RESEARCH ARTICLE |
https://doi.org/10.5005/jp-journals-10028-1610 |
Impact of COVID on Training in Urogynecology in the United Kingdom
1,5Department of Urogynaecology, King’s College Hospital, England, United Kingdom
2Department of Urogynaecology, John Radcliffe Hospital, Oxford University Hospitals, England, United Kingdom
3Department of Urogynaecology, Cambridge University Hospitals, Cambridge, United Kingdom
4Department of Urogynaecology, NHS Greater Glasgow & Clyde (NHSGGC), Glasgow, United Kingdom
Corresponding Author: George Araklitis, Department of Urogynaecology, King’s College Hospital, England, United Kingdom, Phone: +442032993568, e-mail: george.araklitis@nhs.net
Received on: 27 January 2022; Accepted on: 15 June 2022; Published on: 10 April 2023
ABSTRACT
Aim: To assess how training has been impacted in urogynecology by coronavirus disease 2019 (COVID-19) pandemic.
Materials and methods: Questionnaire sent to trainees doing urogynecology advanced training skills module (ATSM) and subspecialty trainers in the United Kingdom.
Results: Around 83% of doctors felt their training had been negatively impacted by the pandemic, with a reduction in operating time being the significant factor. There has also been a reduction in other clinical activities as well as educational courses. Trainees anticipated an extension to their training. Similar findings were confirmed by trainers, where 73% felt their trainee needed at least 6 months of training extension.
Conclusions: The COVID-19 pandemic has had a significant impact on the training of future consultants. The Royal College of Obstetricians and Gynaecologists (RCOG), alongside Health Education England (HEE), has tried to find ways to help with this problem. Training in the future will need to adjust and change with the use of technology and other novel ideas.
Clinical significance: Training in the future will need to adjust and change with the use of technology and other novel ideas.
How to cite this article: Araklitis G, Baines G, Pradhan A, et al. Impact of COVID on Training in Urogynecology in the United Kingdom. J Postgrad Med Edu Res 2023;57(1):15-18.
Source of support: Nil
Conflict of interest: None
Keywords: Advanced training skills module, Education, Observational study, Subspecialty, Training, Urogynecology.
INTRODUCTION
In the United Kingdom, there have been three national lockdowns due to COVID-19 since March 2020. This has led to the suspension of nonemergency medical care, such as face-to-face clinic appointments and elective surgery in the subspecialty of urogynecology. In addition, many trainees, and consultants, were redeployed to other clinical areas to support the needs and demands of the hospital due to the pandemic.1 This resulted in disruption and cancellation of educational activities for trainee doctors.2 Hands-on surgery has always been the most difficult aspect of training for surgical trainees, and the cancellation of surgery due to COVID-19 has had a major impact on the subspecialty of urogynecology.
High-level training in this subspecialty is achieved either through ATSM or subspecialty training (SST).3 The difference between the two training options is that SST involves completion of more surgical competencies, and completion of a research component and is achieved through competitive entry.
The pandemic has led to great anxiety amongst trainee doctors regarding the impact on their training, progression through the annual review of competence progression (ARCP) process, and date of completion of training. The British Society of Urogynaecology (BSUG) training committee aims to improve standards in training. In response to concerns by trainees, the committee wanted to assess the impact of training to inform the RCOG SST committee and plan for future needs.
MATERIALS AND METHODS
A questionnaire was generated to discover if and how COVID-19 had impacted on training in urogynecology. This was circulated via BSUG to ATSM trainees nationally, to the BSUG associate members (trainees) and shared on urogynecology trainee social media groups in April 2021. It was also sent to the 11 urogynecology SST program supervisors (SSTS) on March 2021, to understand their views on the impact that the COVID-19 pandemic has had on their trainees. All responses were anonymized.
RESULTS
ATSM
A total of 24 trainees completed the questionnaire from every region in the United Kingdom. Among them 21% were specialty trainee (ST6), 50% ST7, 4% post Certificate of Completion of Training (CCT) and 25% in a non-training grade. These individuals had registered for the ATSM between February 2016 and June 2020. Three trainees (13%) were registered for the optional laparoscopic module. A total of 67% of respondents were working full time with 33% less than full time. About 29% of individuals had to spend time at home when they would have normally been at work and this time varied from 2 days to 3 months. The average number of hours worked increased for 21% of people and decreased for 8%.
Around 83% (20 doctors) felt that their training had been negatively affected by COVID-19. Changes in operating lists affecting training were reported by 88% of trainees, with 76% reporting changes in urodynamic studies clinics (Table 1). Other factors impacting on training include changes to outpatient clinics, fewer opportunities for teaching and courses and access to educational supervision (Table 1).
| 88% | Operating lists |
| 76% | Urodynamics |
| 66% | Outpatient clinics |
| 58% | Teaching sessions/courses |
| 50% | Inpatient care |
| 38% | Rota changes |
| 17% | Access to educational supervisor |
| 4% | Change in staffing levels |
A total of 75% of trainees anticipate that COVID-19 will affect their training progression or delay their CCT date. A quarter of respondents had already received a COVID-19 outcome (10.1 or 10.2) at their last ARCP, and 83% of these felt that this was due to difficulties with completing the urogynecology ATSM. A COVID-19 outcome recognizes that the trainee was achieving progress, but that acquisition of some capabilities has been delayed by the impact of the pandemic. Nine trainees (38%) stated that they require an extension to training and six trainees (25%) anticipate an extension. Of those people requiring or anticipating an extension to training, the time scale of the extension varied from 3 months to ‘‘at least a year’’ with five trainees (33%) expecting 12 months or more. Due to lack of training, three (13%) trainees had to change to an alternative ATSM due to the concern that completion was not achievable.
Free text comments from the trainees highlighted the importance of operating to progress with the ATSM and the lack of operating available during the pandemic due to the nonurgent nature of urogynecology surgery leading to the cancellation of cases. Some procedures, such as sacrospinous fixation, required travel to other units to complete, which again had been hindered by COVID-19. A word cloud (Fig. 1) highlights common themes from the free text comments.
Fig. 1: Word cloud from free text comments made by ATSM trainees
SST
All 11 SST trainers filled in the questionnaire. Ten (91%) trainers felt that the delivery of their training program had been adversely affected by the pandemic. Only one (9%) trainer felt there was no impact on the delivery of the training in their unit.
In the outpatient setting, 63% of clinics stopped, with only 36% returning back to normal capacity. About 64% were now hybrid clinics with both virtual and face- to face-consultations. Only 18% were pure face-to-face clinics. All trainers felt it had some impact on training, ranging from ‘‘a little’’ (18%), ‘‘moderately’’ (46%) to ‘‘significantly’’ (36%).
From a surgical perspective, no lists were stopped completely over the entire period, but 64% had stopped, restarted, and then stopped again. The majority (46%) had a severe reduction (>50% compared to normal activity). All units had their surgical activity negatively affected.
Around 73% of trainers felt their trainees would need their training time extended. These SSTS felt at least an extra 6 months of training would be needed. This was thought to be due to both outpatient and surgical services being affected (62.5%).
A total of 64% of urogynecology consultants were redeployed to help with on-call rotas and cesarean section lists. The majority of trainers (72%) were not aware at the time of the questionnaire when work would return to a normal pattern.
Free text comments by the trainers, highlighted reduced training activities and surgery, with extension highly likely (Fig. 2).4-9
Fig. 2: Word cloud from free text comments made by SSTS
CONCLUSION
This review of ATSM trainees and SST trainers highlights the big impact the COVID-19 pandemic has had on urogynecology services and, ultimately, on training. The common themes between the two groups were the cancellation or reduction of theatre cases. The majority of ATSM trainees and SSTS, feel that training will need to be extended by at least 6 months. Only 2 units felt that their trainee would not need an extension to their training because they were coming towards the end of training and had most of their competencies signed off already. What was worrying was that with extra training needed due to reduced activity, the majority of trainers were unaware of when normal timetables would return.
These negative views and concerns by both trainees and trainers may have serious implications for future recruitment into urogynecology. Future trainees and consultants may consider that training opportunities and timely completion of training are preferable in other subspecialties of obstetrics and gynecology.
In April 2021, the RCOG released the restoration and recovery document. Patients who need urgent review within 30 days include those having a trial without catheter, urinary retention, and pessary problems such as bleeding, ulceration, and fistulation. All other urogynecology pathologies can be delayed beyond 30 days. Surgical cases have been given priority levels. Most urogynecology procedures are graded as either priority III (up to 3 months) or priority IV (beyond 3 months). Despite this attempt at workload recovery, in some units, theatre lists have become less frequent or shared amongst specialties. This means that urogynecology patients requiring surgery are at the bottom of waiting lists as priority III or IV.
In May 2021, HEE released a statement on training recovery. Their aim is to reduce the number of trainees with learning gaps and thus reduce those requiring extra time in training. To achieve this, they have secured funding from the department of health, although there does not seem to be any specific plan from them. Instead, it involves individual trainers and trainees developing and implementing the recovery solution with the aid of finance. Whether this proves successful is awaited.
The RCOG recognize that surgical training has recently been interrupted by the pandemic, but has also been adversely affected by the European working time directive, change in working patterns, loss of traditional apprenticeship, and development of nonsurgical and outpatient procedures. On a national level, it is suggested that simulation training and courses can help, along with the help of subspecialist societies. They recommend protected time in consultant job plans for surgical and simulation training. The use of surgical theatres in private hospitals may help both reduce waiting lists and improve training. They recognize that training needs to be balanced along with demands on gynecological services from the public.
On a regional and local level, there are plans for a nominated surgical lead to work with college tutors to assess individual training needs and match them to the appropriate surgical jobs. Units can apply for equipment for simulation training and consideration of a laparoscopic box trainer for trainees. Regional leads should work with the industry to identify courses to aid training. This document also helpfully has ‘‘top tips’’ for both trainers and trainees to maximize surgical training.
With the end of the pandemic still not imminent, other innovative solutions and strategies need to be adopted to aid postgraduate education and training. Two emergent technologies are artificial intelligence (AI) and learning analytics. AI uses ‘‘thinking machines’’ to teach and interact, whilst the latter collects data to inform trainers of learning outcomes and progress and predict learning trajectories.
Successful adoption and implementation of new technology by both trainers and trainees will determine if it can improve the mode of teaching. In a survey of students and lecturers at a medical school in South Korea, the majority of students wanted to maintain online teaching, whilst over half of the lecturers wanted to revert back to traditional teaching methods. Although the use of technology has its advantages, trying to initiate a different teaching and learning culture may be a challenge.
This may be successful for certain types of training but nothing can really replace hands-on surgical experience. This is where simulation and virtual reality certainly have a role. Access to this would be through the aid of courses, industry, and hospital skills labs. Surgical simulation app’s, such as Touch Surgery, allows trainee surgeons to maintain their skills. Live streaming of operations with the use of devices such as snapchat glasses may be a useful learning tool.
CLINICAL SIGNIFICANCE
The COVID-19 pandemic has had a profound negative effect on those individuals registered for the urogynecology ATSM and subspecialty trainees. This is predominantly due to reductions in operating lists and access to cases and procedures. The majority either have, or anticipate that they will, require an extension to training. It has highlighted the difficulties within the subspecialty with the nature of urogynecology being nonurgent. It is important to address these problems as significant delays in training may affect trainee completion dates and workforce planning, including recruitment into urogynecology. This survey will help inform the RCOG, trainers, trainees, and regional deaneries about the impact of the pandemic on urogynecology.
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