Keywords
hand trauma - faciomaxillary injury - malignancy reconstruction - aesthetic procedures
- webinar - conferences
Introduction
The coronavirus disease 2019 (COVID-19) pandemic has led to drastic changes in the
practice and training of plastic surgery, especially in India where a prolonged lockdown
was implemented.[1]
[2] As a response to this, policies were formulated to address the pandemic while providing
continuity of care for emergent non-COVID illnesses.[3]
[4]
[5] Although the role of our specialty in direct care of COVID-19 patients is limited,
our role in reconstruction following trauma, burns, and malignant tumor resection
comprises a significant proportion of essential services. There has been a significant
change in the surgical management protocols to ensure judicious use of resources and
minimize COVID-19 exposure risk to patients and doctors.[3]
[4]
Elective services are restarting in a phased manner. However, being apex centers for
COVID-19 care, majority of teaching institutes are yet to return to pre-COVID-19 normalcy.
The hands-on training of residents has been greatly hampered owing to a direct reduction
in the surgeries.[6]
[7] Although alternative modalities such as virtual and simulation training have been
adopted, real-time experience and skill training cannot be matched. Hence, the teaching
and practice of plastic surgery in the institutes which have also doubled up as COVID-19
centers need to be looked at with a newer perspective. The quantification of changes
in the plastic surgery practice is essential to guide policies in restructuring the
patient care delivery and plastic surgery education. This will enable us to achieve
the twin objectives of resident training and efficient patient care. Hence, this study
was undertaken to quantify the changes induced by the pandemic in plastic surgery
practice and training.
There has also been such a sudden surge in number of webinars on a variety of topics
during the lockdown period that this period has often been satirically referred to
as the “webinar pandemic.”[8] The potential benefits of this virtual education system may be incorporated into
teaching curriculum in future after thorough assessment for content and quality.[9]
[10] Although the webinars constitute a virtual knowledge boom and open new avenues,
the responses to these have been varied.[11]
[12] Hence, this study also attempts to look at the impact of the webinars on plastic
surgery education and training from a residents’ perspective, to identify facilitating
and hindering factors that can potentially be used to assess their value.
Methods
This was a retrospective analysis of a prospectively recorded database from the departments
of plastic surgery of two tertiary referral centers of north and south India. The
nationwide lockdown was announced on March 24, 2020. A time frame of 8 weeks before
the lockdown to various unlock phases (February 1, 2020, to September 30, 2020) was
included in the study referred to as “COVID-19 period.” The data from 2019 during
the corresponding months were utilized as control, referred to as “pre–COVID-19 period.”
The details of patients treated, diagnosis and types of surgery, and distribution
of emergency and elective procedures were obtained for both time periods from departmental
databases and compared. The cause of injuries presenting to emergency and regional
variation in the trends were also analyzed.
An online survey on the impact of webinars on plastic surgery was conducted for trainees
across the country. Plastic surgery residents currently in training in various institutes
were included in the study by snowball sampling through personal e-mails and social
media platforms such as WhatsApp and Facebook. The questionnaire comprised 18 questions
addressing the various aspects of training and residents’ perspectives on webinars
during the pandemic. The validation of questionnaire ([Supplementary File S1]; available online only) was carried out on residents currently in training at both
institutes for comprehension and relevance. The time spent on webinars or conferences
by the same resident during both time periods were compared. The correlation of regular
teaching at the training institution and the residents’ perception of utility of the
webinars was also carried out.
Statistical Analysis
The data were analyzed using IBM SPSS Statistics version25. The number and type of
surgeries and cause of injuries were analyzed using Mann–Whitney U test. The survey responses were analyzed using descriptive statistics. The time spent
on webinars or conferences was analyzed using chi-square test for R-by-C table. The
correlation of regular teaching during pre–COVID-19 and the perception of utility
of webinars were carried out using Kruskal–Wallis test. A p-value < 0.05 was considered significant.
Results
Trends in Surgical Case Load and Type of Surgery
There was a significant reduction in total number of surgeries (mean difference: 235.1
± 46.5 cases; p = 0.003) during the lockdown ([Fig. 1]). A significant reduction was noted in elective, emergency, and burn services ([Fig. 1]). There was an increasing trend noted in emergency and burn surgeries during staggered
release of restrictions; however, elective services continue to remain suspended with
few exceptions. The comparison of cases operated in emergency and elective during
two the time periods is shown in [Figure 2]. Although there was a significant reduction in total number of emergency cases,
number of surgeries for hand trauma, faciomaxillary injuries, replantations, and miscellaneous
procedures such as facial lacerations, penetrating chest/abdominal wall injuries were
comparable ([Fig. 3]). There was a significant reduction in combined orthopedic and plastic reconstructive
procedures (p = 0.009) and free-flaps (p = 0.05) ([Fig. 2]). [Fig. 3] illustrates monthly distribution of various emergency cases during both the time
periods. The elective surgeries comprised semiemergency reconstructive cases such
as brachial plexus injuries and peripheral nerve injuries which needed timely intervention
for saving limb functions, subacute posttraumatic reconstruction, and reconstruction
following excision of malignant tumors ([Fig. 4]).
Fig. 1 Comparison of total surgical activity in elective, emergency, and burn surgery during
COVID-19 with the pre–COVID-19 time (p-value by Mann–Whitney U test).
Fig. 2 Comparison of various emergency and elective surgery cases during COVID-19 with the
pre–COVID-19 time (p-value by Mann–Whitney U test).
Fig. 3 Comparison of monthly distribution of various emergency procedures during the two
time periods.
Fig. 4 Comparison of monthly distribution of various elective procedures during the two
time periods.
Assessment of Cause of Injury
The distribution of causes of emergency or burn admissions during the corresponding
months is shown in [Fig. 5]. There was a significant reduction in the road accidents (87 ± 34.3 vs. 151 ± 39.2
cases; p = 0.007) and suicidal injuries (6.12 ± 2.6 vs. 13.37 ± 2.6 cases; p = 0.002) during the COVID-19 period ([Fig. 6]). A significant increase in injuries following assault (14.25 ± 6.8 vs. 6 ± 2.7
cases; p = 0.03) and domestic accidents (39.87 ± 7.18 vs. 16.5 ± 13.7 cases; p = 0.01) were noted. Although there was an increase in proportion of workplace injuries
in April and May ([Fig. 6]), the average between two time frames were comparable (p = 0.638). The regional variation of the trends of the injuries between the two time
periods is shown in [Fig. 6].
Fig. 5 Comparison of monthly distribution trends of various cause of injuries during COVID-19
with the corresponding months in pre–COVID-19 time.
Fig. 6 Upper row: comparison of the cause of injuries between COVID-19 and pre-COVID time
period (p-value by Mann–Whitney U test). Lower row: comparison of regional variation in the trends in the cause of
injuries during the two time periods (p-value by Mann–Whitney U test).
Online Survey on Impact of Webinars on Plastic Surgery Education from Residents’ Perspective
A total of 83 responses were received; 85.5% were MCh and 14.5% were DNB plastic surgery
trainees across the country. Majority (75%) of the webinars were held by national
organizations. [Fig. 7] shows distribution of various topics and formats which trainees found useful. A
usefulness score of >8 was given by 68.7% respondents and 60% felt that it helped
improve both theoretical and practical knowledge levels ([Fig. 8]). There was no significant difference in the mean score of perception of utility
when correlated with hours of dedicated academic program at their institutes ([Fig. 9]). At least one plastic surgery conference or webinar was attended by 60% trainees
during the pre–COVID-19 period. On analyzing proportion of time spent in attending
conferences or webinars by the same resident between two time periods, there was no
significant difference (p = 0.614) ([Fig. 10]). Majority (88%) of the respondents felt that these webinars helped improve their
awareness regarding various procedures carried out worldwide. [Fig. 11] shows the distribution of various hindrances and factors which need improvement.
Attending webinars were regarded as no added stress by 53% respondents, 14% felt it
definitely added to their stress levels, 92% felt that these webinars should continue
in post-COVID times, and 80% suggested a weekly frequency; 21% respondents demonstrated
willingness to attend even if the sessions were paid. Majority (80%) felt that webinars
should be awarded credit hours and 68% felt the need for a hybrid approach to future
conferences.
Fig. 7 Distribution of preferred webinar formats by residents and the various topics of
webinars during the pandemic.
Fig. 8 Residents’ perception of usefulness of webinars on plastic surgery training.
Fig. 9 Correlation of regular academics at the training institutes with the residents’ perception
of utility of webinars (p-value by Kruskal–Wallis test).
Fig. 10 Comparison of the average time spent on webinars during COVID-19 time to the number
of conferences/webinars attended by the corresponding residents in the pre-COVID period
(p = 0.614 by chi-square test for R-by-C table). The larger and smaller circles represent
the COVID-19 and pre–COVID-19 time periods, respectively.
Fig. 11 Residents’ perspective on hindrances and factors that need improvisations for the
conduct of webinars.
Discussion
The destructive effect of COVID-19 has affected the working of hospitals, especially
centers dedicated for COVID-19 care. This study compared trends of various plastic
surgery procedures with that of pre-COVID time in two premier teaching institutes
of the country. The effect of lockdown regulations such as restrictions on the surgical
procedures was quantified to potentially help in future restructuring of training.
The study also showed a change in pattern of injuries with a reduction in road accidents
and suicides and an increase in the assault and domestic injuries during COVID-19
time, indirectly quantifying the social impact. A restructuring of training programs
can potentially happen as we recover from pandemic and the “webinar culture” is likely
to stay. A survey of the residents’ perspective helps to identify preferences and
hindrances faced by trainees which can help in efficient modification of training
programs. In this study, most residents found the webinars a useful adjunct, irrespective
of regular teaching program at their institutes.
As expected, there was a significant reduction in total number of surgeries during
COVID-19 time. There was a drastic reduction even in emergency procedures during the
complete lockdown period which later increased during unlock phases. Similar trends
of a sudden reduction in plastic surgery cases followed by plateau have been reported
from Brazil and Italy.[13]
[14]
[15] Although a significant reduction in complex microsurgical and combined orthopedic
and plastic surgery reconstructions was observed, proportion of hand and faciomaxillary
injuries remain similar to that of pre-COVID-19 era, benefitting residents’ training.
There was a preference for local or regional flaps over complex microsurgical reconstruction
to reduce operating time and patients’ hospital stay.[5]
[16] Routine services were totally suspended, consequences of which is hard to foresee
as conditions such as craniofacial cleft deformities, brachial plexus injuries, nerve
injuries, and burn contractures can potentially become urgent within a limited time
frame. Although, teleconsultation is less feasible in surgical specialties, assessment
of patients through photographs and video calls has helped address problems to a limited
extent.[15]
[16]
The pattern of injuries when compared with pre-COVID-19 times was surprising. There
was a reduction in road accidents whereas pandemic period witnessed an increase in
assault and domestic accidents. These can potentially be attributed to social and
economic impact of pandemic. The lockdown and circumstances of “work-from-home” could
have potentially increased number of domestic or indoor accidents, especially finger-tip
injuries. Studies have demonstrated worsening of psychiatric symptoms and increased
psychological disturbances due to the COVID-19–induced lockdown.[17]
[18]
[19] This is indirectly reflected in increase in assault injuries.
The training of surgical residents is the worst hit. Many institutions have resorted
to alternate modalities such as virtual case discussions and simulation training.[15]
[16] However, these can never match the real-time training. Although webinars were in
existence in pre–COVID-19 era as part of teaching curriculums in the West, there has
been a sudden surge during the lockdown both at national and international levels.[12]
[20] A recent report demonstrated an increase in the Joint Committee on Surgical Training
(JCST) quality indicators for webinars in terms of duration and frequency both for
new and existing webinars for plastic surgery trainees in the United Kingdom.[11] A 3,250% increase in the number of webinars from January to May 2020 was reported.[8]
The “webinar culture” is relatively new in the Indian scenario and has received mixed
responses from both consultants and trainees. A recent survey from India demonstrated
that 65% consultants and 93% residents felt the need to continue virtual teaching
even after the pandemic.[21] Similar results were seen in the present study. Analysis of the residents’ perspective
will help identify factors that students find helpful and those that need improvisation.
Students found case discussions and faculty lecture formats most useful. The inadequately
addressed queries due to lack of direct interaction with speaker and poor moderation
was a concern for many. Dharini et al reported that 67% of residents felt third-party
webinars were better than their regular departmental teaching.[21] In our study, the hours of structured academic program at training institutes did
not affect residents’ perception of the usefulness of webinar significantly. However,
it was surprising that the number of conferences /webinars attended in pre-COVID time
and the proportion of time dedicated for webinars by the corresponding resident during
COVID-19 time were similar. This may indicate that although the awareness and frequency
has increased, the perception of attending too many webinars because of the pandemic
may be an apparent change. However, a detailed analysis of other factors which have
a bearing such as duty schedule, travel, personal factors, and so forth is required
in a larger sample. The virtual classes have a potential role as adjuncts in the training
programs as well as conferences; however, the conduct has to be systematic and regulated.
Conclusion
There has been a drastic reduction of elective procedures during COVID-19 time, thereby
negatively affecting resident training program. The proportion of emergency procedures
is comparable with that of pre–COVID-19 time. Majority of the residents felt that
webinars could find a place in formal resident education program in post–COVID-19
scenario. These quantitative data can potentially help in developing guidelines for
restarting of services and restructuring of the training program.
