The novel coronavirus 2019 (COVID-19) outbreak has had an incredible global impact. In March 2020, the Centers for Disease Control (CDC) declared COVID-19 a pandemic.1 While worldwide “shutdown” initially slowed the infection rate, a steady uptick in COVID-19 cases has the medical community now confronting a second wave of infections.2 It is now clear that neurosurgical training programs must adapt to providing neurosurgical education in the midst of a long-lasting COVID-19 pandemic.3 In the Department of Neurosurgery at Emory University Hospital, the priority has been the following: to protect neurosurgical healthcare workers, provide excellent neurosurgical care, adopt novel techniques to maintain continuity of care, offer assistance to our medical colleagues, and to provide robust medical student, resident, and fellow training in the operating room, the clinic, and the classroom.
Our hospital sites have implemented campus-wide questionnaire and temperature screening protocols to vet healthcare workers and patients for signs and symptoms of COVID-19 infection. The hospital has instituted pre-operative outpatient and inpatient testing, re-testing for symptoms that develop in hospitalized patients, strict use of personal protective equipment by our residents and staff, and personal distancing. Our neurosurgical advanced-practice providers, residents, fellows, and attendings have been proactive in promptly announcing the onset of COVID-19 symptoms. We identify and isolate symptomatic staff, test them, and cover their clinical responsibilities with another team-member. In this way, we have deftly contained infections and exposures, while we continue to run a busy neurosurgical service.
In March and April 2020, all elective neurosurgical cases at our hospital training sites were cancelled. This resulted in a streamlined neurosurgical service that could continue to appropriately respond to neurosurgical emergencies while minimizing exposure to members of our team. In the months of May and June, deferred elective cases resumed at a measured pace, to allow for a full-service, elective neurosurgical practice. With the resurgence in COVID-19 cases that threaten healthcare systems, it is yet unclear if or when the elective case volume will again decline.
Emory Neurosurgery has adopted telemedicine to deliver patient care and provide outpatient trainee interactions with patients.4 To date, our neurosurgical faculty, residents, fellows, and advanced-practice providers have consulted on with hundreds of neurosurgical patients via telemedicine. Though it is impossible to perform a comprehensive neurological exam by video, telemedicine has provided an opportunity for trainees to be creative in their examination skills, and to decide when it is necessary to engage the patient in-person. We expect that the skills developed in remote consults will enrich the educational experience of our residents and fellows. As the pandemic persists and access to telemedicine broadens, these skills will be even more relevant. Given the positive feedback from our patients and efficiency of our telemedicine process, we believe that even after the COVID-19 pandemic, telemedicine will be a medium for delivering high-level neurosurgical care to communities with restricted access.
We have provided increased opportunities in critical care education for our neurosurgical residents as our neurological ICU has expanded to care for patients with COVID-19. Our senior residents participating in clinical and research rotations have volunteered their time to function as advanced practice providers in the neurological ICU. As most of our dedicated time in this unit is spent in our early years, this has provided an educational opportunity for residents to revisit and hone their critical care medicine skills. Our assistance has also supported our larger medical community and engendered a spirit of camaraderie amongst our neurosurgical team and ICU workers on the frontline.
Our neurosurgical academic conference team has transitioned to providing access to our weekly resident/fellow educational didactics with remote-learning platforms such as Zoom Inc. (San Jose, California). We have participated in morbidity/mortality conferences, journal clubs, case conferences, and department-wide meetings using Zoom. There have been opportunities to participate in national and international neurosurgical conferences in virtual space. The neurosurgical team has become facile in using the virtual meeting space to continue didactic neurosurgical education.
Formal teaching and recruitment of undergraduate medical students into neurosurgery has also continued.5 At the onset of the “shutdown,” neurosurgical residents and attendings created a 1-week-long virtual clerkship for 3rd year medical students. Each day was assigned a subspecialty topic, and discussion was based upon material from the Operative Neurosurgery supplement entitled “Essential Neurosurgery for Medical Students.” Fourth year medical students, residents, fellows, and attendings gave lectures. Students joined attendings during their telemedicine clinic visits. Each student also gave a short presentation on a topic of their choice, which served as an opportunity for assessment. Two iterations of the clerkship were completed for five medical students prior to resumption of in-person rotations. Should another “shutdown” mandate removal of medical students from the hospital environment, this structured virtual clerkship could be reinstated and easily modified for their learning needs.
We believe that regular reassessment of our new training methods will be critical in maintaining our high educational standards. We performed an internal assessment of the state of our residency program in April. There was a 52.3% response rate (11 residents), with most classes being well-represented. We found that the impact of COVID-19 changes on resident education was net neutral, specifically, the expected decrease in the surgical cases volume was offset by increased quality of the educational experience. Many residents chose to participate in self-directed study from widely available offerings (e.g. webinars) to augment their education. Others focused on existing clinical duties. Several residents used their additional free-time for research. Our residency leadership gained unique insight into educational activities that could be implemented in the future if we face a similar “shutdown” again.
The COVID-19 pandemic has forced neurosurgical training programs to adapt to keep residents and fellows safe, while providing opportunities for neurosurgical education. Despite the challenges presented by the COVID-19 pandemic, we are confident that we can continue to provide neurosurgical education to residents, fellows, and medical students.
References
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1. Cases in U.S. | CDC. https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html. Accessed April 4, 2020.
2. NY Confronts Second-Wave Covid Risk: Visitors from Florida and Texas – The New York Times. https://www.nytimes.com/2020/07/14/nyregion/coronavirus-ny-travel-cuomo.html. Accessed July 26, 2020.
3. Bray DP, Stricsek GP, Malcolm J, et al. Letter: Maintaining Neurosurgical Resident Education and Safety During the COVID-19 Pandemic. Neurosurgery. April 2020. doi:10.1093/neuros/nyaa164
4. Greven ACM, Rich CW, Malcolm JG, et al. Letter: Neurosurgical Management of Spinal Pathology Via Telemedicine During the COVID-19 Pandemic: Early Experience and Unique Challenges. Neurosurgery. 2020;87(2). doi:10.1093/neuros/nyaa165
5. Dawoud RA, Philbrick B, McMahon JT, et al. Letter to the Editor “Virtual Neurosurgery Clerkship for Medical Students.” World Neurosurg. 2020;139:456-459. doi:10.1016/j.wneu.2020.05.085
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