Dear Editor,

We read the article with great interest by Abdelazeem et al. “Orthopaedic training during COVID-19 pandemic: should action be taken?” [1]. It gave valuable insight into the perspective of residents and physicians during the pandemic globally. This letter addresses additional factors contributing to the larger picture of what trainees and physicians faced during the pandemic.

Initially, there was heightened anxiety and depression regarding the consequences of getting COVID. The healthcare facilities were overwhelmed during the first and second variant outbreaks of COVID. However, it appears that the survey results were obtained from the time of the third variant outbreak. The results could have been different if the survey was conducted earlier in the pandemic, during the first or second waves. Earlier, civilians were more compliant with quarantine, and the government leaned in on finding a resolution to the pandemic—there was a hope and drive to fix the problem [2]. However, further into the pandemic, the unpredictability of the different COVID variants increased burnout rates among healthcare professionals and the public due to a sustained issue with no resolution [3]. A survey study showed that increased levels of uncertainty were associated with higher levels of stress for healthcare workers during this pandemic [4]. It would be interesting to see how these results changed based on which wave of the pandemic the participants were answering the survey questions.

Additionally, orthopaedic elective cases were suspended because of the pandemic hindering these trainees’ ability to engage in the material they wanted to learn [5]. Being forced to cross-train in treating conditions in medical and ICU services rather than an orthopaedics service may have disillusioned and burned-out orthopaedic trainees before they got the chance to learn the material they were eager to learn in the first place. While they did gain valuable medical and ICU-related skills that can, ideally, transfer to their chosen specialty, they were still behind on their orthopaedic training, which they had to work longer to catch up on.

Lastly, the survey seems to have received more responses from physicians working in urban settings than those from rural areas. Rural locations may have carried different challenges in terms of availability of resources and quantity of COVID cases in contrast to urban areas. These differences can drastically change the burnout rates among trainees and physicians in these two areas. According to a study conducted in China, physicians and trainees in urban settings had higher rates of burnout secondary to patient volume overload, increased risk of exposure, and greater media and information influx about negative aspects of COVID [6]. Ultimately, those working in rural areas were not experiencing the same level of anxiety regarding COVID-19. However, it would be interesting to see more studies performed in different countries regarding this to see regional differences.