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REVIEW SPECIAL TOPIC
The Impact of COVID-19 on Plastic Surgery Residents Across
the World: A Country-, Region-, and Income-level Analysis
Georgios Karamitros
1,2
•Paraskevas Kontoes
3
•Maria Wiedner
3
•
Sofoklis Goulas
4,5,6,7
Received: 21 February 2023 / Accepted: 25 April 2023
ÓThe Author(s) 2023
Abstract
Background The COVID-19 pandemic has upended
graduate medical education globally. We investigated the
COVID-19 impact on learning inputs and expected learn-
ing outputs of plastic surgery residents across the world.
Methods We administered an online survey capturing
training inputs before and during the pandemic and
retrieved residents’ expected learning outputs compared
with residents who completed their training before COVID.
The questionnaire reached residents across the world
through the mobilization of national and international
societies of plastic surgeons.
Results The analysis included 412 plastic surgery residents
from 47 countries. The results revealed a 44% decline
(ranging from -79 to 10% across countries) and an 18%
decline (ranging from -76 to across 151% countries) in
surgeries and seminars, respectively, per week. Moreover,
74% (ranging from 0 to 100% across countries) and 43%
(ranging from 0 to 100% across countries) of residents
expected a negative COVID-19 impact on their surgical
skill and scientific knowledge, respectively. We found
strong correlations only between corresponding input and
output: surgeries scrubbed in with surgical skill (q=
-0.511 with p\0.001) and seminars attended with sci-
entific knowledge (q=-0.274 with p=0.006).
Conclusions Our ranking of countries based on their
COVID-19 impacts provides benchmarks for national
strategies of learning recovery. Remedial measures that
target surgical skill may be more needed than those tar-
geting scientific knowledge. Our finding of limited substi-
tutability of inputs in training suggests that it may be
challenging to make up for lost operating room time with
more seminars. Our results support the need for flexible
training models and competency-based advancement.
Level of evidence V This journal requires that authors
assign a level of evidence to each article. For a full
description of these Evidence-Based Medicine ratings,
please refer to the Table of Contents or the online
Instructions to Authors http://www.springer.com/00266.
Keywords COVID-19 Plastic surgery training
Residency training Global plastic surgery Pandemic
impact Learning losses Survey Cross-sectional study
Introduction
The spread of the novel coronavirus forced healthcare
systems globally to optimize resource allocation and re-
deploy healthcare personnel to save lives [1,2]. As a result,
the increased needs of patient care eclipsed other hospital
priorities and often impeded medical doctors’ training [3].
Early studies explored the impact of the COVID-19 pan-
demic on residents’ training [4–7]. Residents’ education in
&Georgios Karamitros
karamitrosgiorgos@gmail.com;
georgios.karamitros@ldh.nhs.uk; pmd100116@uoi.gr
1
Department of Plastic Surgery, University Hospital of
Ioannina, Stavrou Niarchou Avenue, 45500 Ioannina, Greece
2
Medical School, University of Ioannina, Stavrou Niarchou
Avenue, 45500 Ioannina, Greece
3
International Society of Aesthetic Plastic Surgery,
Mount Royal, NJ, USA
4
Brookings Institution, Washington DC, USA
5
World Bank, Washington DC, USA
6
Aletheia Research Institution, Palo Alto, CA, USA
7
Hoover Institution, Stanford University, Stanford, CA, USA
123
Aesth Plast Surg
https://doi.org/10.1007/s00266-023-03389-w
surgical specialties in particular is found to be more
severely impacted by the pandemic [8–17]. Recent studies
have revealed substantial learning losses among plastic
surgery residents in specific regions [18–22]. In this study,
we investigate the impact of the COVID-19 pandemic on
learning outcomes of plastic surgery residents at the
country and continent level worldwide.
Our cross-sectional survey study goes beyond previous
research in four important ways. First, we target plastic
surgery residents across the world, while previous studies
have explored the impact of COVID-19 at a national or a
regional level. Our analysis makes comparisons between
countries and provides benchmarks for national strategies
of learning recovery. Second, we investigate the impact of
the pandemic directly on expected learning outcomes,
overcoming the challenge of identifying the intermediate
relation between learning inputs, such as surgeries and
seminars, and outputs, such as surgical competence. Third,
the data collection for our study began two years after the
pandemic had started, giving us the opportunity to capture
a rather complete picture of the impact of COVID-19 on
plastic surgery residents across the world. According the
CDC, prior pandemics lasted 1–2 years on average [23].
Fourth, our analysis provides two contextual benchmarks
of pandemic-related impact: each country’s COVID-19
disease burden and its income level. These benchmarks
allow us to investigate how the pandemic severity and
resource availability may contribute to the magnitude of
resident learning losses during COVID-19.
Methodology
We combined data from multiple sources. First, we col-
lected survey responses from plastic surgery residents
across the world regarding their learning inputs and outputs
prior to and during the COVID-19 pandemic. Second, we
obtained data on each country’s COVID-19 cases and
COVID-19-related deaths per million through 2021 from
the Institute for Health Metrics and Evaluation (IHME)
[24]. The severity of the COVID-19 pandemic in each
country, measured by COVID-19 cases and deaths, may be
associated with the operational pressure on local healthcare
systems and any interruptions in resident training. Third,
we retrieved each country’s classification in economic
development from the World Bank [25]. The financial
context in each country is likely to influence the opera-
tional resilience of healthcare systems and consequently
the level of disruption in resident training during COVID-
19.
Survey Data
We developed a survey to capture demographics, reported
changes in surgeries and seminars attended prior to and
during the COVID-19 pandemic, and expected impact on
surgical skill and scientific knowledge at the end of the
training program due to the pandemic of plastic surgery
residents across the world. The survey was administered
automatically through an online link in English between
January 10th and February 6th, 2022.
We followed Aucejo et al. in directly asking individuals
for their expected learning outcomes with and without
COVID-19 [26]. The responses allowed us to directly
calculate the resident-level subjective treatment effect. Our
approach builds on an established literature that uses sub-
jective expectations on education outcomes to understand
decision making under uncertainty [27–29]. The validity of
our methodology relies on the assumption that residents
have well-formed expectations regarding their learning
outcomes in both in a reality with the COVID-19 pandemic
and in a version of reality without the pandemic. This study
was approved by the Institutional Review Board at Stan-
ford University and followed the STROBE reporting
guidelines [30].
We identify key learning inputs for plastic surgery res-
idents: surgeries participated/scrubbed in and seminars
attended. Residents were asked to report the number of
surgeries and seminars per week or month before and
during the COVID-19 pandemic. For each learning input,
we calculated the percentage change in the number of
surgeries and seminars attended per week, respectively,
between prior to and during the pandemic. This informa-
tion allowed us to understand the severity of the pandemic-
related disruption in training inputs across the world. We
focused on two main learning outcomes: surgical skill and
scientific knowledge. We explicitly asked residents whe-
ther the impact of the pandemic on their surgical skill and
scientific knowledge has been significantly negative,
slightly negative,zero,slightly positive,orsignificantly
positive relative to residents who completed their training
prior to the COVID-19 pandemic. For each leaning out-
come, we created binary variable that takes the value one
when the respondent replied slightly or significantly less/
negative impact.
With the help of the International Society for Aesthetic
Plastic Surgery (ISAPS) we reached plastic surgery resi-
dents around the world. ISAPS is the leading professional
body for board-certified plastic surgeons with a network of
residents in more than 100 countries. The survey link was
disseminated by 63 associations of plastic surgeons,
including ISAPS, to their resident members via email and
social media. The survey questions and the dissemination
strategy are reported in Supplementary Appendix. All
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Aesth Plast Surg
residents in plastic surgery programs in training when the
pandemic started in early 2020 were eligible to participate
in the survey. From administrative sources, we inferred that
ISAPS had 1314 plastic surgery members in 2022. If half
of them were in training during the pandemic, the maxi-
mum potential sample we could have would be around 657
residents.
Results
Demographics
A total of 664 plastic surgery residents responded to the
survey request. Two hundred and fifteen residents did not
complete the survey.
1
Eleven responses were excluded
from respondents who were not in training during the
pandemic. Six duplicate responses were dropped. Twenty
countries with single responses were excluded. The ana-
lytic sample included 412 respondents from 47 countries.
Table 1presents summary statistics of characteristics of
participants and their training settings.
Females represent 42% of respondents. The majority
(61%) of participants are non-Hispanic white. Sixty-three
percent have prior general surgery experience of up to 2
years, while 42% of residents have had plastic surgery
training prior to their residency. Our sampled residents are
roughly equally distributed in PGY 1 through 5?. Nearly
60% of participants work in university-affiliated hospitals,
followed by community (18.7%) and tertiary (13.1%)
healthcare centers. More than 90% of respondents worked
in a hospital that treated COVID-19 patients, while roughly
46% of those were redeployed to COVID-19 wards.
Learning Inputs
Figure 1shows the average number of surgeries and
seminars plastic surgery residents attended per week prior
to and during the COVID-19 pandemic. The average
number of surgeries declined from 10.01 to 5.61 per week,
a 44% decrease. At the same time, the number of seminars
decreased from 1.36 to 0.93 per week, an 18% decline.
Table 2shows the percentage change in surgeries and
seminars attended between prior to and during the pan-
demic by respondents in each country (also shown in
Figure 2). Respondents from every country except for the
Dominican Republic report a decrease in the number of
surgeries they scrubbed in. Trainees from the Dominican
Republic report that they participated in 10% more
Table 1 Resident characteristics
Mean
Female sex (%) 41.7
Race (%)
White 61.4
Asian 25.0
Multi-racial 5.6
Black 2.4
Other 5.6
Mean age (yr) 32.1
Have dependents (%) 31.0
International medical school graduate (%) 16.3
Prior general surgery training up to 2 years (%) 63.0
Prior plastic surgery training (%) 42.1
Mean training duration (yr) 4.7
Year of training (%)
PGY-1 17.0
PGY-2 21.6
PGY-3 21.4
PGY-4 20.4
PGY-5?
Hospital type (%)
19.7
University 59.5
Community 18.7
Tertiary 13.1
Private 5.8
Military 2.9
Residents in hospitals treating COVID-19 patients (1=yes) 91.3
Residents redeployed to COVID-19 wards (1=yes) 45.9
N412
This table reports mean values of respondent characteristics
PGY: postgraduate year
Fig. 1 Reported Surgeries and Seminars before and during COVID-
19. Notes: This figure shows the average number of surgeries (left two
columns) and seminars (two right columns) before and during to
COVID-19
1
The average survey completion rate for those was less than 30%.
123
Aesth Plast Surg
Table 2 Changes in surgeries and seminars attended during COVID-19 by country
Country Reported change in N COVID-19 cases
(per million)
COVID-19 deaths
(per million)
Income
Surgeries Seminars
Rank % Rank %
Dominican Rep. 1 10 25 -26 10 37,295 378 UMI
Moldova 2 -10 40 -53 5 114,927 3139 LMI
Japan 3 -12 22 -22 9 13,984 148 HI
UK 4 -12 10 0 5 191,647 2627 HI
Indonesia 5 -13 34 -50 2 15,473 523 LMI
South Korea 6 -16 29 -35 12 12,260 109 HI
Finland 7 -18 19 -21 4 48,880 309 HI
New Zealand 8 -19 46 -76 4 2,723 9 HI
Russia 9 -22 23 -25 9 71,316 2092 UMI
USA 10 -23 14 -1 26 162,301 2441 HI
Austria 11 -24 43 -67 3 142,155 1,881 HI
Norway 12 -26 17 -16 8 72,550 240 HI
Taiwan 13 -27 26 -26 44 713 36 HI
Sweden 14 -29 34 -50 4 124,632 1451 HI
Germany 15 -31 41 -57 38 85,767 1343 HI
Syria 16 -33 34 -50 2 2,272 131 LI
Morocco 17 -38 9 8 2 25,711 396 LMI
Turkey 18 -39 27 -33 5 111,113 965 UMI
Colombia 19 -42 4 40 11 99,422 2505 UMI
South Africa 20 -45 44 -69 2 57,740 1522 UMI
Bulgaria 21 -47 18 -17 6 110,161 4564 UMI
Czechia 22 -47 32 -44 4 235,919 3443 HI
India 23 -47 3 96 17 24,599 340 LMI
Serbia 24 -48 20 -21 7 189,090 1850 UMI
Philippines 25 -48 5 30 5 24,611 446 LMI
Argentina 26 -49 1 151 16 124,245 2575 UMI
Ethiopia 27 -50 45 -75 2 3,407 56 LI
Peru 27 -50 10 0 2 67,455 5953 UMI
Belgium 29 -50 10 0 4 180,624 2431 HI
Pakistan 30 -54 30 -38 2 5,495 123 LMI
Poland 31 -55 34 -50 2 103,073 2435 HI
Albania 32 -57 6 25 4 73,962 1132 UMI
Mexico 33 -57 8 14 8 31,213 2348 UMI
Greece 34 -57 42 -63 23 116,597 2002 HI
Venezuela 35 -59 31 -42 8 15,711 188 UMI
Denmark 36 -61 33 -46 9 136,410 555 HI
Italy 37 -62 16 -9 33 103,759 2327 HI
Spain 38 -64 47 -88 7 132,358 1880 HI
Brazil 39 -65 15 -8 3 103,532 2876 UMI
Paraguay 40 -66 6 25 2 68,739 2452 UMI
Netherlands 41 -68 21 -22 4 179,544 1196 HI
Romania 42 -69 27 -33 15 92,012 2989 HI
Egypt 43 -71 23 -25 16 3,474 196 LMI
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Table 2 continued
Country Reported change in N COVID-19 cases
(per million)
COVID-19 deaths
(per million)
Income
Surgeries Seminars
Rank % Rank %
Canada 44 -71 2 125 2 57,828 788 HI
Uruguay 45 -72 34 -50 2 120,773 1803 HI
Kenya 46 -75 10 0 2 5461 100 LMI
Slovakia 47 -79 34 -50 2 242,951 2948 HI
Average -44 -18 83,955 1537
Median -48 -25 73,962 1451
This table shows the average percentage change in the number of surgeries participated/scrubbed in and the number of seminars attended
between prior to and during the COVID-19 pandemic in each country. Countries with fewer than two respondents are excluded. Ranking of
countries was based on percentages with up to five decimal points. Shown percentages are rounded to full percentage points. Countries are sorted
based on reported change in surgeries residents participated/scrubbed in. Each country’s COVID-19 cases and COVID-19-related deaths per
million through 2021 were obtained from the Institute for Health Metrics and Evaluation (IHME) [24]. Income classification comes from the
World Bank [25]. The average and median are obtained across countries
Fig. 2 Reported Changes in
Learning Inputs during COVID-
19 by Country Panel A:
Surgeries Participated/Scrubbed
in. Panel B: Seminars Attended.
Notes: This map shows the
percentage change between
prior to and during the COVID-
19 pandemic of surgeries
residents participated/scrubbed
in (Panel A) and seminars
attended (Panel B) by country.
Darker shades reflect more
negatively impacted countries.
123
Aesth Plast Surg
surgeries during the COVID-19 pandemic. Residents from
Moldova, Japan, and the UK report the least decrease in
their operation room time: -10%, -12%, and -12%,
respectively. On the other extreme, residents from Canada,
Uruguay, Kenya, and Slovakia report that their surgical
training decreased more than 70%.
The median percentage change during the pandemic is
four and seven percentage points closer to zero than the
corresponding averages in surgeries (-48% versus
-44%) and seminars (-25% versus -18%), respec-
tively. This suggests that a limited number of countries had
negligible or even positive percentage change in learning
inputs during the pandemic, while the preponderance of
nations experienced substantial declines in resident training
inputs.
Learning Outputs
Figure 3plots the survey responses regarding the impact of
COVID-19 on residents’ skill and scientific knowledge.
We find that 74% of the residents report a slightly negative
(43.69%) or significantly negative (30.10%) impact on
their surgical skill. In contrast, the scientific knowledge of
plastic surgery residents was relatively preserved with
43.45% claiming slight or significant losses in their sci-
entific knowledge attributed to the pandemic.
Table 3shows the percentage of respondents in each
country reporting slightly or significantly negative impact
on their surgical skill and scientific knowledge due to the
pandemic (also shown in Figure 4). Residents in the
Dominican Republic, Russia, the USA, and Taiwan are the
least likely to report surgical skill losses due to COVID-19.
On the other extreme, residents from Turkey, the Nether-
lands, Mexico, Italy, Albania, Brazil, Czech Republic, and
Denmark were the most likely to report a negative COVID-
19 impact on their surgical dexterity. Respondents from
Morocco were the only ones who did not report any
surgical skill loss. Our analysis reveals a portion of coun-
tries in which residents cruised through the pandemic with
their scientific knowledge intact. Six countries, Belgium,
Canada, Morocco, the Netherlands, Pakistan, and Syria,
had zero percent of trainees reporting scientific knowledge
loss due to COVID-19. At the same time, Ethiopia,
Venezuela, Serbia, and Egypt were the most heavily
impacted with respect to the scientific knowledge of their
trainees.
We find that the median losses level is four and one
percentage point higher than the corresponding averages in
surgeries (82% versus 78%) and scientific knowledge (41%
versus 40%), respectively. This suggests that a limited
number of countries had limited or negligible impact of
COVID-19 on residents’ surgical skill, while the prepon-
derance of nations reported sizable losses in surgical skill.
We investigate the statistical association between
changes in surgeries and seminars during COVID-19 and
the share of respondents reporting declined surgical skill (q
=-0.511 with p\0.001 for surgeries; q=-0.079 with
p=0.600 for seminars) and decreased scientific knowledge
(q=-0.118 with p=0.428 for surgeries; q=-0.274 with
p=0.006 for seminars). It is important to note the signif-
icant correlations between corresponding input and output
(i.e., surgeries scrubbed in with surgical skill). We find
weak cross-correlations between inputs and outputs (i.e.,
surgeries attended with scientific knowledge and seminars
attended with surgical skill). This suggests limited substi-
tutability of inputs in training. In other words, it may be
challenging to make up for lost operating room time with
more seminars.
COVID-19 Pandemic Burden
The COVID-19 burden of disease may reflect pressures to
each country’s healthcare system and is likely to have
influenced disruptions in resident training during the
Fig. 3 Reported Change in
Surgical Skill and Scientific
Knowledge of Plastic Surgery
Residents due to COVID-19.
Notes: These figures show the
percentage of respondents
reporting changes in their
surgical skill (left) and scientific
knowledge (right) due to
COVID-19.
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Aesth Plast Surg
Table 3 Losses in surgical skills and scientific knowledge due to COVID-19 by country
Country Rank % Rank % N COVID-19 cases
(per million)
COVID-19 deaths
(per million)
Income
Morocco 1 0 1 0 2 25,711 396 LMI
Dominican Rep. 2 10 7 10 10 37,295 378 UMI
Russia 3 44 11 22 9 71,316 2092 UMI
USA 4 46 9 19 26 162,301 2441 HI
Finland 5 50 13 25 4 48,880 309 HI
Taiwan 5 50 21 36 44 713 36 HI
South Korea 5 50 25 42 12 12,260 109 HI
Kenya 5 50 27 50 2 5461 100 LMI
New Zealand 5 50 27 50 4 2723 9 HI
Serbia 10 57 45 86 7 189,090 1850 UMI
Argentina 11 63 13 25 16 124,245 2575 UMI
Austria 12 67 18 33 3 142,155 1881 HI
Japan 12 67 26 44 9 13,984 148 HI
Spain 14 71 8 14 7 132,358 1880 HI
Colombia 15 73 37 55 11 99,422 2505 UMI
Belgium 16 75 1 0 4 180,624 2431 HI
Albania 16 75 13 25 4 73,962 1132 UMI
Sweden 16 75 13 25 4 124,632 1451 HI
Venezuela 16 75 46 88 8 15,711 188 UMI
Philippines 20 80 10 20 5 24,611 446 LMI
UK 20 80 23 40 5 191,647 2627 HI
Moldova 20 80 38 60 5 114,927 3139 LMI
Egypt 23 81 44 81 16 3474 196 LMI
India 24 82 24 41 17 24,599 340 LMI
Greece 25 83 43 70 23 116,597 2002 HI
Bulgaria 26 83 41 67 6 110,161 4564 UMI
Romania 27 87 41 67 15 92,012 2989 HI
Germany 28 87 40 66 38 85,767 1343 HI
Norway 29 88 22 38 8 72,550 240 HI
Canada 30 100 1 0 2 57,828 788 HI
Netherlands 30 100 1 0 4 179,544 1196 HI
Pakistan 30 100 1 0 2 5495 123 LMI
Syria 30 100 1 0 2 2272 131 LI
Denmark 30 100 11 22 9 136,410 555 HI
Czechia 30 100 13 25 4 235,919 3443 HI
Brazil 30 100 18 33 3 103,532 2876 UMI
Italy 30 100 18 33 33 103,759 2327 HI
Indonesia 30 100 27 50 2 15,473 523 LMI
Mexico 30 100 27 50 8 31,213 2348 UMI
Paraguay 30 100 27 50 2 68,739 2452 UMI
Peru 30 100 27 50 2 67,455 5953 UMI
Poland 30 100 27 50 2 103,073 2435 HI
Slovakia 30 100 27 50 2 242,951 2948 HI
South Africa 30 100 27 50 2 57,740 1522 UMI
Uruguay 30 100 27 50 2 120,773 1803 HI
Turkey 30 100 38 60 5 111,113 965 UMI
Ethiopia 30 100 47 100 2 3407 56 LI
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Aesth Plast Surg
pandemic. Tables 2and 3report the pandemic-related
burden of disease in each country next to the corresponding
pandemic-related change in learning inputs and outputs,
respectively.
We investigate the association between pandemic-in-
duced changes in plastic surgery residents’ learning inputs
and outputs, and the number of COVID-19 cases and
COVID-19-related deaths through the end of 2021. We find
substantial correlations between COVID-19 prevalence per
country until the end of 2021 and the percentage change in
the number of surgeries residents scrubbed in during
COVID-19 (q=-0.188 with p=0.206 for cases; q=
0.202 with p=0.174 for deaths). We find limited associ-
ation between COVID-19 prevalence and the percentage
Table 3 continued
Country Rank % Rank % N COVID-19 cases
(per million)
COVID-19 deaths
(per million)
Income
Average 78 40 83,955 1537
Median 82 41 73,962 1451
This table shows the percentage of respondents in each country reporting slightly or significantly negative change in surgical skill or scientific
knowledge due to the COVID-19 pandemic. Countries with fewer than two respondents are excluded. Ranking of countries was based on
percentages with up to five decimal points. Shown percentages are rounded to full percentage points. Countries are sorted based on reported
surgical skill loss. Each country’s COVID-19 cases and COVID-19-related deaths per million through 2021 were obtained from the Institute for
Health Metrics and Evaluation (IHME) [24]. Income classification comes from the World Bank [25]. The average and median are obtained across
countries.
Fig. 4 Reported loss in learning
outputs due to COVID-19 by
country. Panel A: surgical skill.
Panel B: scientific knowledge
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Aesth Plast Surg
change in seminars residents attended during the pandemic
in each country (q=-0.056 with p=0.709 for cases; q=
0.077 with p=0.605 for deaths). Turning to learning
outputs, we find sizable correlations between COVID-19
prevalence per country until the end of 2021 and the share
of respondents reporting declined surgical skill (q=0.207
with p=0.163 for cases; q=0.2840 with p=0.053 for
deaths). The correlation of COVID-19 disease burden and
reported decreased scientific knowledge is found to be
relatively weak (q=-0.094 with p=0.530 for cases;
q=0.120 with p=0.422 for deaths).
Regional Analysis
Tables 4and 5show the COVID-19 impact on learning
inputs (outputs) by geographical region. South America
reports the largest decline in surgeries and surgical skill
during the pandemic compared with other regions. Trainees
in Europe, Asia, and Africa follow in terms of surgical skill
losses. Plastic surgery residents in North America and
Oceania seem to be the least affected by the pandemic.
Even at the regional level, we observe smaller losses in
areas with lower input declines (e.g., residents from North
America report attending 28% more seminars during the
pandemic and only 20% of them claim a negative COVID-
19 impact on their scientific background).
World Bank Income Classification
Table 6shows the percentage change in surgeries and
seminars by respondents from countries in each World
Bank income-level classification. We find that the decline
in reported surgeries was roughly 40%, on average, across
all four income classifications, suggesting a ubiquitous
impact of COVID-19 on operating volume across countries
regardless of their income. In contrast, we find varying
levels of COVID-19 impact on the seminars trainees
attended. Residents from low-income countries reported
the most dramatic negative impact on seminars (i.e., more
than 60% decrease). Table 7shows the percentage of
respondents reporting negative impact on their surgical
skill and scientific knowledge due to the pandemic in
Table 4 Changes in surgeries
and seminars attended during
COVID-19 by region
Region Reported change in N Countries COVID-19 cases
(per million)
COVID-19 deaths
(per million)
Surgeries (%) Seminars
Africa -56 -32 24 5 19,159 454
Asia -31 -15 107 10 28,184 491
Europe -46 -34 187 20 133,851 2037
North America -35 28 46 4 72,159 1489
Oceania -19 -76 4 1 2723 9
South America -57 17 44 7 85,697 2622
This table shows the average percentage change in the number of surgeries participated/scrubbed in and the
number of seminars attended between prior to and during the COVID-19 pandemic in each region.
Countries with fewer than two respondents are excluded. Each country’s COVID-19 cases and COVID-19-
related deaths per million through 2021 were obtained from the Institute for Health Metrics and Evaluation
(IHME) [24].
Table 5 Losses in surgical skills and scientific knowledge due to COVID-19 by region
Region Reported loss in N Countries COVID-19 cases
(per million)
COVID-19 deaths
(per million)
Surgical skill Scientific knowledge
%%
Africa 66 56 24 5 19,159 454
Asia 77 32 107 10 28,184 491
Europe 83 40 187 20 133,851 2037
North America 64 20 46 4 72,159 1489
Oceania 50 50 4 1 2723 9
South America 87 50 44 7 85,697 2622
This table shows the percentage of respondents in each region reporting slightly or significantly negative change in surgical skill or scientific
knowledge due to the COVID-19 pandemic. Countries with fewer than two respondents are excluded. Each country’s COVID-19 cases and
COVID-19-related deaths per million through 2021 were obtained from the Institute for Health Metrics and Evaluation (IHME) [24].
123
Aesth Plast Surg
countries in each World Bank income-level classification.
Residents from low-income countries stand out, as 100% of
them report a negative impact in their surgical skill and
half of them report a decline in their scientific knowledge
as a result of COVID-19.
Discussion
Our results show that the preponderance of plastic surgery
residents across the world expects their surgical skill and
scientific knowledge to be lower compared with previous
cohorts due to the pandemic. Residents are much more
likely to report surgical skill losses than scientific knowl-
edge losses (i.e., 73.79% versus 43.45%). At the same time,
pockets of residents may have experienced positive con-
sequences from COVID-19 on personal and professional
dimensions, such as trauma and emergency case care
[14,17]. Roughly one-third (31.31%) of residents reported
no COVID-19 impact on their scientific knowledge, while
more than one-fifth (20.87%) experienced a positive impact
from the pandemic. Some residents might have been able
to invest time in self-study or research during the pan-
demic, preserving their knowledge capital from deprecia-
tion [18,31–33].
Digital resources, such as video recordings of opera-
tions, webinars, and teleconferences, might have also
benefited residents’ scientific knowledge [18,34]. Reme-
dial measures that target surgical skill may be more needed
than those targeting scientific knowledge. Potential reme-
dial strategies include a surgical skills laboratory or sim-
ulating surgical procedures on practice models [35,36].
Our results corroborate previous studies on the COVID-
19 impact on the surgical logged hours of residents across
surgical specialties at the national and regional level
[6,37,38]. This suggests that our findings on learning
outputs of plastic surgery residents may constitute a
benchmark for the pandemic-related learning losses of
residents more broadly [39–44].
Our finding that surgical skill is primarily driven by the
surgeries residents scrub in and less so by seminars pro-
vides clear guidance regarding the necessary remedial
strategies. Program directors, health policy makers, and
health system administrators can leverage our findings into
designing recovery plans that provide residents with
operation room exposure to help mitigate their pandemic-
induced learning losses [45].
Our results support the need for flexible training models,
competency-based advancement, and regular assessment of
trainees. This training approach may be best suited to
Table 6 Changes in surgeries and seminars attended during COVID-19 by income Level
Income level Reported change in N Countries COVID-19 cases
(per million)
COVID-19 deaths
(per million)
Surgeries Seminars
%%
High Income (HI) -43 -30 264 23 111,281 1539
Upper Middle Income (UMI) -45 1 93 14 82,928 2243
Lower Middle Income (LMI) -44 -4 51 8 27,469 658
Low Income (LI) -42 -63 4 2 2,840 94
This table shows the average percentage change in the number of surgeries participated/scrubbed in and the number of seminars attended
between prior to and during the COVID-19 pandemic in countries in each income level. Countries with fewer than two respondents are excluded.
Each country’s COVID-19 cases and COVID-19-related deaths per million through 2021 were obtained from the Institute for Health Metrics and
Evaluation (IHME) [24]. Income classification comes from the World Bank [25].
Table 7 Losses in surgical skills and scientific knowledge due to COVID-19 by income level
Income level Reported loss in N Countries COVID-19 cases
(per million)
COVID-19 deaths
(per million)
Surgical skill Scientific knowledge
%%
High Income (HI) 79 35 264 23 111,281 1539
Upper Middle Income (UMI) 77 48 93 14 82,928 2243
Lower Middle Income (LMI) 72 38 51 8 27,469 658
Low Income (LI) 100 50 4 2 2840 94
This table shows the percentage of respondents from countries in each income level reporting slightly or significantly negative change in surgical
skill or scientific knowledge due to the COVID-19 pandemic. Countries with fewer than two respondents are excluded. Each country’s COVID-
19 cases and COVID-19-related deaths per million through 2021 were obtained from the Institute for Health Metrics and Evaluation (IHME)
[24]. Income classification comes from the World Bank [25].
123
Aesth Plast Surg
mitigate crisis-driven training deficits [1]. National asso-
ciations such as the American Board of Plastic Surgery and
the Accreditation Council for Graduate Medical Education
can lead the efforts to design effective recovery plans for
plastic surgery residents [46].
Our study brings forth two contextual benchmarks of the
impact of COVID-19 on the plastic surgery residents in
each country: the COVID-19-related disease burden and
the income level. Countries with substantial learning losses
and a COVID-19 caseload close to the average (e.g.,
Mexico) may experience low system resilience more gen-
erally [47].
2
These countries may need to invest in forti-
fying their healthcare system (e.g., through resource
redundancy) and in the learning recovery of their residents
to ensure they become effective health professionals.
Each country’s income level may be correlated with
resource availability that would make healthcare systems
and training programs more resilient to crises and more
likely to bounce back after a crisis. Residents in high-in-
come countries like Japan, the UK, South Korea, and New
Zealand, who suffered lower loss levels, may have better
access to tools that would help them recover compared
with their counterparts in less affluent countries.
This study has certain limitations. First, our focus on
plastic surgery trainees limits the statistical power of our
analyses. Future studies can potentially reach residents
across multiple specialties. Second, our convenient non-
random sample of participants represents a broad geo-
graphic distribution of resident experiences during the
pandemic. At the same time, the severity of pandemic may
influence the likelihood of plastic surgery residents from
specific countries to participate in the study. Future studies
might be able to capture the pandemic-related training
disruptions of plastic surgery residents in countries or
communities not reachable at this time.
Third, our self-reported measures of learning inputs and
anticipated outputs may contain recall and expectation
bias. Further research could explore the availability of
administrative data on log books and board examinations
scores to measure training inputs and outputs and obtain
more accurate estimates of the COVID-19 impact.
At the same time, this study can serve as a blueprint for
future research on resident training inputs and outputs,
especially following system-wide shocks. The COVID-19
pandemic impaired resident training across the world.
Future epidemics, natural phenomena associated with cli-
mate change, geopolitical instabilities also pose a signifi-
cant threat to resident training in the future [48–50]. Our
study contributes to a broader understanding of the resi-
lience of each country’s resident training programs to
crises. Our approach to quantifying resident learning inputs
and expected outputs is general and can be applied in more
contexts and specialties. Our measures of learning outputs,
in particular, speak to current proposals to develop a
‘‘Surgical Preparedness Index’’ (SPI) to assess, monitor,
and improve the resilience of training programs and
healthcare systems across the world [48].
Author’s Contribution SG has full access to all the data in the study
and takes responsibility for the integrity of the data and the accuracy
of the data analysis. SG, GK helped in study concept and design,
drafting of manuscript, critical revision of the manuscript for
important intellectual content, and study supervision. GK, SG, PK,
MW contributed to survey dissemination. GK acquired the data. SG
was involved in statistical analysis and interpretation of data.
Funding Open access funding provided by HEAL-Link Greece.
Declarations
Conflict of interest The authors declare that they have no conflicts of
interest to disclose.
Human or Animal Rights This article does not contain any proce-
dures with human participants or animals.
Informed Consent This study obtained informed respondent
consent.
Ethical Approval This study was approved by the Institutional
Review Board at Stanford University (protocol #63918).
Supplementary InformationThe online version contains
supplementary material available at https://doi.org/10.1007/s00266-
023-03389-w.
Open Access This article is licensed under a Creative Commons
Attribution 4.0 International License, which permits use, sharing,
adaptation, distribution and reproduction in any medium or format, as
long as you give appropriate credit to the original author(s) and the
source, provide a link to the Creative Commons licence, and indicate
if changes were made. The images or other third party material in this
article are included in the article’s Creative Commons licence, unless
indicated otherwise in a credit line to the material. If material is not
included in the article’s Creative Commons licence and your intended
use is not permitted by statutory regulation or exceeds the permitted
use, you will need to obtain permission directly from the copyright
holder. To view a copy of this licence, visit http://creativecommons.
org/licenses/by/4.0/.
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