Impact of a global pandemic on surgical education and training- review, response, and reflection

Abstract

The catastrophic effects of the coronavirus disease-2019 global pandemic have revolutionised human society. The unprecedented impact on surgical training needs to be analysed in detail to achieve an understanding of how to deal with similar situations arising in the foreseeable future. The challenges faced by the surgical community initiated with the suspension of clinical activities and elective practice, and included the lack of appropriate personal protective equipment, and the self-isolation of trainees and reassignment to coronavirus patient-care regions. Together, all these elements had deleterious effects on the psychological health of the professionals. Surgical training irrespective of specialty is equally affected globally by the pandemic. However, the global crisis inadvertently has led to a few constructive adaptations in healthcare systems, including the development of tele-clinics, virtual academic sessions and conferences, and increased usage of simulation. The current review article was planned to highlight the impact of corona virus disease on surgical training and institutions' response to the situation in order to continue surgical training, and lessons learnt from the pandemic.

Full text

Abstract
The catastrophic effects of the coronavirus disease-2019
global pandemic have revolutionised human society.
The unprecedented impact on surgical training needs to
be analysed in detail to achieve an understanding of
how to deal with similar situations arising in the
foreseeable future. The challenges faced by the surgical
community initiated with the suspension of clinical
activities and elective practice, and included the lack of
appropriate personal protective equipment, and the
self-isolation of trainees and reassignment to
coronavirus patient-care regions. Together, all these
elements had deleterious effects on the psychological
health of the professionals. Surgical training irrespective
of specialty is equally affected globally by the pandemic.
However, the global crisis inadvertently has led to a few
constructive adaptations in healthcare systems,
including the development of tele-clinics, virtual
academic sessions and conferences, and increased
usage of simulation. The current review article was
planned to highlight the impact of corona virus disease
on surgical training and institutions' response to the
situation in order to continue surgical training, and
lessons learnt from the pandemic.
Keywords: Surgical education, Training, COVID 19,
Pandemic, Trainees.
Introduction
Global pandemic, which started from the Chinese city of
Wuhan in December 2019, has changed almost every
aspect of life.1 From thinking to living and from behaviour
to attitudes nothing is what it was like previously. The
coronavirus disease-2019 (COVID-19) has not only
claimed millions of lives, but has also had challenged
significantly the entire global healthcare system. The
healthcare system, which was once thought to be
promising and flourishing, particularly in the developed
world, now looks very feeble, insubstantial and wobbling
in face of the viral surge, spread and now its recurrent
waves. Although every walk of life has been affected by
the pandemic, it is the healthcare system that has been hit
the most.
In recent years, surgery has gained recognition as a major
public health issue and access to surgical care has been
deemed an essential component of human rights. The
impact of COVID-19 on surgical practice is widespread
and priorities in various surgical institutions stand
changed2 (Figure-1). The current pandemic has not only
challenged the provision of good surgical care, but has
significantly affected surgical training and education
programmes in various countries. The extent of this
impact on surgical training is yet to be estimated and
might be revealed in the years to come, but several
changes have been witnessed in various surgical training
programmes.
Surgical trainees have been uniquely impacted by
these changes. The drastic changes triggered by
COVID-19 necessitate a re-evaluation of surgical
education and training. Institutions have had to adapt
to different ways in which their surgical trainees learn,
practice and reproduce surgical tasks safely and
effectively. The pandemic has also presented a huge
opportunity to reconstruct the method by which
surgical trainees learn and adapt to their curricular
activities, and revisit contemporary methods of
learning and gaining surgical expertise.
J Pak Med Assoc (Suppl. 1)
Surgical Education and Training: Developing Standards S-49
LITERATURE REVIEW
Impact of a global pandemic on surgical education and training- review,
response, and reflection
Sabah Uddin Saqib,1 Omair Saleem,2 Amna Riaz,3 Qamar Riaz,4 Hasnain Zafar5
1-3Department of Surgery, 4Department of Educational Development,
5Consultant Surgeon, Aga Khan University, Karachi, Pakistan.
Correspondence: Sabah Uddin Saqib. Email: sabah.saqib@aku.edu Figure-1: Priorities of the department of surgery during a pandemic.

The current review article was planned to highlight the
current evidence and to offer recommendations for
changes to surgical training after the COVID-19 surge in
the light of global trends in this regard.
Methods
The review article comprised search on MEDLINE,
PubMed, Google Scholar and Cochran databases using
the keywords 'coronavirus' OR 'SARS-CoV-2' OR 'COVID-
19', 'surgical education' OR 'surgical training' OR 'surgical
residency' OR 'resident' OR 'virtual surgical training' OR
'surgical skills'. The reference lists of the identified papers
were also searched for relevant articles. The search was
further amplified by a manual search of most relevant and
accessible journals.
Results
The review of the identified literature provided an insight
into the impact of COVID-19 on surgical education and
training in terms of challenges, responses and
opportunities.
A. Challenges for surgical training
The sudden spread of COVID-19 pandemic led to abrupt
changes in the field of surgical training, leading to major
challenges stemming from the impact on surgical
practice and extending to involve trainees' wellbeing
(Figure-2).
I) Suspension of clinical activities
All aspects of surgical education have been severely
impacted by the pandemic. As both surgical training
and academic sessions are deemed unsafe due to social
distancing measures, academic activities, including
morbidity and mortality meetings, case discussions,
journal clubs and tumour boards, were initially
cancelled before they were restored with less
interactive forms.3
II) Shortage of personal protective
equipment and surgical exposure
The shortage of personal protective equipment (PPE)
resulted in a major hindrance in clinical work. Italy faced
high rates of cross-infection due to such a shortage.4 The
preservation of the available PPE limited the residents'
exposure in an operation room (OR) setting.5 The
available PPE provided by the institutions was also a
matter of concern. In a survey by Caruana et al., 22.54%
trainees were concerned regarding the PPE provided at
their respective institutions.6
III) COVID-19 exposure/ testing/
self-isolation of trainees
The resident workforce was recruited in
multiple centres to provide medical coverage
in COVID-19 units, meaning further exclusion
from the surgical domain.7 Trainees working in
the areas were subject to exposures and were
later either quarantined or tested. In a study,
33% trainees reported having to take time off
from work due to pandemic-related health
issues.6
IV) Cancellation of elective surgeries
Surgical departments were made to
reschedule all elective surgeries to limit the
spread of COVID-19, reducing hospital
admissions.8,9 This substantially compromised
the education of trainees. Amparo et al.
reported reduction in training for final year
residents in urology from 84% to 44%
(p<0.001) of minimally invasive surgery (MIS)
and from 82% to 46% (p=0.002) of open
surgery.10 Ellison et al. reported11 an 87%
reduction in exposure in elective surgeries
among trainees. In a survey by Caruana et al.,6
trainees reported a 78% reduction in OR
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S-50 Surgical Education and Training: Developing Standards
Figure-2: Concerns of surgical residents during a pandemic.

exposure.
V) Senior surgeons only performing
emergency surgeries
Training opportunities were further reduced when
consultants, to limit the exposure, preserve PPE and
decrease operative time, performed procedures by
themselves.3,12 Bernardi et al.13 reported decreased
inclusion in operative procedures of senior residents.
VI) Psychological health of trainees
At the peak of the surge, trainees went through fatigue
and burnout,14 with one study reporting 33.1% trainee
burnout.15 Ellison et al.11 found a severe impact on
trainees' emotional wellbeing up to 27%. Caruana et al.6
said 32% trainees relayed concerns regarding their
mental wellbeing.
Moreover, the psychosocial stress of the risk of infecting a
family member was profound, with one study reporting
72.7% prevalence of such stress.14
B. Specialty-based impact
All surgical specialties globally suffered drastic setbacks
after COVID-19 reached the pandemic status. Some
specialties were more affected in comparison to others.
The impact of few of these specialties provides insight
into the ground reality in different countries.
I) Oral and maxillofacial training
Maxillofacial training was adversely affected by the
pandemic.16 In a study, 14% residents had to be
reassigned to alternative clinical areas, treating COVID-
19 patients. This reassignment was indicative of time
lost in training. Residents expecting to complete
training in 2022 had genuine concerns regarding their
completion of training and their decreased operative
exposure.16
II) Cardiothoracic training
Cardiac surgery training also suffered major changes.
Shafi et al.17 extensively described the state of cardiac
surgery training during this period in the United
Kingdom. The intensive care unit (ICU) is an integral
component of cardiac surgery, but the unprecedented
ICU need for COVID-19 patients lead to cardiac surgery
practice being confined to two out of seven centres,
with trainees in five centres getting deprived of
surgical training. The vast majority of cardiac surgery
patients were carrying high risk, meaning that the
procedures were performed by a consultant rather
than trainees. After the lockdown was enforced, the
outpatient services were limited, thereby affecting
cardiac training elective exposure. Moreover, the
study postulated that the resumption of cardiac
surgery after lockdown will see a backlog of
postponed surgical cases and that will have a
deleterious effect on surgical training.17
III) Otorhinolargyology training
The impact of COVID-19 on otolaryngology training has
been well described by Guo et al.18 in the United States
and Canada. Almost all residents (98%) reported a
decrease in clinical activities and 94% reported decreased
operative exposure; both of these being surrogate
markers of surgical training. Almost 64% residents
reported that they were not involved in clinic visitations.
However, programmes utilising technology meant that
majority of the residents did not report a reduction in
educational training.
IV) General surgery training
Italy was one of the countries worst affected by the
COVID-19 pandemic. Bernardi et al. described the
effect of general surgery training in Italy. The
unprecedented impact of the pandemic lead to a
significant decrease in operative exposure due to
cessation of surgery for the benign general surgical
condition, and the operative exposure was limited to
emergency surgeries on patients with delayed
presentations usually forcing the involvement of the
consultants due to the difficulty of the procedure,
limited PPE and risk of exposure. Elective surgeries
were limited to non-deferrable oncologic procedures
that were often done by consultants due to the
difficulty of the case, to decrease operative time, and
to decrease the risk of complications. However, there
was an increase in non-clinical educational activities
that were conducted from home.13
V) Surgical oncology training
Surgical oncology was one of the specialties relatively
less affected by the global pandemic. Pawlik et al.19
described these effects in the United States. Complex
general surgical oncologic training requires intensive
training. Integral aspects of training include rotating in a
variety of distinct patient populations, developing
management strategies, and exposure to operative
procedures. Reassignment of trainees to provide care to
COVID-19 units led to the disruption of training. The
surgical volumes decreased due to surgical candidates
being limited to non-deferrable oncologic cases. And
these urgent cases were more often dealt with via open
technique as opposed to the laparoscopic approach due
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Surgical Education and Training: Developing Standards S-51

to the risk of aerosol generation. The use of
prolongation of aggressive neoadjuvant regimens also
decreased the number of patients undergoing surgery,
adversely affecting training.
C. Adaptations of surgical training
programmes
Surgical training programmes globally were forced to
adapt in accordance with the need of the hour. Few of
these alterations were innovative and will possibly serve
to strengthen surgical training in future.
I) Evidence-based use of PPE
Healthcare workers (HCWs) are at significant risk of
COVID-19 infection,20 but the correct use of PPE
mitigates this risk. Direct exposure to bio-hazardous
waste put surgical staff, particularly trainee residents, at
a significant risk of contracting infection during surgery.
A study of 205 COVID-19 patients by Wang et al.21
investigated the bio-distribution of severe acute
respiratory syndrome coronavirus 2 (SARS-CoV-2)
ribonucleic acid (RNA) using real-time reverse
transcription-polymerase chain reaction (RT-PCR).
Results showed the highest rate in bronchoalveolar
fluid, followed by sputum and nasal swabs. Few other
studies demonstrated high viral load in stool, urine and
blood. Evidence-based teaching was done along with
training of surgical staff on donning and doffing PPE to
minimise the spread of COVID-19.21,22 PPEs are now
worn as per World health Organisation (WHO) and
Centers for Disease Control and Prevention (CDC)
guidelines.23 Double-gowning and gloving is the
preferred option with proper use of fit test-approved
N95 mask or respirator (Figure-3).
II) Surgical e-learning
The current unprecedented crisis has created the
opportunity to innovate, accelerate and enhance e-
learning solutions for surgical education.
Epidemiological forecasts, even if they are often
imprecise, demonstrate that intermittent social
distancing measures may be necessary until 2022.
WebSurg and the French: Institute for Research into
Cancer of the Digestive System (IRCAD) surgical videos
offer free-of-charge operative videos which help in
remote surgical training.24 Garcia et al. reported that
during the emergency phase of the COVID-19
pandemic from April to May, 2020, the average number
of surgical videos viewed on the WebSurg platform was
1161 views per month versus 161 views per month in
the same period in 2019 (+621%).24 Image-guided
simulation trainers and virtual simulators used
frequently in the COVID-19 era not only provide the
opportunity of safe learning, but also a very promising
paradigm shift from contemporary expert-based
apprentice model to competency-based training.
III) Tele-clinics
A survey done in 84 residency programmes in the US
reported implementation of tele-clinics in 90.5% of the
programmes (76/84). Another 22(26.2%) reported that
inpatient consults were being seen remotely via different
electronic moods of communication.25 This adaptation
greatly reduces the risk of exposure of surgical residents
with asymptomatic carriers. Vreeland et al.18 mentioned
that their institution moved towards increased
dependence on tele-health clinics with the aid of online
video conference software. Although their tele-clinic
model is in evolution, trainees make the initial contact
with patients through video links, take all information on
illness, and formulate a management plan as they
normally used to do in the pre-COVID-19 era. The trainee
then discusses the case with the attending surgeon over
the phone. The attending and the trainee then conduct a
multiuser video conference with the patient so that the
resident can participate in the counselling of the patient
and formulation of the final plan. Finally, the attending
and the trainee discuss after the patient has signed off to
finalise the encounter. Even though such patients'
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S-52 Surgical Education and Training: Developing Standards
Figure-3: The use of level III personal protective equipment (PPE) during emergency
trauma surgery. A limited surgical team comprising a consultant surgeon, trauma
fellow, and a technician.

interviews have lots of interruptions and there is no
opportunity for clinical examination, this is an important
and worthwhile initial effort.
III) Simulation platforms
As we work to define the new normal in surgical
education and professional development, digital surgery
will be critical for continued growth and progress. During
the COVID-19 era, OR simulators and virtual simulation
labs have widely been accepted as an effective media to
continue surgical training. Currently, over 20 computer-
based platforms, covering 9 surgical specialties, are
available on the internet and are accessible from home to
enhance the surgical skills of trainees and provide them
real-time environment very close to that of an OR. There
are 15 computer-based platforms freely accessible, 1
platform, Incision Academy, is offering a 4-week free trial
during the pandemic, and 7 platforms require paid
accounts.
IV) Virtual conferences and webinars
As an adaptive measure, surgical training programmes
had to take their in-person academic sessions and
meeting to virtual meetings for the continuation of
didactic training. Virtual conferences and webinars are
being held all over the world. Webinars are interactive
online mini-conferences that allow surgeons an
opportunity to select the content that best matches their
interests and learning needs. Some hashtags about
COVID-19 and surgery, like #COVID19surgery,
#COVID19ESCP and #COVIDSurg, are being widely used
by young surgeons all over the world.
D. Learning reflections after Pandemic
The effects of the pandemic are huge and devastating,
disrupting nearly every sphere of life, including surgical
education and training. However, as they say, 'every
cloud has a silver lining', this pandemic has served as the
missing catalyst to change the current exhausted
framework and to reconsider a novel approach for
optimising medical and surgical education.
I) Time for innovations
While the hospitals were busy fighting against the
pandemic, institutions identified several ways and means
to ensure continuity of education and training using
virtual platforms for remote learning. These ranged from
podcasts and vodcasts to synchronous lectures, seminars
and conferences.26 Learners participated in virtual rounds,
journal clubs and tele-clinics that were taken very
positively by the learners globally because of the
flexibility of time and place.24,27 Simulations and artificial
intelligence (AI) allowed the trainees to observe
procedures, experience ORs and participate in triage
while being at home.28-30 Social media, otherwise
considered a waste of time, was effectively utilised as a
discussion board for official and academic meetings as
well as for virtual classes.31 Reading courses in the form of
books, atlases and scientific journals was made freely
accessible, augmenting the phenomenon of knowledge-
sharing. Educationists and faculty learned to create and
use virtual rooms for teaching and learning while
applying concepts of ethical principles in virtual settings.
Even assessments for knowledge and clinical and
technical skills were conducted virtually without
compromising on their validity. COVID-19 changed the
common perceptions of the 'on-the-job training' for the
postgraduates and allowed them time for their formal
education.32
Inter-professional education was another area that was
explored for continuing professional development
(CPD) during the pandemic, mainly to adjust to feasible
timings and to cut down cost while ensuring diversity.
Also, diversity in the form of inter-professional
education enriched learning experiences.
All these measures were especially important for low-
resource countries. The pandemic equipped us with
knowledge, experience, resources and infrastructure that
can be used to continue our academic activities for both
undergraduate and postgraduate programmes33 even
after the situation returns to normal, allowing time for
self and family as well as promoting self-directed
learning.9,28
II) Wellbeing of surgical trainees
What came as an unexpected benefit was the time to
reflect and ponder on issues that were earlier discussed
in meetings and published in journals but were never
really applied and addressed to in their core either due
to service load or because it was never a priority. One
such area was mental health and wellbeing of surgical
trainees. Different programmes started weekly online
counselling and stress management sessions /
workshops and peer support teams for trainees and
programme directors to combat the effect of pandemic-
related stress and to ensure psychological health.
Clinical services ran with fewer healthcare professionals,
allowing adequate work-life balance.34,27 These
initiatives can be turned into regular activity even in the
post-pandemic time without compromising service and
patient-care.
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III) ‘Me time’
While people were locked down and practicing social
distancing, many felt bored as lockdowns got extended,
and started thinking out of the box to fill their time with
something. The world witnessed the largest number of
researches conducted and papers published during this
time across all disciplines. Many of these turned out to be
great innovations suggesting the value of time for
reflection and critical thinking.
Conclusion
The COVID-19 global pandemic has adversely affected
surgical specialties, resulting in major lapses in training,
but has also thrown up a few unexpected useful
adaptations. The pandemic, like many other disasters, has
taught us lessons for survival and has also served as an
impetus for pedagogical novelties and reshaped training
for improving the quality of education and life.
Disclaimer: None.
Conflict of Interest: None.
Source of Funding: None.
References
1. Pan A, Liu L, Wang C, Guo H, Hao X, Wang Q, et al. Association of
Public Health Interventions With the Epidemiology of the COVID-
19 Outbreak in Wuhan, China. JAMA 2020;323:1915-23. doi:
10.1001/jama.2020.6130.
2. Al-Jabir A, Kerwan A, Nicola M, Alsafi Z, Khan M, Sohrabi C, et al.
Impact of the Coronavirus (COVID-19) pandemic on surgical
practice - Part 1. Int J Surg 2020;79:168-79. doi:
10.1016/j.ijsu.2020.05.022.
3. Dedeilia A, Sotiropoulos MG, Hanrahan JG, Janga D, Dedeilias P,
Sideris M. Medical and Surgical Education Challenges and
Innovations in the COVID-19 Era: A Systematic Review. In Vivo
2020;34(Suppl 3):1603-11. doi: 10.21873/invivo.11950.
4. Ranney ML, Griffeth V, Jha AK. Critical Supply Shortages - The
Need for Ventilators and Personal Protective Equipment during
the Covid-19 Pandemic. N Engl J Med 2020;382:e41. doi:
10.1056/NEJMp2006141.
5. Bambakidis NC, Tomei KL. Editorial. Impact of COVID-19 on
neurosurgery resident training and education. J Neurosurg
2020;2020:1-2. doi: 10.3171/2020.3.JNS20965. [ahead of print]
6. Caruana EJ, Patel A, Kendall S, Rathinam S. Impact of coronavirus
2019 (COVID-19) on training and well-being in subspecialty
surgery: A national survey of cardiothoracic trainees in the United
Kingdom. J Thorac Cardiovasc Surg 2020;160:980-87. doi:
10.1016/j.jtcvs.2020.05.052.
7. Gupta N, Agrawal H. COVID 19 and Surgical Education: Time for
Innovations. Indian J Surg 2020:1-2. doi: 10.1007/s12262-020-
02422-5.
8. Moletta L, Pierobon ES, Capovilla G, Costantini M, Salvador R,
Merigliano S, et al. International guidelines and recommendations
for surgery during Covid-19 pandemic: A Systematic Review. Int J
Surg 2020;79:180-88. doi: 10.1016/j.ijsu.2020.05.061.
9. Juanz-González A, Barreras-Espinoza JA, Soualhi A, Leyva-Moraga
E, Leyva-Moraga FA, Leyva-Moraga F, et al. COVID-19: an
opportunity to restructure surgical education. Eur Surg
2020;2020:1-2. doi: 10.1007/s10353-020-00651-2. [ahead of print]
10. Amparore D, Claps F, Cacciamani GE, Esperto F, Fiori C, Liguori G,
et al. Impact of the COVID-19 pandemic on urology residency
training in Italy. Minerva Urol Nefrol 2020;72:505-09. doi:
10.23736/S0393-2249.20.03868-0.
11. Ellison EC, Spanknebel K, Stain SC, Shabahang MM, Matthews JB,
Debas HT, et al. Impact of the COVID-19 Pandemic on Surgical
Training and Learner Well-Being: Report of a Survey of General
Surgery and Other Surgical Specialty Educators. J Am Coll Surg
2020;231:613-26. doi: 10.1016/j.jamcollsurg.2020.08.766.
12. Porpiglia F, Checcucci E, Amparore D, Verri P, Campi R, Claps F, et
al. Slowdown of urology residents' learning curve during the
COVID-19 emergency. BJU Int 2020;125:e15-17. doi:
10.1111/bju.15076.
13. Bernardi L, Germani P, Del Zotto G, Scotton G, de Manzini N.
Impact of COVID-19 pandemic on general surgery training
program: An Italian experience. Am J Surg 2020;220:1361-63. doi:
10.1016/j.amjsurg.2020.06.010.
14. Juprasert JM, Gray KD, Moore MD, Obeid L, Peters AW, Fehling D,
et al. Restructuring of a General Surgery Residency Program in an
Epicenter of the Coronavirus Disease 2019 Pandemic: Lessons
From New York City. JAMA Surg 2020;155:870-75. doi:
10.1001/jamasurg.2020.3107.
15. Aziz H, James T, Remulla D, Sher L, Genyk Y, Sullivan ME, et al.
Effect of COVID-19 on Surgical Training Across the United States:
A National Survey of General Surgery Residents. J Surg Educ
2020;2020:1931-7204(20)30271-3. doi:
10.1016/j.jsurg.2020.07.037. [ahead of print]
16. Huntley RE, Ludwig DC, Dillon JK. Early Effects of COVID-19 on Oral
and Maxillofacial Surgery Residency Training-Results From a
National Survey. J Oral Maxillofac Surg 2020;78:1257-67. doi:
10.1016/j.joms.2020.05.026.
17. Shafi AMA, Atieh AE, Harky A, Sheikh AM, Awad WI. Impact of
COVID-19 on cardiac surgical training: Our experience in the
United Kingdom. J Card Surg 2020;35:1954-57. doi:
10.1111/jocs.14693.
18. Chick RC, Clifton GT, Peace KM, Propper BW, Hale DF, Alseidi AA,
et al. Using Technology to Maintain the Education of Residents
During the COVID-19 Pandemic. J Surg Educ 2020;77:729-32. doi:
10.1016/j.jsurg.2020.03.018.
19. Pawlik TM, Tyler DS, Sumer B, Meric-Bernstam F, Okereke IC,
Beane JD, et al. COVID-19 Pandemic and Surgical Oncology:
Preserving the Academic Mission. Ann Surg Oncol 2020;27:2591-
99. doi: 10.1245/s10434-020-08563-x.
20. Nguyen LH, Drew DA, Joshi AD, Guo CG, Ma W, Mehta RS, et al.
Risk of COVID-19 among frontline healthcare workers and the
general community: a prospective cohort study. medRxiv
[Preprint] 2020:2020.04.29.20084111. doi:
10.1101/2020.04.29.20084111.
21. Wang W, Xu Y, Gao R, Lu R, Han K, Wu G, et al. Detection of SARS-
CoV-2 in Different Types of Clinical Specimens. JAMA
2020;323:1843-44. doi: 10.1001/jama.2020.3786.
22. Afzal A. Molecular diagnostic technologies for COVID-19:
Limitations and challenges. J Adv Res 2020;26:149-59. doi:
10.1016/j.jare.2020.08.002.
23. Centers for Disease Control and Prevention (CDC). CDC
Guidelines. [Online] [Cited 2020 December 08]. Available from
URL: https://www.cdc.gov/infectioncontrol/basics/transmission-
based-precautions.html
24. García Vazquez A, Verde JM, Dal Mas F, Palermo M, Cobianchi L,
Marescaux J, et al. Image-Guided Surgical e-Learning in the Post-
COVID-19 Pandemic Era: What Is Next? J Laparoendosc Adv Surg
Tech A 2020;30:993-7. doi: 10.1089/lap.2020.0535.
25. White EM, Shaughnessy MP, Esposito AC, Slade MD, Korah M, Yoo
PS. Surgical Education in the Time of COVID: Understanding the
Vol. 71, No. 1 (Suppl. 1), January 2021
S-54 Surgical Education and Training: Developing Standards

J Pak Med Assoc (Suppl. 1)
Surgical Education and Training: Developing Standards S-55
Early Response of Surgical Training Programs to the Novel
Coronavirus Pandemic. J Surg Educ 2020;2020:1931-
7204(20)30270-1. doi: 10.1016/j.jsurg.2020.07.036. [ahead of
print]
26. Vervoort D, Dearani JA, Starnes VA, Thourani VH, Nguyen TC.
Brave New World: Virtual conferencing and surgical education in
the Coronavirus Disease 2019 era. J Thorac Cardiovasc Surg
2020;2020:0022-5223(20)32268-6. doi:
10.1016/j.jtcvs.2020.07.094. [ahead of print]
27. Laloo R, Giorga A, Williams A, Biyani CS, Yiasemidou M. Virtual
surgical education for core surgical trainees in the Yorkshire
deanery during the COVID-19 pandemic. Scott Med J
2020;65:138-43. doi: 10.1177/0036933020951927.
28. Mirchi N, Ledwos N, Del Maestro RF. Intelligent Tutoring Systems:
Re-Envisioning Surgical Education in Response to COVID-19. Can
J Neurol Sci 2020;2020:1-3. doi: 10.1017/cjn.2020.202. [ahead of
print]
29. McKechnie T, Levin M, Zhou K, Freedman B, Palter VN,
Grantcharov TP. Virtual Surgical Training During COVID-19:
Operating Room Simulation Platforms Accessible From Home.
Ann Surg 2020;272:e153-54. doi:
10.1097/SLA.0000000000003999.
30. Babidge WJ, Tivey DR, Kovoor JG, Weidenbach K, Collinson TG,
Hewett PJ, et al. Surgery triage during the COVID-19 pandemic.
ANZ J Surg 2020;90:1558-65. doi: 10.1111/ans.16196.
31. ElHawary H, Salimi A, Alam P, Gilardino MS. Educational
Alternatives for the Maintenance of Educational Competencies in
Surgical Training Programs Affected by the COVID-19 Pandemic. J
Med Educ Curric Dev 2020;7:e2382120520951806. doi:
10.1177/2382120520951806.
32. Keller DS, Grossman RC, Winter DC. Choosing the new normal for
surgical education using alternative platforms. Surgery (Oxf)
2020;38:617-22. doi: 10.1016/j.mpsur.2020.07.017.
33. Chao TN, Frost AS, Brody RM, Byrnes YM, Cannady SB, Luu NN, et
al. Creation of an Interactive Virtual Surgical Rotation for
Undergraduate Medical Education During the COVID-19
Pandemic. J Surg Educ 2020;2020:1931-7204(20)30232-4. doi:
10.1016/j.jsurg.2020.06.039.
34. Al-Jabir A, Kerwan A, Nicola M, Alsafi Z, Khan M, Sohrabi C, et al.
Impact of the Coronavirus (COVID-19) pandemic on surgical
practice - Part 2 (surgical prioritisation). Int J Surg 2020;79:233-48.
doi: 10.1016/j.ijsu.2020.05.002