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\begin{document}

\title{Impact of the COVID-19 pandemic on Otolaryngology trainee
education}



\author[1]{Ehab Y. Hanna, MD, FACS}%
\affil[1]{The University of Texas MD Anderson Cancer Center }%


\vspace{-1em}



  
  \date{March 14, 2025}


\begingroup
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\selectlanguage{english}
\begin{abstract}
\textbf{Background} The COVID-19 pandemic has reduced clinical volume
with a negative impact on trainee education.~ ~{}\textbf{Methods} Survey
study of Otolaryngology trainees in North America, during the COVID-19
pandemic in April 2020.~ \textbf{Results} Of 216 respondents who
accessed the survey, 175 (83\%) completed the survey. Respondents
reported a universal decrease in clinical activities (98.3\%). Among
participants who felt their program utilized technology well, there were
significantly decreased concerns to receiving adequate educational
knowledge (29.6\% vs. 65.2\%, p=0.003).~ However, 68\% of trainees still
expressed concern in ability to receive adequate surgical training. In
addition, 54.7\% of senior trainees felt that the pandemic had a
negative impact on their ability to secure a job or fellowship after
training. \textbf{Conclusions} Trainees universally felt a negative
impact due to the COVID-19 pandemic.~ Use of technology was able to
alleviate some concerns in gaining adequate educational knowledge, but
decreased surgical training remained the most prevalent concern.%
\end{abstract}%



\sloppy




\section*{\texorpdfstring{Theresa Guo, MD,\textsuperscript{1} Kimberley L
Kiong, MBBS, \textsuperscript{1} Christopher MKL Yao, MD,
\textsuperscript{1} Melina Windon, MD,\textsuperscript{2} Denna Zebda,
MD, \textsuperscript{3} Yelda Jozaghi, MD, \textsuperscript{1} Xiao
Zhao, MD, PhD, \textsuperscript{1} Amy Hessel, MD, \textsuperscript{1}
Ehab Hanna, MD,
FACS\textsuperscript{1}}{Theresa Guo, MD,1 Kimberley L Kiong, MBBS, 1 Christopher MKL Yao, MD, 1 Melina Windon, MD,2 Denna Zebda, MD, 3 Yelda Jozaghi, MD, 1 Xiao Zhao, MD, PhD, 1 Amy Hessel, MD, 1 Ehab Hanna, MD, FACS1}}

{\label{114800}}

\textsuperscript{1}Department of Head \& Neck Surgery, The University of
Texas MD Anderson Cancer Center, Houston, TX, United States

\textsuperscript{2}Department of Otolaryngology-Head \& Neck Surgery,
Johns Hopkins University School of Medicine, Baltimore, MD, United
States

\textsuperscript{3}Department of Otorhinolaryngology-Head \& Neck
Surgery, McGovern Medical School, The University of Texas Health Science
Center at Houston, Houston, TX, United States

Funding: 2T32DC000027-26 (MW)

Corresponding Author: Ehab Hanna, MD University of Texas MD Anderson
Cancer Center 1400 Pressler Street Houston, TX 77030 Office:
(713)-835-1001 Fax: (713)-794-4662 E-mail: {eyhanna@mdanderson.org}

Running title: Impact of COVID-19 on Otolaryngology education

Key words: Resident education; surgical training; COVID-19; didactic
education; career planning

\par\null

\textbf{Introduction}

Due to the COVID-19 pandemic, there has been a significant decrease in
clinical activities, reduction of elective surgeries, and restriction of
workforce to essential personnel in hospitals nationwide including among
Otolaryngology departments.\textsuperscript{1} Otolaryngology programs
have faced significant reductions in surgical case volume to conserve
resources, with many institutions limiting trainee
coverage.\textsuperscript{2-4} In addition, some trainees have been
redeployed to practice outside of their specialty to meet the rising
need for COVID-19 related medical care.\textsuperscript{5} As these
parameters only begin to ease, their impact on education and
specifically surgical training is limited,\textsuperscript{6,7} and
questions have been raised as to whether surgical training will need to
be extended to ensure adequacy.\textsuperscript{6,8}

In Otolaryngology, concerns regarding reduction in surgical and
specialty-specific clinical training are layered with concerns regarding
personal safety and protection. Among healthcare providers,
otolaryngologists have been reported as among the highest risk for
exposure and infection due to close contact with mucous membranes that
may contain high viral load\textsuperscript{9,10} and performance of
high risk procedures such as mucosal surgery and
tracheostomy.\textsuperscript{11}

In the setting of social distancing, didactic teaching sessions have
moved to virtual classroom and lecture
models.\textsuperscript{8,12}Models of online education, such as the
Global On-Line Fellowship program, have shown the potential efficacy of
remote learning within Otolaryngology-Head and Neck
Surgery.\textsuperscript{13} In addition to changes in clinical
experiences, national gatherings that contribute to trainee education
and career advancement including national conferences, oral board
examinations, and accreditation testing have been either postponed or
cancelled.\textsuperscript{6,8} Lastly, some trainees are preparing to
begin their careers at a time of uncertainty both for the healthcare
system and the economy.

A recent resident survey during the COVID-19 area showed that 73\%
residents continue to feel concerned about contracting the virus and its
impact on their training.\textsuperscript{4} To further explore the
impact of the COVID-19 pandemic on Otolaryngology trainee education and
impact on future career, we performed a survey of Otolaryngology
residents and fellows in the United States (US) and Canada regarding
educational experiences, use of technology and related concerns
surrounding safety and future career during the COVID-19 pandemic.

\textbf{Materials \& Methods}

After exploratory discussions with trainees at differing levels of
training, a 45-question survey was generated to evaluate changes in
Otolaryngology trainee experiences related to participation in clinical
activities, concerns regarding safety and future career. IRB exemption
was obtained through MD Anderson Institutional Review Board through
expedited review. Responses were binary (yes or no) or measured on a
5-point Likert scale, with select open ended questions regarding impact
on future career, greatest challenges, and skills gained. Additional
demographic information including trainee level, length of training
program and geographic location was collected. Geographic location
included broad regions within the United States, based on US census
regions and Canada. Participation was voluntary and solicited
electronically. Program directors from the US and Canada were invited to
share the survey to their trainees. To maintain anonymity and compile
adequate data for evaluation, a minimum of 100 survey results were
sought. Survey responses were collected between April 14-21, 2020,
during the COVID-19 pandemic.

Descriptive statistics were performed on aggregated survey results.
Subgroups were analyzed based on geographic location. Geographic
location was considered to be a high COVID-19 region if there were on
average greater than 100 COVID-19 cases per 100,000 persons, captured
April 21, 2020 (Supplemental Table 1). In addition, subgroups were
analyzed based on trainee level (Junior, PGY 1-3, compared to senior
level trainees, PGY 4-5 \& fellows). Likert scale responses were treated
as ordinal categorical variables. Comparisons were made among answers
and respondent characteristics using Pearson's Chi-squared test.
Correction for multiple testing was performed using the
Benjamini-Hochberg method. Statistical analysis was performed using
Microsoft Excel (2016, Microsoft Corporation, Seattle, WA) and Stata
version 14.1 (StataCorp, College Station, TX).

\textbf{Results}

A total of 216 trainees accessed the survey, and 175 respondents (83\%)
completed the online survey, including 159 residents and 16 fellows
(Table 1), and all regions of the continental US, and Canada were
represented (Figure 1). Half of the respondents (88, 50.3\%) responded
from high COVID-19 geographic locations.

\emph{Clinical activities}

Nearly all participants (98.3\%) reported an overall decrease in
clinical activity at their training hospital. Likewise, 97\% reported a
reduction in their involvement with in-person clinic visits and 94\%
reported a reduction in participation in the operating room (OR). Most
trainees (64\%) reported that they were not participating in any
in-person clinic visits, though 25\% of respondents reported some
participation in telemedicine visits. Fewer participants reported a
reduction in inpatient and on-call duties (54.3\%) with 33.7\% reporting
an increase in these duties.

\emph{Non-clinical educational activities}

A majority (62.3\%) of participants reported an increase in didactic
educational activities and 65.7\% reported that their program had
instituted a required educational curriculum (Table 2). Interestingly, a
significantly higher proportion of participants in high COVID-19 regions
reported an increase in didactic activities (p=0.011) and a required
curriculum (p=0.035). Most participants (86.9\%) felt their department
utilized technology to good effect for educational activities, and again
this was higher among participants from high COVID-19 regions (95.4\%
vs. 78.2\%, p=0.011). Educational activities included participation in
collaborative multi-institutional educational efforts (61.7\%) as well
as institution based education (62.3\%). Tools utilized during social
distancing included Zoom \& WebEx for lectures including collaborative
consortiums, resident lectures and journal clubs. Additional electronic
resources used included OtoSim, AAO courses, COCLIA, Headmirror podcasts
and online textbook reading.

With regard to conducting research, about one third of participants
(29.1\%) reported a reduction in research activities, a third reported
no change, and a third reported an increase in research activity
(34.9\%). A greater proportion of participants reported a reduction in
research activities if their research prior to the pandemic involved
recruitment of clinical subjects (71.4\%) or laboratory-based research
(71.4\%).

Most respondents felt that their education during the pandemic was
either extremely or very important (57\%) or somewhat important
(30.3\%), while 13\% felt that their education was not so important
during the pandemic. This did not differ by training level (p=0.10), but
participants in high COVID-19 areas trended towards a stronger feeling
that their education was either extremely or very important (65.9\% high
COVIDvs. 47.1\% low COVID, p=0.072).

Despite acknowledging the importance of education, the majority (89.7\%)
of respondents felt that their education and training had been
negatively impacted by the pandemic. In particular, two-thirds of
participants were concerned about receiving adequate surgical training.
Smaller proportions of participants expressed concern about receiving
adequate training in clinical decision making (42.9\%) and educational
knowledge (34.3\%). Concerns regarding adequate training did not
significantly differ by trainee level, however, there was a trend
towards fewer senior level trainees expressing concerns for adequate
training (Table 2). Notably, 29.1\% (n=51) of participants expressed
concern in their ability to complete key indicator cases needed to
graduate, and these concerns were acknowledged similarly by both junior
(27.2\%) and senior residents (39.2\%, p=0.116, fellows excluded).

Participants in high COVID-19 regions reported less concern about
receiving adequate educational knowledge (23.8\% vs. 44.8\%, p=0.025)
and a trend towards less concern in receiving adequate training in
clinical decision making (32.9\% vs. 52.9\%, p=0.062) compared to
participants in low COVID-19 regions. These differences were not seen
when examining concerns regarding adequate surgical training.

Concerns regarding adequate educational knowledge were decreased (29.6\%
vs. 65.2\%) among participants who felt their program was able to
utilize technology well (p=0.003), though not significantly correlated
with whether a program had a required educational curriculum (p=0.250),
or participation in collaborative education effort (p=0.403). Use of
technology was not associated with concerns regarding adequate training
in clinical decision-making (p=0.199) or surgical training (p=0.690).

\emph{Safety and other concerns}

The majority of trainees reported that they were provided adequate PPE
for participation both in the operating room (81\%) and in the inpatient
or ER setting (82.3\%, Table 3). However, 43\% still reported that they
also acquired their own PPE. Most participants (76\%) felt safe and
protected performing their clinical duties, and 85\% of respondents felt
that their department was supportive of suggestions and feedback. While
trainees overall felt supported by their departments, some major
concerns included exposure to the virus (70\%), infecting others with
the virus (87.3\%), and the safety of co-workers (72.8\%). Challenges
that trainees reported facing included ``changing policies and
guidelines'' surrounding PPE, ``lack of transparency of leadership''.
Additional challenges included ``coping with collective and personal
anxiety'', ``feeling not useful'', ``dealing with the unknown'' and
hoping for more ``mental health resources.'' The most frequent
challenges cited (half of respondents) were related to reduced
``surgical training,'' decreased clinical experience, and junior
residents not being able to participate in OR or inpatient encounters.

\emph{Impact on future}

Participants were asked to report their level of concern regarding a
variety of additional factors. 59\% of trainees expressed feeling
worried about ``not receiving enough training before I graduate,'' and
43.9\% expressed concerns about their ability to achieve future career
goals. Cancellation of training courses and conferences directly
impacted 60-70\% of participants. For those nearing the completion of
training, 16.6\% reported that they were impacted by cancellation or
rescheduling of interviews, and 23.4\% were impacted by change in
qualifying exam schedules. A third of respondents (35.3\%) felt that the
pandemic has had a negative impact on their ability to secure a job or
fellowship at the completion of training, and 14.9\% reported that the
pandemic had impacted decisions regarding their future. These concerns
were more prevalent in senior level trainees, with a majority (54.7\%)
reporting a negative impact on their ability to secure a job or
fellowship (Table 3). These impacts included loss of opportunities
(``decreased job availability''; ``missing out on a full rotation'';
``diminished surgical experience \ldots{} will not be able to perform
{[}specific{]} cases as a generalist, previously had aimed to''),
considering fellowship training versus general ENT practice (``was
considering private practice\ldots{} (will need to) see what economics
of the practices will look like''; ``considering if fellowship will be
necessary to increase \ldots{} exposure to surgical cases''),
considering private practice vs. academic practice (``less likely to go
to an academic institution''; ``academics {[}have{]} more financial
protection'') and needing to delay next steps (``have to delay my
fellowship''; ``impact my career timeline'').

\textbf{Discussion}

Otolaryngology trainees have been faced with the challenge of achieving
clinical knowledge and technical competency in the midst of lost
clinical volume and new threats to personal safety caused by the
COVID-19 pandemic. Herein, we report the results of a survey of North
American Otolaryngology residents and fellows, providing additional
insight into their perspective on the effects of the pandemic on their
education, safety, and future. Building on current published
reports,\textsuperscript{4} we found a near-unanimous reduction in
clinical volume, a dominant feeling that the pandemic has negatively
affected surgical training as has been previously
reported.\textsuperscript{4} In addition, we found that use of
technology in high COVID prevalent areas was able to alleviate some
concerns in receiving adequate educational knowledge and further
describe how the pandemic may impact future career.

Otolaryngology programs have experienced vast reductions in surgical
case load in response to the American College of Surgeons and the
Surgeon General's encouragement for cancellation of elective
cases.\textsuperscript{1,4,14} Atop a lighter case load, resident
participation in the operating room (OR) at more than 60\% of
institutions in a recent survey limiting cases to faculty alone or
senior level trainees.\textsuperscript{4} Two-thirds of survey
participants expressed concern regarding their ability to receive
adequate surgical training, representing one of the most prevalent
concerns across trainee level and geographic area. This apprehension
appeared to be more closely related to personally developing surgical
expertise rather than fulfilling administrative case requirements, as
concern around ability to graduate and complete key indicator cases were
only around half as prevalent. Indeed, a survey of surgical head and
neck fellows showed 82\% had already reached adequate case numbers for
certification by mid-April of 2020.\textsuperscript{15} The ACGME issued
a special communication to address resident concerns regarding training
requirements in the current context wherein the reduction in elective
operations and the potential for training extension was recognized.
Graduation of trainees will be based on the discretion of the program
director of the trainee's surgically competency.\textsuperscript{7,16}

A lower proportion (43\%) of participants were concerned about training
in clinical decision-making. Although almost all participants
acknowledged a reduction in in-person clinic participation, about a
quarter of respondents reported participation in telemedicine visits.
For trainees, telemedicine visits allow for engagement in patient care,
and familiarity with a new patient care setting that may be a part of
their future practice. With the reduction in surgical caseload, the
inpatient census has likewise seen a decrease. Half of trainees in the
survey reported reduced participation in call or inpatient duties, which
remain a critical aspect of training.\textsuperscript{17,18} Call duties
present new challenges to personal safety, with potential high risk
exposures through performance of aerosol generating procedures, where
residents are at the frontline of initial
evaluation.\textsuperscript{3,19} If adequate PPE is not immediately
available, trainees must weight their duty to patients with a duty to
protect themselves from undue risk of harm.\textsuperscript{20} Given
the risk of aerosol generation during common otolaryngology procedures
including flexible laryngoscopy and mucosal surgery, multiple sources
have recommended the use of at least N95 or equivalent mask, surgical
masks, gown, gloves and eye protection.\textsuperscript{21,22} Some
institutions are limited by resource availability, and 93\% of
otolaryngology residents reported concerns regarding PPE shortages in a
recent publication.\textsuperscript{4} Some hospitals have requested the
re-use of N95 masks, and sterilization techniques have been
described.\textsuperscript{23}

It is thus heartening to note that more than 80\% of respondents had
been provided with adequate PPE. On the other hand, up to 50\% of survey
respondents indicated that they acquired their own PPE. We did not
explore the reasons for this, but postulate that reasons may include
differential hospital PPE guidelines, availability, and personal comfort
level. From the results of our survey, it is apparent that safety is the
top concern for trainees. Similar to prior survey findings,
communication and transparency is critical to allay trainee concerns and
impart a sense of control.\textsuperscript{4}

In response to the pandemic, many institutions have rapidly transitioned
to use of technology for delivery of didactic or interactive lectures,
including strategies such as ``flipped classroom'', social media-based
platforms with online practice questions, and
teleconferences.\textsuperscript{7,24} Examples of tremendous
collaborative efforts to supplement otolaryngology resident education
include the Collaborative Multi-Institutional Otolaryngology Residency
Education Program (CMIOREP, University of Southern
California),\textsuperscript{25} Great Lakes Otolaryngology Consortium
(GLOC, Case Western Reserve University),\textsuperscript{26} and the
Consortium of Resident Otolaryngology kNowledge Attainment (CORONA,
University of Kentucky).\textsuperscript{27} These programs boast wide
participation---CORONA, for example, includes 42 collaborator
institutions, and reports over 400 daily participants globally.

Interestingly, we found that trainees in high COVID-19 prevalence
regions had a greater increase in didactic activities, more often had a
required curriculum and felt technology was used to good effect for
educational activities. Accordingly, we found that trainees whose
programs utilized technology well, had fewer concerns in regards to
obtaining adequate education knowledge. These differences may reflect
that regions with high COVID-19 prevalence were prescient towards the
education needs during this changing environment, and implemented
curricular changes at an earlier time. We also found there was a trend
towards junior residents expressing greater concern towards their
ability to receive adequate training in clinical and surgical
experiences. This may reflect preferential case coverage by senior
residents, or concern about the effects of the pandemic lasting longer
than these few months, potentially impact their training in the long
term. While increased didactic activities had an impact in allaying
concerns about adequate educational knowledge, the concerns regarding
adequate surgical training were prevalent across all levels and regions.
In the setting of limited clinical operations, surgical training may
require supplements through developing virtual simulation-based
training, cadaver courses, and increased involvement of trainees in the
operating room when restrictions ease.

Trainee responses were heterogeneous regarding research productivity.
Various national research institutions including National Institute for
Health Research (NIHR), biotechnology, and pharmaceutical companies
across the world have had to suspend clinical
trials,\textsuperscript{28,29} and research laboratories across the
country have likewise suspended non-essential research. As expected,
trainees in our study pursuing laboratory based and research requiring
contact with clinical research subjects felt a decrease in their ability
to continue research work, but others were able to increase clinical
research activities. For surgical trainees who have seen their clinical
volumes reduced, devoting time to clinical research may represent a
valuable opportunity to develop an important skill set during this time.

Lastly, otolaryngology trainees are looking to begin their future
careers at a time when companies conduct massive layoffs and many
hospitals are imposing hiring freezes.\textsuperscript{30} Our study
found a majority of senior trainees felt a negative impact on their
ability to secure a job or fellowship at the completion of training.
Some decided to ``choose (a) job that I wouldn't have necessarily
chosen'' or defer entering the job market while entertaining the idea of
further training to ``increase certain exposure of surgical cases''.
Several respondents reflected that private physicians with a career
performing elective surgeries may be more affected by a pandemic and
economic pressures, and have begun rethinking their career goals. As a
major goal of training is preparing for the next steps in future career,
training programs will need to consider how to support their senior
level trainees during this time of uncertainty.

\textbf{Conclusions}

The COVID-19 pandemic has challenged our community to consider how we
balance our needs for educating trainees for future practice, and our
call to duty to conserve resources in fighting this global pandemic as
physicians. As take small steps forward in reopening clinical
operations, additional limits, safety precautions and social distancing
measures are likely to continue in the near future. We show that use of
technology can mitigate some of the negative impact of decreased
clinical exposure, and in the era of social distancing programs should
continue develop virtual curriculums for training education. However,
there is still room for improvement in ensuring trainees receive
adequate surgical training to prepare for their future careers during
this pandemic.

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\textbf{Hosted file}

\verb`Tables_COVID_trainee_HED-20-1112.docx`  available at \url{https://authorea.com/users/312328/articles/461372-impact-of-the-covid-19-pandemic-on-otolaryngology-trainee-education}



\textbf{Hosted file}

\verb`Supplemental_Table_1_HED-20-1112.docx`  available at \url{https://authorea.com/users/312328/articles/461372-impact-of-the-covid-19-pandemic-on-otolaryngology-trainee-education}

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