Article Text

Impact of SARS-CoV-2 on training and mental well-being of surgical gynecological oncology trainees
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1. Faiza Gaba1,2,
2. Oleg Blyuss3,4,
3. Isabel Rodriguez5,
4. James Dilley6,
5. Yee-Loi Louise Wan7,
6. Allison Saiz8,
7. Zoia Razumova9,
8. Kamil Zalewski10,
9. Tanja Nikolova11,
10. Ilker Selcuk12,
11. Nicolò Bizzarri13,
12. Charalampos Theofanakis14,
13. Maximilian Lanner15,
14. Andrei Pletnev16,
15. Mahalakshmi Gurumurthy1 and
16. Ranjit Manchanda6,17
1. 1 Department of Gynaecological Oncology, NHS Grampian, Aberdeen, UK
2. 2 Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
3. 3 Department of Physics, Astronomy and Mathematics, University of Hertfordshire, Hatfield, UK
4. 4 Department of Pediatrics and Pediatric Infectious Diseases, Institute of Child's Health, Sechenov University, Moskva, Russian Federation
5. 5 Department of Gynecologic Oncology, University of Washington, Seattle, Washington, USA
6. 6 Department of Gynaecological Oncology, Barts and The London NHS Trust, London, UK
7. 7 Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
8. 8 Department of Gynecologic Oncology, Northwestern University in Chicago, Chicago, Illinois, USA
9. 9 Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
10. 10 Department of Gynecologic Oncology, Świętokrzyskie Cancer Centre, Kielce, Poland
12. 12 Department of Gynecologic Oncology, Ankara City Hospital, Ankara, Turkey
13. 13 UOC Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Policlinico Agostino Gemelli IRCCS, Rome, Italy
14. 14 Department of Gynaecological Oncology, General Hospital of Athens Alexandra, Athens, Attica, Greece
15. 15 Department of Obstetrics/Gynaecology, Kardinal Schwarzenberg'sches Krankenhaus, Schwarzach, Steiermark, Austria
16. 16 Department of Gynecology and Obstetrics, University of Zielona Góra, Zielona Góra, Poland
17. 17 Wolfson Institute of Preventive Medicine, Barts CRUK Cancer Centre, Queen Mary University of London, London, UK
1. Correspondence to Dr Faiza Gaba, Department of Gynaecological Oncology, NHS Grampian, Aberdeen, UK; faiza.gaba1{at}abdn.ac.uk; Prof Ranjit Manchanda; r.manchanda{at}qmul.ac.uk

## Abstract

Introduction The SARS-CoV-2 global pandemic has caused a crisis disrupting health systems worldwide. While efforts are being made to determine the extent of the disruption, the impact on gynecological oncology trainees/training has not been explored. We conducted an international survey of the impact of SARS-CoV-2 on clinical practice, medical education, and mental well-being of surgical gynecological oncology trainees.

Methods In our cross-sectional study, a customized web-based survey was circulated to surgical gynecological oncology trainees from national/international organizations from May to November 2020. Validated questionnaires assessed mental well-being. The Wilcoxon rank-sum test and Fisher’s exact test were used to analyse differences in means and proportions. Multiple linear regression was used to evaluate the effect of variables on psychological/mental well-being outcomes. Outcomes included clinical practice, medical education, anxiety and depression, distress, and mental well-being.

Results A total of 127 trainees from 34 countries responded. Of these, 52% (66/127) were from countries with national training programs (UK/USA/Netherlands/Canada/Australia) and 48% (61/127) from countries with no national training programs. Altogether, 28% (35/125) had suspected/confirmed COVID-19, 28% (35/125) experienced a fall in household income, 20% (18/90) were self-isolated from households, 45% (57/126) had to re-use personal protective equipment, and 22% (28/126) purchased their own. In total, 32.3% (41/127) of trainees (16.6% (11/66) from countries with a national training program vs 49.1% (30/61) from countries with no national training program, p=0.02) perceived they would require additional time to complete their training fellowship. The additional training time anticipated did not differ between trainees from countries with or without national training programs (p=0.11) or trainees at the beginning or end of their fellowship (p=0.12). Surgical exposure was reduced for 50% of trainees. Departmental teaching continued throughout the pandemic for 69% (87/126) of trainees, although at reduced frequency for 16.1% (14/87), and virtually for 88.5% (77/87). Trainees reporting adequate pastoral support (defined as allocation of a dedicated mentor/access to occupational health support services) had better mental well-being with lower levels of anxiety/depression (p=0.02) and distress (p<0.001). Trainees from countries with a national training program experienced higher levels of distress (p=0.01). Mean (SD) pre-pandemic mental well-being scores were significantly higher than post-pandemic scores (8.3 (1.6) vs 7 (1.8); p<0.01).

Conclusion SARS-CoV-2 has negatively impacted the surgical training, household income, and psychological/mental well-being of surgical gynecological oncology trainees. The overall clinical impact was worse for trainees in countries with no national training program than for those in countries with a national training program, although national training program trainees reported greater distress. COVID-19 sickness increased anxiety/depression. The recovery phase must focus on improving mental well-being and addressing lost training opportunities.

• COVID-19
• surgery

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### HIGHLIGHTS

• COVID-19 has negatively impacted the training, income, and mental well-being of gynecological oncology trainees.

• COVID-19 sickness increased anxiety/depression among trainees.

• The recovery phase must focus on improving mental well-being and addressing lost training opportunities.

## Introduction

On March 11, 2020 the World Health Organization declared the outbreak of coronavirus disease-2019 (COVID-19) a pandemic given its spread and severity. The cause was identified as a novel coronavirus named severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). SARS-CoV-2 has swept the world infecting 164 million individuals and causing 3.4 million deaths worldwide (as of May 2021).1

Globally, an array of guidelines have been produced and implemented to restrict/modify elective surgical and oncology practice during the pandemic.2 These guidelines are intended to reduce pressure on healthcare systems, intensive care units, and ventilator usage and to minimize the risk of nosocomial SARS-CoV-2 infection and the post-operative sequelae that may ensue. Many recommendations are pragmatic deviations from standard of care management, aiming to balance the risk of treatment and available resources during this pandemic. It remains to be seen how short-term and long-term oncological outcomes will be affected.3 4

While data are emerging on the impact of the pandemic on surgical outcomes following cancer surgery and its impact on healthcare systems, there is paucity of data on the impact on trainees and no data on the impact specifically on gynecological oncology trainees. We present data from an international survey on the impact of the SARS-CoV-2 pandemic on: (1) clinical practice, (2) medical education, and (3) mental well-being of surgical gynecological oncology trainees.

## Methods

We sent an anonymised web-based voluntary open survey to trainee surgical gynecological oncology members of the European Network of Young GynaeOncologists (ENYGO), the Society of Gynecologic Oncology (SGO), and the British Gynaecological Cancer Society (BGCS) between May and November 2020. A survey link was circulated via social media and email to ENYGO/BGCS/SGO members and included in society newsletters. The survey was in English. Participants were informed of the length of time of the survey, how data were stored, investigator names, and the purpose of the study.

### Questionnaire Development

An initial hard copy draft was developed following a literature review. Each question was systematically discussed and reviewed by gynecological oncology clinicians (5 trainees/5 trainers from UK/US/India/Sweden) in an initial consensus meeting held face-to-face virtually. Each item was given a relevance score from 1 (least relevant) to 4 (most relevant) based on knowledge/experience and additional questions were identified. A second face-to-face virtual consensus meeting was held with the same 10 gynecological oncology clinicians to review the initial questionnaire responses, delete low-relevance items, optimize questionnaire length, and facilitate compliance. A pilot of the electronic survey was undertaken for usability/technical functionality/layout. For the pilot, 20 ENYGO/BGCS/SGO members reviewed the electronic survey.

### Statistical Analysis

Descriptive statistics were calculated for baseline characteristics, clinical activities/pathways, PPE, COVID-19 sickness, and medical education. The Wilcoxon rank-sum test and Fisher’s exact test were used for testing differences in means and proportions, respectively.

Multiple linear regression was used to model the effect of variables on the HADS, IES, and mental well-being scales. Multiple analyses were adjusted for gender, ethnicity, income, marital status, religion, income, age, and postgraduate experience. Two-sided p values are reported for all statistical tests. Statistical analysis was performed using R version 3.5.1. In accordance with the journal’s guidelines, we will provide our data for the reproducibility of this study in other centers if such is requested.

## Results

A total of 127 participants from 34 countries responded. Using the human development index (HDI) classification (a composite index of life expectancy, education, and per capita income indicators used to rank countries into four tiers of human development: very high, high, medium, low),7 100 respondents were from very high HDI countries (Australia 1, Austria 2, Belgium 2, Canada 2, France 2, Germany 2, Hungary 2, Ireland 1, Italy 3, Kazakhstan 1, Netherlands 2, Poland 1, Portugal 1, Romania 1, Russia 2, Singapore 4, Slovenia 2, Spain 2, Switzerland 1, Turkey 5, UK 24, USA 37), 10 were from high HDI countries (Azerbaijan 2, Brazil 1, Colombia 1, Indonesia 1, Philippines 1, Serbia 2, Sri Lanka 1, Ukraine 1), and 17 were from medium HDI countries (Guatemala 1, India 15, Nepal 1). Baseline characteristics are shown in Table 1. In total, 52% (66/127) of respondents were from countries with national training programs (UK/USA/Netherlands/Canada/Australia) and 48% (61/127) were from countries without national training programs. Trainees from countries with national training programs were earlier on in their fellowship than those from countries with no national training program (p<0.01), but the mean total length of fellowships (p=0.27) and mean years of postgraduate experience (p=0.14) were similar. The pandemic caused a negative impact on household income for 28% (35/125) of respondents, more so for those from countries with no national training program (47.5% (28/59)) than for those from countries with a national training program (10.6% (7/66); p<0.01). Almost a quarter (31/127) reported to be shielding (Table 1). Shielding was defined as ‘staying at home at all times and avoiding any face-to-face contact if you or someone in your household are clinically extremely vulnerable’. This was more common for trainees from countries with no national training program than for those from countries with a national training program (p<0.01). While shielding, 83.9% (26/31) of respondents were performing research activities, 35.5% (11/31) audits, 41.9% (13/31) telephone clinics, and 9.7% (3/31) were performing no work-related activities.

Table 1

Baseline characteristics of cohort

Overall, 28% (35/125) of trainees (28.8% (19/66) from countries with a national training program; 27.1% (16/59) from countries with no national training program) had been off work with suspected/confirmed COVID-19. Only 82.9% (29/35) reported access to SARS-CoV-2 testing. Since the onset of the pandemic, 20% (18/90) of trainees (10.4% (5/48) from countries with a national training program vs 31% (13/42) from countries with no national training program, p=0.02) chose to self-isolate from their household.

In total, 52% (66/127) of respondents administered chemotherapy, with 32% (21/65) reporting an increase in administration. The mean (SD) proportion increase was similar for trainees from both countries with and those without national training programs (20.9 (11.6)% (range 10–50%) vs 28.3 (14.6)% (range 10–50%), p=0.19). A total of 85% (108/127) of trainees stated multidisciplinary team/tumor board meeting logistics had changed with no statistically significant differences between trainees from countries with a national training program and those from countries with no national training program (p=0.71). Overall, 80.6% (87/108) of trainees stated that meetings became virtual (instead of face-to-face), 16.7% (18/108) reported shorter face-to-face meetings, and 18.5% (20/108) had less frequent meetings. When evaluating recruitment to gynecological oncology studies, 74.4% (93/125) stated that this had completely stopped/somewhat reduced, 23.2% (29/125) reported no change, and 2.4% (3/125) reported it had somewhat increased/increased.

### Supplemental material

In total, 13.5% (17/126) of trainees were redeployed, with the majority redeployed to obstetrics and gynecology (64.7%, 11/17). Trainees from countries with a national training program were redeployed for shorter times than those from countries with no national training program (mean (SD) 35.1 (30.3) days (range 3–80) vs mean (SD) 49.6 (52.8) days (range 1–120), p=0.88). Overall, 88.2% (15/17) of trainees had adequate supervision during redeployment while 29.4% (5/17) felt/were asked to work beyond their level of clinical competence (more likely for those from countries with no national training program, p=0.03; see Online supplemental table S2). Overall adequate pastoral support (defined as allocation of a dedicated mentor/access to occupational health support services) during the pandemic was reported by 62/125 (49.6%) all of the time and by 40/125 (32%) some of the time (see Online supplemental table S3). This was greater for trainees from countries with a national training program (87.5% (56/64)) than for those from countries with no national training program (75.4% (46/61)).

Pre-pandemic training involved rotation to different hospitals for 56.1% (37/66) of trainees from countries with a national training program and for 33.3% (20/60) of those from countries with no national training program (p=0.01). Rotations were suspended due to SARS-CoV-2 for 36.8% (20/57) of the respondents, more likely for trainees from countries with no national training program (75% (15/20)) than for those from countries with a national training program (16.2% (6/37) (p<0.01). Departmental teaching continued throughout the pandemic for 69% (87/126) of trainees, although predominantly virtually for 88.5% (77/87), at reduced frequency for 16.1% (14/87), and without practical hands-on teaching for 21.8% (19/87) (see Online supplemental table S4). In total, 70.1% (61/87) and 62.9% (78/124) were ‘very satisfied/satisfied’ with departmental teaching during and before the pandemic, respectively (see Online supplemental table S5). The majority (88%, 110/125) accessed e-learning resources during the pandemic (see Online supplemental table S6). National training program trainees were more likely to access BGCS/SGO e-learning while those from countries with no national training program preferred ESGO/IGCS (International Gynecologic Cancer Society) e-learning. The mean satisfaction with quality of e-learning provided by ESGO/IGCS/BGCS/SGO was overall high, ranging from 7.1 to 8.6 (where 1=not at all satisfied and 10=very satisfied) (see Online supplemental table S7).

Half (63/126) of the trainees reported reduced surgical exposure (‘yes’ respondents). Table 2 summarizes the mean (%) reduced exposure according to surgical modality/procedure. Greater levels of reductions were seen in trainees from countries with no national training program compared with those from countries with a national training program. Online supplemental table S8 summarizes the reasons for reduced exposure, with the most common reasons being postponement of cases (76.2%, 48/63) and referral reduction (57.1%, 36/63).

Table 2

Mean reduction in surgical exposure for trainees according to surgical modality and procedure from countries with and without a national training program during the SARS-CoV-2 pandemic

Overall, 68.5% (87/127) reported a decrease in outpatient workload with the mean (SD) decrease similar for trainees from countries with or without national training programs (46.6 (24.3)% (range 12–100%) vs 47.5 (19.8)% (range 10–100%), p=0.59). Reasons reported for reduced outpatient workload included reduced referrals from primary care/community practitioners (44.9% (57/127) cases) and patients not attending scheduled outpatient appointments (41.7% (53/127) respondents). Just 15.2% (19/125) of trainees stated their overall workload had increased and 84.8% (106/125) reported decreased overall workload. Degree of workload reduction for national training program trainees was lower than for those with no national training program ((27.5 (13.1)% (range 10–50%) vs 41.2 (18.6)% (range 15–100%), p=0.04).

Overall, 32.3% (41/127) of trainees (16.6% (11/66) national training program trainees and 49.1% (30/61) trainees with no national training program, p=0.02) believed they would need additional time (those who responded ‘definitely/probably’) to complete their training fellowship (Online supplemental table S9). The duration of additional training time anticipated did not significantly differ between trainees from countries with and without national training programs (mean (SD) 5.1 (2.8) months (range 3–12) vs 7.8 (5.6) months (range 1–24), p=0.11) or trainees at the beginning/end of their fellowship (mean (SD) 6.2 (3.1) months (range 2–13) vs 6.8 (2.9) months (range 2–15), p=0.12).

Mean (SD) HADS-total (combined anxiety and depression scores), HADS-anxiety, HADS-depression, and IES scores were 10 (6.7) (range 0–29), 6.62 (3.8) (range 0–17), 4 (3.6) (range 0–13), and 18.72 (16) range (0–73), respectively. Higher scores indicate greater levels of anxiety/depression/distress. Multiple linear regression models were used to analyse the association of covariates with HADS and IES mean scores (Tables 3, 4 and online supplemental table S10). Trainees with higher household income ($>150 000 vs$<50 000, p=0.02) and adequate pastoral support (all/some of the time vs no most of the time/not at all, p=0.002) had lower levels of anxiety and depression (Table 3). However, being off work from COVID-19 sickness was associated with higher levels of anxiety and depression (p=0.02). Trainees from very high/high versus medium HDI countries (p=0.02) and those who received adequate pastoral support (p<0.001) had lower levels of distress. However, distress levels were higher in trainees from countries with a national training program than in those from countries with no national training program (p=0.01) (Table 4). The mean (SD) mental well-being score pre-pandemic was higher (p<0.01) than the post-pandemic score (8.3 (1.6) (range 2–10) vs 7 (1.8) (range 2–10)). Mental well-being mean scores were not significantly associated with any covariates of interest on multiple linear regression (Table 5).

Table 3

Factors affecting HADS total mean scores

Table 4

Factors affecting IES mean scores

Table 5

Factors affecting mental well-being mean scores since the onset of the SARS-CoV-2 pandemic

## Discussion

### Summary of Main Results

The SARS-CoV-2 pandemic has negatively impacted surgical training and the overall well-being of gynecological oncology trainees. Overall, 28% of trainees had suspected/confirmed COVID-19, 28% experienced a fall in household income, 24% were shielding, 20% were self-isolating from their households, 13.5% were redeployed, 45% were re-using PPE, and 22% had to purchase their own. One-half reported a reduction in surgical exposure and one-third felt they required additional time to complete their training fellowship. This negative impact on surgical training was worse for trainees from countries with no national training program than for those from countries with a national training program and was seen across most surgical procedures. For 69% of trainees, departmental teaching continued and 88% had access to e-learning resources. Trainees with adequate pastoral support had significantly lower anxiety and depression (p=0.02) and lower distress levels (p<0.001). National training program trainees had higher levels of distress than those with no national training program (p=0.01). Mean mental well-being scores were higher pre-pandemic than post-pandemic (p<0.01).

### Results in the Context of Published Literature

Our data demonstrate a profound detrimental impact from the pandemic on surgical training, the training environment, and well-being of gynecological oncology trainees. The fact that 50% of trainees experienced reduced surgical training and 13.5% were redeployed supports existing data that elective surgery across hospitals was reduced/stopped to increase critical care bed capacity for patients with SARS-CoV-2 and release staff to support wider hospital responses.8–11 This was compounded by staff shortages and sickness, reduced theater availability, and supply chain scarcities. National/international guidelines were developed to provide a framework for continuing gynecological cancer care and aid difficult management decisions.3 12 This identified groups of patients where therapy may be ‘delayed’ for a period of time until the SARS-CoV-2 pandemic was controlled. Rapid guidance was produced for principles of delivering radiotherapy13 and systemic anti-cancer treatment.14 Mitigation strategies resulted in changes to surgical and systemic chemotherapy plans, treatment delays, and introduction of regimens requiring less frequent treatment administration. The mean reduction in surgical training opportunities for trainees observed across surgical modalities of 37.2–80% is consistent with the overall reduction in surgical cases resulting from the above strategies and findings from a global modeling analysis suggesting 38% of cancer surgeries and 82% of benign surgeries may be postponed during the pandemic.15 This is also in keeping with data from other surgical specialities where trainees reported a reduction (50–90%) in surgical training opportunities.16–18 These effects are corroborated by our data, which report increased chemotherapy administration, postponement of surgical cases, reduced referrals, treatment pathway modification, and reprioritization as key reasons for reduced surgical exposure.

Trainees from countries with a national training program were less likely to think that they would need additional time to complete their training fellowship than those from countries with no national training program (p=0.02). This may be because they were earlier in their fellowship (mean 1.6 vs 2.3 years). It also reflects benefits of structured accredited training programs in gynecological oncology which are associated with better educational climates along with better quality/higher training satisfaction.10 19 20 Such programs are more likely to adapt and implement changes to ensure timely progression and completion of training. It is encouraging that, despite the increased pressure on global healthcare systems, delivery of departmental teaching continued for 69% and, consistent with the move towards remote/virtual working practices, was predominantly delivered via virtual platforms in 89% of cases. However, there was no practical hands-on teaching for 21.8% of trainees. Simulation training has long been used in general surgery as a supplement to clinical surgical training as part of a balanced curriculum and has been shown to flatten the learning curve of complex surgical procedures and enhance patient safety.21–24 It is a teaching method often underused in gynecological oncology that warrants greater attention to enable the continued development of surgical skills in times of reduced exposure. The majority of trainees (88%) had access to e-learning resources during the pandemic with high levels of satisfaction (mean satisfaction 7.1–8.6). Access to ESGO/IGCS e-learning was lower among trainees with a national training program (predominantly UK/USA trainees) potentially because a larger proportion were accessing national teaching resources produced by national organizations (BGCS–UK/SGO-USA).

### Strengths and Weaknesses of the Study

The strengths of this study include the fact that it is the first study internationally reporting the impact of SARS-CoV-2 on surgical gynecological oncology trainees. Validated questionnaires were used to evaluate psychological/mental well-being and changes in pre-and post-pandemic mental well-being were quantified through comparison of a customized mental well-being scale. The risk of recall bias was minimized by circulating the survey during the first pandemic wave. Limitations of the study include the fact that, because the survey was circulated during the first SARS-CoV-2 wave and a large proportion of countries have subsequently experienced multiple waves with sustained pressure on healthcare systems, the responses demonstrate short-term impact and long-term impact has not been evaluated. The results may not be completely generalizable to trainees globally as a number of countries are not well represented, the survey was available in English only excluding non-English speakers, there may have been an element of selection bias due to the use of social media platforms to circulate the survey link, and because the majority of respondents were members of BGCS/SGO/ENYGO and likely to be motivated by career development. Responses received for subjective questionnaire items may have been influenced by the current mental state of respondents.

### Implications for Practice and Future Research

It must be the responsibility of employers in tandem with government agencies to ensure adequate supply of PPE and to put in place provisions to ensure income protection. This may include the provision of free staff accommodation for individuals requiring to self-isolate or subsidized childcare costs. Training program directors and societies have a responsibility to ensure continuation of development of surgical skills through the provision of virtual learning (webinars/surgical videos) and simulation training. Study budgets could be used to purchase simulation equipment with simulation training included in national/international curriculums as a method for achieving surgical competencies. Pastoral support should be governed by codes of conduct with training program directors, educational offices responsible for producing clear guidelines on how this may be accessed. The onus must be on trainees to access this support when needed. A future cohort study evaluating the long-term impact of the SARS-CoV-2 pandemic on clinical training, education, and mental well-being of trainees would help guide the recovery phase.

## Conclusion

Data show the SARS-CoV-2 pandemic has negatively impacted surgical training and mental well-being of surgical gynecological oncology trainees. Recognizing medical practitioners are exposed to additional unique work-related stressors as well as shared common stressors experienced by the general population secondary to the pandemic is vital. In addition to lost training opportunities, focusing on improving the mental well-being of trainees is vital for the recovery phase.

## Data availability statement

Data are available upon reasonable request.

## Ethics statements

### Ethics approval

The study has been approved and registered with the Quality Improvement & Assurance Team (QIAT) at NHS Grampian (project ID 4963), UK.

## Acknowledgments

We thank the trainees/fellows who participated in the study and are grateful to the entire administrative staﬀ at the Quality Improvement & Assurance Team NHS Grampian who worked on this study and to ENYGO, BGCS Fellows and SGO for increasing awareness of our study.

• ## Supplementary Data

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