How I maximised my training during the COVID-19 pandemic

Abstract

The COVID-19 pandemic was declared in March 2020 and London maternity units were among the first in the United Kingdom to report maternal infection and vertical transmission. To manage resources, over half of all Obstetrics and Gynaecology trainees were redeployed to support front-line specialities such as Core Medicine and Accident and Emergency. The vignettes in this article illustrate how three trainees maximised their limited training opportunities in the face of exceptional disruption, lack of surgical training opportunities and workload pressures.

Keywords:

• COVID-19
• training
• challenges
• teaching
• obstetrics & gynaecology trainees

Introduction

During the COVID-19 pandemic, London maternity units were among the first in the United Kingdom to report maternal infection and vertical transmission (WHO 2020, WHO 2023). To manage resources, over half of Obstetrics and Gynaecology (O&G) trainees in the UK were redeployed to support front-line specialities such as Core Medicine and Accident and Emergency (RCOG 2020). As a result, one-fifth of O&G trainees felt they were unable to prepare for their professional examinations (GMC NTC 2021) and two-thirds said they were unable to compensate for any loss of training opportunities through transferable skills (GMC NTC 2022). Post pandemic studies globally (Bitonti et al. 2020, Gothwal et al. 2022, Afridi et al. 2023) report that O&G trainees still express anxiety about their professional careers and concerns relating to irreversible training compromise. The impact of the pandemic continues to be felt as only half of O&G trainees this year reported that they were on course to gain enough experience in operative procedures that they needed for their stage of training (GMC NTC 2022).

In the UK, the O&G speciality training (ST) programme is divided into basic (ST1-2), intermediate (ST3-5) and advanced training (ST6-7) years. This article relates how three trainees, each at different stages of their training, maximised their limited training opportunities despite exceptional disruption, lack of surgical training opportunities and workload pressures.

LB, ST1 at the time of pandemic

What happened to my trust

During the first wave, I was an O&G ST1 in a teaching hospital with a high capacity of critical care beds, which was extended to meet the needs of the pandemic. During the second wave, I was an ST2 trainee in a district general hospital, which had one of the highest rates of COVID-19 infections in the country and a limited capacity for critical care beds, which put immense strain on inpatient medical services.

How it affected my training

During ST1, I was redeployed to the Intensive Care Unit. Consequently, I found myself revising long-forgotten medical school notes on lung physiology and completing online modules on how to assess and manage critical care patients. This gave me a more instinctive understanding of the critically unwell patient which would serve me well when caring for patients within my speciality in the future.

During ST2, I remained within the department, however several services were streamlined and elective gynaecology work was suspended. I was desperate to perform as many obstetric procedures as possible ahead of my annual review for completion of 'basic’ training and step up to the registrar level.

How I overcame challenges in training

As the Trainee Representative for my region, I advocated for specialist trainees to remain within their speciality wherever feasible for the trust and fed back to the regional Programme Directors regarding the level of redeployment.

Virtual platforms enabled all local teaching opportunities, such as perinatal meetings and Cardiotocography (CTG) case presentations to be moved online. This empowered trainees to attend when they had a shorter period free during an on-call, or even from home. In response to a decrease in gynaecological operations, virtual masterclasses for specific surgical procedures or themes utilising previously recorded operations were initiated in place of trainees physically assisting in theatre. Ultrasound scanning opportunities also decreased; in response, junior trainees made use of the International Society of Ultrasound Scanning in Obstetrics & Gynaecology (ISUOG) virtual modules to boost their ultrasound skills.

HS, ST3 at the time of pandemic

What happened to my trust

In response to the clinical demands during the pandemic, hospitals had to adopt measures to prioritise the provision of frontline emergency care as well as maximise intensive care capacity. O&G trainees in my unit were not redeployed to other specialities but instead manned a modified ‘COVID rota’. Based on this rota, more trainees were rostered to work an on-call shift at a higher frequency to cope with the fluctuating demands on the department as pregnant women were more susceptible to severe illness with COVID-19.

How it affected my training

Surgical skills were negatively impacted due to the reduction of elective gynaecological procedures. On Labour Ward, practical procedures including Caesarean sections and instrumental deliveries had to be performed by registrars rather than junior trainees to reduce exposure. This limited teaching opportunities and prevented junior trainees from building on their skill set. Cancellations of elective work also meant that trainees could not be allocated to specialised sessions relating to sonography training, outpatient hysteroscopy or colposcopy. Antenatal and gynaecology clinics adopted a hybrid approach with a majority of remote consultations along with a few selected face-to-face appointments.

How I overcame challenges in training

During this time, I used the opportunity to widen my theoretical knowledge and focus on self-directed study, by signing up for webinars and completing E-learning modules on topics I was less familiar with. I volunteered to update local guidelines as well as to produce a concise guideline relating to the management of pregnant women presenting with suspected COVID-19.

I practised my laparoscopic skills using a box trainer and continued to observe teaching videos relating to gynaecology operations.

During on-calls, I encouraged my juniors to lead Labour Ward rounds and offered bedside CTG teaching. I focused on completing the medical education, effective communication and non-technical skills for surgeons (NOTSS) competencies on my portfolio. Despite various challenges, the pandemic has taught me to take on a more proactive role to optimise my learning and facilitate my training requirements.

VS, ST5 at the time of the pandemic

What happened to my trust

The pandemic caused significant disruptions in the training programmes, a complete pause in elective work led to reduced clinical exposure and a shift towards remote learning. I had intended to pursue the benign gynaecology advanced training specialist module (ATSM) and build on my gynaecological surgery foundations and COVID-19 lead to a drastic reduction in gynaecological operating.

How it affected my training

During the pandemic, oncological surgery was prioritised where possible which provided an additional route to gain surgical training. There is significant surgical overlap with benign gynaecology, with procedures such as hysterectomy, salpingo-oophorectomy and adhesiolysis being pertinent to both subspecialties. Embracing an interest in oncology allowed me to continue developing both open and laparoscopic surgical skills. Outpatient hysteroscopy was a beneficial tool to develop operative hysteroscopic skills and was available as it was outpatient-based and represented a significant part of diagnostic oncology. Becoming proficient in outpatient hysteroscopy required additional finesse due to the patient being awake and the need to minimise pain.

How I overcame challenges in training

The importance of leadership and human factors training has been highlighted in several national reports and I took opportunities to develop these skills. I led a business case for centralised CTG monitoring, which needed to facilitate rapid reviews whilst reducing cross-infectivity between staff. I developed guidelines especially around COVID-19 and obstetric care, ensuring women were kept safe and had up-to-date medications. These were all valuable projects which I used towards securing a consultant job at the end of ST7.

Comments

Contrary to the belief that gynaecology operating services have been restored to pre-pandemic levels, 70% of respondents in the RCOG member survey indicated that they were currently operating less than they were before the start of the pandemic (RCOG 2022). Training opportunities are still significantly impacted as pressures to reduce waiting lists would further reduce the training time available, as providing experience for trainees lengthens the amount of time it takes to get through surgical lists and clinics. Gynaecology waiting lists across the UK have now reached a combined figure of over 570,000 women, which is over a 60% increase on pre-pandemic levels (RCOG 2022). A robust gynaecological training programme, with defined and measurable goals, combining simulation and operative room training, needs to be implemented so that trainees can consolidate their skills and knowledge as they ascend the ranks of the training program (Ferreira et al. 2020).

Although not explicitly mentioned in the above vignettes, Duggan et al. 2022 noted that 60% of trainees reported an ongoing negative impact on their mental health, despite the onset of the pandemic being three years ago. A General Medical Council survey identified that 23% of trainee doctors were more likely to be at moderate-to-high risk of burnout post-pandemic compared to pre-pandemic levels while the British Medical Association reported that the pandemic played a crucial role in instigating burnout, emotional distress and fatigue (Gunasekera et al. 2022). This should be addressed as a priority as deteriorating mental health is likely to result in increased sick leave and staff turnover with implications on patient safety and satisfaction (Powell et al. 2014).

Conclusion

Although training during COVID-19 was extremely challenging, it was still possible to develop and progress using alternative pathways. All of these principles described by the three authors, who were at different stages of training, still apply and can be utilised by current trainees to further their careers. However, more needs to be done to continue to provide more practical opportunities and pastoral support is fundamental to replenish the psychological reserves of current trainees.

Ethics committee approval

Not required due to the descriptive nature of the article.

Acknowledgements

The authors would like to thank colleagues and consultants who supported their training during the pandemic.

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.