How COVID continues to impact training of surgeons in Canada: ‘Not business as usual’

Training of surgeons in Canada has taken a heavy knock from the chaos of the COVID-19 pandemic, and some doctors say their clinical education has been delayed again in recent months as many hospitals across the country cancelled elective procedures to keep up with emergency care.

Far from looking forward to entering the workforce, some newly graduated surgeons say they are worried and frustrated about backlogs that have put operations on hold.

“I went months without participating in regular surgeries,” said Dr. Kelly Brennan, a general surgery trainee in eastern Ontario.

Delays also affected less urgent specialty procedures such as endoscopies, Brennan added.

Provinces are taking different measures to address surgical backlogs. The Ontario government recently said in a release it’s investing over $300 million over the next year and launching a new software tool aimed at managing the wait list. This month Premier Doug Ford also announced a plan to expand the number and types of procedures to be offered at private clinics.

According to a report commissioned by the Canadian Medical Association released last September, British Columbia plans a $303-million investment over the next three years to speed up diagnostic imaging and surgical procedures.

Manitoba’s 2022 budget included a $110-million investment to reduce backlogs while Saskatchewan plans to ascribe $21.6 million to addressing the surgical wait-list as it anticipates a return to pre-COVID wait times by the end of March 2025. Nova Scotia similarly endorsed a plan to return to national benchmarks for surgical wait times by 2025.

Despite this infusion of government money, it’s unclear whether there will be enough medical professionals, including nurses, to accomplish these goals, Brennan said about Ontario’s plans.

“Nurse staffing continues to be a challenge,” she said, noting also that hospital patient volumes are high, there’s a shortage of beds, and elective cases are often disproportionately affected by delays.

“While things are improving, it is not business as usual,” said Dr. Najma Ahmed, a trauma surgeon and educator in Toronto.

“University hospitals are doctor factories. When they are not running it causes teaching delays that are to the detriment of learners,” she added.

“Nothing replaces going to the operating room,” Ahmed said.

A University of Toronto study published in July 2021 found that about four out of five doctors in plastic surgery residency training programs across Canada believed the pandemic curtailed their exposure to operations and clinical skills, damaging their future educational and practice plans.

Dr. Sultan Al-Shaqsi, a plastic surgeon and one of the study’s authors, said that during much of 2020 there were fewer residents than usual in operating rooms, and even fewer medical students.

In the case of surgical specialties like orthopaedics or plastic surgery, many have missed on-the-job training, especially involving “intricate elective surgical procedures, which have been delayed by COVID,” says Al-Shaqsi.

Moving to a largely online format of lectures, surgical videos and simulations made it harder to teach the technicalities of procedures and give feedback, Al-Shaqsi said.

When the pandemic struck in March 2020, medical schools expanded virtual care and reassigned learners to COVID-19 and vaccine-related work. The Canadian Institute for Health Information estimates the number of surgeries plummeted by 600,000 in the first 18 months of the pandemic compared to expected numbers for that period.

And while service is improving at some hospitals, a triple threat of COVID-19, flu and respiratory syncytial virus (RSV) illnesses this past fall hit many institutions hard as they dealt with an influx of patients, many of them children. Pediatric hospitals across the country cancelled or limited elective procedures.

Al-Shaqsi said he worries that some surgical residents have delayed further subspecialty training, including cancer surgery, or minimally invasive procedures, until surgical care stabilizes.

As fellowship training often focuses on highly specialized and infrequent surgeries, Al-Shaqsi said learners are concerned they will not receive enough training if surgeries don’t return to normal volumes soon.

This means that while most surgical residents are graduating and entering the workforce on schedule, they are potentially doing so without the further specialty skills they would garner in a fellowship program _ at a time when patients can least afford to wait.

The National Resident Matching Program (NRMP), which governs entry into many surgical subspecialty programs in the United States and Canada, listed only 43 Canadian applicants in 2022, down from 70 in 2018. That’s despite an increase in available positions over that same period.

In Al-Shaqsi’s own specialty of craniofacial surgery, which regularly filled all specialty spots before COVID-19, more than half a dozen fellowship spots now go unfilled.

“Elective procedures such as knee ligament repairs and other sports injuries were also delayed,” said Dr. Youjin Chang, an orthopedic surgeon who completed her final fellowship training in 2022 and is based in Ontario’s Durham region.

“Even as we are emerging from the worst of the pandemic, staffing pressures in hospitals are still preventing a return to normalcy,” Chang said, adding daily operating room schedules are “often hours behind,” and “smaller elective cases are the most likely to be affected.”

The delays took a physical and emotional toll on patients stuck in the backlog.

“Our trainees, and patients, suffered greatly,” Ahmed said.

“Initially, we were operating only on very sick patients. It made teaching and mentoring very difficult,” she said of the early days of the pandemic.

“Now, the backlog is so large we need health and human resource solutions.”

A recent Fraser Institute report said “Canada’s health-care wait times reached 27.4 weeks in 2022 _ the longest ever recorded _ and were 195 per cent higher than the 9.3 weeks Canadians waited in 1993.

The Professional Association of Residents of Ontario, which advocates for early-career doctors, flagged concern about changes made to surgical education early in the pandemic.

According to a mid-2020 survey of its members, over 40 per cent of respondents reported they had been assigned to direct patient care instead of attending surgeries and clinics. Nearly 45 per cent of residents noted increased work hours and on-call requirements to cover sick colleagues.

In response to the findings in their survey, PARO is pushing for universities to base student evaluations on a holistic view of a resident’s performance during training, as well as their skill set, rather than a minimum number of clinical hours spent in a certain rotation.

This is part of a broader evolution in medical education towards competency-based, instead of time-based, evaluation of skills.

The Royal College of Physicians and Surgeons of Canada has also signalled it wants a more flexible approach to medical education.

“Perfection is not the goal,” the college says in a publication, updated in early 2022, with guidance on changes to training during the pandemic. They reinforce that “patient care takes precedence” and individual accommodations may be needed as “graduating residents and trainees must be competent to practise unsupervised.”

Advances in augmented reality and simulation-based training for surgeons may also enable new surgical residents to gain more operating experience than their predecessors.

While Al-Shaqsi is optimistic about the role of simulation and augmented reality in the future of surgical education, he noted these technologies are not yet advanced enough to provide comparable education to actual surgeries.

Ahmed said that it will take more than high-tech solutions to deal with the current backlog.

More post-acute care, rehabilitation, elder care, long-term care and resources across the spectrum are needed in order to improve surgical care throughout the country, she said.

“With COVID, at first, it was all hands on deck,” Ahmed said.

But “now there is a lack of trained humans” due to the staffing crisis facing Canada’s hospitals, she said.

This report by The Canadian Press was first Jan. 27, 2023

Dr. Adam Pyle is an emergency medicine physician and lecturer at the University of Toronto, and a journalism fellow at the Dalla Lana School of Public Health.