A survey of young ophthalmologists’ perception of training in Asia during COVID-19

Dear Editor,

The outbreak of the coronavirus disease 2019 (COVID-19) has resulted in the need to increase ward and critical care capacity, leading to temporary suspension of elective ophthalmic surgeries worldwide.¹ There has been significant reduction in outpatient activity and postponement of ophthalmology-based examinations.² Many trainees have been redeployed elsewhere. Ophthalmology congresses have been cancelled or converted to webinars, while residency teaching has been reduced or moved to virtual platforms where possible. These measures have mitigated the impact on residency training but cannot substitute the experience in clinics and time in the operating theatre. Prior plans made, such as fellowship training, may be postponed or cancelled, hindering career progression.

Young ophthalmologists (YOs) are trainees and early career ophthalmologists within the first 5 years of independent practice. The implications of the pandemic for training and career are expected to differ. We conducted a survey to determine how training for YOs have been affected by the pandemic in various countries and territories (Singapore, Malaysia, Taiwan, Hong Kong and India), between 6 May 2020 and 16 June 2020. It was adapted from the North West School of Surgery COVID-19 Training Disruption Notification Form³ and Impact of the COVID-19 pandemic on urology residency training in Italy.⁴ All respondents responded to all questions in the survey.

A total of 242 responses were obtained (response rate of 69.3%). Distribution was equal in sex (50.8% men) and training year (51.2% trainees). There was no significant difference in COVID-19 duties involvement. In total, 52 (21.5%) of the total respondents were involved in COVID-19 duties outside of routine ophthalmological practice, of whom 9 out of 52 (17.3%) were involved daily, while 43 (82.7%) were involved more than once a week. Of the 52 respondents, 25 (48.1%) were deployed out of their primary institution.

The current COVID-19 pandemic has seen examination postponement or cancellation affecting 52% of trainees (P<0.001). There were 22 ophthalmologists who had their fellowship plans delayed (P=0.027). There was a significant impact on YO training in multiple domains that have affected trainees disproportionately more than early-career ophthalmologists.

Table 1 shows areas where ophthalmological training were affected. Cancellation of teaching sessions have significantly affected trainees more than ophthalmologists, of which Singapore had the highest overall rate of cancellation, followed by Hong Kong (P<0.001).

More acute cases were reviewed in Singapore (38.1%) compared to Hong Kong (13.2%). Conjunctivitis is one of the most common ocular conditions diagnosed in the emergency department.⁵ In Hong Kong,⁶ those with acute conjunctivitis had their appointments postponed for at least 14 days. By then, a large proportion of the self-limited cases would have been resolved.⁷

YOs were redeployed from ophthalmology-related duties to critical care, emergency department, COVID-19 wards and screening facilities, worker dormitories and other locations. In view of outbreak in the worker dormitories, Singapore had the greatest change in clinical placement and this could affect residency training. Both ophthalmologists and trainees were affected by leave cancellations. Cancellation of training leave/conference leave was lowest in India. In fact, during the lockdown phase in India, 85.2% of respondents reported an increased frequency of attending webinars, with almost half attending more than 10 webinars on different disciplines.⁸

Additionally, 14 YOs returned to work earlier from their hospitalisation or non-acute illness medical leave. Staffing issue is prevalent worldwide amid the pandemic, and healthcare workers are stepping up voluntarily during times of need. However, it is worrying that some with symptoms of acute respiratory infection may feel pressured to return to work sooner than recommended. There may be a need for advocacy groups to increase awareness of the dangers of this culture to patients, YOs and affiliated healthcare workers.

Our survey has shown that almost all YOs have decreased exposure to surgical cases and 50–60% had practically complete suppression. Outpatient procedures such as intravitreal injections and laser procedures have seen substantial reduction. In all the countries and territories surveyed, surgical volume was reduced during the pandemic and restricted to urgent or emergent conditions.⁹ A survey done by Rohan et al.¹⁰ highlighted cataract surgery as ophthalmic trainees’ biggest concern during the pandemic, especially for those who were starting.

Trainees are expected to have completed a minimum number of phacoemulsification cataract procedures by the end of training, have broad clinical exposure and be clinically competent.¹¹ With the reduction in surgical numbers, those who are completing ophthalmology residency or in their fellowship are the ones most affected.¹² Some may have to compensate for the deficiency by extending their training. Residency requirements are being looked into to allow YOs to progress reasonably through their programme. Any changes proposed could be shared across residency programmes to benefit YOs across the Asia-Pacific region.

The multiple enforced restrictions have created a perfect opportunity to brainstorm and reinvent the way ophthalmology is taught. New technologies can be shared among institutions. Currently, programme directors are seeking ways to re-introduce teachings on virtual platforms, and conferences are still proceeding via online formats. Courses could be provided to tutors, illustrating methods for effective online teaching. With a lack of hands-on experience during the pandemic, surgeries that do take place could be streamed for real-time learning. Surgical simulators, where available, are valuable adjuncts to hands-on training. YOs should be given protected time to attend these sessions. Virtual fellowships could be introduced, especially for fellowships affected by the pandemic. These strategies could overcome geographical boundaries and benefit a greater number of trainees.

We recognise that a limitation of this study was the number of YOs surveyed, as the percentage of YOs surveyed was not uniform across the various geographies. However, it was impractical to do so, especially in a large country like India that has more than 2,000 YOs.

In conclusion, the COVID-19 pandemic has decreased patient load, reduced exposure to surgical training, and pushed educational activities to a digital format. There is significant impact on ophthalmic training that has not been adequately addressed. Key stakeholders including academic institutions, professional bodies and YOs need to collaborate and reinvent ophthalmic education.

REFERENCES

1. Bakshi SK, Ho AC, Chodosh J, et al. Training in the year of the eye: the impact of the COVID-19 pandemic on ophthalmic education. Br J Ophthalmol 2020;104:1181-3.
2. The Royal Australian and New Zealand College of Ophthalmologists. 2020 RANZCO Examinations Timetable, 2020. Available at: https://ranzco.edu/wp-content/uploads/2020/05/Revised- 2020-RANZCO-Examinations-Timetable-06052020.pdf. Accessed on 3 March 2021.
3. North West School of Surgery COVID-19 Training Disruption Notification Form. Available at: https://forms.office.com/Pages/ResponsePage. aspx?id=K5Gn_5ewMUGcD9DoB1Wyq2DExoUw6gZDq_ TYdlawCSVUOUlFQlk1UlNZNk5XWVZYOUhHUUlEQ0Q5Ni4u. Accessed on 3 March 2021.
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