Coronavirus Disease 2019—An Impetus for Resident Education Reform?

Coronavirus disease 2019 (COVID-19) has affected nearly every aspect of medicine, magnifying the strengths and faults of our current health care system while simultaneously creating opportunities for change and innovation. Social distancing has prompted the rapid expansion of telemedicine; equipment shortages have inspired ingenious design solutions; and the search for a vaccine has prompted unprecedented industry collaboration. But how has the worldwide pandemic affected medical training, specifically within the field of otolaryngology? To investigate this topic further, we will discuss 2 major components of medical education: curriculum delivery and surgical skill development.

With calls for nationwide social distancing, residency education has been catapulted into the new millennium. In late March, the Collaborative Multi-Institution Residency Education Program, spearheaded by the Department of Otolaryngology–Head and Neck Surgery at the University of Southern California, developed a venture to continue resident curricula delivery within California during the period of enforced social distancing. This effort quickly expanded to the national level in the following weeks.¹ The concept is simple: lectures by experts in all subdisciplines are streamed online via Zoom (Zoom Video Communications Inc). Live or recorded lectures are available free to all residents regardless of training program (and more recently to all practicing otolaryngologists). The website has welcomed more than 4200 viewers since inception with an average of 300 views per lecture.¹ Similar efforts have followed at the fellow and society level across multiple subspecialties, including neurotology, rhinology, and pediatric otolaryngology. Another resource developed in response to the COVID-19 crisis is Headmirror’s podcast “ENT in a Nutshell.” For those less inclined to long-format lectures, it offers a rapidly expanding library of high-yield, focused topical reviews that can be automatically downloaded to a mobile device.² Now, otolaryngology trainees worldwide can access and follow the same core curriculum simultaneously or at their leisure.

This sudden shift to accessible, standardized, high-quality content offers significant advantages over previously siloed educational efforts—especially for smaller programs whose offerings for diversified curriculum rely heavily on external interactions with community faculty and national meetings.³ This informal foray into curricula standardization bodes well for future attempts to create a formal nationwide otolaryngology curriculum for residents. Further, it provides a broader sense of community for trainees, an important benefit under any circumstances, but especially in light of the unique challenges facing our field.

Otolaryngology residency programs are admittedly late to the game. COVID-19 has forced training programs across the world to modernize their educational content in a way that medical students are already familiar with. For more than a decade, compelled by increasing emphasis on United States Medical Licensing Examination scores, medical students effectively created a nationwide standardized virtual curriculum composed of the best high-yield content available in online or electronic format (eg, Pathoma, recorded board prep, and others). Indeed, the colossal reimagining of medical education has been underway for years, with the realization that the true value of medical school education lies in clinical experiences instead of the classroom.⁴ Anecdotal evidence supports that by graduation, many US medical students will have engaged with this virtual curriculum, which parallels and supplements structured medical school curricula. Many students would argue that these resources surpass those offered by their own institutions and that with the standardization of resources, STEP board scores are no longer the great equalizer. As a result, medical students advance into residency with a more standardized knowledge base than their predecessors, as well as a broader sense of shared educational experience, regardless of their medical school alma mater.

While changes in curriculum delivery are reason for optimism, concern remains about COVID-19’s effect on residents’ surgical skill attainment. At most institutions, safety and resource constraints have resulted in drastic cuts in elective procedures. Given otolaryngology’s relative proportion of elective surgeries and the high risk for intraoperative COVID-19 exposure, the impact on our discipline has been especially pronounced.⁵ Program leadership now has the difficult task of balancing risks to residents’ physical welfare and their ability to gain surgical proficiency. Consequently, trainees at many centers have had surgical experience limited to trauma, emergencies, and oncologic procedures deemed urgent enough to proceed. One published abstract reported a decrease of 44.2% to 62.1% in “surgical” activity training exposure for urology residents during Italy’s outbreak.⁶ Both the Accreditation Council for Graduate Medical Education (ACGME) (Thomas Nasca, email, March 24, 2020) and the American Board of Otolaryngology–Head and Neck Surgery (Brian Nussenbaum, email, April 1, 2020) have acknowledged this predicament in email correspondence to residents, as well as the reality that residents and fellows may be required to focus their clinical duties on supporting COVID-19 responses rather than on otolaryngology patients, and as a result, may not meet surgical key indicator thresholds prior to graduation. This may result in an increased role for the program director and other staff in deeming a resident appropriate for graduation on an individual basis.

The reaction from learners is mixed: Some are apprehensive about how this will affect their ability to practice independently after graduation; others welcome this as an overdue recognition that “key indicator” numbers do not adequately reflect surgical skill acquisition. If a resident fails to meet the prerequisite case numbers after having decreased surgical volume for 2 months (at this time), were the chosen key indicator cases reflective of current otolaryngology practice? One alternative to the key indicator system, which often has residents focus on obtaining a certain number of cases rather than actual mastery, would be a standardized and objective assessment of competence with similar component factors, such as a 2005 study developed to assess resident surgical skills at tonsillectomy.⁷ This would prevent discrepancies in coding (such as multiple residents logging the same procedure as primary surgeon), but may lead to a new problem for programs with low case numbers.

In the absence of hands-on surgical experience, what options are available to trainees? Surgical simulators, cadaveric dissection, and video atlases may be able to mitigate some of COVID-19’s impact. However, they are not a substitute for learning in the surgical field. As with changes to curriculum delivery, COVID-19 may offer opportunities for improving surgical training, but it is hard to avoid the conclusion that the pandemic will have a negative, albeit temporary, effect on surgical training.

It will take months or years to appreciate fully the effect of COVID-19 on medical education. However, we are already witnessing both promising and concerning effects on resident and fellow education. We are encouraged by the rapid embrace of an effective, community-building strategy for curriculum delivery, and we are optimistic that future otolaryngology trainees will benefit from these changes. Simultaneously, many of us worry about our chance to fully develop the surgical skills we need to treat patients safely and effectively. However, one thing is certain; those of us training during this period will be forever changed as we grow in our roles as physicians, investigators, educators, and leaders. We are committed to making the most of this experience, for ourselves, for our patients, and for future learners.

Corresponding Author: Hillary A. Newsome, MD, Department of Otolaryngology, Medical College of Wisconsin, 8701 Watertown Plank Rd, Wauwatosa, WI 53226 (hnewsome@mcw.edu).

Published Online: July 9, 2020. doi:10.1001/jamaoto.2020.1587

Conflict of Interest Disclosures: None.