay. Many residents use these opportunities to supplement their income, aid in loan repayment, and provide for their families. COVID has impacted the ability to extend, as residents who would have been eligible in previous years have been unable to obtain their license from the MCC due to examination cancellation. More than two scheduled sittings of this examination have been cancelled during 2020, and examinations for the foreseeable future will be completed remotely as opposed to the traditional objective structured clinical examination-style method⁷. The oral portion of the Royal College Examination also was cancelled in 2020. Residents graduating in 2020 did not have the opportunity to be evaluated in this practical context. This may have implications on their future ability to be hired and may lead to subsequent graduating years questioning the necessity for this expensive and resource-intensive portion of the examination.

Medical student matching to a residency program is also susceptible to the pandemic.⁸ Canadian medical students have been precluded from pursuing electives in other provinces. This not only limits their exposure to other programs but also the program’s experience to potential applicants. The process of matching, facilitated by the Canadian Resident Matching Service (CaRMS), typically involves in-person interviews at each potential site. This process has been replaced in 2021 by online interviews. This is a disadvantage for students in several ways. The CaRMS tour, particularly meeting residents from each program at the interviews and social events, allows applicants to determine where they might fit in by exposing them to the program, the residents in that program, and the city. Additionally, touring with other hopefuls builds a spirit of camaraderie with those who will be future colleagues. Accepting applicants into a residency position is an important commitment for the programs as positions are limited and applicants will reflect on the institution. There is concern that programs will be biased toward candidates from their home schools, as they have had a chance to work with and get to know these candidates and they may be seen as less of a risk.

Perhaps the most important impact of the COVID-19 pandemic on anesthesia residents is the psychological stress. It is well established that healthcare workers have experienced increased anxiety, stress, depression, and insomnia during the pandemic.⁹ Isolation is a concern, particularly in anesthesia where learners work one-on-one with staff and have limited interaction with others in their cohort. Residents depend on academic days, resident gatherings, and annual retreats to come together and establish support and a sense of community. Many residents are also experiencing separation from their families and facing a lack of support and encouragement. Further adding to the strain is the loss of outlets like team activities, gyms, social clubs, and similar experiences, which many people rely on to stay happy and healthy. A component of fear is also involved – fear of personal exposure, uncertainty surrounding PPE guidelines and supplies, and concern for the safety of loved-ones. Limited time and resources during residency mean that, for many residents, wellness often takes a back seat, and this has been greatly compounded by the feelings of isolation associated with COVID-19. We do have a formalized mentorship program that pairs residents with specific, voluntary members of staff for support. Residents see each other via Zoom during academic half days, and we have a group-wide WhatsApp chat, started in the wake of the pandemic and exclusive to anesthesia residents. Additionally, designated wellness representatives are available at each site for support during this time.

Focusing on the negative impacts of the pandemic on Canadian anesthesia residents’ training is easy, but there are some positive impacts as well. As previously mentioned, increased opportunity and funding is available in research related to the pandemic. Educational opportunities also have become available; at our center, an anesthesia-resident run simulation session was held to help internal medicine residents meet critical airway program requirements. Many have felt a sense of responsibility to their communities and satisfaction that comes with contributing to care in a time of true need. This pandemic has provided a chance for residents to show professionalism and to see this exemplified in the staff members they aspire to emulate. Training for practice during this trying time is a unique experience that tests learners but also provides unique opportunities.

Rebecca Entz, BSc, MD, is a year-2 resident in the department of anesthesiology and pain medicine at the University of Alberta in Edmonton, Canada.

References

1. Sneyd JR, Mathoulin SE, O'Sullivan EP, et al. Impact of the COVID-19 pandemic on anaesthesia trainees and their training. Br J Anaesth. 2020;4:450-455. https://doi.org/10.1016/j.bja.2020.07.011.
   
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3. El-Boghdadly K, Wong DJN, Owen R, et al. Risks to healthcare workers following tracheal intubation of patients with COVID-19: a prospective international multicentre cohort study. Anaesthesia. 2020;11:1437-1447. https://doi.org/10.1111/anae.15170.
   
4. Begley JL, Brazil V. Assessing the risk of nosocomial infection posed by COVID‐19 tracheal intubation: the first intubateCOVID results. Anaesthesia. 2020;75:1544. https://doi.org.login.ezproxy.library.ualberta.ca/10.1111/anae.15219.
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7. Medical Council of Canada Website. Ottawa, ON: Medical Council of Canada. Available at: https://mcc.ca/. Accessed March 19, 2021.
   
8. Niburski K, Nguyen DD, Ingelmo P, Buu N. Impact of COVID-19 on Canadian anesthesia resident matching: challenges and opportunities for applicants. Can J Anesth/J Can Anesth. 2021;68:430–431. https://doi.org/10.1007/s12630-020-01878-z. 
9. Vizheh M, Qorbani M, Arzaghi SM, Muhidin S, Javanmard Z, Esmaeili M. The mental health of healthcare workers in the COVID-19 pandemic: A systematic review. J Diabetes Metab Disord. 2020;19:1967–1978. https://doi.org/10.1007/s40200-020-00643-9.