Impact of the Coronavirus Disease 2019 Pandemic on Working and Training Conditions of Neurosurgery Residents in Latin America and Spain

Abstract

Background

The coronavirus disease 2019 (COVID-19) pandemic has exerted a significant impact on health care workers. Recent studies have reported the detrimental effects of the pandemic on neurosurgery residents in North America, Asia, and Italy. However, the impact of the pandemic on neurosurgical training in Latin America and Spain has not yet been reported. In the present report, we describe effects of COVID-19 on training and working conditions of neurosurgery residents in these countries.

Methods

An electronic survey with 33 questions was sent to neurosurgery residents between September 7, 2020 and October 7, 2020. Statistical analysis was made in SPSS version 25.

Results

A total of 293 neurosurgery residents responded. The median age was 29.47 ± 2.6 years, and 79% (n = 231) were male. Of respondents, 36.5% (n = 107) were residents training from Mexico; 42% surveyed reported COVID symptoms and 2 (0.7%) received intensive care unit care; 61.4% of residents had been tested for COVID and 21.5% had a positive result; 84% of the respondents mentioned persisted with the same workload (≥70 hours per week) during the pandemic. Most residents from Mexico were assigned to management of patients with COVID compared with the rest of the countries (88% vs. 68.3%; P < 0.001), mainly in medical care (65.4% vs. 40.9%; P < 0.001), mechanical ventilators (16.8% vs. 5.9%; P = 0.003), and neurologic surgeries (94% vs. 83%; P = 0.006).

Conclusions

Our results offer a first glimpse of the changes imposed by the COVID-19 pandemic on neurosurgical work and training in Latin America and Spain, where health systems rely strongly on a resident workforce.

Introduction

Coronavirus disease 2019 (COVID-19) is an infection of the respiratory tract, caused by the SARS-COV-2 (severe acute respiratory syndrome coronavirus 2) virus.^{1 , 2} It is a potentially fatal disease with a mortality of 3%–4% reported by the World Health Organization.³ COVID-19 represents a challenge for health care personnel, including neurosurgeons and neurosurgery residents.

The quality of resident training has been negatively affected as a result of the COVID-19 pandemic.4, 5, 6, 7 Neurosurgery residents face a great challenge, especially those who work in hospitals caring for a high number of patients with COVID-19. Strategies to increase the capacities of intensive care units (ICUs) include a reduction of all (especially elective) surgical activities.⁶ Many neurosurgical centers have postponed their elective surgeries, which decreases the exposure of residents with typical neurosurgical diseases and their treatment.^{4 , 5 , 8 , 9} Several programs have reduced the number of residents for neurosurgical activities, ordering the remaining trainees to stay at home.⁷ Nearly all neurosurgical programs worldwide have switched their academic face-to-face meetings to online communication in an attempt to reduce physical contact.

Few investigators have yet evaluated the impact of COVID-19 on neurosurgical residents (Supplementary Table 1). Hence, it was our objective to survey the impact of this pandemic on theoretic education and training strategies, practical exposure to neurosurgical procedures and management of neurosurgical and patients with COVID-19, as well as on health of neurosurgery residents in Latin America and Spain.

Methods

The survey was created using Google Forms Survey. It was based on previous studies of COVID-19 and its impact on neurosurgical practice and residents (see Supplementary Table 1), but adapted in terms of content and response options to our particular interests. The final survey consisted of 33 questions organized in 4 sections (Supplementary Appendix 1).

The questions referred to demographic data of residents, postgraduate year (PGY), countries of origin and of neurosurgical training, academic strategies and resident workload, the guidelines in neurosurgical and nonsurgical management of COVID-positive patients, the effect on emergency and/or neurosurgical procedures, the use of personal protective equipment (PPE), the supervision that residents received for the management of patients with COVID and the areas in which residents were assigned for nonneurosurgical management of patients with COVID. Besides the impact of the pandemic on neurosurgery residency, we also assessed its impact on both physical and mental health of residents.

Survey links to versions in Spanish and Portuguese were distributed via e-mail to different training programs to those countries between September 7, 2020 and October 7, 2020. Project collaborators included neurosurgeons involved in the development of academic programs in their respective countries and contributors to both the European Association of Neurosurgical Societies and FLANC (Federation of Latin American Neurosurgical Societies), which helped with the distribution of the survey among certified neurosurgical programs. All results were collected in a Google Forms database. Neurosurgery residents who participated in the survey and agreed to have their names published in this manuscript are seen in the Supplementary Table 2.

Statistical Analysis

Descriptive statistical analysis was performed using SPSS version 25 (IBM Corp., Armonk, New York, USA). We performed a univariate analysis using a χ² test in search of the association of the variables within the main topics: work hours before COVID-19 and during the pandemic (≥70 hours vs. <70 hours per week), academic hours before COVID-19 and during the pandemic (>10 hours vs. ≤10 hours per week), polymerase chain reaction (PCR) test positive for COVID-19, percentage of emergency and elective surgeries during COVID-19, analysis by training countries (Mexico vs. other countries), and analysis by academic training year (junior residents, PGY 1–3 vs. senior residents, PGY 4–5).

The medians of the working hours and academic hours spent before COVID and during the pandemic were obtained to analyze its impact.

Results

Survey Responses: Demographic Information

A total of 301 responses were obtained, and we included in our analysis the 293 responses from the neurosurgical residents (97.34%). The mean age was 29.49 ± 2.6 years (range, 24–40 years), and 78.8% were male (n = 231) and 21.2% female (n = 62) (Table 1 ). Residents in training from Mexico comprised 37% of respondents to the survey, followed by Brazil (21%), Colombia (12.9%), and Argentina (7.8%). Spain comprised 2.7% (n = 8) (Figure 1 ).

Table 1.

Sociodemographic Information

Total of Residents	293
Number of residents per center, mean (range)	10.8 ± 7.8 (1–40)
Age (years), mean (range)	29.47 ± 2.6 (24–40)
Gender
Female	62 (21.2)
Male	231 (78.8)
Neurosurgical training duration (years), mean (range)	4.99 ± 0.392 (3–5)
3	4 (1.4)
4	11 (3.8)
5	278 (94.9)
Postgraduate year, mean (range)	3.10 ± 1.483 (1–5)
1	54 (18.4)
2	61 (20.8)
3	59 (20.1)
4	47 (16)
5	72 (24.6)
Neurosurgery training country
Mexico	107 (36.5)
Other	186 (63.5)
Type of center
Exclusive hospital for neurologic diseases	18 (6.1)
Medical specialty hospital that includes neurosurgery department	138 (47.1)
General hospital that includes neurosurgery department	135 (46.1)
Others	2 (0.7)

Values are number (%) except where indicated otherwise.

Figure 1.

Distribution of Residents Among Country Of Origin And Neurosurgery Training Country; 36.5% (n = 107) were residents with surgical training in Mexico, the rest of the respondents (63.5%) mentioned surgical training in another country.

Neurosurgical Guidelines for Patients with COVID-19

Most responders (90%) worked at centers admitting both patients with COVID and patients without COVID (hybrid hospitals). At the time of the survey, 87.4% (n = 256) were taking part in neurosurgical procedures performed on patients with COVID. Almost 80% (n = 233) reported that these procedures were carried out only if appropriate PPE was available, whereas 20% (n = 57) reported that emergency neurosurgical surgeries were still performed even if adequate PPE was not available at their centers (Table 2 ).

Table 2.

Neurosurgical Guidelines in Patients with COVID-19

	n	%
COVID hospital
Exclusive COVID hospital	10	3.4
COVID hybrid hospital	264	90.1
Hospital does not treat COVID	17	5.8
I’m not sure	2	0.7
Neurologic surgeries in patients with COVID-19	256	87.4
Neurosurgical guidelines in patients with COVID-19
The department refuses to perform the surgery, even if there is adequate PPE	3	1
Surgery is done, even if there is no proper PPE	57	19.5
Surgery is done, only if there is adequate PPE	233	79.5
Procedures/sessions canceled
Emergency surgeries	2	0.7
Elective surgeries	276	94.2
External consultation	272	92.8
Meetings and conferences	291	99.3
Strategies to reduce resident exposure to COVID-19
No changes	67	22.9
Reduction of the duration of the working shifts	76	25.9
Reduction of the number of workdays per week	150	51.2
Academic activities
No teaching activity has been carried out in the last 6 months	21	7.2
Increased	128	43.7
No changes	50	17.1
Decreased	94	32.1
Academic strategies
Teleconference	257	87.7
Face-to-face in small groups	31	10.6
Simulation laboratory	14	4.8
Online questionnaires	40	13.7
No changes	7	2.4
Work hours
Weekly work hours before COVID-19 (≥70)	280	95.6
Weekly work hours during COVID-19 (≥70)	245	83.6
Academic hours
Weekly academic hours before COVID-19 (>10)	44	15
Weekly academic hours during COVID-19 (>10)	59	20.1
Your hospital asks you to treat patients with COVID
No	71	24.2
Yes	222	75.8
Type of care/services requested by your hospital in patients with COVID
ICU COVID	83	28.3
Medical care units	146	49.8
Mechanical ventilators in patients with COVID	29	9.9
Emergency units	93	31.7
Received supervision in the management of patients with COVID?
No	126	43
Yes	167	57
Do you feel comfortable treating patients with COVID?
Very comfortable	13	4.4
Comfortable	30	10.2
I do not care	68	23.2
Uncomfortable	133	45.4
Very uncomfortable	49	16.7
Do you feel competent treating patients with COVID?
Very competent	13	4.4
Competent	119	40.6
Little competent	143	48.8
Incompetent	18	6.1
Distribution of PPE in your hospital
The hospital does not provide PPE	6	2
Enough PPE	151	51.5
Insufficient PPE	136	46.4
Received training in the use of PPE
No	64	21.8
Yes	229	78.2
Did you have symptoms of COVID-19?
No	170	58
Yes	123	42
Symptoms that occurred
Fever or chills	58	19.8
Cough	71	24.2
Shortness of breath	27	9.2
Fatigue	59	20.1
Muscle or body pain	78	26.6
Headache	89	30.4
Loss of smell or taste	39	13.3
Sore throat	61	20.8
Stuffy or runny nose	52	17.7
Nausea or vomiting	23	7.8
Diarrhea	52	17.7
Chest pain or pressure	14	4.8
Confusion	3	1
Inability to wake up or stay awake	6	2.0
Perioral cyanosis	1	0.3
Respiratory disease that warrants hospitalization	5	1.7
Respiratory disease that warrants management in the ICU	2	0.7
COVID-19 test
The COVID test is not available in my hospital or region	3	1.0
Yes, the test was positive	63	21.5
Yes, the test was negative	117	39.9
No, I have not had the test	110	37.5
COVID-19 had a negative impact on your training?
No	99	33.8
Yes	194	66.2
COVID-19 affected your physical or mental health?
No	40	13.7
Yes, my physical health	47	16.0
Yes, my mental health	45	15.4
Yes, my physical and mental health, both equally	161	54.9

ICU, intensive care unit; PPE, personal protective equipment.

Working Hours Before and During the COVID-19 Pandemic

Approximately half of residents (51%, n = 150) reported a reduction in the number of workdays per week. Before the pandemic, most residents (95.6%, n = 280) dedicated ≥70 working hours per week. During the pandemic, workload was reduced by 12% (Table 2 and Figure 2 ). Although >80% of those surveyed mentioned persisting with the same workload during COVID (280 residents responded that they worked ≥70 hours per week before the pandemic, and 86.1% of these residents [n = 241] reported persisting with this workload during the pandemic [P <0.001]), no association was found with the presence of serious respiratory disease that warranted intensive care (P < 0.001). The results of the analysis of working hours during the pandemic and the other variables were not statistically significant (Table 3 ).

Figure 2.

Work hours before and during COVID-19 pandemic.

Table 3.

Analysis by Working Hours Before COVID-19 and During the Pandemic

	Weekly Work Hours Before COVID-19 (≥70), n (%)	P	Weekly Work Hours During COVID-19 (≥70), n (%)	P
Junior resident (PGY 1–3)	167 (59.6)	0.677	144 (58.8)	0.631
Senior resident (PGY 4–5)	113 (40.4)		101 (41.2)
Neurosurgery training country
Mexico	105 (37.5)	0.105	92 (37.6)	0.407
Other country	175 (62.5)		153 (62.4)
Hospital type
Exclusive hospital for neurologic diseases	15 (5.4)	0.078	12 (4.9)	0.179
Medical specialty hospital	133 (47.5)		119 (48.6)
General hospital	130 (46.4)		112 (45.7)
Others	2 (0.7)		2 (0.8)
COVID hospital
Exclusive COVID hospital	∗	∗	8 (3.3)	0.762
COVID hybrid hospital	∗	∗	222 (90.6)
Hospital does not treat COVID	∗	∗	13 (5.3)
Strategies to reduce resident exposure to COVID-19:	∗	∗	120 (49)	0.069
Reduction of the number of workdays per week
Neurologic surgeries in patients with COVID-19 (Yes)	∗	∗	212 (86.5)	0.5
Your Hospital asks you to treat patients with COVID (Yes)	∗	∗	182 (74.3)	0.181
Did you have a respiratory disease that required intensive care?	∗	∗	0 (0)	0.001†
Positive polymerase chain reaction COVID-19 test	∗	∗	51 (20.8)	0.775

PGY, postgraduate year.

^∗Variables that cannot be assessed before the pandemic.

^†Statistically significant variables P < 0.05 obtained by the χ² test.

Academic Strategies During the COVID-19 Pandemic

Approximately 90% of surveyed residents reported that outpatient clinical activities, academic meetings, and conferences were canceled (Table 2). Of these respondents, 43.7% (n = 128) reported an increase in academic activity, whereas 32% (n = 94) mentioned that it decreased, and 17% (n = 50) answered that it remained unchanged. Teleconferences were the most frequent strategy described among respondents (87.1%, n = 256) (Table 2). Of the residents who responded that they spent >10 academic hours per week (AHW) before COVID (n = 44), 52.3% of those surveyed persisted with the same AHW during the pandemic (P < 0.001) (Figure 3 ).

Figure 3.

Academic hours before and during COVID-19 pandemic. Box-and-whisker plot representing the number of academic sessions conducted by departments during the pandemic compared with before the pandemic. The line in the middle of each bar represents the median. Of the residents who responded spending >10 academic hours a week before COVID (n = 44), 52.3% of those surveyed persisted with the same academic time during the pandemic (P < 0.001).

Mexico reported more AHWs (>10 hours) before COVID compared with other countries (57% vs. 43%; P = 0.002). However, during COVID-19, the other countries reported a greater AHW than did Mexico, although the result was not statistically significant (52% vs. 47%; P = 0.051). According to the type of hospital, before COVID-19, the medical specialty hospitals presented a greater AHW compared with the other types of hospitals (43%; P = 0.003), but during the pandemic, the general hospitals spent more AHW (47.5%; P = 0.004); this is probably because residents of medical specialty hospitals presented a higher percentage of positive COVID tests compared with residents in other hospitals (57.1%; P < 0.001) which did that sick residents require disability due to the disease. Regardless of the type of hospital, most were transformed into COVID hybrid hospitals (61% of the exclusive hospitals for neurologic diseases, 95% of the medical specialty hospitals, and 90% of the general hospitals; P < 0.001); in addition, 83% of respondents in hybrid COVID hospitals mentioned spending >10 AHW compared with respondents in other hospitals (P <0.001) (Table 4 ).

Table 4.

Analysis by Academic Hours before COVID-19 and During the Pandemic

	Weekly Academic Hours Before COVID-19 (>10), n (%)	P	Weekly Academic Hours During COVID-19 (>10), n (%)	P
Junior resident (PGY 1–3)	30 (68.2)	0.197	32 (54.2)	0.368
Senior resident (PGY 4–5)	14 (31.8)		27 (45.8)
Neurosurgery training country
Mexico	25 (56.8)	0.002∗	28 (47.5)	0.051
Other country	19 (43.2)		31 (52.5)
Hospital type
Exclusive hospital for neurologic diseases	5 (11.4)	0.003∗	9 (15.3)	0.004∗
Medical specialty hospital	19 (43.2)		21 (35.6)
General hospital	18 (40.9)		28 (47.5)
Others	2 (4.5)		1 (1.7)
COVID hospital
Exclusive COVID hospital	†	†	0 (0)	<0.001∗
COVID hybrid hospital	†	†	49 (83.1)
Hospital does not treat COVID	†	†	8 (13.6)
Strategies to reduce resident exposure to COVID-19:	†	†	38 (64.4)	0.021∗
Reduction of the number of workdays per week
Academic strategies: Teleconferences	†	†	56 (94.9)	0.059
Neurologic surgeries in patients with COVID-19 (Yes)	†	†	42 (71.2)	<0.001∗

PGY, postgraduate year.

^∗Statistically significant variables P < 0.05 obtained by the χ² test.

^†Variables that cannot be assessed before the pandemic.

Role of Neurosurgical Residents in the Management of Patients with COVID-19

Three quarters of participants (76%; n = 222) reported that neurosurgery residents take part in the management of patients with COVID-19 at their hospital. In 84.7% (n = 256) of cases, the residents are assigned to neurologic surgeries, 49.8% (n = 146) assigned to medical care, 32% (n = 93) to the emergency area, 28% (n = 83) to the ICU, and 10% (n = 29) helped in the management of mechanic ventilators. Only 57% of residents (n = 167) were supervised in the management of patients with COVID in both surgical and medical procedures. Of respondents, 51.5% (n = 151) answered that appropriate PPE was provided at their center, whereas 46.4% (n = 136) reported insufficient equipment. Of the residents, 78.2% (n = 229) considered that training provided for the use of PPE was adequate. Of residents, 45.4% reported being uncomfortable while handling patients with COVID-19 and 55% responded that they did not feel competent in the management of these patients (Table 2).

Surgeries During the COVID Pandemic

Although 87.4% (n = 256) of those surveyed answered that their hospitals performed surgeries on patients with COVID, approximately 92.4% of residents (n = 276) reported that elective surgeries were postponed at their hospital. Two responders (0.7%) answered that emergency surgeries were canceled (Table 2 and Figure 4 ). Of the respondents, 98% answered that surgeries decreased ≥50% and despite having sufficient PPE, elective surgeries decreased in >50% of those surveyed (51.2%; P = 0.044). The workload during COVID was inversely related to the number of elective surgeries, because 84.3% (n = 242) of the residents who persisted with a workload of ≥70 hours per week reported a reduction in surgeries. However, the decrease in scheduled neurosurgery did not prevent residents from becoming ill: 1.4% of the residents (n = 4) had respiratory disease that warranted hospitalization (P = 0.006) and 1 resident (0.3%) required management in the ICU (P < 0.001) (Table 5 ).

Figure 4.

Elective and emergency surgeries during COVID-19 pandemic.

Table 5.

Impact of the COVID-19 Pandemic on Elective Surgeries and Emergency Neurologic Surgeries

	Elective Surgeries During COVID-19				Emergency Surgeries During COVID-19
	Decreased, n (%)	Without Changes, n (%)	Increased, n (%)	P	Decreased, n (%)	Without Changes, n (%)	Increased, n (%)	P
Junior resident (PGY 1–3)	172 (60)	1 (20)	1 (100)	0.140	151 (64)	19 (36.9)	4 (44.4)	0.005∗
Senior resident (PGY 4–5)	115 (40)	4 (80)	0 (0)		85 (36)	29 (60.4)	5 (55.6)
Neurosurgery training country
Mexico	106 (36.9)	1 (20)	0 (0)	0.553	89 (37.7)	13 (27.1)	5 (55.6)	0.183
Other country	181 (63.1)	4 (80)	1 (100)		147 (62.3)	35 (72.9)	4 (44.4)
Hospital type
Exclusive hospital for neurologic diseases	17 (5.9)	1 (20)	0 (0)	0.823	15 (6.4)	2 (4.2)	1 (11.1)	0.614
Medical specialty hospital	136 (47.4)	2 (40)	0 (0)		115 (48.7)	18 (37.5)	5 (55.6)
General hospital	132 (46)	2 (40)	1 (100)		104 (44.1)	28 (58.3)	3 (33.3)
COVID hospital
Exclusive COVID hospital	10 (3.5)	0 (0)	0 (0)	0.906	10 (4.2)	0 (0)	(0)	0.707
COVID hybrid hospital	259 (90.2)	4 (80)	1 (100)		210 (89)	46 (95.8)	8 (88.9)
Hospital does not treat COVID	16 (5.6)	1 (20)	0 (0)		14 (5.9)	2 (4.2)	1 (11.1)
Strategies to reduce resident exposure to COVID-19:	148 (51.6)	2 (40)	0 (0)	0.372	131 (55.5)	13 (27.1)	6 (66.7)	0.002∗
Reduction of the number of workdays per week
Weekly work hours during COVID-19 (≥70)	242 (84.3)	3 (60)	0 (0)	0.027∗	199 (84.3)	39 (81.3)	7 (77.8)	0.776
Neurologic surgeries in patients with COVID-19 (Yes)	250 (87.1)	5 (100)	1 (100)	0.927	204 (86.4)	43 (89.6)	9 (100)	0.593
Your hospital asks you to treat patients with COVID (Yes)	217 (75.6)	4 (80)	1 (100)	0.830	186 (78.8)	28 (58.3)	8 (88.9)	0.007∗
Respiratory disease that warrants hospitalization	4 (1.4)	1 (20)	0 (0)	0.006∗	4 (1.7)	1 (2.1)	0 (0)	0.906
Respiratory disease that warrants management in the intensive care unit	1 (0.3)	1 (20)	0 (0)	<0.001∗	1 (0.4)	1 (2.1)	0 (0)	0.431
Positive polymerase chain reaction COVID-19 test	59 (20.6)	3 (60)	1 (100)	0.163	53 (22.5)	8 (16.7)	2 (22.2)	0.088
Sufficient PPE	147 (51.2)	3 (60)	1 (100)	0.044∗	118 (50)	27 (56.3)	6 (66.7)	0.543
PPE training (yes)	223 (77.7)	5 (100)	1 (100)	0.425	194 (82.2)	28 (58.3)	7 (77.8)	0.001∗

PGY, postgraduate year; PPE, personal protective equipment.

^∗Statistically significant variables P <0.05 obtained by the χ² test.

Impact of COVID-19 on the Health and Training of Residents

Four of 10 residents (42%; n = 123) reported presenting symptoms compatible with COVID-19 infection. The main symptoms were headache (30%), muscle and body pain (27%), and cough (24%) (Supplementary Figure 1). Fever was reported in only 20% of cases. Hospitalization and intensive care were required in 5 (1.7%) and 2 (0.7%) cases, respectively. At the time of the survey, 180 residents (61%) had been tested for COVID-19 and 21.5% (n = 63) had obtained a positive result (Table 2).

Supplementary Figure 1.

Symptoms of COVID-19 presented by residents.

In the statistical analysis, a positive PCR test for COVID-19 was presented more frequently in hospitals of medical specialties (57.1%; P < 0.001), and 8% of these patients (n = 5) presented with a severe respiratory disease that warranted hospitalization (P <0.001). Having sufficient PPE or receiving adequate training in the use of PPE was not enough to protect residents from the disease (46% of residents with sufficient PPE [P < 0.001] and 81% of those who received PPE presented a positive PCR for COVID-19 [P = 0.010]). Of the patients with symptoms, 94% had a positive PCR result (Table 6 ). In addition, female residents had a higher percentage of positive PCR results than did males (27.4% vs. 20%; P = 0.467) and a higher percentage of respiratory disease that warranted hospitalization (3.2% vs. 1.3%; P = 0.298). On the other hand, male residents presented with a severe respiratory disease that warranted management in the ICU (0.9% vs. 0%; P = 0.462) (Table 7 ).

Table 6.

Variables Influencing a Positive Polymerase Chain Reaction Test Result for COVID-19

	Positive COVID-19 Polymerase Chain Reaction Test Result, n (%)	P
Hospital type
Exclusive hospital for neurologic diseases	2 (3.2)	<0.001∗
Medical specialty hospital	36 (57.1)
General hospital	25 (39.7)
Others	0 (0)
Neurologic surgeries in patients with COVID-19 (Yes)	58 (92.1)	0.063
Strategies to reduce resident exposure to COVID-19:	31 (49.2)	0.717
Reduction of the number of workdays per week
Your hospital asks you to treat patients with COVID (Yes)	50 (79.4)	0.563
Respiratory disease that warrants hospitalization	5 (7.9)	<0.001∗
Respiratory disease that warrants management in the intensive care unit	2 (3.2)	0.061
Neurosurgical guidelines in patients with COVID-19
The department refuses to perform the surgery, even if there is adequate PPE	0 (0)	0.227
Surgery is done, even if there is no proper PPE	15 (23.8)
Surgery is done, only if there is adequate PPE	48 (76.2)
Decrease in emergency surgeries <50%	39 (61.9)	0.022∗
Received supervision in the management of patients with COVID?(yes)	32 (50.8)	0.434
Sufficient PPE	29 (46)	<0.001∗
PPE training (yes)	51 (81)	0.010∗
Did you have symptoms of COVID-19? (yes)	59 (93.7)	<0.001∗

PPE, Personal protective equipment.

^∗Statistically significant variables P < 0.05 obtained by the χ² test.

Table 7.

Gender and Influence on COVID-19 Infection

Gender	Male	Female	P
Positive polymerase chain reaction test result for COVID-19	46 (19.9)	17 (27.4)	0.467
Respiratory disease that warrants hospitalization	3 (1.3)	2 (3.2)	0.298
Respiratory disease that merits intensive care unit	2 (0.9)	0 (0)	0.462

Two thirds of participants (66%, n = 194) believed that COVID-19 negatively affected their neurosurgical training. More than half of surveyed residents (54.9%, n = 161) reported that the COVID pandemic affected either their mental or physical health (Table 2). Male residents reported a greater negative impact of COVID-19 on their neurosurgical training compared with female residents (75% vs. 25%; P = 0.036). Despite the fact that the most used strategy to reduce the exposure of residents to COVID-19 was the reduction of workdays (reduction of the number of working days per week), 55% of the residents who underwent this type of strategy mentioned a negative impact of COVID-19 in their neurosurgical training (P = 0.04), and the management of patients with COVID was also a variable that negatively influenced neurosurgical training according to the results obtained by the surveyed residents (81% vs. 64%; P = 0.002).

Analysis by Place of Neurosurgical Training: Mexico vs. Other Countries

Residents with neurosurgical training in Mexico reported a higher percentage of positive responses to the management of patients with COVID compared with the other countries (88% vs. 68.3%; P < 0.001). These residents were mainly assigned in medical care (65.4% vs. 40.9%; P < 0.001), management of mechanical ventilators (16.8% vs. 5.9%; P = 0.003), and neurologic surgeries (94% vs. 83%; P = 0.006). The neurosurgery residents of Mexico also reported a greater negative impact on their neurosurgical training than did those in other countries (72.9 vs. 62.4; P = 0.066) (Table 8 ).

Table 8.

Analysis by Countries: Mexico vs. Other Countries

	Other Countries	Mexico	P
Hospital type
Exclusive hospital for neurologic diseases	10 (5.4)	8 (7.5)	<0.001∗
Medical specialty hospital	62 (33.3)	76 (71)
General hospital	113 (60.8)	22 (20.6)
Others	1 (0.5)	1 (0.9)
Neurologic surgeries in patients with COVID-19 (yes)	155 (83.3)	101 (94.4)	0.006∗
Strategies to reduce resident exposure to COVID-19:	65 (34.9)	85 (79.4)	<0.001∗
Reduction of the number of workdays per week
Academic strategies: Teleconferences	156 (83.9)	101 (94.4)	0.008∗
Your hospital asks you to treat patients with COVID (yes)	127 (68.3)	95 (88.8)	<0.001∗
ICU COVID	45 (24.2)	38 (35.5)	0.038∗
Medical care area	76 (40.9)	70 (65.4)	<0.001∗
Mechanical ventilators in patients with COVID	11 (5.9)	18 (16.8)	0.003∗
Emergency area coverage	55 (29.6)	38 (35.5)	0.293
COVID-19 had a negative impact on your training? (yes)	116 (62.4)	78 (72.9)	0.066
Positive polymerase chain reaction COVID-19 test result	42 (22.6)	21 (19.6)	0.679
Respiratory disease that warrants hospitalization	4 (2.2)	1 (0.9)	0.439
Respiratory disease that warrants management in the ICU	2 (1.1)	0 (0)	0.282
Increase in theoretic and scientific activity	90 (48.4)	38 (35.5)	0.005∗
Neurosurgical guidelines in patients with COVID-19
The department refuses to perform the surgery, even if there is adequate PPE	1 (0.5)	2 (1.9)	0.2
Surgery is done, even if there is no proper PPE	41 (22)	16 (15)
Surgery is done, only if there is adequate PPE	144 (77.4)	89 (83.2)
Received supervision in the management of patients with COVID? (yes)	98 (52.7)	69 (64.5)	0.05
Sufficient PPE	98 (52.7)	53 (49.5)	0.471
PPE training (yes)	141 (75.8)	88 (82.2)	0.199

ICU, intensive care unit; PPE, personal protective equipment.

^∗Statistically significant variables P <0.05 obtained by the χ² test.

Neurosurgical Training Year

Junior residents were more frequently assigned to the management of patients with COVID compared with senior residents (82% vs. 66.4%; P = 0.002), mainly in medical care (57.5% vs. 38.7%; P = 0.002) and emergency units (36.8 vs. 24.4; P = 0.025), whereas senior residents were assigned mainly to the ventilator management (14.3 vs. 6.9; P = 0.038) and neurologic surgeries (73.1 vs. 59.8%; P = 0.019); 2 (1.7%) of the senior residents presented with severe respiratory disease that merited ICU management, whereas no junior resident needed this type of care (Table 9 ).

Table 9.

Analysis by Neurosurgical Training Year

	Junior Resident (PGY 1–3)	Senior Resident (PGY 4–5)	P
Neurosurgery training country
Mexico	73 (42)	34 (26.8)	0.019∗
Other country	101 (58)	85 (71,4)
Hospital type
Exclusive hospital for neurologic diseases	11 (6.3)	7 (5.9)	0.015∗
Medical specialty hospital	95 (54.6)	43 (36.1)
General hospital	67 (38.5)	68 (57.1)
Others	1 (0.6)	1 (0.8)
Strategies to reduce resident exposure to COVID-19:	98 (56.3)	52 (43.7)	0.049∗
Reduction of the number of workdays per week
Your hospital asks you to treat patients with COVID	143 (82.2)	79 (66.4)	0.002∗
ICU COVID	48 (27.6)	35 (29.4)	0.733
Medical care area	100 (57.5)	46 (38.7)	0.002∗
Mechanical ventilators in patients with COVID	12 (6.9)	17 (14.3)	0.038∗
Emergency area coverage	64 (36.8)	29 (24.4)	0.025∗
Neurologic surgeries	104 (59.8)	87 (73.1)	0.019∗
Positive polymerase chain reaction COVID-19 test result	35 (20.1)	28 (23.5)	0.793
Respiratory disease that warrants hospitalization	2 (1.1)	3 (2.5)	0.373
Respiratory disease that warrants management in the ICU	0 (0)	2 (1.7)	0.086

PGY, postgraduate year; ICU, intensive care unit.

^∗Statistically significant variables P < 0.05 obtained by the χ² test.

Discussion

The COVID-19 pandemic affected the neurosurgical training of residents in Latin America and Spain in multiple ways. Several reports have evaluated the impact of COVID and hospital strategies to reduce residents' exposure to the infection. The reduction of neurosurgical procedures and hours of work caused an increase in the development of theoretic knowledge; however, a negative impact was observed in the practical and surgical training of neurosurgery residents worldwide.10, 11, 12, 13, 14

Strategies by Center

Our results show that the most popular strategy was reducing the number of working days per week in Latin America and Spain (51%). In other countries, it was decided to initially restrict resident access to hospitals.^{10 , 11} In North America and the Middle East, a reduction in the number of resident working days per week was intended to decrease their exposure.¹² In Italy, no neurosurgery residency program stopped working, but the length of stay in the service was shorter.¹⁵

Neurologic Surgeries

In the literature, a reduction of neurologic surgeries from 67.5% to 99.5% was reported, affecting mainly elective surgeries and older residents.^{10 , 11 , 13 , 14 , 16 , 17} In some centers, emergency surgeries were also suspended.¹³ Approximately 88% of our respondents performed neurologic surgeries on patients with COVID-19, whereas 92% mentioned that elective surgeries were suspended and <1% mentioned that emergency surgeries were canceled. However, the decrease in scheduled neurosurgery did not prevent the residents from becoming ill, and it was reported that 1.4% (n = 4) of residents had respiratory disease that required hospitalization (P = 0.006) and 1 resident (0.3%) required intensive care (P < 0.001).

Working Hours

Shorter workday hours reduced residents' exposure to the disease. Other investigators have reported a 44.8%–74.8% reduction in weekly working hours.^{11 , 14 , 18} During the pandemic, we found in our study that 83.6% of the residents persisted with a workload ≥70 hours per week; however, no association was found with the presence of severe respiratory disease that required intensive care (P < 0.001) despite the high hours per workweek exposure.

Academic Hours

The reduction in working hours and the number of neurosurgical procedures favored an increase in academic hours and clinical research studies.^{10 , 12 , 14 , 18} In line with previous reports in other regions,^{12 , 14 ,} 16, 17, 18, 19, 20 teleconferences became the most common format for seminars and classes in Latin America and Spain. Mexico reported a greater number of hours for academics per week (>10 hours) before COVID compared with other countries (57% vs. 43%; P = 0.002). However, during COVID-19, the other countries reported a higher number of academic hours than Mexico, although this finding was not statistically significant (52% vs. 47%; P = 0.051). Depending on the type of hospital, before COVID-19, medical specialty hospitals had a greater number of weekly academic hours compared with other types of hospitals (43%; P = 0.003), but during the pandemic, general hospitals spent a higher number of AHW (47.5%; P = 0.004), probably because residents of medical specialty hospitals showed a higher percentage of positive COVID tests compared with other hospitals (57.1%; P < 0.001), which caused ill residents to require disability due to illness.

Management of Patients with COVID-19

Wittayanakorn et al.¹³ and Dash et al.¹⁷ reported that 87%–88% of their respondents work in a hybrid hospital, whereas 90% of our respondents work in a hospital with the same characteristics. Italy reported that 70.4% of their residents do not participate in the treatment of patients with COVID.¹⁴ Canada, United States, India, and other countries in the Middle East reported that 35.1%–91.1% of residents provided nonneurosurgical care to patients with COVID.^{10 , 11 , 17 , 18} In our study, approximately 75.8% of residents were assigned to manage patients with COVID, although only 57% mentioned working under supervision, and PPE was sufficient in only 51.5% of responses.

The assignment of residents to medical care services for patients with COVID, especially in ICUs, was a matter of concern for residents, resulting in discomfort because of the lack of skills for this work,11, 12, 13 in addition to a higher probability of becoming ill with COVID-19.¹⁶

A few respondents were assigned to COVID ICU (28%) and management of mechanical ventilators (10%). Residents mentioned feeling uncomfortable (45.4%) and incompetent (55.1%) in the management of these patients. Furthermore, 87.4% of the residents at the time of the survey mentioned that they were participating in neurosurgical procedures performed on patients with COVID-19 and 79.5% mentioned that these surgeries were performed only if adequate PPE was available, whereas 20% reported that they were performed even without PPE. Residents of Mexico were more exposed to patients with COVID than were residents in the rest of the surveyed countries (88% vs. 68.3%; P < 0.001) in the same way as junior residents (82% vs. 66.4%; P = 0.002). Junior residents were assigned mainly in the areas of medical care (57.5% vs. 38.7%; P = 0.002) and coverage of emergency units (36.8 vs. 24.4; P = 0.025), whereas senior residents were assigned mainly to ventilator management (14.3 vs. 6.9; P = 0.038) and neurologic surgeries (73.1 vs. 59.8%; P = 0.019; 2 of the senior residents (1.7%) presented with severe respiratory disease that warranted management in the ICU, whereas no junior residents required intensive care.

Impact on the Health and Training of Residents

Despite the availability of the test in many participating countries, it was not performed routinely and most of the tests were performed in residents with symptoms and exposure to COVID-positive patients.¹³ In the reported studies, >60% of residents were not tested for COVID-19, which could condition many asymptomatic carriers.¹⁴ At the time of our survey, 180 residents (61%) were tested for COVID-19 and 21.5% (n = 63) had obtained a positive result. A positive PCR test result for COVID-19 was obtained more frequently in the hospitals of medical specialties (57.1%; P < 0.001), and 8% of these patients (n = 5) presented with a serious respiratory disease that required hospitalization (P < 0.001). Women had a higher percentage of positive PCR results than did men (27.4% vs. 20%; P = 0.467) and a higher percentage of respiratory disease that warranted hospitalization (3.2% vs. 1.3%; P = 0.298), but female residents did not warrant management in the ICU in contrast to males (0% vs. 0.9%; P = 0.462)

Another issue that concerns residents is not reaching the minimum number of cases to be accredited by their training program.^{12 , 17 , 18} Although this variable was not included in our study, we consider it to be an important problem in all grades of neurosurgery residency because it represents a potential deficit, both academic and skills, the loss of which is unlikely to be compensated, especially in senior residents. This situation is particularly important because the pandemic seems to continue with different waves and yet there is no end in sight.

Negative Impact of COVID on Neurosurgical Training

Pelargos et al.¹¹ reported a negative pandemic impact in a third of their respondents, and Wittayanakorn et al.¹³ mentioned a 74% deficit in training. In our study, two thirds (66%, n = 194) of the participants reported that COVID-19 negatively affected their neurosurgical training. More than half (54.9%, n = 161) reported that the COVID pandemic affected their mental or physical health. Alhaj et al¹⁰ concluded that this pandemic affected social life in 100% and mental health in 90% of the participants.

Other situations about which residents mentioned being concerned, not evaluated in our survey, were the marked decrease in their practical surgical experience, uncertainty about their degree examination and possible delay in professional advancement, the increased number of delayed elective surgeries, the risk of acquiring COVID-19 in the workplace, and the possible transmission of COVID-19 to their relatives.^{13 , 17 , 18}

Strengths and Limitations of the Study

This survey is the first carried out of neurosurgery trainees in Latin America and Spain. It is shocking how 21% of those surveyed reported a positive PCR test result for COVID. According to our results, it is unquestionable that residents, despite hospital strategies to reduce the risk of infection, were exposed to COVID-19 in areas in which patients are carriers of a higher viral load, such as ICUs, or the operating room. We did not evaluate hospital policies for conducting the presurgical COVID-19 test within the surveyed countries, which could increase exposure in the centers in which surgical procedures continued to be performed, and in the same way, we did not evaluate the impact on admissions that occurred during the pandemic and quarantine periods applied to residents, whether infected or not, as did other investigators.^{16 , 17} We also did not evaluate the impact of burnout and professional satisfaction that our residents experienced during this pandemic and how it could negatively influence their personal satisfaction.¹⁸ The specific type of surgical procedure was not evaluated, even when 88% of our residents reported that they performed neurologic procedures in patients with COVID in their hospitals. Despite their persisting neurosurgical practice, we are unaware of the complexity of the procedures performed, which undoubtedly may skew the real impact on their neurosurgical training, biased by more emergency surgeries, such as placement ventriculostomy, valves, or trephine drainage, which are surgeries that require less complexity.

Conclusions

Reduction of neurologic surgeries and workdays, as well as teleconferences, has been the most popular strategy during this pandemic to reduce residents' exposure to COVID-19. However, the negative impact on practical training and health of the neurosurgery residents reported in the survey is an evident problem. Our study represents the first approximation to measure the impact of COVID-19 pandemic on neurosurgery training in Latin America and Spain. New strategies to improve neurosurgical procedures in the operating room must be found to continue with integrated formation of our residents during this pandemic.

CRediT authorship contribution statement

María F. De la Cerda-Vargas: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing - original draft, Writing - review & editing. Martin N. Stienen: Methodology, Formal analysis, Writing - review & editing. José A. Soriano-Sánchez: Investigation. Álvaro Campero: Methodology, Investigation. Luis A.B. Borba: Investigation. Bárbara Nettel-Rueda: Investigation. Carlos Castillo-Rangel: Methodology, Investigation. Luis Ley-Urzaiz: Investigation. Luis H. Ramírez-Silva: Investigation, Methodology, Project administration, Validation, Visualization, Writing - original draft, Writing - review & editing. B.A. Sandoval-Bonilla: Methodology, Investigation, Formal analysis, Writing - review & editing, Final approval of the version to be published.

Supplementary Appendix 1. Survey

Situational Diagnosis in the Training of Neurosurgery Residents in Latin America, and Spain: Impact on the Covid-19 Era

Introduction

The quality of resident training has been negatively affected as a result of the recent COVID-19 pandemic. As the number of infected cases increases significantly, neurosurgeons in different countries are significantly affected in multiple ways. Neurosurgery residents face a great challenge, especially those who work in hospitals with a high number of patients with COVID-19. Also, some residents are fully responsible for patients with this infection. The reduction of elective and urgent neurosurgical procedures, online classes, the reduction of shifts in the hospital, have been used as a strategy to increase the number of residents in areas of care for patients with COVID-19, which has led to up a 50% reduction in residents in person at the hospital.

The objectives of this survey are:

• 1)Collect the number or percentage of elective or emergency neurosurgical procedures, hours of work, as well as strategies used in each hospital to propose adjustments in the training and education of neurosurgery residents in the Era of Covid-19.
• 2)Analyze hospital strategies in the face of the pandemic and how they impact the training of neurosurgery residents in Latin America.

What we offer you:

Any participant who contributes to the collection of information will have a mention in an appendix at the end of the article as a reward, and their full name will appear indexed in PubMed, unless the participant prefers to remain anonymous.

Please note that all data will be collected and analyzed anonymously. Other than indexing purposes, the participant's name will not be displayed and in particular individual data will not be displayed.

Email address:

Instructions: Please read the questions below carefully. Respond as you consider relevant to the situation that arises.

Do you want your full name to appear in the appendix of the article publication and indexed in PubMed? ∗

• •Yes
• •No, I prefer to remain anonymous

If you answered Yes, write your full name. Otherwise, continue to the next

• 1.
  Are you a resident in neurosurgery? ∗

  • •
    Yes
  • •
    No
• 2.How many residents work in your Neurosurgery department? (just answer with number) ∗
• 3.
  What is your gender? ∗

  • •
    Woman
  • •
    Man
• 4.Age (in years):
• 5.What is your country of origin? (place of birth):.
• 6.In which country are you doing your residency program in neurosurgery?:.
• 7How many years does your educational neurosurgery residency program in your country include? (not counting years of previous general surgery):.
• 8
  What year are you currently studying in the neurosurgery residency? (not counting years of previous general surgery) ∗

  • •
    1st year
  • •
    2nd year
  • •
    3rd year
  • •
    4th year
  • •
    5th year
  • •
    6th year or more
• 9.
  The hospital where you are currently residing is: ∗

  • •
    Exclusively from neurological diseases
  • •
    Hospital of Medical Specialties that includes Neurosurgery
  • •
    General Hospital including Neurosurgery
  • •
    Others:

COVID-19

• 10.
  Which of the following strategies has your department adopted to reduce residents' exposure to COVID-19? Please check the one that best applies to your hospital. ∗

  • •
    You go fewer hours but every day.
  • •
    I work for guards.
  • •
    There have been no changes.
• 11.
  How many hours per week, on average, did you work in your residency program prior to the COVID-19 pandemic? ∗

  • •
    70 or more
  • •
    60–69
  • •
    50–59
  • •
    40–49
  • •
    less than 40
• 12.
  How many hours per week, on average, do you currently work in your residency program during the COVID-19 pandemic? ∗

  • •
    70 or more
  • •
    60–69
  • •
    50–59
  • •
    40–49
  • •
    less than 40
• 13.
  Does the hospital in which you are currently carrying out your residency hospitalize patients with COVID-19? ∗

  • •
    Yes, exclusive hospital COVID
  • •
    Yes, COVID hybrid hospital (Admits positive and negative patients with COVID)
  • •
    No, the hospital does not receive patients with COVID
  • •
    I'm not sure
• 14.
  Does your hospital perform neurosurgical procedures on patients with probable or confirmed COVID-19? ∗

  • •
    Yes
  • •
    No
  • •
    I'm not sure
• 15.
  Which of the following services were canceled at your hospital? You can check more than one or NOT check any if they were not canceled ∗

  • •
    Emergency surgeries
  • •
    Elective surgeries
  • •
    External inquiries
  • •
    Meetings and conferences
• 16.
  What percentage of EMERGENCY neurosurgical procedures are currently being performed compared to the pre-pandemic period (6 months)? ∗EMERGENCY neurosurgical surgeries are defined as surgeries that can result in death or significant morbidity if not performed within 24 hours.

  • •
    Decrease less than 50%
  • •
    Decreased more than 50% (or emergency cases were not allowed)
  • •
    Without changes
  • •
    Increase less than 50%
  • •
    Increase more than 50%
• 17.
  What percentage of ELECTIVES neurosurgical procedures are currently performed compared to the pre-pandemic period (6 months)? ∗

  • •
    Decrease less than 50%
  • •
    Decreased more than 50% (or elective surgeries were not allowed)
  • •
    Without changes
  • •
    Increase less than 50%
  • •
    Increase more than 50%
• 18.
  If a patient needs an EMERGENCY neurosurgical procedure and has tested positive for COVID-19, what is common practice in your department? ∗

  • •
    Surgery is done, even if there is no proper personal protective equipment
  • •
    Surgery is done, only if there is adequate personal protective equipment
  • •
    The department refuses to perform the surgery, even if there is adequate personal protective equipment
  • •
    Neurosurgery Online Learning
• 19.
  The theoretical (conferences, seminars, magazine clubs, ...) and scientific (production of scientific papers, research projects, etc.) activities in the last 6 months have ... ∗

  • •
    Increased
  • •
    Remained unchanged
  • •
    Diminished
  • •
    No teaching activity has been carried out in the last 6 months
• 20.
  Has your hospital of residence modified the academic sessions, and if so, how? Check the ones that are necessary ∗

  • •
    Teleconferences (eg Zoom, GoToMeeting, ...)
  • •
    Face-to-face (in small groups)
  • •
    Simulation laboratories
  • •
    Online questionnaires
  • •
    Academic meetings and conferences canceled
  • •
    They remained unchanged
• 21.
  How many hours per week did your program dedicate to didactic learning before the COVID pandemic? ∗

  • •
    More than 10
  • •
    7–9
  • •
    5–6
  • •
    3–4
  • •
    1–2
  • •
    None
• 22.
  How many hours per week does your program currently dedicate to didactic learning in the COVID-19 pandemic? ∗

  • •
    More than 10
  • •
    7–9
  • •
    5–6
  • •
    3–4
  • •
    1–2
  • •
    None

Care For Patients With COVID-19

• 23.
  Has your hospital asked you to provide medical services to treat COVID-positive patients? ∗

  • •
    Yes
  • •
    No

If your answer is yes, please specify which of the following: ∗

• •ICU with positive patients with COVID
• •Health care area
• •Fan handling
• •Coverage of emergency areas
• •Neurological surgeries in COVID-positive patients
• 24.
  How comfortable are you providing non-neurosurgical medical care to COVID-positive patients (ICU, ventilator management, triage in the emergency room, etc.) if requested by your hospital? ∗

  • •
    Very comfortable
  • •
    Comfortable
  • •
    I do not care
  • •
    Uncomfortable
  • •
    Very uncomfortable
• 25.
  How competent do you consider yourself to treat COVID-positive patients? ∗

  • •
    Very competent
  • •
    Competent
  • •
    Little competent
  • •
    Incompetent
• 26.
  Have you been under supervision in the management of positive patients with COVID? ∗

  • •
    Yes
  • •
    No
• 27.
  How would you describe the supply of personal protective equipment (PPE) in your hospital? ∗

  • •
    Enough
  • •
    Insufficient
  • •
    The hospital does not provide PPE
• 28.
  Did you receive any formal training on how to use and remove personal protective equipment (PPE) during this pandemic? ∗

  • •
    Yes
  • •
    No
• 29.
  Have you ever had symptoms of COVID-19? ∗

  • •
    Yes
  • •
    No
• 30.
  If you answered Yes to the previous question, please specify what symptoms you experienced

  • •
    Fever or chills
  • •
    Cough
  • •
    Difficulty breathing
  • •
    Fatigue
  • •
    Muscle and body aches
  • •
    Headache
  • •
    Loss of smell or taste
  • •
    Sore throat
  • •
    Stuffy or runny nose
  • •
    Nausea or vomiting
  • •
    Diarrhea
  • •
    Persistent chest pain or pressure
  • •
    Confusion
  • •
    Inability to wake up or stay awake
  • •
    Perioral cyanosis
  • •
    Respiratory disease requiring hospitalization
  • •
    Respiratory disease requiring intensive care unit
• 31.
  Have you ever had a PCR test for COVID-19? ∗

  • •
    Yes, and the test came back positive
  • •
    Yes, and the test came back negative.
  • •
    No, I haven't had the test
  • •
    COVID-19 testing is not available in my hospital/region
• 32.
  Do you think the COVID-19 pandemic will have a significant NEGATIVE impact on your neurosurgery training? ∗

  • •
    Yes
  • •
    No
• 33.
  Do you think your health could be affected during this pandemic?

  • •
    Yes, mainly my physical health
  • •
    Yes, mainly my mental health
  • •
    Yes, my physical and mental health, both equally
  • •
    No

Supplementary Table 1.

Surveys Reported Evaluating the Impact of COVID-19 Pandemic in Neurosurgery Residents

Reference	Country	Application Time	Targeted Resident Population	Response Rate, n (%)	Number of Questions
Alhaj et al., 202010	Canada, United States, Saudi Arabia, Kuwait, Serbia, and Italy	April 14–28, 2020	300	52 (17.33)	27
Cheserem et al., 202016	Africa	April 16 and May 21, 2020	123	NA	52
Pelargos et al., 202019	Canada United States (29 states)	April 17–30, 2020	1300	197 (15.15)	31
Khalafallah et al., 202018	United States (members of the American Association of Neurological Surgeons)	May 2020 (2 weeks)	1374	167 (12.2) (only 111 completed responses)	26
Zoia et al., 202014	Italia	May 3–11, 2020	331	192 (58)	18
Dash et al., 202017	India	May 7–16 2020	118	NA	36
Wittayanakorn et al., 202020	Indonesia, Malaysia, Philippines, Singapore, and Thailand	May 22–31, 2020	470	298 (63)	33
Pennington et al., 202012	Neurosurgery programs accredited by Accreditation Council for Graduate Medical Education	2 weeks	116 programs	57 programs (49.1) (average of 2 residents per postgraduate year)	25

NA, not applicable.

Supplementary Table 2.

Survey responding participants

Andres Francisco Rojas Gallegos

Jesús Eduardo Chan Cerecer

Pablo Andrés Peña Puga

Victoria Evelia Iban Berruete

Florencia Rodriguez Basili

Paulo Fiori

Paola Alejandra Quevedo Castedo

Ronmel José Maldonado Machuca

Azcona Sergio Víctor

Lucas Maximiliano Gimenez

Alejandro Benjamin Romero Leguina

Angeles Casale

Camila Casal

Tomas Wessel

Rubby Juliana Romero Chaparro

Héctor Osvaldo Hernández Velázquez

José David Salazar Bello

Sindel Guadalupe Lucatero Rolon

Mallyolo Eliezer Pelayo Salazar

Catalina Sánchez Delgado

Luis Abraham Castro Toscano

Nadia Pérez Peña Rosas

Ramos Delgado José Miguel

Katherine Paola Gallego Henao

G Faust

Alberto Antonio Mejía Frías

Janina Margoth Cueva Ludeña

Marco Antonio Jiménez Manrique

Ernesto Javier Delgado Jurado

Cristina Romero López

Sergio Vera Navarrete

Andres Felipe Mendez Gutierrez

Jorge Herreria-Franco

Abrahan Alfonso Tafur Grandett

Dr. Miguel Angel Ramirez Sosa

Arturo Gómez Jiménez

Verónica Martínez Zerón

Juan Carlos Jiménez Romo

Angela Maria Tapicha

Ruben de Jesus Ramírez Rios

Francisco Vargas

JC Aguirre

Raul Frade Flores

Gustavo Parra-Romero

Lucy Ivonne Perez Avila

César Alexander Peñate Ahuath

Juan Angel Rangel Estrada

Kevin César Arián Arce Vera

Oscar Josue Montes Aguilar

Juan Alberto Torri

Sergio Arizona Garcia

Gamaliel Velasquez Jimenez

María José Cristaldo Santacruz

Eguzki Izukaitz Noguera

Gloria Moreno-Madueño

Juarez-Rebollar Daniel

Alan Walter Cerrogrande Ancasi

Patricio Sepulveda Massone

Evelyn Elena Cornejo Cortez

Guillermo Luna Alvarez

Maria Carolina Portela Fernandez

José Ernesto Chang Mulato

Donellia Carboni

Nestor Fabián Romero Del Puerto

Daniela Puerta Bedoya

Henry Giovanni del Cid Solares

Gerardo Yoshiaki Guinto Nishimura

Javier Alfonso Bellido Rodriguez

Isaac Enrique Tello Mata

Frederico Bartz Noy

Francisco Rojas Ramos

Ramón Castruita Meza

Hazzim Israel Benavides Giles

Carlos Gonzalez

Kevin Rafael Rojas

Nadin Jesus Abdala Vargas

Érico Samuel Gomes Galvão da Trindade

Henry Cabrera Medina

Jorge Kevin Bejarano Cardenas

Alvaro Bedoya Gómez

Hugo Garcia

Hernán Pombo

Alexandra María Granados Ferrufino

Juan Manuel Torres

Hebert David Pimienta Redondo

Rogelio Nava Esquivel

José Ramón Olivas Campos

Naiara Wiggers de Souza

Esteban Idarraga Vanegas

Juan Jose Baquiax -yax

Amparo Saenz

Marlon David Solano García

Carlos Betancourt Quiroz

Daniel Alejandro Vega Moreno

Luis Alberto Rodriguez Hernandez

Rodrigo Uribe-Pacheco

Adán Soto Ramírez

Juan Pablo Ichazo Castellanos

Isaura Zoé Chávez Valderrama

Eduardo Cruz García

Emmanuel Moreno Ortiz

Luis Flores Robles

Job Jesús Rodríguez Hernández

Aldair Buckcanan Vargas

Zita Elizabeth Salazar Ramírez

Christian Janis Sandoval Ramírez

Jose Luis Gonzalez Hurtado

Carlos Alberto Mendoza García

Josué Alejandro Cervantes González

David de Jesús Mercado Rubio

María Eugenia badaloni

Maidana Florencia Antonella

Pierini Yanel Natalia

Liezel Ulloque Caamaño

Christopher Arturo Gonzalez

Bourilhon Facundo

Emmanuel Maciel-Ramos

Rafael Román Cuéllar

Carmen Rosa Georgina Yanque Baca

Carlos Antonio Cruz Argüelles

Pablo Adrián Luna Pérez

Mera Cedeño Javier Alejandro

Gastón Ezequiel Bumaguin

Rodríguez Gacio, Leonardo Nicolás

Mikail da Conceição Sallé

Nelson Andres Cedeño Baird

Mariano Teyssandier

Jorge Daniel Pérez Ruiz

Carlos Perez Cataño

Alfredo Vara Castillo

Carlos Morales Valencia

Yovany Andrés Capacho Delgado

Wilson Quispe Alanoca

Gabriela Yesenia Contreras Montes

Diego Tonathiu Soto Rubio

Pierre Yves Fonseca Mazeau

Sebastian JM Giovannini

Juan Felipe Mier Garcia

Juan David Rivera G.

Alejandro Gomez Martínez

Teresa Martinez Villegas

Vicente Casitas Hernando

Antonio Selfa Rodriguez

Andres Vargas-Jiménez

Alberto Acitores Cancela

Andoni García-Martín

Daniel de Frutos Marcos

José Antonio Uehara González

Macario Jose Arellano Beltran

Pedro Miguel González Vargas

María López Gutiérrez

Aurora Castro Ruiz

César Adán Almendárez Sánchez

Oscar Noe Garcia Galaviz

Edwin Rolando Sánchez Vallejo

Nestor Emmanuel Sanchez Ochoa

Saúl Solorio Pineda

Renato Carvalho Santos

Diego do Monte Rodrigues Seabra

José Alcantara Filgueira Junior

Vithor Ely Bortolin da Silva

Vinicius Rosa de Castro

Antônio Delacy Martini Vial

Éder Rodrigues Queiroz

Jhoney Francieis Feitosa

Matheus Torres Dutra Maia da Costa

Igor Barreira Magro

Emmanuel De Oliveira Sampaio Vasconcelos e Sá

Matheus Pereira Dias

Victor Perez Meireles de Souza

Fernando Levi Alencar Maciel