Introduction

The coronavirus disease 2019, also referred to as COVID-19, was first reported in Wuhan City, China in December 2019. Within a short time, the World Health Organisation (WHO) declared the COVID-19 outbreak a global pandemic (WHO 2020). The pandemic has since rapidly spread around the world, causing a global lockdown of education institutions, disrupting teaching and learning activities. In Malaysia, as of 13 October 2021, there have been over 2 million confirmed cases with nearly 30,000 deaths reported (WHO 2021). Along with its impact on the education system in Malaysia in unprecedented ways, the COVID-19 pandemic has caused major disruption to the medical education process, particularly in terms of body donation for anatomical dissection teaching. Cadaveric dissection is an integral component of medical anatomy education and is one of the pillars of medical education as it contributes tremendously to the shaping of future physicians and health experts (Wong et al. 2021a). The Silent Mentor Programme (SMP, formerly called the ‘Cadaver Donation and Caring Unit’) was established in 1996 by the Department of Anatomy, Tzu Chi Medical College (now known as Tzu Chi University, Taiwan). The program aims to provide knowledge and surgical skill training and infuse humanistic values in simulation surgery training classes using a ‘Silent Mentor’ (Saw 2018; Wong et al. 2021b). The ‘Silent Mentor’ or body donor denotes a cadaver that quietly allows medical students to acquire surgical skills from it; even in death, they teach medical students. The Universiti Malaya in Malaysia initiated the SMP in the year 2012 (Saw 2018) to provide basic surgical simulation training for final-year medical students before their exit examination. These procedures include endotracheal intubation, chest tube insertion, central venous line insertion, bladder catheterization, and suturing of skin wounds. Most of these procedures are performed on silent mentors preserved by freezing to ensure that the condition of the soft tissue closely resembles that of the living bodies. Similar to most other medical schools in Malaysia, the Universiti Malaya adopts the so-called system-based learning that involved repeated exposure to relevant regional anatomy over a period of two years. Currently, teaching anatomy in this country is not using silent mentors.

Most of the donors in the SMP would have registered as pledgers long before they were ill. The next-of-kin of the pledger was made known to contact the centre when the pledger is critically ill. Upon the death of the pledger, the body will have to reach the silent mentor centre within 8 h of the time of death. The bodies will be frozen between − 17 and – 30°C until the initiation of a training session. A training session will usually be organized within six months after the death of a mentor, and it will involve between four to six silent mentors. Firstly, participating students visit their mentor’s home and interact with the family members about one to two months before their formal training session. During the home visit, students learn about their mentors’ life history to better appreciate their mentors’ personality and behavior. During this training session, the family members are invited to attend four events: (1) the opening ceremony- where the students will show slides to introduce their assigned mentors (on the day before the cadaveric dissection workshop commenced); (2) the initiation ceremony- where the family members will meet the mentors for the last time (in the morning the first workshop); (3) the gratitude ceremony in an auditorium of the medical faculty that is open to the public (one day after the last workshop); and lastly, (4) the sending-off ceremony within the University campus before leaving for the crematorium (following the gratitude ceremony). During the gratitude ceremony, the family members and all attendees will be shown the life history of the mentors and the synopsis of the training program conducted over the previous four days. The important aim of these processes is to cultivate a sense of compassion among medical students toward their future patients. A flowchart of the process in the SMP is shown in Fig. 1.

Fig. 1
figure 1

Process follow of the Silent Mentor Program

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The COVID-19 pandemic has also had a severe impact on the conduct of SMP at the Universiti Malaya. One of the measures in the safe handling of bodies of deceased persons is to test for COVID-19 to ensure cadavers are free of SARS-CoV-2 infection before enrolment into the SMP programme. This has resulted in numerous pledgers of the SMP being unable to donate their bodies. In some cases, COVID-19 test results could not be obtained within the period after death and before admission of the body to the SMP facility. In addition, travel restrictions and applications for interstate travel approval resulted in the delay in sending donors’ bodies to the SMP facility. Due to educational requirements, the body should reach the SMP facility no more than eight hours after death. Many potential donors could not be entered into the programme because of these travel restrictions and delays in obtaining a full medical evaluation of the bodies within the stipulated eight hours after death. Due to institutional closure, the conduct of cadaveric dissection training has been postponed.

The pandemic has also had a profound impact on the traditional conduct of a series of SMP programme ceremonies. Preceding the pandemic, the SMP programme involved home visits with the donor’s family members to learn more about the donor’s life, followed by a brief introduction, initiation, gratitude (memorial service), and sending-off ceremonies (Saw 2018). All ceremonies have been well-attended and were very meaningful for students and next-of-kin and family members of the mentors. Enforcement of social distancing rules resulted in physical visiting and interacting with the family members being replaced with virtual sessions. Furthermore, a limited number of family members and relatives were allowed to join the sessions (including home visits, introduction, gratitude and sending-off ceremonies).

While the pandemic is yet to regress in most countries, its associated disruptions require consideration by medical educators globally. This situation is perplexing, and indeed the major concerns in these unprecedented times are the negative impacts on learners, the family members of pledgers who could not accomplish their last wish, and most importantly impeded the core principles of the SMP training programme. To the best of our knowledge, no research has yet explored the impacts of the COVID-19 pandemic on the conduct of body donations and simulation surgery training, particularly in the context of the SMP. Therefore, this qualitative study sought to investigate these phenomena from the perspectives of programme organisers and next-of-kin of pledgers concerning the challenges in the conduct of SMP body donation and simulation surgery training during the COVID-19 pandemic. Specifically, this study aimed to uncover the challenges faced by the organizing committee on the conduct of body donation and the impact of the pandemic on their program activities. Secondly, from the perspective of the next-of-kin of pledgers, we hope to understand their emotional feelings over having their loved one not being able to become a Silent Mentor. To our best knowledge, no researchers have examined the impact, mitigated the challenges, and found a way forward in terms of increasing resiliency in such contexts. We believe that this research contributes to providing important insights into improving the conduct of SMP body donation in the current COVID-19 pandemic as well as future pandemics.

Methods

Qualitative study design

This study was an exploratory qualitative study using in-depth interviews to provide extensive insight from programme organisers of the SMP and the next-of-kin of pledgers’ regarding their experiences during the COVID-19 pandemic.

Study sample and recruitment

Probabilistic sampling method was used to recruit members of the SMP programme organising committee. Only senior members of the SMP organizing committee were interviewed and they were affiliated with the SMP in the same organization. Universal sampling was used in recruiting the family members of all SMP pledgers. All family members of all SMP pledgers that reached out to donate their loved one’s body during the COVID-19 pandemic but were turned down were invited to take part in the study.

Data collection

As the study was carried out during the era of the COVID-19 pandemic, virtual interviews were more conducive, so we performed online interviews with the participants. All interviews were audio recorded. Saturation could not be achieved due to the limited number of interviews conducted.

The discussions were carried out with the organising committee surrounding the issues of how the pandemic impacted the conduct of body donation and SMP activities. Interviews with the next-of-kin of pledgers were exclusively focused on the experience and the emotional feelings of having their loved one not being able to become a Silent Mentor. The interview guide is shown in Appendix 1.

Analysis

Interviews were transcribed verbatim and the data were analysed using thematic analysis. Two members of the research team identified the themes and inter-coder reliability was assessed. As we are aware of the need for ensuring rigour and transparency in data analysis in qualitative research, themes were identified independently to counter possible bias. In interpreting and analysing the evidence, we were also aware of the assumptions upon which our perspective was based and did not, therefore, make any assumptions about others’ perspectives.

Ethical considerations

Ethical approval was obtained from the University of Malaya Research Ethics Committee approved this study (approval code: UM.TNC2/UMREC—999). The subjects were assured that confidentiality would be maintained. All responses were kept confidential.

Results

All interviews were conducted between August and October 2021. We conducted a total of six in-depth interviews, i.e. three interviews with senior organising committee members of the SMP and three interviews with the next-of-kin of pledgers of the SMP who passed away during the pandemic and were not admitted to the programme. The organising committee members reported that, during the pandemic, approximately 10 family members of pledgers contacted the programme upon the deaths of their loved ones to fulfil their final wish to be the mentors of the SMP. However, only two bodies were successfully enrolled in the SMP facility to become mentors. As some of the next-of-kin of pledgers may still have been grieving the loss of their loved one, and often discussions recreate some forms of sadness and sorrow, when the next-of-kin of pledgers were invited to take part in the study, many refused. Only three pledgers’ family members agreed to be interviewed. Among the common reasons for refusal were that the matter was over and they did not wish to bring it up. The respondents’ quotes were anonymized by sequential number committee member 1 (CM1) to CM3 and next-of-kin 1 (NK1) to NK3.

Interviews with organising committee members of the SMP

During the pandemic, COVID-19 test requirements were added to the screening tests that all pledgers underwent before they could be accepted as a donor. Many were not able to produce COVID-19 reverse-transcription-polymerase chain reaction (RT-PCR) test results in the window period of 8 hours upon death. Most unsuccessful attempts were due to family members contacting the SMP organiser after the pledger’s death, not knowing the new mandatory requirement for the COVID-19 RT-PCR test, and that in most circumstances the test takes a few days to obtain the test report.

“We want to ensure the donor is free from COVID-19 for the safety of the trainees. If the family members inform us after the death of pledgers, it is very unlikely possible to produce the COVID-19 RT-PCT test report on time. We advise pledgers to contact us when the pledger is at a critical stage (nearing death) and not after.” –CM1

“In most of these cases, the family member contacted us after the death of the pledgers, and the body had not tested negative for COVID-19. During that time (early phase of the pandemic), little was known about the disease, the committee took careful precautionary measures to protect students and trainees. Donors have to test negative for COVID-19 before acceptance by the facility.”-CM1

Informing the pledgers or potential donors is a challenge as pledgers may feel uneasy receiving calls from the organising committee. Often, the topic of death is taboo to many people, particularly if a person has pledged as a donor, receiving calls from the programme is sensitive.

“We are unable to contact or inform our pledgers about the requirement for the COVID-19 test as it is sensitive or taboo to mention death or dying. We did not contact our pledgers, as our website is our communication channel. We quickly updated our website and announced the new requirement for a COVID-19 test and the importance of the timely production of complete medical reports upon the death of the pledger.” –CM1

The committee members were queried as to whether rejection of body donations led to a negative emotional state, a sense of loss, and regret in the family members of pledgers:

“Family members did not have an extremely negative response, but they understood and heartily accepted. Before the unprecedented pandemic, they were briefed that the donor has to be free of any infectious diseases that could potentially harm trainees, and certainly, in the event of the COVID-19 pandemic, it (the COVID-19 test) cannot be excluded.” –CM1

“They did not openly tell me they were very remorseful when I informed them that without the full medical report and especially the confirmation of a negative COVID-19 test, we could not accept the donation; however, I could hear the disappointment in their voices. I remember one family member said… that this was her (the pledger) wish all these years.” –CM1

The pandemic had both positive and negative impacts on the aims of the SMP to provide surgical skill training and cultivate humanistic values. Approximately 20 months into the pandemic, schools, universities, and higher education institutions in Malaysia have closed face-to-face education. The SMP conducted only one simulation surgery training during the pandemic, whereas, previous to the pandemic, there were approximately four to five workshops conducted in a year. During the first 20 months of the COVID-19 pandemic, only one workshop was conducted. The postponements of cadaveric dissection training resulted in students graduating as it was no longer feasible to attend the session.

From the student perspective, the pandemic has certainly had some impact on the philosophy of the teaching of the SMP. Conventionally, home visits are the most important session where students visit the home of their mentor and learn about the life history of the mentor. During the pandemic, face-to-face home visits were converted into virtual home visits. The committee members feared that virtual communication with family members of mentors was not a substitute for face-to-face learning. In the absence of face-to-face interaction, students may feel less connected with their mentors.

“The home visit is where students have physical contact and get the real feeling of their mentors’ lives. Information about mentors is gleaned from home visits and interaction with mentors’ family members. I view the virtual home visit as being not as effective as face-to-face.” –CM2

The movement restrictions have limited the number of family members attending the briefing introduction, initiation, gratitude, and sending-off ceremonies. Inevitably, the sessions were less lively compared with before the pandemic. The committee members also worried that it may be less impactful in cultivating humanistic values or a sense of compassion among students and trainees.

In each SMP session, the synopsis of training workshops showing how students gained skills in the training programme in their utmost respectful manner is documented and presented during the gratitude ceremony along with the mentors’ life stories and their final words to students. The video documentaries exert an important influence on the humanistic values of medical students. For family members, the documentary and video presentation during the gratitude ceremony denote the utmost pride and honour of their loved ones’ contributions. However, the committee members of the SMP viewed that the documentary of the SMP session conducted during the pandemic appeared less impactful owing to some sessions being conducted virtually and the limited in-person attendance imposed by the inter-state and inter-district travel restrictions.

“Definitely we are short of meaningful documentary materials for the video presentation. Formerly, our video presentation was very impactful……virtual home visits and smaller crowds at the sending-off ceremony… so the impact is somehow less.” –CM3

Prior to the pandemic, the surgical simulation training session begins with a theoretical briefing before moving to the dissection hall. As the COVID-19 pandemic prompted a sudden shift to online or remote learning, and theoretical briefing was conducted online before the training day. On a positive note, this resulted in trainees having more time in hands-on cadaver training on the day of the surgical simulation training workshop. The committee members and trainers viewed that virtual theoretical briefing can be as good as classroom learning. In the future, a hybrid platform merging of online theoretical briefing and practical training would be considered.

Interviews with the next-of-kin of pledgers

Overall, the duration of death of pledgers and the date of interview with their next-of-kin was between 8 and 12 months. When participants were asked to describe their emotional feelings over the missed opportunity of their loved ones to be Silent Mentors, all three of the next-of-kin of pledgers expressed sorrow and remorse. However, all reported that they could accept the loss.

“We do not have a harsh feeling as we know the situation is very complicated during the pandemic. Not easy for us to go through at the time. At the very last minute, were informed that he (the pledger) needed a COVID test. We were told that the test could take 3 days. We wanted things to be simple, without any delay, so that we could grieve properly.” –NK1.

A pledger’s next-of-kin noted that the duration of waiting for the COVID-19 RT-PCT test was the reason why the family members of the deceased collectively decided to forgo donation:

“If the test result takes a few hours or a day we could probably consider it, but three days is a lengthy wait. It was not an easy situation during that time, we wanted to settle it quickly so that we could grieve and move forward.” –NK1

On the whole, the conversations surrounding missing the opportunity to be a donor in the SMP were somber. Although the participants did not state it expressly in words, two participants were in tears when they shared their experiences in trying to arrange the body donation of their loved ones upon their death. Although the family members of pledgers did not voice their disappointment over the requirement that they were unaware of, their sadness was evident in the interview:

“This was my mother’s wish. Before she passed away, she mentioned several times being a mentor. Very unfortunate that she could not make it…. we were unable to fulfill her final wish (sigh).” -NK2

“She passed away unexpectedly. She told us specifically where to find the card if she passed away. I recalled what she told us, and the card was in another house. I had to travel to get the card and contact the Silent Mentor programme. There was a lot we needed to do, including going to the police station in addition to the pandemic and travel restrictions. When the ambulance and medical officer arrived, her body was cold and stiff. Furthermore, we were not sure when she had passed away, which made her ineligible to be a donor. We are very remorseful that she could not make it to the programme”. –NK2

“She said this is a noble thing and she made clear to us that she would donate her whole body, and I was very supportive. We were sad that she could not make it”. –NK2

“I am really sad that she could not make it. She suffered a lot before her death.” –NK3

Discussion

The COVID-19 pandemic is a communicable disease outbreak that poses the utmost threat to the health and well-being of humans. It has highlighted the importance of cadaver screening for COVID-19 before delivering cadaveric training. To ensure the safety and health of individuals handling the donor bodies and students during cadaveric dissections, the SMP programme during the pandemic was not able to accept donations from individuals that had not been previously tested for COVID-19. The long duration of the RT-PCR test and the huge backlogs during the pandemic resulted in pledgers missing the opportunity to be Silent Mentor. The SMP organising committee took immediate action and announced the new mandatory requirement on the SMP website, but the next-of-kin of pledgers may have missed the announcement. Body donation is a scarce and extremely valuable resource for simulation surgical training, so missing a donation opportunity is a great loss to medical education. A recent report noted that the decline of cadaveric dissection in anatomy education during the COVID-19 pandemic is likely to affect future surgeons’ competency (Chytas et al. 2021). A reminder will be useful in the event if there are new regulations such as new screening requirements during an infectious disease pandemic. Death is a challenging topic to raise with either pledgers or their next-of-kin unless they have in prior contact with the SMP informing that pledgers are near death. It remains a concern about the sensitivity surrounding sending out such information. The next-of-kin of pledgers should be encouraged to constantly check for updated information about the SMP programme for pledgers not to miss out on the opportunity to become a Silent Mentor.

In a previous study, organ donor families reported that the donation of their loved one’s organs was a kind of comfort or relief in their grief (De Groot et al. 2015). Similarly, the altruistic donation of the Silent Mentors may also bring some relief to grieving family members. The evidence from this study implies the importance of not overlooking the psychological impact of the next-of-kin of pledgers who did not make it into the donation programme. Grieving and mourning over the death of loved ones may have health-damaging effects (Buckley et al. 2012). Grieving the death of a loved one and in addition to feeling remorse for not being able to fulfill their wish could potentially have very detrimental consequences. Reaching out to the family members of pledgers to provide support for bereavement and grief counselling or guiding them to seek professional grief support and counselling is imperative.

The core philosophy of many in the SMP is to cultivate humane attributes such as compassion, care, and empathy among prospective medical doctors. The SMP is an important course in the medical curriculum that nurtures the humanistic qualities of medicine. These humanistic qualities of medicine, encompassing caring, compassion, altruism, empathy, respect for others, and trustworthiness are values healthcare professionals should embrace in their careers. It is unfortunate that the COVID-19 pandemic has forced universities to limit face-to-face education and bring their courses online. This has had profound impacts on the physical interactions among students and family and friends of the Silent Mentors before the commencement of training. In the context of the cultivation of humanistic values, compassion, and empathy, which is the prime philosophy of the SMP programme, physical touch is inevitable. It is feared that remote learning and ceremonies held with a limited number of attendees during the pandemic may impede the altruistic teachings of SMP.

These humanistic values being imparted to students in the medical curriculum have been shown to have a positive impact on their future doctor-patient relationships (Guo et al. 2020). Compassionate care has important effects on patient care quality. Likewise, the postponement of the SMP surgical simulation workshop due to the COVID-19 pandemic is disheartening as some students have graduated and missed compassionate training opportunities. Medical students who have lost out the learning opportunities may be deprived of such values and this may affect future doctors’ empathy and provision of compassionate care to patients. Hence, an opportunity to attend the programme post-graduation, by, for example, inviting them back or giving priority to those who have missed training during the pandemic is imperative.

Indeed, the profound impact of COVID-19 might change the conduct of cadaveric dissection training in the future. As it is uncertain as to when the post-pandemic world will return to normalcy, educators may need to continually modify the conduct of workshop training so that future doctors and healthcare experts are not deprived of learning humanistic values in medical education. The SMP programme utilises fresh frozen donors on one-time cycle use. The freeze-thaw donor is used in a series of tightly scheduled surgical training over a period of 5 days. Traditional surgical simulation training consists of theoretical briefing and practical skills scheduled on the same day. In the pandemic, clinical trainers used online platforms to deliver theoretical teaching to reduce face-to-face interaction. The flexibility of online theoretical learning being carried out on a different day allows more time for practical skill training. Incorporating online theoretical learning was found to be as good as in-person classrooms. On the positive side, students benefitted from both the flexibility of online learning and acquired longer practice time.

Of important note, the goal of this qualitative study is not to generalize but rather to provide a rich, contextualized understanding of experiences in the conduct of the SMP program during the COVID-9 pandemic. As COVID-19 is a new coronavirus that has not been previously identified, the exploratory nature of qualitative research and the process of naturalistic inquiry that seeks an in-depth understanding of a phenomenon is most ideal to be used to scrutinize issues surrounding the impact of the new pandemic on the conduct of anatomy training. Despite being a qualitative study, this research is novel and offers insights into the emotional and psychological impact of the next-of-kin of body donors during the pandemic. The SMP has a limited number of organizing committee members, therefore, the interviews were conducted with only three main people in the program. Therefore, the main limitation of this qualitative study is we are unable to continue interviewing until data saturation has been reached. Although only three main persons were interviewed, the data collected was comprehensive as they are the prime persons on the committee and in direct contact with the next-of-kin of pledgers and students/trainees in clinical teaching. Further, due to the sensitivity of discussion surrounding the death of their loved one, many next-of-kin of pledgers refused to be interviewed. Due to the small number of participants, the opinions of the next-of-kin of pledgers may not be representative of the wider population. Those who refused to participate were perhaps more likely to experience greater distress. Additional research with a larger number of the next-of-kin of pledgers would be useful to provide empirical evidence on how the COVID-19 crisis has impacted their emotional well-being. Owing to the small sample, the findings may not be able to provide scientific evidence, but it provides a concise narrative from the key persons in the study context. Nevertheless, the findings from the study should be interpreted with caution.

Few empirical studies had explored the psychological impact of grief or bereavement of next-of-kin of pledgers who missed the opportunity to become donors. Firstly, our study has helped shed light on the importance of counteracting these negative emotional impacts and suggests the provision of counselling interventions and professional grief support. Secondly, our results suggest that pledgers and their next-of-kin should be informed when signing up to always seek updated information or be in touch with the donation programme for updated information. Finally, more effort should be put into helping students who have missed training opportunities. This could be achieved through education continuity or the provision of opportunities to students who have missed the training to join the programme post-graduation. To conclude, despite COVID-19 cases has gradually declines, it still remains a threat and may continue to pose a significant impediment to achieving the educational outcomes of Silent Mentoring in surgery training, as well as result in a shortage of body donations, efforts to make up for these gaps are essential. Despite the challenges, cadaveric dissection in the SMP not only helps students to acquire better surgical training using fresh-frozen cadavers but most importantly it also helps students acquire the skill of empathy, which will make them more compassionate doctors in the future. Of note, the process of chemical preservation of human bodies required large human and financial resources. The university is currently looking into the possibility of conducting short demonstration sessions of selected anatomical regions using freeze-preserved silent mentors since only four SMP sessions are organized in one year.