Abstract
The COVID-19 pandemic has led to a major public health crisis. Residents entered the frontline in triaging and treating COVID-19 patients, working overtime to meet the growing demand. Surgical practice and educational activities were restricted, thus affecting resident training. There was also a great risk to their mental health. Our study aims to assess the academic impact and quality of life including mental health status among year I, year II and year III otorhinolaryngology residents during the pandemic. A cross-sectional study was conducted among postgraduates and junior residents working in otorhinolaryngology departments in institutions across South India in October 2020. Quality of life, severity of anxiety and depression, and academic impact were assessed using the WHOQOL-BREF, GAD-7, PHQ-8 and Academic impact questionnaires respectively via Google Forms. A total of 303 responses were obtained. Inpatient and outpatient clinical activity were affected irrespective of the year of training. Surgical training was also affected especially among the final-year residents (year III) with a mean score of 4.42. The maximum median WHOQOL-BREF score of 14.66 was found in the social domain and 13.33 in the psychological and social domains in men and women respectively. The majority (43%) of 114 men had mild anxiety, while among women, a slight preponderance (33.9%) of severe anxiety was noted. Most of the residents (75% of men and 66.6% of women) had no symptoms suggestive of depressive disorder, however, 19.3% of the men and 29.6% of the women were found to have major depression. The impact of the pandemic on resident training and mental health has been immense. The study outcome may help residents comprehend and perceive the extent of the same, and explore methods to be equipped and overcome similar circumstances in the future.
Keywords: Academic training, Anxiety, COVID-19, Depression, Health, Otorhinolaryngology, Quality of life, Residency
Introduction
The emergence and rapid spread of the COVID-19 pandemic since December 2019 across 187 countries globally has led to a major public health crisis [1]. To date, millions of people have been infected globally with the SARS-CoV-2 virus [2]. The rapidly growing emergency forced governments to impose actions such as quarantine, resource reorganization and interruption of business operations. The healthcare systems were restructured to handle the calamity [3]. In the Indian scenario, residents entered the frontline in triaging and treating COVID-19 patients, working overtime to meet the growing demand. Surgical practice was restricted to essential procedures; non-urgent surgeries and appointments were rescheduled or cancelled. Surgeons and physicians were deputed to areas outside their specialities. The general caseload dropped drastically to lessen the spread of the infection and conserve resources, equipment and hospital beds. The restricted surgical and clinical exposure and the interruption of in-hospital educational activities significantly affected resident training [3]. Furthermore, the residents were concerned for the protection of themselves, their near and dear ones, and their patients. Therefore, beyond the danger to their physical well-being, there was also a great risk to their mental health [4].
Many studies were conducted to analyze the impact of COVID-19 on the healthcare sector however there have not been well-designed studies investigating the influence of the pandemic on otorhinolaryngology resident education in India. Our study aims to assess the academic impact and quality of life including mental health status among year I, year II and year III otorhinolaryngology residents during the pandemic.
Materials and Methods
A cross-sectional study was conducted over one month in October 2020 among 303 postgraduates/ junior residents of otorhinolaryngology departments in various institutions across South India. The protocol was approved by the institutional ethics committee. A Google Forms link containing subject information and digital consent was provided; respondents were asked to complete the demographic and basic information in the proforma along with WHOQOL-BREF (The World Health Organization Quality of Life), GAD-7 (Generalized Anxiety Disorder Assessment-7), PHQ-8 (Patient Health Questionnaire depression scale) to assess the quality of life, and to screen for anxiety and depression respectively. A validated questionnaire was used to assess academic impact including the reduction of clinical activities, the perceived impact on resident skills, the type of training activity attended and the perceived benefit. Higher the score, more severe was the problem [5]. Statistical analysis was performed utilizing the Statistical package SPSS version 22.0. Categorical variables were depicted as frequency and percentage. Chi-square test, Mann Whitney U test and Kruskal Walli’s test were done to see the association between the variables. A p-value < 0.05 was considered significant.
Results
Demographic Details and Academic Impact
Three hundred and three residents participated in the survey. The mean age, gender, marital status, workplace and history of any medical illness as per year of training were noted (Table 1). Most of the respondents (90.76%) were less than 30 years of age. Female residents were more than male residents (189 and 114 respectively). Thirty per cent (91) of respondents worked exclusively in public hospitals; 40% (121) worked in private hospitals and 30% (91) worked in both public and private setups. Residents working in private hospitals (39.93%) were more than those working in public hospitals (30.03%). Twenty-one (6.9%) residents had comorbidities with or without a history of COVID-19 infection. There was an equal distribution of respondents from all three years of training (101 each).
Table 1.
Demographic details
| Variable | Year of training N (%) | ||
|---|---|---|---|
| I | II | III | |
| Age | 25.33±1.45 | 27.49±2.23 | 28.79±2.49 |
| Gender | |||
|
Male Female |
37 (36.6) 64 (63.4) |
36 (35.6) 65 (64.4) |
41 (40.6) 60 (59.4) |
| Marital status | |||
|
Unmarried Married |
93 (92.1) 8 (7.9) |
81 (80.2) 20 (19.8) |
64 (63.4) 37 (36.6) |
| Workplace | |||
|
Public hospital Private setup Public & private setup |
34 (33.7) 37 (36.6) 30 (29.7) |
26 (25.7) 44 (43.6) 31 (30.7) |
31 (30.7) 40 (39.6) 30 (29.7) |
| Comorbidities | |||
|
No Yes |
90 (89.1) 11 (10.9) |
100 (99) 1 (1) |
92 (91.1) 9 (8.9) |
Academic Impact
The academic impact, surgical training and utility of alternative learning during the pandemic were assessed according to the year of training (Table 2). Inpatient and outpatient clinical activity were affected irrespective of the year of training. Surgical training was also affected especially among the final-year residents (year III) with a mean score of 4.42. Dissection lab training and online lecture attendance were almost comparable among residents of all three years of training. Alternative learning methods and online learning benefited the year III residents the most (mean scores of 2.83 and 3 respectively).
Table 2.
Academic impact
| Variable | Year of training (Mean ± SD) | ||
|---|---|---|---|
| I | II | III | |
| Impact of COVID-19 on clinical activity | |||
| 1. Properly informed about COVID-19 | 2.70 ± 1.39 | 2.30 ± 1.70 | 2.31 ± 1.74 |
| 2. Fear of contracting SARS-CoV2 | 3.32 ± 1.32 | 3.38 ± 1.34 | 3.32 ± 1.44 |
| 3. Inadequate protection against SARS-CoV2 exposure | 3.33 ± 1.46 | 3.20 ± 1.49 | 3.12 ± 1.53 |
| 4. Inadequate skills in relation of year of residency | 3.45 ± 1.37 | 3.34 ± 1.35 | 3.23 ± 1.72 |
| 5. Reduction of global learning during pandemic | 3.66 ± 1.16 | 3.97 ± 1.17 | 3.97 ± 1.17 |
| 6. Reduction of learning activity in the inpatient clinic | 3.81 ± 1.14 | 4.04 ± 1.21 | 4.16 ± 1.10 |
| 7. Reduction of learning activity in the outpatient clinic | 3.70 ± 1.22 | 3.79 ± 1.20 | 3.83 ± 1.25 |
| 8. Reduction of surgical training during pandemic effects on training | 4.06 ± 1.13 | 4.39 ± 1.07 | 4.42 ± 1 |
| 9. Impact of COVID-19 on global training | 3.74 ± 1.17 | 4.09 ± 1.02 | 3.96 ± 1.13 |
| 10. Impact of COVID-19 on surgical skills | 4.01 ± 1.17 | 4.38 ± 1.06 | 4.35 ± 1.05 |
| Alternative learning | |||
| 11. Perceived utility of alternative learning methods | 2.54 ± 1.39 | 2.64 ± 1.33 | 2.83 ± 1.25 |
| 12. Frequency of activity in dissection lab | 2.28 ± 1.49 | 2.08 ± 1.50 | 2.08 ± 1.56 |
| 13. Utility of dissection lab training | 2.31 ± 1.54 | 2.07 ± 1.53 | 2.20 ± 1.65 |
| 14. Online Journal Club/lectures attendance | 2.72 ± 1.45 | 2.99 ± 1.39 | 2.98 ± 1.36 |
| 15. Utility of online learning | 2.76 ± 1.32 | 2.82 ± 1.21 | 3 ± 1.28 |
| 16. Participation to in-house tumor board | 2.18 ± 1.49 | 1.46 ± 1.30 | 2.04 ± 1.63 |
| 17. Utility of online tumor board | 2.16 ± 1.55 | 1.56 ± 1.29 | 2.06 ± 1.54 |
SD–standard deviation
Quality of Life
The maximum median score of 14.66 was found in the social domain and 13.33 in the psychological and social domains in men and women respectively (Table 3). Among unmarried residents, domain 1 had the highest median score of 14.28 compared to 14.66 in the social domain among married residents. No significant difference was found in the domains based on gender and marital status. The presence of comorbidities most affected the psychological and social domains with median scores of 10 and 10.66 respectively. Domain 1 had the highest median scores among residents working in public hospitals and those working in public as well as private establishments (domain scores of 14.28 and 14.85 respectively); whereas the social domain had better scores in residents working in private centres (domain score of 14.66). Statistical significance was noted for the presence of comorbidities with p-values of 0.03, 0.01, 0.02 and 0.01 in each domain respectively. Comparison of the workplace also revealed statistical significance for all except domain 3 with p-values of < 0.001, 0.002, 0.057 and 0.006 respectively for each domain.
Table 3.
– WHOQOL-BREF domains based on various parameters
| Domain Median (Q1, Q3) |
Gender | Mann Whitney U | P-value | |||
|---|---|---|---|---|---|---|
| Male | Female | |||||
|
Domain 1 Domain 2 Domain 3 Domain 4 |
14.28 (12, 16) 13.33 (11.33, 15.33) 14.66 (11.66, 16) 13 (11.50, 14.50) |
14.28 (12.57, 16) 13.33 (11.33, 14.66) 13.33 (10.66, 16) 13 (11.50, 14.50) |
10695.5 10432.5 10,611 10,743 |
0.91 0.64 0.82 0.96 |
||
|
Domain Median (Q1, Q3) |
Marital status | Mann Whitney U | P-value | |||
| Unmarried | Married | |||||
|
Domain 1 Domain 2 Domain 3 Domain 4 |
14.28 (12.57, 16) 13.33 (11.33, 15.33) 13.33 (10.66, 16) 13 (11.50, 14.50) |
14.28 (12.57, 15.42) 13.33 (11.33, 15.33) 14.66 (11.33, 16) 13 (11.50, 14.75) |
7526.5 7602.5 6791 7677.5 |
0.73 0.83 0.12 0.92 |
||
|
Domain Median (Q1, Q3) |
Comorbidities | Mann Whitney U | P-value | |||
| No | Yes | |||||
|
Domain 1 Domain 2 Domain 3 Domain 4 |
14.28 (12.57, 16) 13.33 (12, 15.33) 14.66 (11.66, 16) 13 (11.50, 14.50) |
12.57 (10.85, 14.57) 10 (9.33, 14.66) 10.66 (6.66, 15.33) 11.50 (9, 13.50) |
2158.5 2043 2090 1991 |
0.03 0.01 0.02 0.01 |
||
|
Domain Median (Q1, Q3) |
Workplace | Kruskal Walli’s | P-value | |||
| Public hospital | Private setup | Public & Private setup | ||||
|
Domain 1 Domain 2 Domain 3 Domain 4 |
14.28 (12.57, 15.42) 13.33 (11.33, 14) 13.33 (10.66, 16) 13 (11.50, 14) |
13.14 (12, 15.42) 12.66 (10.66, 15.33) 14.66 (10.66, 16) 12.50 (9.75, 14.50) |
14.85 (13.71, 16.57) 14 (12, 16) 14.66 (12, 16) 13.50 (12, 14.50) |
15.64 12.68 5.73 10.31 |
< 0.001 0.002 0.057 0.006 |
|
Anxiety
The majority (43%) of 114 men had mild anxiety, while among women, a slight preponderance (33.9%) of severe anxiety was noted (Table 4). Mild anxiety was present in 37.4% of unmarried residents, whereas the majority of 35.4% of married residents had moderate anxiety. Most (44.7%) of year I residents had mild anxiety, while around 42% of year II and year III residents had moderate anxiety. Most of the residents (37.4%) working in public hospitals had moderate anxiety, and 35.5% of the residents working in private setups had severe anxiety. Surprisingly, a majority of 47.3% of residents working in both setups had only mild anxiety. There was no statistically significant difference in the severity of anxiety based on gender, marital status, year of training and workplace with p-values of 0.06, 087, 0.17 and 0.08 respectively. Among the residents with comorbidities, 61.9% had severe anxiety, whereas most (37.9%) of the residents without any illness had mild anxiety. A statistically significant difference was noted with a p-value of 0.003.
Table 4.
– Severity of anxiety based on various parameters
| GAD | Gender N (%) | Chi-square | P-value | |||
| Male | Female | 5.52 | 0.06 | |||
|
Mild Anxiety Moderate Anxiety Severe Anxiety |
49 (43) 40 (35.1) 25 (21.9) |
62 (32.8) 63 (33.3) 64 (33.9) |
||||
| Marital status N (%) | ||||||
| Unmarried | Married | 0.27 | 0.87 | |||
|
Mild Anxiety Moderate Anxiety Severe Anxiety |
89 (37.4) 80 (33.6) 69 (29) |
22 (33.8) 23 (35.4) 20 (30.8) |
||||
| Comorbidities | 11.51 | 0.003 | ||||
| No | Yes | |||||
|
Mild Anxiety Moderate Anxiety Severe Anxiety |
107 (37.9) 99 (35.1) 76 (27) |
4 (19) 4 (19) 13 (61.9) |
||||
| Workplace N (%) | 8.29 | 0.08 | ||||
| Public hospital | Private setup | Public & Private setup | ||||
|
Mild Anxiety Moderate Anxiety Severe Anxiety |
30 (33) 34 (37.4) 27 (29.7) |
38 (31.4) 40 (33.1) 43 (35.5) |
43 (47.3) 29 (31.9) 19 (20.9) |
|||
| Year of training N (%) | 6.36 | 0.17 | ||||
| Year I | Year II | Year III | ||||
|
Mild Anxiety Moderate Anxiety Severe Anxiety |
42 (44.7) 26 (27.7) 33 (32.7) |
31 (34.4) 38 (42.4) 32 (31.7) |
38 (41.8) 39 (42.9) 24 (23.8) |
|||
Depression
Most of the residents (75% of men and 66.6% of women) had no symptoms suggestive of depressive disorder, however, 19.3% of the men and 29.6% of the women were found to have major depression (Table 5). A quarter of unmarried and married residents (25.6% and 26.2% respectively) had major depression. Major depression was noted in 27.5%, 28.9% and 19.8% of the residents working in public hospitals, private centres, and both setups respectively. While 57.1% of the residents with comorbidities had major depression, 23.4% of those without any illness also suffered from major depression. Major depression was the most frequent (30.7%) among year II residents, followed by 28.7% among year I residents, and the least (17.8%) among year III residents. A statistically significant difference was noted on comparison of the severity of depression with workplace and comorbidities with p-values of 0.04 and 0.003 respectively. PHQ-8 score was compared with gender, marital status, and workplace and the p-value obtained were 0.43, 0.68 and 0.12 respectively. Statistical significance was found on comparison of PHQ-8 score with the presence of comorbidities (p-value of 0.03).
Table 5.
– Profile of residents with and without depression based on PHQ-8 score
| Variable | Number of residents (%) | Chi square | P-value | ||
|---|---|---|---|---|---|
| Normal | Major depression | Severe major depression | |||
| Sex | |||||
|
Male Female |
86 (75.4) 125 (66.1) |
22 (19.3) 56 (29.6) |
6 (5.3) 8 (4.2) |
3.99 | 0.13 |
| Marital status | |||||
|
Unmarried Married |
167 (70.2) 44 (67.7) |
61 (25.6) 17 (26.2) |
10 (4.2) 4 (6.2) |
0.47 | 0.79 |
| Comorbidities | |||||
|
No Yes |
203 (72) 8 (38.1) |
66 (23.4) 12 (57.1) |
13 (4.6) 1 (4.8) |
11.86 | 0.003 |
| Workplace | |||||
| Public hospital | 63 (69.2) | 25 (27.5) | 3 (3.3) | 9.61 | 0.04 |
|
Private setup Public & Private setup |
76 (62.8) 72 (79.1) |
35 (28.9) 18 (19.8) |
10 (8.3) 1 (1.1) |
||
| Year of training | |||||
| I | 68 (67.3) | 29 (28.7) | 4 (4) | 8.06 | 0.08 |
|
II III |
68 (67.3) 75 (74.3) |
31 (30.7) 18 (17.8) |
2 (2) 8 (7.9) |
||
Discussion
The analysis of academic impact, surgical training and utility of alternative learning during the pandemic showed that both the inpatient and outpatient clinical activity was affected in all residents. Inpatient clinical training was more influenced than outpatient training. Maximal surgical exposure and training are provided to the outgoing (year III) batch of residents; hence, they were the most impacted during the pandemic. Online case-based discussions, seminars, journal clubs, dissection lab activities, and virtual multidisciplinary tumour board interactions served as remedial measures of teaching and learning. Residents may be encouraged to use artificial intelligence-based technologies and simulation to sustain surgical skills and utilize the prospect to exercise complex operative techniques [6].
In a study done by Dosemane et al. [7], the quality of life among otolaryngology specialists was superior in men in comparison with women respondents. Extremely high statistical significance for three of the four WHOQOL-BREF domains (p-value < 0.001) was found. In the present study, no significant difference was noted in the four domains of the WHOQOL-BREF questionnaire among male and female residents indicating that COVID-19 had affected both genders equally. There was a significant difference in all four domains based on comorbidities indicating that the quality of life of residents with comorbidities was poorer when compared to those without (p-value 0.03, 0.01, 0.02, 0.01 respectively in each domain). Residents working in private and public hospitals fared better in all except the social domain when compared with those working in single setups (p-value in each domain < 0.001, 0.002, 0.057, 0.006 respectively). The social quality of life was equally affected in all strata due to restrictions, precautions and limitations that were imposed. Quality of life was better in those working in public hospitals in all except the social domain when compared with residents working in private establishments, however, it was not statistically significant. This could probably be attributed to public hospitals being equipped with greater manpower, thus equally distributing the workload among the residents.
GAD-7 questionnaire was used for screening and grading anxiety among residents during the pandemic. Around 29% of the respondents had severe anxiety; previous studies have revealed anxiety in 29–47% of otolaryngology residents, with 7–8% having severe anxiety [4, 8, 9] Anxiety was almost equally prevalent in all residents irrespective of marital status, workplace or year of training; with no statistical significance. Mild anxiety was present in 37.9% of residents without any comorbidities; when compared with those with comorbidities, statistical significance was present (p-value of 0.003), suggesting the occurrence of anxiety unrelated to medical illness. Korkmaz suggested adequate provision of protective equipment, better work hour regulations and salary hikes to reduce fatigue, burnout, and anxiety and improve morale of residents [10].
PHQ-8 questionnaire was used for screening and grading depression among residents. In the present study, 30.36% of the respondents had depressive disorder; this figure is much greater than the results of previous studies which showed depression in 10–16% of otolaryngology and head and neck surgery residents [4, 8]. Major depression was more predominant in women than in men; preponderance was similar in unmarried and married residents. Although more than half of the respondents with comorbidities had major depression, around a quarter of those without any medical illness also suffered; the difference was statistically significant (p-value of 0.003) implying that major depression may be independent of the comorbidity. The workplace also played a part in determining the severity of depression; nearly 37% of the residents working in private establishments suffered from a depressive disorder, compared to 30.77% of public hospital residents. The difference was statistically significant (p-value of 0.04). However, Fond found no significant difference in depression between public and private sectors [11]. Depressive disorder impacted year I and year II residents slightly more than final year residents (32.67% and 25.74% respectively), possibly due to greater work pressure and duties in the initial years of training. Mata conducted a systemic review on depression in residents and concluded that prevalence of depression increased with increasing calendar year [12]. Improving work organization, providing access to evidence-based care, personalized psychotherapy and group therapy are strategies to curb depression in healthcare workers [11].
The pandemic is gradually regressing and healthcare practice has evolved to adapt to a new normality, but we must be prepared for newer pandemics in the future. Otolaryngology residents have the highest risk for COVID-19 infection as they are the first line of contact [13]. Instrumentation and examination of the upper airway including the oral cavity, nasal cavity, and larynx must be treated as high-risk procedures for COVID-19 transmission [14]. Establishment of comprehensive guidelines to address the practical, psychological and financial aspects of limited-resource centres is vital. Protection of residents and proper training are essential to avoid a collapse of the healthcare system [13].
There are only a few studies in the literature that provide details on the effect of the pandemic on otorhinolaryngology resident training along with mental and physical health issues. Limitations of our study were that it was more of a subjective analysis and prone to sampling bias as it was an online digital questionnaire. However, as this study was conducted during the pandemic, it was the most feasible, cost-effective and practical approach.
Conclusion
There has been an immense impact on quality of life, mental health status and academic activity among otorhinolaryngology residents in India during the COVID-19 pandemic. The study outcome may help residents perceive and comprehend the extent to which the pandemic has affected various walks of life, and explore methods to face, be equipped and overcome similar circumstances in the future.
Acknowledgements
The authors are deeply grateful to Dr. Francesco Bandi for providing the “Questionnaire for academic impact, surgical training and utility of alternative learning during the pandemic” and also the editor of European Archives of Otolaryngology and Head & Neck Surgery for permitting the use of the questionnaire (Copyright clearance centre’s rights link service order number: 4922240140421).
Author Contribution
All authors contributed to the conception and design. Material preparation, data collection was performed by RS. The first draft of the manuscript was written by RS, MNK. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.
Funding
No funding obtained.
Data Availability
data transparent.
Code Availability
not applicable.
Declarations
Ethical Approval
The report was approved by Institutional Ethics Committee, KMC Mangalore (IEC KMC MLR 09/2020/271). The report complies with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. No animals were involved.
Consent to Publish
Obtained.
Conflict of Interest
The authors declare that they have no conflict of interest.
Research Involving Human Participants and/or Animals
The report was approved by Institutional Ethics Committee, KMC Mangalore (IEC KMC MLR 09/2020/271). The report complies with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. No animals were involved.
Informed Consent
Written informed consent was obtained.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
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Data Availability Statement
data transparent.
not applicable.