Impact of Covid 19 Pandemic on Post Graduate Medical Residency in a Medical College of Mumbai

• Page 1 of 8 • Wani et al. Int Arch Public Health Community Med 2021, 5:058 Citation: Wani RJ, Relwani HP, Wankhedkar S, Shah Y (2021) Impact of Covid 19 Pandemic on Post Graduate Medical Residency in a Medical College of Mumbai. Int Arch Public Health Community Med 5:058. doi.org/10.23937/2643-4512/1710058 Accepted: June 28, 2021; Published: June 30, 2021 Copyright: © 2021 Wani RJ, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. DOI: 10.23937/2643-4512/1710058 ISSN: 2643-4512


Introduction
The World Health Organization (WHO) declared Coronavirus disease 2019 (COVID19) as pandemic on 11 th March 2020 [1]. To contain and prevent the pandemic, Government of India announced many steps such as nationwide lockdown on March 25, 2020, promoting social distancing and infection control guidelines including the use of masks, personal protective equipment (PPE) [2,3].
The novel Covid-19 pandemic marked our lives in an indelible way, changing the reality we were used to. It affected negatively the educational training for all students worldwide; Given the social distancing recommendations, the Coronavirus emergency has led to significant modification within hospitals [4], especially postgraduate training experience in many ways [5].

Abstract
The novel Covid-19 pandemic marked our lives in an indelible way. It affected negatively the educational training for all students worldwide; with significant modification within hospitals, especially postgraduate (PG) training experience in many ways.
We conducted an online survey among currently pursuing PG students of all departments working in HBTMC & Dr. R. N. Cooper Hospital, Mumbai to find out the impact of COVID-19 on PG teaching and learning. Difficulties and problems faced by them during the pandemic in terms of the progress in dissertation, lectures, seminars, clinical case discussions, surgical training, re-deployment challenges and the effect on their mental health was enquired.
Out of 250 students contacted, 136 (54%) responded. Nearly half (48%) were from surgical branches, and 106 (78%) had been deployed for Covid related duties. There was a decrease in PG teaching, as felt by students in terms of frequency and modality of classes. Only 29 of 136 (21.3%) had no problem with their thesis, all others encountered difficulties. Majority of residents (80.99%) felt their basic learning is affected in these times. Only 6% reported no stress but 42.6% felt stressed most or all of the time.
Our study highlighted the need to focus on PG training in a different way, give support to mental health, and have consideration for thesis work in these difficult times.

Statistical analysis
The data collected through Google forms was in Excel format and its analysis was done with the help of Microsoft office (SPSS software).

Results
The

Change of place of stay post-covid
Prior to covid pandemic, 101 Residents stayed in hostel, 31 stayed at home and 4 stayed outside in private hostels. After the start of Covid-19 Pandemic, 23 Residents (16.9%) who stayed at home changed their place of stay.

Effect on post-graduate teaching
Frequency of classes: There has been reduction in the amount of Clinical teaching and number of classes taken for post-graduate residents since the start of Covid Pandemic. 49 students (36%) said that they did not have any classes prior to covid, whereas this number rose to 107(79%) post Covid (Figure 2).

Academic Progression Hampered
Medical students are recognised as high risk group for developing anxiety disorder as compared to general population, even under normal circumstances especially for those residing in the Middle East Asia. But, unlike other students, they have deeper understanding of the disease, which could increase awareness of its severity and impact [6].
There are few Indian studies analysing the effect on PG teaching, hence we conducted an online survey among currently pursuing PG students of all departments working in HBTMC & Dr. R. N. Cooper Hospital, Mumbai to find out the impact of COVID-19 on PG teaching and learning. Difficulties and problems faced by them during the pandemic in terms of the progress in dissertation, lectures, seminars, clinical case discussions, surgical training, re-deployment challenges and the effect on their mental health was enquired into.

Aims & Objectives
Our study evaluated the effect of Covid Pandemic on

Study design
This cross-sectional study (online survey) was conducted from January 15, 2021 to January 30, 2021, to study the problems faced by PG students pursuing post-graduation (DNB and CPS), of all departments working in HBTMC & Dr. R. N. Cooper Hospital, Mumbai.
A Google form questionnaire was created and circulated among students, mentioning the questionnaire is completely voluntary, anonymous and participation is considered implied consent for study survey. Ethics Committee approval for consent waiver was applied for.

Thesis work
22% of residents had already submitted their thesis, and 21% had no problem in their thesis work. The residents of Clinical branches suffered the maximum difficulties in thesis work as, 29% residents complained the follow up cases are not coming to hospital, 21% had difficulty in recruitment of new cases, 25% had difficulties due to shutting down of elective OTs hence no surgical cases (Figure 4). 80.9% (110) Residents reported that their basic learning is affected due to cancellation of elective OTs, speciality OPDs, lab and research work for surgical branches, medical branches and para clinical branches respectively.

Effect on online CMEs/seminars
65.4% (89) Residents opined that it was confusing at times regarding what topic to attend, 21.3% (29) felt that easy to attend along with work and 13.2% (18) felt that this is a good opportunity to attend multiple topics at a time) ( Figure 5).
Mode of online teaching: 79% residents had no classes followed by 12% where Virtual method of online classes both lectures and case presentation was the common method (Table 1) (Figure 3).
On enquiring about the satisfaction of Residents with mode and method of teaching, only 11% (15) residents were 100 percent satisfied, whereas 8.8% (12) residents are not satisfied at all. And 30% (41) residents are mediocrely satisfied. 91.2% (124) residents still feel that face to face teaching is important and cannot replace virtual teaching especially for clinical case discussion.   • Lost confidence in performing surgeries/ procedures Most common reason for stress was being away from family in 67% residents followed by lots of surgical training period and procedures in 40%, fear of contracting covid infection in 32% and long working hours in covid wards in 27% residents) ( Figure 6). 13.2% residents needed to consult counselor, 94% had access to counselor but only 68.7% actually consulted counselor (Table 2).

Discussion
Post-graduate Residency is already a stressful period in a life of Medical Student. Covid pandemic has further caused unprecedented changes in their lives, daily challenges regarding their own health and their training many ways [5].

Reduced learning opportunities
In our study, 49 students (36%) said that they did not have any classes prior to covid, whereas this number rose to 107 (79%) post-Covid. In survey conducted by Upadhyay Gaurav, et al. [7] during the COVID-19 pandemic, the number of PG classes have been significantly reduced to none as reported by 65.81%. 61.8% (84) Residents admitted that attending these virtual classes/seminars/CMEs helped knowledge grow academically.
Reason for stress evaluated were as follows ( Figure 6) • Delay in thesis due to non-recruitment of cases   demonstration of many clinical skills [7]. This is also reflected in our study seen in Figure 4.

Mental well being
COVID-19 pandemic has had effect on mental health and wellbeing according to World health Organization (WHO) [10]. Since student distress and untreated anxiety are reported to negatively impact academic performance, professionalism and empathy towards patients, and contribute to academic dishonesty and attrition from medical school [6].
Mental well-being is often overlooked. COVID-19 has impacted the surgical training period. And there is lot of uncertainty regarding future prospects. They expose not only themselves but their family members too through them to COVID-19. Some are not able to visit their families because of lockdown measures.
Lasheras I, et al. [6] reported the overall prevalence of anxiety in medical students was 28% in systemic review with meta-analysis. Stress factors identified included worry about economic influences, academic delays, and the impact on their daily life. Curricular factors of unstructured or online learning, might promote distress and contribute to anxiety.
Saddik B, et al. [11] also reported mild to severe anxiety in medical students during COVID-19 pandemic which decreased after the introduction of online teaching programmes. Most of the stress was academics related, few studies revealed the introduction of online learning methods eased their burden and reduced anxiety levels [12]. Our study highlights the mental issues faced by our residents (Figure 6).
However, stress levels reported were less in our institution, compared to study done in Orthopedic residents in Delhi (96%) [7]. Major reasons cited by them were the loss of surgical training period (83.8%), fear of contracting COVID-19 (70.7%), uncertainty about professional life due to COVID-19 (66.6%), being away from family (63.64%). Positive changes in learning pattern were also seen, the inclusion of virtual learning environment results in increased trainee participation and consultant input in the virtual journal club and casebased discussions.
Lasheras I, et al. [6] in their review, the prevalence of anxiety is lower than the prevalence of anxiety prior to COVID-19 for medical students globally (33.8%). This finding also contrasts the tendency of anxiety rates in general population, where it is increased by four fold [6,12]. This could be explained by several reasons, the medical students have perceived higher grade of information on COVID's prognosis, transmission and broader knowledge of the disease as compared to other students [6,11] and general population, which them to build preventive behavioral response to the epidemic and reduce fear and anxiety. Their high levels In our study, 12% classes taken by virtual method either ZOOM, Google meet etc. About the satisfaction of Residents with mode and method of teaching, 11% (15) residents were 100 percent satisfied, whereas 8.8% (12) residents are not satisfied at all. And 30% (41) residents are mediocrely satisfied. In comparison with survey by Upadhyay Gaurav, et al. [7] only 27.27% PG students were satisfied with the virtual classes; 40.9% were not satisfied and 31.8% were satisfied only to some extent.
Palan, et al. [8] have reported their exposure of conducting virtual learning systems and 'virtual' journal clubs. There are both advantages and disadvantages of virtual learning methods. Advantages being: a) Easy accessibility of the educational content, b) Facility of attaching images and radiographs to web based platforms (which can provide more valuable information and stimulate discussion), c) No risk of exposure to COVID-19 and d) Confer utilisation of time at home. However, the disadvantages include: a) No compulsion to attend the classes online, b) The virtual classes are time bound (the educators need to finish lecture and discussion with stipulated time), c) Lack of two ways discussion, in many such lectures, d) The infrastructure remains a potential hurdle for successful implementation of virtual learning platforms, and e) The success largely depends upon the consultant and faculty participation and input that guides and control the discussion [8].
• Lectures and theoretical classes have been cancelled in the teaching hospitals and institutions to prevent and contain the spread of COVID-19 [9].
• Special COVID services: The focus of the trainee has shifted to COVID-19. Historically postgraduate medical training was well rounded. If this paradigm shift continues for too long, trainees in medical specialties may lose or never develop skills in managing a broad range of medical pathologies.
• Trainees in specialized non-primary care specialties are on standby for covid wards due to markedly reduced patient volume in these specialties, this will reduce the learning opportunities for trainees to become competent in their respective fields.

Thesis work
Thesis preparation and submission is important part of post-graduate residency. And due to Covid pandemic shunting of residents to covid wards, prolonged working hours and reduction in the number of routine opds [9] and research work, thesis preparation, collection of data, statistical analysis and submission has been difficult.
The reduced patient load has affected the of adaptive coping strategies and resilience have further contributed.
Most of the stress was academics related, few studies revealed the introduction of online learning methods eased their burden and reduced anxiety levels [6,13].
A community based meta-analysis [12] on the prevalence of anxiety revealed fourfold increase among general population (25% now as compared to 7.3% prior to pandemic) as compared to anxiety in medical students. The anxiety levels are significant higher in women. The reasons could be their more socialising behaviour [14], more emotional and being them the main caregivers within the family [15], they make them more vulnerable to stress due to increased house chores, closure of schools and work from home for working women.
The prevalence of anxiety was more seen in young age population [12], which is also seen in our study, where maximum (84%) PG residents belonged to 25-30 years of age group. Uncertainty about the future of jobs and careers, financial worries and being techno-savvy, more active on social websites increases their exposure to news and increases the stress [12,[16][17][18].
It was also seen, anxiety levels were high in people living alone or unmarried people [12]. Several studies [18,19] reported that the feelings of loneliness and lack of social support were among the strongest correlators with anxiety during the pandemic. 67% of PG residents in our study were stressed due to social isolation, being away from home.
Occupation is the independent factor determining the degree of stress. The prevalence of stress in medical students is less as compared to general population [12]. The stress was seen less in people working from home [20] or who remained physically active or took the opportunity to pursue hobbies [14,15]. Santabarbara J, et al. [21] conducted meta-analysis of prevalence of anxiety in different occupational categories of HCW (i.e., nurses, medical doctors and frontline HCW). The prevalence of anxiety reported were high as 25%, 27% and 17% in HCW, nurses and doctors respectively.

Conclusion
Our study shows the disruptive effects of COVID-19 pandemic on the education and training of our PG students and the impact on their mental health.
Attention to these issues for our budding doctors is very important and this will help in developing a stable healthcare infrastructure to combat COVID. The way forward is having regular meetings, audits and discussions to facilitate our residents training and work patterns, and measure to keep their mental well being stable.