The COVID-19 pandemic has presented unforeseen and unprecedented challenges for surgical training worldwide, including here in Ireland. The almost complete cessation of elective surgery has profoundly impacted the operative surgical experience for trainees. This is clearly reflected in the electronic logbook records of trainees at all levels of training. But there has also been a significant reduction in urgent surgery (eg cancer surgery) and even emergency surgery (due partly to a reduction in major road trauma and sports injuries). However, the impact on surgical training goes significantly beyond the operating theatre.  There has also been a marked reduction in outpatient clinic activity, endoscopy, and even routine ward work. In many cases, trainees have had less interaction with their trainers with consequent effects on role-modelling and mentorship. In some cases, trainees have been redeployed to other non-surgical areas of the hospital, sometimes for prolonged periods of time. In addition, many trainees have been off work due to illness or self- isolation as a result of contact with COVID patients or staff. 

The net effect of all these challenges has been that trainees have had a significant reduction in training opportunities including reduced clinical decision-making and other areas of professional development.

 The impact of COVID-19 has also affected other elements of the surgical curriculum including national selection, workplace- based assessments, teaching activities in the hospitals and in RCSI, CAPA/ARCP reviews and conduct of MRCS/FRCS examinations.

In an era of competency-based education and training, the current pandemic will have a significant impact on career development and progression for many surgical trainees. RCSI has been pro-actively working to mitigate the effects of the current pandemic on surgical trainees at all levels of training.

The current wave of COVID-19 is now waning rapidly in this country and, luckily, the expected “surge” of cases did not occur. It is now time to focus on a return to normal clinical activity in our hospitals, albeit a “new normal”.  An important part of this focus must be mitigation of the negative effects of the pandemic on surgical training over the past 4 months and maximising the training opportunities going forward.

In planning for the next 12-18 months, there are certain realities which need to be considered:

• There will be a significant backlog of both urgent and elective clinical activity which will compound the already unmanageable waiting lists in our hospitals. The backlog will relate not only to surgical procedures but also to outpatient appointments and access to diagnostic services (e.g. endoscopy and radiology).

• There will be an ongoing need for social distancing/use of PPE in all clinical environments. This will significantly impact numbers of cases in operating theatres, OPD clinics and endoscopy lists.

• There will be major capacity issues in our public hospitals as the traditional overcrowding in the wards, Emergency Departments and OPD clinics cannot be allowed to happen as before.  Most major hospitals will probably need to function at much less than full occupancy. This issue will certainly be compounded by the annual “winter surge” of non-COVID related admissions.

• There will be a need to develop new approaches to patient consultations/interactions both in the wards and in OPD clinics.

• There will be pressures on consultants to do operative cases themselves, rather than assist trainees, in order to maximise patient turnover in a reduced capacity environment

• The major infrastructural deficits in our health system were brought into sharp focus during the pandemic (e.g. national shortage of ICU beds/IT infrastructure issues/manual medication prescribing etc).  These problems have still not been addressed and will continue to be a challenge when we return to “normal”.

• The issues highlighted above will require “rethinking” of the working day/week in our hospitals.  For example, there will undoubtedly be pressures to extend the working day in operating theatres, OPD clinics and diagnostic services and also to carry out these activities at weekends. Also, there will be a need to contract out certain surgical services to the private hospital sector because of capacity issues in our public hospitals. All of this will have implications for surgical trainees. Whilst access to increased training opportunities must be protected, we need to be mindful of the implications of these new arrangements for trainees in relation to domestic issues such as childcare, schooling and creches.

For surgical trainees, a major concern will be getting access to sufficient surgical cases to achieve the indicative numbers required in order to be “signed off” for CCST. Our College will campaign pro-actively to establish the core principle that trainees must be facilitated to “follow the patients”.  This will almost certainly involve working in environments other than your main teaching hospital. That will bring it’s own challenges but rest assured that RCSI will do everything possible to ensure that trainees have full access to the cases they need in order to be trained.  The College will also work with each specialty to enhance the role of simulation in surgical training, not only in our world-class simulation centre in York Street but also in regional centres around the country.

Disruption to training as a result of the COVID-19 pandemic has meant that, through circumstances beyond their control, there have been difficulties for some senior trainees in acquiring the competencies/capabilities required to progress or complete their training programme. Where possible, the usual ARCP Outcomes will be used in 2020. However, where the acquisition of competencies/capabilities have been delayed due to COVID-19 and there are no serious concerns about the trainee, one of the two “new ARCP outcomes”, Outcome 10.1 or Outcome 10.2, will be used as agreed with our sister colleges in the UK through JCST. These have been introduced as “no fault” outcomes. The aim of introducing these new ARCP outcomes has been to enable trainees to progress to the next stage of their training or complete their programme where possible. Full details of these “new ARCP outcomes” are on the JCST website.

A major concern for many trainees has been completion of the required examinations, both MRCS (for Core Surgical Trainees) and Intercollegiate Specialty FRCS (for Higher Specialty Trainees).  These examinations have been suspended since the start of the pandemic.

Nevertheless, the MRCS is a requirement for progression to ST3 and the FRCS is a requirement for CCST.  I am pleased to report that the MRCS Part A will be held again in Ireland (but not in overseas centres) in September 2020 (in an online format) and the MRCS Part B will be held in October 2020 (again, in Ireland only). It is hoped that these examinations will run as normal in 2021. Applications for the Part A and Part B exams in autumn 2020 have already closed and I strongly urge Core Surgical Trainees to watch the RCSI website closely for details of the early 2021 diets of the examinations. The Intercollegiate Specialty Fellowship examinations are more challenging to deliver and there is currently no definite date for resumption of these exams.  It is hoped that Section 1 exams will resume in November 2020 but possibly with reduced capacity. Section 2 exams are currently being planned and it is hoped that they may also run in November 2020.  Again, I strongly urge potential applicants to follow the JCIE website closely.

Throughout the COVID 19 pandemic and beyond, a priority for RCSI has been to ensure the physical safety and emotional wellbeing of our trainees by putting formal support structures in place which are easily accessed by trainees at all times. This includes consideration of the impact of extraneous or domestic factors such as altered school schedules, reduced creche facilities and other childcare implications. A suite of “wellness” programmes and other supports are available on the trainee app mSurgery.

Although the next 12-18 months will present major challenges for surgical training there will nevertheless be opportunities to develop novel education and training strategies and also utilise existing platforms in a way that transcends current geospatial and temporal limitations. By doing this, our College will do everything  possible to maintain a rigorous educational experience for all surgical trainees despite the limitations imposed by COVID-19 and the post-COVID era.