Letter to the Editor: Decrease in Neurosurgical Program Volume During COVID-19: Residency Programs Must Adapt

Letter:

The 2019 novel coronavirus disease (COVID-19) pandemic has had wide-reaching impact on medical care across the globe in both outpatient and inpatient settings. In the United States, it remains unknown how long and to what degree we will remain in the new status quo of social distancing and state-by-state lockdown. However, the short-term impact on neurosurgical resident and medical student education has begun to be realized, and the long-term implications on residency training could be vast. To demonstrate the degree of change, we report the dramatic decrease in operative, outpatient clinic, and consultation volume at our institution, Albany Medical Center, an Academic Level 1 Trauma Center in upstate New York.

Overview

The first case of COVID-19 in New York State was reported on March 1, 2020. By March 8, there were 106 confirmed cases, and a state of emergency had been declared. On March 14, the first deaths were confirmed, soon followed by closure of the public school system and a statewide stay-at-home order known as “New York State on PAUSE.”¹ Treatment of elective cases was mandated to stop on March 25. While our region has not experienced an overwhelming surge in COVID-19 cases, local concern, hospital and statewide policies, and concern for departmental safety have led to a noticeable change in our practice. Since the first case was reported, we have tracked our operative, clinic, and consultation volume, which we report here.

Clinic and Referral Volume

Similar to reports by other groups, we have seen a significant decrease in outpatient clinic visits, necessitating the need for alternative methods of administering patient visits.² We rapidly trialed and implemented a video conference telehealth system by the end of March and have seen a dramatic shift in our clinic practice while continuing to provide appropriate patient care (Figure 1 ). Overall, new patient visits, which are a reflection of referrals, have decreased by 38%, whereas established patient visits have decreased by only 27%.

Figure 1.

Comparison of in-person and telehealth visits between 2019 and 2020.

Inpatient Consultation Volume

Despite reassurances about the safety of emergency department care, the public continues to avoid hospital visits, and there has been widespread news coverage about the decrease in hospitalizations for stroke and myocardial infarctions. At our center, this trend has held true for all neurosurgical consultations except those for shunt failure and intraparenchymal hemorrhage, which have shown a minimal increase. In particular, as the highest-volume trauma center in New York State, there has been a marked decrease in consultations for traumatic brain (22%) and spine (35%) injuries, which is presumably due to decreased motor and recreational vehicle activity (Figure 2 ). Despite a 23% reduction in large vessel occlusion stroke consultations, the rate of thrombectomy has increased dramatically. Overall, there has been a 27% reduction in all consultations since the New York State stay-at-home order compared with the same period in 2019.

Figure 2.

Comparison of emergency department and in-patient consultations between 2019 and 2020. AVM, arteriovenous malformation; consults, consultations; IPH, intraparenchymal hemorrhage; Post-Op, postoperative.

Operative Volume

The most noticeable change to the residency program has been the decrease in both elective surgery volume (53%) and total surgical procedures (42%; Figure 3 ). Our resident service was split into an on-call and backup team owing to the decrease in case volume as well as to limit exposure to COVID-19 and provide coverage in the neurointensive care unit. Neuroangiography has seen a similar decline. Bedside procedures, such as placement of ventricular drains, have remained stable. Of note, despite the overall decline in stroke consultations, thrombectomies have increased by 21%. Operative cranial traumas have decreased by 18%, which is consistent with the decrease in consultations.

Figure 3.

Operating room procedures in 2019 versus 2020. OR, operating room.

Discussion

Most neurosurgical residency programs are located at academic hospitals in urban or suburban centers—the areas hardest hit by COVID-19. Our program has seen a significant reduction in consultations and operations over the past 3 months despite being in a region with a linear case rise that has not been overwhelmed by the pandemic.³ While short-term fluctuations in volume are normal, the long-term consequences of a sustained decrease in volume will significantly impact resident education. If COVID-19 persists or future case surges occur, programs could see a reduction in patients of well over 25% over the course of a year. Individual programs will be affected differently, and we propose consideration of the following mitigation strategies:

• •Intern year rotations may need to shift to incorporate more neurosurgical experiences, as they will likely be exposed to fewer neurosurgical patients over the course of their year.
• •Resident and medical student participation in clinic should be increased.
• •All nonemergent cases should require preoperative testing. These cases could be considered relatively safe for residents to “double scrub” (i.e., 2 resident physicians scrub on a case together with 1 attending) while still limiting possible COVID-19 exposure.
• •Mentorship models for junior residents may provide a means of distributing consultation, clinic, operative, and neuroangiography experiences.
• •Programs should invest in and consistently use dissection laboratories to teach, learn, and reinforce surgical approaches.
• •Virtual conferences can be used for didactic sessions using platforms such as Microsoft Teams or Zoom. These also provide an inexpensive way to invite guest lecturers from other programs to speak.
• •Online academic resources can be used, such as the Virtual Visiting Professor series being hosted by the Congress of Neurological Surgeons⁴ and the Resident Education Courses produced by the American Association of Neurological Surgeons and Neurosurgical Education & Research Foundation.⁵

Conclusions

The COVID-19 pandemic has led to a dramatic decline in elective neurosurgical procedures, consultations, and clinic visits. The long-term implications of the outbreak are unclear, but neurosurgical residency programs must consider the long-term effects on resident education and develop an internal roadmap moving forward.