1 Introduction

The COVID-19 pandemic has upended the global public health landscape, overwhelmed healthcare infrastructures worldwide and taxed hospital resources with an uncertain timeline and an unprecedented magnitude.^1,2 With physicians of frontline medical disciplines working at maximum capacity, physicians of non-frontline medical disciplines including residents-in-training were redeployed to the frontlines of COVID-19 care, and orthopedic resident physicians were of no exception.^3–8 The orthopedic resident physicians worldwide play an indispensable role in the global healthcare workforce given the essential need for trained healthcare professionals for the management of trauma and disaster victims.

In line with the recommendations of the WHO (World Health Organization) and CDC (The US Centers for Disease Control and Prevention), healthcare systems worldwide had implemented radical changes by adopting system-sustaining measures of isolation, resource conservation and manpower reallocation strategies, considering the uncertain timeline of this crisis.^3–5,9 A few regional studies have assessed the impact of these changes on the well-being, safety, and training of orthopedic resident physicians at a national/regional level.^{4–8,10–13} However, there is limited quantitative data available from these studies.

The challenges confronted by the orthopedic resident physicians redeployed to the COVID-19 frontlines are unique, considering their unfamiliarity in handling critical medical illness, coupled with the loss of valuable on the ground learning activities due to the decrease in clinical and surgical case volumes. The varying intensity of the pandemic across countries and the capacity of each nation's health infrastructure to handle the pandemic could likely have a direct influence on their resident workforce.^14–17 This study aims to comprehensively investigate the impact of the COVID-19 pandemic on the well-being, safety, and training of orthopedic residents at a global level, as well as to analyze the challenges confronted by orthopedic residency programs across the world to safeguard and train their residents during this period. It also aims to provide an insight into possible regional variations.

2 Materials and methods

3 Results

Of the 1193 participants, 1077 (960 males, 117 females) responded(response rate of 90·3%). Mean respondent age was 30·3 ± 3·6 years(range, 24–50 years). Other demographic data are showed in Table 1.

3.1

3.1 Resident work schedule

Significant changes were observed in the structure of the orthopedic residency curriculum globally during the COVID-19 pandemic, Table 2, Fig. 1(Supplemental Digital Content). The total hours per week spent on residency program-related activities decreased by an average of 24·7 h (95% CI, −26·5 to −22·9;p < 0.001), with the reduction in residency work hours being significantly greater in the more affected as compared to less-affected countries (28·9 h versus 22·8 h, respectively). Further breakdown found a significant decrease in time spent on emergency trauma care services, outpatient clinics, faculty lectures, and clinical demonstrations/case discussions (p-values<0·001), with the impact being more significant in the more affected countries, Table 2s (Supplemental Digital Content).

Table 2 Comparison of orthopedic residency training before and during the COVID-19 pandemic.

	Before COVID-19	During COVID-19		p-value
	Frequency (%)	Frequency (%)
aQ8 vs Q19. Hours per week spent in orthopedic residency program (mean ± SD)	63.6 ± 28.0	38.8 ± 30.7		<0.001 mean difference = −24.7 (95% CI, −26.5 to −22.9)
Q9 vs Q20. Hours per week spent on emergency trauma care services/duty				<0.001
None	4 (0.4)	0
≤6 h	166 (15.5)	44 (31.3)
7–12 h	200 (18.7)	333 (22.7)
13–24 h	275 (25.7)	241 (20.0)
25–48 h	266 (24.8)	213 (15.1)
49–72 h	99 (9.2)	34 (3.2)
>72 h	62 (5.8)	37 (3.5)
Q10 vs Q21. Hours per week spent in orthopedic outpatient clinic				<0.001
Orthopedic clinics closed	11 (1.0)	171 (16.0)
≤2 h	93 (8.6)	237 (22.2)
3–5 h	165 (15.3)	280 (26.2)
6–10 h	381 (35.4)	223 (20.9)
11–15 h	239 (22.2)	91 (8.5)
>15 h	188 (17.5)	65 (6.1)
Q11 vs Q22, Q23. Hours per week spent in Operation Theatre (OT)		Elective (n = 1069)	Emergency (n = 1051)
None	1 (0.1)	307 (28.7)	4 (0.4)
≤2 h	25 (2.3)	161 (15.1)	350 (33.3)
3–5 h	48 (4.5)	222 (20.8)	282 (26.8)
6–10 h	189 (17.6)	154 (14.4)	215 (20.5)
11–15 h	256 (23.8)	83 (7.8)	79 (7.5)
16–20 h	236 (22.0)	42 (3.9)	43 (4.1)
>20 h	319 (29.7)	100 (9.4)	78 (7.4)
Q12 vs Q24. Hours per week spent attending faculty lectures				<0.001
None	51 (4.8)	272 (25.7)
≤2 h	36 (3.4)	284 (26.8)
3–5 h	303 (28.4)	276 (26.0)
6–10 h	465 (43.5)	151 (14.2)
>10 h	213 (19.9)	77 (7.3)
Q13 vs Q25. Hours per week spent attending clinical demonstration				<0.001
None	174 (16.3)	422 (39.6)
≤2 h	11 (1.0)	374 (35.1)
3–5 h	425 (39.8)	192 (18.0)
6–10 h	459 (42.9)	77 (7.2)
Q14 vs Q26. Teaching methods used
Lectures by faculty	750 (70.3)	355 (34.5)		<0.001
Clinical demonstration	701 (65.7)	269 (26.2)		<0.001
Journal club, interactive discussion	626 (58.7)	261 (25.4)		<0.001
Symposia	318 (29.8)	106 (10.3)		<0.001
Webinars, online symposia	190 (17.8)	589 (57.3)		<0.001
Telecasting recorded lectures	57 (5.3)	211 (20.5)		<0.001
Telecasting recorded video of orthopedic surgery with discussion by faculty	55 (5.2)	103 (10.0)		<0.001
Q27. Usefulness of teaching methods as rated by residentsc, median [IQR]
Lectures by faculty	4 (3–5)	··
Clinical demonstration	4 (3–5)	··
Journal club, interactive discussion	3 (2–4)	··
Symposia	3 (2–4)	··
Webinars, online symposia	3 (2–4)	··
Telecasting recorded lectures	3 (2–4)	··
Telecasting recorded video of orthopedic surgery with discussion by faculty	3 (3–4)	··
Changes in final year residency curriculum ( b N=327)	Frequency (%)
Q37. Residency duration extended	162 (49.5)	··
Q38. Postponement of certification examination	231 (70.6)	··
Q39. Preponement of certification examination	77 (23.5)	··

a “Q” denotes the question number in the survey questionnaire.

b “N” denotes the number of final year residents who participated in the survey (calculated from questions 6 and 7). The analysis for questions 37,38,39 considered only responses from the final year residents.

c Scored on a 5-point Likert scale (1- least useful and 5- most useful).

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Fig. 1 Impact of COVID-19 pandemic on residency curriculum, resident education, and resident well-being.

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3.2

3.2 Impact on resident training

A significant decrease in faculty-delivered lectures (70.3%–34.5%, p < 0.001), clinical case demonstrations/discussions (65.7%–26.2%, p < 0·001), journal clubs (58.7%–25.4%, p < 0.001) and symposia (29.8%–10.3%, p < 0.001), with a corresponding increase in the use of webinars/online symposia (17.8%–57.3%, p < 0.001), telecasting of recorded lecture s(5.3%–20.5%, p < 0.001), and surgical videos moderated by faculty (5.2%–10.0%, p < 0.001) were observed, Table 2. This change in the landscape of orthopedic residency education was radical in the more affected than less-affected countries, evidenced by a two-fold increase in the adoption of modern teaching tools (webinars, online symposia, telecasting of lectures and surgical videos), Table 2s (Supplemental Digital Content). A regional analysis showed that the use of virtual educational methods was lesser in Africa (11·3%), Asia (16·1%) and the Middle East (18·5%) as compared to North America (36·1%), South America (29·3%), and Europe (24·4%), Fig. 2A (Supplemental Digital Content). However, the average satisfaction level for online teaching methods (3 out of 5 [IQR 2–4]) was lower than that for traditional teaching methods (4 out of 5 [IQR 3–5]), Table 2.

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Fig. 2 Regional variations in the challenges confronting the global orthopedic resident workforce during the COVID-19 pandemic.

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4 Discussion

Residency training constitutes a limited timeframe during which a resident must acquire the core competencies of medical knowledge, patient care, practice-based learning, kinesthetic skills (for surgical specialties), leadership, interpersonal and communication skills, and professionalism to meet the accepted standards of graduation.¹⁸ Achieving a balance between clinical work, surgical training, academic endeavors and research in ideal circumstances, is in itself a challenging task. The COVID-19 pandemic has profoundly disrupted this balance.

Our finding that orthopedic residents were redeployed to perform duties outside their residency curriculum was similarly observed in other studies although the percentage of redeployed residents varied between countries.^{4–8,11,12,19} Recent studies show that more orthopedic residents from Europe (18%–20.9%) were redeployed to the COVID-19 frontlines as compared to USA (7%), which aligns with our observations that a greater percentage of residents from the Middle East, Asia and Europe were redeployed to the COVID-19 frontlines.^4,7 This could likely be attributed to the increased demand to manage the relatively greater number of COVID-19 cases in these regions, at the time of survey, coupled with a lower physician:population ratio in Asia and the Middle East.^14,15,17 Our observation that most residents were involved in the care of stable COVID-19 patients in wards and in screening for COVID-19 illness at fever clinics/emergency departments aligns with the findings of Chang D et al.⁶

From our data, only 46.5% and 58.4% of residents underwent training in critical care or PPE usage, respectively. A significantly lesser percentage of residents from North America, Europe, and Africa had received critical care training as compared to other regions. A recent study from USA reported that 79.2% of their residents had received training on PPE usage.⁴ Another study from Europe reported that 60.3% of redeployed orthopedic residents had not received any specific training for COVID-19 care.⁷ A survey of orthopedic residents from South Korea reported that 42.4% of residents had not received PPE training.⁶ Redeploying resident physicians of surgical specialties to work outside the zone of their expertise without adequate training can increase the likelihood of errors due to lack of competency and can impose a great psychological burden on them.^20,21 Residents of non-frontline medical specialties should be trained in life support skills and critical care before being redeployed for the care of seriously ill COVID-19 patients. Restructuring residency programs globally to integrate life support skills and critical care training, will ensure better preparedness of the resident workforce for possible future public health crisis.

A recent survey on orthopedic residents from South Korea reported that the major zones of exposure to SARS-CoV-2 were in the COVID-19 wards and fever clinics/emergency departments, which aligns with our findings.⁶ With our data showing that, only 58.4% of the surveyed residents had been trained on the appropriate use of PPE, and 15.4% of residents (a greater percentage of them from Africa, Europe, and Asia) concerned about the adequate availability of PPE, they are at a substantial risk of being infected with SARS-CoV-2. In a recent study from USA, 35% of residents expressed concerns on the adequate availability of PPE which aligns with our findings.⁴ High-exposure risks, insufficient protective measures, and health system unpreparedness are important factors responsible for the increased risk of infection in healthcare workers(HCWs).²² With healthcare systems dependent on an adequate resident physician workforce, it is vital to safeguard them by ensuring adequate availability of high-quality PPE, implementing context-dependent appropriate PPE usage, minimizing exposure by adopting a rotating team strategy with “active-duty” and “self-isolated remotely-working” resident teams, conducting regular health assessments and self-isolating residents with comorbid illness.^23,24

From our data, 28.5% of the surveyed residents (greater percentage of them from Africa, Middle East, and South America), reported that their institutions lacked formal guidelines to tackle infectious outbreaks and 23% residents reported lack of institutional updates on current COVID-19 scenarios and guidelines, with residents expressing only moderate satisfaction with their institution's management of COVID-19 crisis. Our finding that residents expressed lack of confidence in their institution's ability to handle the COVID-19 crisis was similarly observed in another study from the USA.⁴ Governments should ensure that their healthcare systems formulate guidelines and contingency plans to tackle the ongoing and possible future public health crisis. Healthcare structures should maintain active communication channels with their resident physician workforce, providing constant updates about current scenarios, updated guidelines and their implications for residents. This will help mitigate residents' uncertainty on the ability of their institution and nation to manage the crisis, while boosting their morale to work confidently.⁴

Our finding of a decrease in time spent on key resident training activities (outpatient clinics, orthopedic surgeries) was similarly observed in studies from Europe, Italy, USA, Pakistan, Iran, and Singapore.^{4,5,7,8,10,11,13,19,21} However, no quantitative data is available from these countries. A more recent study from South Korea, quantitatively assessed the significant decrease in time spent in outpatient clinics, elective and emergency orthopedic surgeries which aligned with our observations.⁶ In a recent study from Europe, 58.6% of orthopedic residents reported that their surgical training was significantly impaired.⁷ This is likely attributed to the direct effects of measures taken for minimizing the transmission of infection, resource conservation and reallocation, thereby resulting in cancellation of outpatient clinics and elective surgeries, with redeployment of residents to COVID-19 work, and self-isolation or quarantine.^3,4,9,20,25 Our data shows that 48.8% of residents were kept in self-isolation to minimize exposure to infection, which was similarly observed by Chang D et al.⁶ Recent studies show that most hospitals adopted a rotating-team policy with active-in-duty and remotely working self-isolated teams.^{3,4,6,7,19,23,26} A significant decrease in in-person teaching activities like faculty-led didactics and clinical case discussions was observed in our study with similar observations reported from Europe, USA, South Korea and Singapore.^{4–7,10,11,21}

The significant decrease in time spent in outpatient clinics and faculty-supervised elective surgeries deprives residents of opportunities to hone their clinical and surgical skillsets through repeated practice and real-case experiences, resulting in inability to meet their board eligibility and graduation requirements. Institutions across the world should embrace technology-based virtual teaching methods to maximize learning amidst in-person restrictions.^18,27–29 Educational institutions, national/international academic bodies and professional societies around the world should collaborate to restructure residency programs to integrate technology-based training, develop structured e-learning resources and virtual didactic curriculums with free access and make education globally accessible, through online centralized/regionalized teaching sessions and virtual academic conferences. With the use of virtual teaching platforms and video-conferencing technologies, learning can be made accessible to residents across geographical boundaries. Resident participation in telehealth clinics will be useful to maintain their clinical learning experience.^12,23,28 Video-based coaching,^29,30 and surgical simulation tools^31,32 will be a valuable aid for residents to sharpen their kinesthetic skills in addition to the limited hands on surgical experience available from participation in essential and emergency surgeries.

Our observation of an increase in the use of technology-based virtual teaching modalities, aligns with findings from other studies.^{4–8,10,11,13,20} However, we observed that this transition to a technology-based virtual education was significantly marked in the Americas and Europe as compared to Africa, Middle East, and Asia. While previous studies have reported the usefulness of these techniques,^18,29,30 we observed that residents’ satisfaction level for these techniques was lower than for the traditional methods of learning. Similar observations were made by Chang D et al.,⁶ and Funke K et al.²⁷

Our observation that residents had their residency duration extended and certification examinations postponed aligned with the findings of recent studies from USA and Europe.^3,4,7,11,12 Program leaderships and academic bodies must come up with innovative and objective methods to assess resident competencies together along with restructuring of the minimum graduation requirements and EPA(Entrustable Professional Activity) targets to accommodate the new technology-based training methods.^18,23,27,28

With 80.5% (n = 860) of our surveyed residents having no previous experience working in infectious outbreaks, they are prone to psychosocial stress and burnout. Despite adopting a variety of coping methods to overcome their stress, residents' self-rated QOL dramatically decreased during the pandemic, with similar findings from Chang D et al.⁶ Our data showed that the most significant stressors for residents was the concern for their family's health, followed by personal health, uncertainty surrounding the timeline of residency and inadequate training. A recent study from South Korea, recorded similar observations.⁶ In a study involving general surgery residents from Boston, 100% residents reported that their most significant concern related to COVID-19 outbreak was the health of their family.⁴ Other studies have shown that residents were concerned about fulfillment of graduation requirements, inadequate training and residency timeline.^{4,5,7,11,12,31} Healthcare institutions should ensure the availability of professional psychological support and resident wellness programs, establish crisis hotlines, maintain active communication channels to address residents' concerns, and host routine virtual social hours to foster camaraderie between faculty and residents.^4,11,31 Though redeployment has forced residents of non-frontline medical specialties to work beyond the scope of their training, it is a valuable opportunity for them to work in concert with colleagues from other medical disciplines, foster camaraderie, and broaden their professional network, that will enable them to provide holistic patient care through a multidisciplinary team approach in future. By working in crisis situations like this, residents gain valuable lessons in systems-based practice, resource optimization, teamwork, and also acquire attributes like courage, empathy, resilience, grit in the face of adversity, adaptability and leadership, which will prepare them to face future crisis.

Author contributions

AB and HWDH conceptualized the research question. AB, HWDH and NRU designed the study methodology. All the authors were involved in investigation and data curation. AB, HWDH, NRU, HWT, and JB were involved in formal analysis and interpretation of the data. HWDH and HWT did the statistical analysis of the acquired data. AB, HWDH, HWT wrote the original draft. AB, HWDH, IA, NRU, MC supervised the work. All the authors critically reviewed the manuscript, provided critical feedbacks, and gave approval for the final version to be published. All the authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Role of the funding source

Nil.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Submission declaration

The research has not been previously presented or published elsewhere or is currently under consideration for publication elsewhere. This publication is approved by all authors and tacitly or explicitly by the responsible authorities where the work was carried out, and that, if accepted, it will not be published elsewhere in the same form, in English or in any other language, including electronically without the written consent of the copyright-holder.

CRediT authorship contribution statement

Aju Bosco: Conceptualization, Methodology, Investigation, Data curation, Formal analysis, Writing – original draft, Writing – review & editing, Supervision, Project administration. Hui Wen Tay: Investigation, Data curation, Formal analysis, Writing – original draft, Writing – review & editing, Software. Ilyas Aleem: Investigation, Data curation, Writing – review & editing, Supervision. Mustafa Citak: Investigation, Data curation, Writing – review & editing, Supervision. Nalli Ramanathan Uvaraj: Methodology, Investigation, Data curation, Formal analysis, Writing – review & editing, Supervision, Project administration. Jong-Beom Park: Investigation, Data curation, Writing – review & editing. Morio Matsumoto: Investigation, Data curation, Writing – review & editing. Oliver Marin-Penna: Investigation, Data curation, Writing – review & editing. Janakiraman Buvanesh: Investigation, Data curation, Writing – review & editing, Formal analysis, Software. Moin Khan: Investigation, Data curation, Writing – review & editing. Hwee Weng Dennis Hey: Conceptualization, Methodology, Investigation, Data curation, Formal analysis, Writing – original draft, Writing – review & editing, Supervision, Project administration.