How has the COVID-19 pandemic affected junior doctor training? A survey analysis

Abstract

In response to the COVID-19 pandemic, major changes were made to clinical responsibilities and shift patterns.
Methods: An anonymised electronic survey was carried out to assess the impact on training, the clinical experience and mental wellbeing of junior doctors.
Results: Response from 60 doctors from all medical and surgical specialties was collated. 18 (30%) had been redeployed to another clinical area and 42 (70%) had not. Doctors redeployed generally felt well supported and that they were providing a valuable contribution. Anxiety, depression and burnout was described in both groups (45% overall), with a significant impact on training. The use of technology enabled improved communication and learning opportunities.
Conclusions: The COVID-19 pandemic has had a significant impact on clinical practice, training and mental health; however, these can be mitigated by taking the initiative to learn from this unique experience, develop insights and make use of novel training opportunities, especially through technology.

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TJTO&C - The Transient Journal of Trauma, Orthopaedics and the Coronavirus
How has the COVID-19 pandemic affected junior doctor training? A survey analysis
How has the COVID-19 pandemic affected junior
doctor training? A survey analysis
By Andrew P Dekker, D, Danielle M Lavender, David I Clark, Amol A Tambe
Department of Trauma & Orthopaedic Surgery, University Hospitals of Derby and Burton NHS
Foundaon Trust, UK
Corresponding author e-mail: andrew.dekker@nhs.net
Published 15 June 2020
Introducon
On March 11th 2020, the World Health Organisaon (WHO) declared the novel severe acute
respiratory syndrome coronavirus 2, also known as coronavirus disease 2019 (COVID-19) outbreak a
global pandemic . This also represented a major incident for the Naonal Health Service (NHS)
given the serious threat to the health of the community and large numbers of crically unwell
paents requiring hospital admission for venlatory support , and on 30 January 2020 NHS
England declared a Level 4 Naonal incident .
Naonal guidelines from NHS England have provided a framework for the redeployment of our
workforce and changes in clinical management of emergency and roune condions during this
crisis.
Reflecve learning from major incidents is crical and improves our preparedness and subsequent
ability to recover faster from future events .
COVID-19 has been shown to have a significant impact on the emoonal and psychological health
of medical staff and to risk worsening of pre-exisng mental health problems .
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A survey is an appropriate tool to invesgate emoon and opinion and rapidly collect knowledge
and experiences from this unprecedented event . Although recent surveys looking at impact on
mental health have been performed , to our knowledge no prior survey gathering informaon on
the impact of COVID-19 on training and redeployment is available in the published literature.
The aim of this study was to determine the impact of the COVID-19 pandemic on junior doctors
training and percepons of their experiences during the pandemic.
Materials and methods
An electronic survey (Google forms) was performed between 1st May 2020 and 1st June 2020. The
survey was distributed by email to all doctors in training including foundaon trainees, core surgical
trainees, registrar and junior and senior clinical fellows within a single NHS Trust. The survey format
was totally anonymised and confidenal.
Quesons were asked relang to grade and clinical area, redeployment, shi paern, mental
health, effect on training, communicaon, personal protecve equipment and learning points from
the experience.
Responses were analysed by two main groups; those not redeployed to another clinical area, and
those doctors redeployed to another clinical area.
Results
60 Doctors responded in total; 31 foundaon trainees, three core surgical trainees, 17 registrars,
three junior clinical fellows and six senior clinical fellows. Doctors were from all medical and
surgical speciales: acute medicine (1); crical care (3), emergency medicine (1), ear, nose and
throat surgery (3), general pracce (1), general surgery (3), general pracce (3), general medicine
(11), neurosurgery (1), obstetrics and gynaecology (4), paediatrics (3), trauma and orthopaedic
surgery (25), urology (1).
Of these, 18 (30%) were redeployed to another clinical area and 42 (70%) were not, (Figure 1).
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Figure 1: Pie chart showing redeployment of doctors. ED = Emergency Department.
All redeployed doctors were supervised by consultants. Those redeployed generally felt well
supported and that they were providing a useful contribuon, (Figure 2). The level of training
before redeployment was considered mixed, (Figure 3).
Figure 2: Bar chart showing support for redeployed doctors.

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Figure 3: Bar chart showing training for redeployed doctors.
The median hours worked was 31-40 hours in both groups, (Figure 4), and the median days worked
per week was four in those not redeployed and 4.5 in those redeployed, (Figure 5). Five doctors
reported working in excess of 48 hours per week; all had not been redeployed and were working in
psychiatry, obstetrics and gynaecology, general surgery, trauma and orthopaedic surgery. All were
junior grade (foundaon, junior clinical fellow, senior house officer) and all felt burnout. Three
doctors reported working an average six days per week.
Figure 4: Bar chart of hours worked for redeployed and not redeployed doctors.

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Figure 5: Bar chart of days worked for redeployed and not redeployed doctors.
A high incidence of anxiety, depression and burnout (45% overall) was seen in both groups, (Figure
6). Burnout was more common in those not redeployed (24%) than those redeployed (11%).
Figure 6: The incidence of anxiety, depression and burnout.
While surgical skills seemed to have been impacted in a prominent manner across both groups,
over 70% of the junior doctors felt their clinical skills were not negavely impacted, (Figure 7).
Research was impacted negavely across both groups equally. Overall the redeployed group had a
more posive experience with respect to clinical skills and knowledge base.

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Figure 7: Bar chart of the effect on training for redeployed and not redeployed doctors.
The use of learning tools was lower across all categories in those not redeployed, with 21% of those
not redeployed using no learning tools. All redeployed doctors used learning tools, (Figure 8).
Figure 8: Bar chart of learning tools used for redeployed and not redeployed doctors.

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Electronic teamworking applicaons such as ‘Microso Teams’ were used by 83% of redeployed
and 74% of not redeployed doctors since the COVID-19 pandemic. The use of teamworking
applicaons was felt to improve communicaon and doctors felt they were likely to use the
technology in the future, with no negave responses, (Figure 9).
Figure 9: Bar chart for the use of technology and the impact on communicaon for all doctors.
58% of doctors felt they understood which type of personal protecve equipment (PPE) to use for
different clinical scenarios, (Figure 10).
Figure 10: Confidence in the appropriate personal protecve equipment (PPE) to be used for
redeployed and not redeployed doctors.
The overall impact on change of clinical pracce for the future was significant, with 68% of doctors
responding agree or agree strongly, (Figure 11).

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Figure 11: The overall impact on change of clinical pracce for the future for redeployed and not
redeployed doctors.
Discussion
The COVID-19 pandemic has had an unprecedented impact on all aspects of clinical work. This
survey has revealed the impact on training and wellbeing for junior doctors.
Nearly one third of respondents were redeployed to another clinical area; mainly medicine and
crical care. Training in new clinical areas brought its own challenges and the feedback from
responders indicates that there was some inial uncertainty of role and requirements. The
fluctuang level of demands on the department meant at mes some doctors felt they were not
required.
Many hospital trusts entered the COVID-19 period with a sense of urgency in up-skilling their staff
and facilies to deal with a potenal mass influx of unwell COVID-19 cases. This meant that training
opportunies had to be provided within fairly short meframes. This is reflected in the responses
received. Many doctors took the opportunity to gain skills and knowledge from the new clinical
area when not directly involved in caring for paents and ward-based training especially from
crical care consultants was rated very highly. A similar experience of improving clinical skills and
knowledge by gaining further experience managing crically unwell paents whilst redeployed
during the COVID-19 pandemic was reported by Gonzi et al. .
100% of those redeployed to another area had the benefit of direct consultant led supervision; this
demonstrates that despite the pressures on the system, consultants were accessible and provided
appropriate support and advice as required. This was especially relevant in the crical care areas.
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One third of redeployed doctors felt there was room for improvement in the generic or specialty
training provided prior to redeployment; despite this however, the overwhelming majority of
doctors felt well supported in their roles and valued in their contribuon to the department.
This highlights a key learning point in planning ahead for future major incidents or pandemics with
specialty specific training programmes prepared in advance and ready to be acvated. Junior
doctor training may benefit from the integraon of major incident training to help prepare for
future events. Keeping the workforce up to date with mandatory training to ensure generic skills
are preserved would also prevent anxiees about shoralls in generic skills. A prepared emergency
rota template with stages of redeployment with stepwise escalaon depending on the severity of
the incident would be another way to lessen the workload in the acute response phase and
reassure doctors of the plan going forward. The importance of the development of strategies to
deliver training whilst adhering to social distancing was emphasised by Bakewell et al. who
suggested adapng training in real me and keeping abreast of naonal guidance by delivering
policies at the trust management level to harmonise local decision-making and facilitate essenal
training .
As the crisis eased, doctors were appropriately stood down from redeployment when it was
recognised their presence was no longer required and almost all doctors in both groups worked less
than six days of the week and less than 48 hours per week.
Naonal guidelines from Public Health England were evolving during the survey period as more
research was provided on this novel disease. The hospital trusts had to quickly respond to the
rapidly changing naonal advice with regard to PPE. Different departments also had their own risk
assessments and produced area and specialty specific advice; therefore it is not surprising that 42%
of respondents had some anxiety or uncertainty about which PPE to wear for each clinical situaon.
Effecve communicaon and maintaining physical distancing was a key issue as the pandemic
progressed. Communicaon of rota changes using technology (Microso Teams) was well received
and a junior doctor group electronic messaging group via a mobile phone applicaon facilitated
rapid feedback on required changes as the crisis evolved. Our impression is that these technologies
have had a major impact on how we effecvely work and communicate during the current
pandemic and the benefits felt will influence clinical interacon going forward.
Consistent with recent studies , our cohort of junior doctors reported a considerable impact on
mental health with 70% of the respondents reporng anxiety, depression or burnout.
Recommendaons to migate this include training in psychological skills of medical staff . Such
training was not specifically assessed in this study however a trust ‘virtual wellness group’ had been
put in place by the trust already. Some junior doctors reported accessing this on Microso Teams.
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Feedback from responding doctors was that a posive atude, managing expectaons and
accepng the unprecedented crisis to the healthcare system, being ready to adapt to a changing
environment and demands were common coping strategies. These aributes are commendable
and show that the junior doctor / workforce were realisc about their situaon and despite
common anxiees developed insights and coping mechanisms that no doubt helped them through
the peak period of the pandemic. Using technology to keep connected to friends and family was
also helpful.
Many doctors indicated that they had taken up more exercise to help with their wellbeing. Exercise
is an established effecve method to reduce depression and anxiety and in parcular running has
been proven just as effecve as psychotherapy in alleviang symptoms of depression .
The workplace changes had a significant effect on training, with surgical skills most negavely
impacted, aributable to the cessaon of elecve surgical procedures and most emergency
procedures being led by consultant teams.
Clinical skills were generally not adversely affected. Knowledge was adversely affected in those not
redeployed however those redeployed reported a posive impact on knowledge which can be
aributed to teaching provided in the new clinical area and iniave to self-educate with webinars
and reading to perform well whilst redeployed. While surgical skills seemed to have been impacted
in a prominent manner across both groups, over two thirds of junior doctors felt that their clinical
skills were not negavely impacted. Connued clinical engagement is key to maintain junior doctor
engagement across the spectrum of clinical acvies despite the changing clinical environment.
Research was impacted negavely across both groups.
Use of learning tools differed greatly between the two groups. All redeployed doctors employed
some form of tool to advance their knowledge, with over half undertaking virtual teaching and
webinar. 21% of those not redeployed did not use any learning tools and although some used
virtual learning plaorms, their use was much more limited. Feedback has shown that those taking
iniave towards direcng their own training had a more posive experience.
The use of technology for the improvement of communicaon and teamwork has been developing
in the modern era with known benefits but has proven invaluable in order to adhere to social
distancing guidelines and permit working from remote locaons such as home. This has had
clinical, educaonal and research applicaons. Respondents using technology have been able to
further their academic goals and migate lost training opportunies. Doctors using webinar, virtual
learning plaorms such as Zoom, Skype and Microso Teams reported a beer ability to keep
knowledge up to date and retain a feeling of advancing training. Technology enabled virtual clinical
and academic meengs allowed aendance whilst maintaining social distancing, which was oen
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also more convenient than meeng in person. This shows the importance of evaluang the changes
in pracce put in place during major incidents, to idenfy those innovaons that will be valuable to
implement long term.
Overall, non-redeployed doctors were more likely to feel burnout, and less likely to report posive
impacts on training than their redeployed counterparts. This suggests that the personal and
professional development consequences were at least as substanal for those not redeployed,
despite their lower workload and unchanged clinical area.
Ulmately the majority of doctors felt that their pracce would change in the future as a result of
the experience. Doctors felt reflecve pracce has helped them learn from this experience and
recommended being proacve and taking on leadership roles.
This study had limitaons including that they total number of recipients was unknown therefore a
response rate could not be calculated. The rates of anxiety, depression and burnout before the
COVID-19 pandemic were unknown and to retrospecvely survey this was considered unreliable,
therefore the impact of COVID-19 on mental wellbeing cannot be fully determined. Data on hours
worked and training undertaken was enrely self-reported and not verified.
Conclusions
The COVID-19 pandemic has had a significant impact on clinical pracce, training and mental
health; however, these can be migated by taking the iniave to learn from this unique
experience and make use of novel training opportunies, especially through technology.
Preparedness for future episodes that impact or affect the health care systems in a major fashion is
a key issue. To ensure that junior doctors feel confident in taking on new roles and working under
the stress of pandemic like condions, training strategies will need to be evolved and built into
teaching and training systems. Clinical engagement and ability and strategies to maintain some
form of training during pandemic periods will ensure that junior doctors do not feel distanced from
core learning and maintaining surgical skills.
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