by Elizabeth Hofheinz, M.P.H., M.Ed.
Was Covid-19 a disaster for orthopedic training? No. Were cases missed? Yes. But, orthopedic residents and fellows were forced to adjust…forced to rise to the occasion and bring their best in this new normal. Covid was a surprise…and what is better training for the OR…where there are sometimes big surprises?
Due to their training being overshadowed by Covid-19, residents and fellows are asking themselves questions such as, “What did I miss? Is this going to affect my fellowship (or job) prospects?” 
Dan Riew, M.D., is Director of cervical spine surgery at Columbia University in New York. Regarding residents, he told OSN, “They are not getting the caseloads that they would typically get. There has been a lock-down since mid-March and it will be another few months before we get back to a normal schedule, which represents a lot of missed learning opportunities.”
“For a myriad of reasons, as we progress towards normal, we need to do as many cases as possible each day…so that makes it harder to spend as much time teaching. I would guess that the average resident may end up missing only around 5% of his or her training, since the entire training period is 5 years and they will be about 50% as busy for a 6-month period.”
Initial concerns have begun to dissolve
Dr. Riew: “At first residents were very worried about not having sufficient or appropriate PPE. However, as time went on, we saw that the illness rate of medical workers was much lower than the average New Yorker, despite much higher exposure, suggesting that the PPE hospitals were providing was highly effective.”
For the most part, however, residents did not voice their concerns. “I don’t think they opened up to the attendings or anyone else about their worries. Frankly, most doctors are taught to be stoic and not complain.”
Dr. Riew says that orthopedic fellows are in a more difficult situation. “A fellowship is only one year so I’m a bit more concerned about those trainees. They are essentially losing 40-50% of their education. Overall, it depends on how the fellowship is structured. We have two six-week rotations on each service, separated by 6 months. So everyone got their 1st rotation in but they missed out on a substantial part of their 2nd 6-week rotation.”
This is particularly true, says Dr. Riew, with spine deformity surgery. “Our fellows are fortunate to be trained by Larry Lenke, who teaches them how to work on complex thoracolumbar deformities…those are the cases that you have to do hundreds of before you are adept and comfortable with the procedure.”
Asked to look into the future, Dr. Riew states, “These trainees are moving into an environment where beginning their careers depends somewhat on the development of a vaccine or an effective treatment. If it is really another 12-18 months until we get a vaccine, then we will be in partial lockdown mode for a long time. So for the average orthopedic surgeon, that means you can’t see the number of patients you were seeing before. You cannot have a lot of patients waiting in your waiting room.’”
Jeff Konopka, M.D., is an orthopedic fellow at Harvard, Massachusetts General Hospital, and Brigham and Women’s Hospital. He told OSN, “During the first part of fellowship you are learning techniques from each individual attending. Toward the last third of fellowship you have graduated autonomy where you get the opportunity to put all the pieces together from what you learned during the rotations. COVID unfortunately had its impact on the last 1/3 of our fellowship. This created a unique challenge that the fellows and attendings have had to adapt to. They have established a very good didactic curriculum that includes four sessions of case review/journal club/technique talks. It’s great because these are things you don’t always have the opportunity to do if you are operating all the time. Another benefit is that while senior surgeons are often too busy in clinic to do a lot of storytelling about their cases, they have had plenty of time during Covid to pass that knowledge on to us.”
“Our facilities have been making accommodations to keep things on track prioritizing urgent cases and increasing the number of cofellow cases. Our system has already started ramping back up so hopefully some light at the end of the tunnel. My primary concerns about coming out of fellowship are still very similar to pre-Covid. Starting a new practice will certainly be a challenge but I have great future partners at Indiana Spine Group and fellowship/resident mentors that I will always be able to count on along the way.”
Dr. Konopka says he is fortunate that his fellowship case volume is still very strong despite the recent decrease due to the pandemic. “I also am very thankful my residency training at Emory was very spine intensive.”
From “go go go” to “slow slow slow”…
Nathan Olszewski, M.D., is a fourth-year orthopedic surgery resident at Boston University (BU) who will begin a fellowship in July 2021 at Harborview Medical Center in Seattle. “At BU we have been fortunate to have not been pulled to the medicine floors to handle Covid cases. It has been tough adjusting from the ‘go go go mind set’ to ‘don’t operate.’”
“There are also things that you don’t take into account, like performing daily tasks while wearing PPE”, says Dr. Olszewski. “I recall going up four flights of stairs in PPE and not thinking about it, but when I got to the top, I couldn’t catch my breath.”
Mental surgery…
“In our residency there are block weeks, we get the opportunity for multiple rotations. I am currently on my joint rotation and I was beginning to understand the intricacies of decision making in the operating room, however, Covid has taken away the repetitions that allow me to further improve my decision making and my surgical skills. To make up for that I am diligent about doing mental repetitions and engaging in a lot of case discussions with the attendings. On the other hand, this time has been somewhat positive as it has allowed me the opportunity to catch up on my reading. I am also fortunate to have a chief who is one year ahead of me and who is very knowledgeable.”
“I am in charge of organizing talks and case presentations from trauma attendings across the country. Every night from Monday to Friday the attendings review cases and foster discussions via video. In order to assist current and future residents, we record these sessions and put them on our BU AAOS channel. This provides opportunities for us to make up for what Covid has taken away, namely, learning how to make clinical decisions.”
“The physical skills will come …that is not an issue. However, learning how to deal with the unexpected difficulties or complications in the operating room has been difficult to make up for. Such an environment is hard to replicate. Possibly the most difficult aspect of all of this is that no one knows where this is going and when it will end, but those in charge are doing their utmost to help the residents manage this difficult time. For example, we have a weekly meeting with an ACGME representative at our facility review resident issues.”
And if we see another round of Covid in the fall? “I am confident that our leadership will find a way to get residents the training they need and we will graduate as well-rounded surgeons.”
Joe Lombardi, M.D., a fellow at Columbia University, says his primary concern is missing out on two months of cases. “As if that was not enough, it is so difficult to predict case volume going forward. Columbia is a deformity-focused spine fellowship and unfortunately these are cases that require an enormous amount of resources, including PPE and postop ICU care (ventilators, ICU beds) so these will be the very last cases to return. From an academic standpoint we have lost the opportunity to more deeply understand appropriate indications and surgical planning.”
But they have found other ways. “We almost immediately started having educational zoom meetings three times per week. Two times these are led by our faculty and then the third session includes institutions from all across the country. Not only are we trying to put as many cases as possible on the schedule, but we have set up a cadaver lab run by the attendings. One attending and one fellow go through various steps in the procedures—osteotomies, corpectomies, etc. Device companies have been great about stepping up and offering educational resources, including hands-on cadaver labs and training.”
“We have had a unique experience here in New York as many of us have been redeployed to ICUs and ERs. We did a top to bottom analysis from an institutional and spine standpoint on our approach toward Covid. This included everything from how we deployed staff to how we managed spine consults, the health and wellness of our orthopedic team, etc. We also worked with anesthesia to develop a protocol for intubation and extubation.”
Alex Ha, M.D., a fifth year resident at Columbia University, considers himself fortunate overall. “We halted elective cases in mid-March, which is about the time that our training tends to wind down. The vast majority of surgeries had already been performed during the first half of the year. Overall, I probably missed out on 10 cases…but I did have extra time to study for the boards. I am a bit concerned that my fellowship will be affected as we have no clear idea of how the virus will act over the next few months.”
And in the end, Covid will have likely provided opportunities that would not have existed in a normal training situation. In the words of Epictetus, “It’s not what happens to you, it’s how you react to it.” So overall, Covid-19 has been a chance for these up-and-coming surgeons to test their mettle.