Keywords

1 Introduction

1.1 COVID Pandemic in Turkey

The first case of the COVID-19 pandemic was reported in March 2020 in Turkey [1, 2]. Following the National Scientific Board risk assessment meeting on January 22, 2020, various preventive measures were implemented including land border closures and international flight restrictions [2, 3]. In March, additional restrictions were introduced by the government; by March 13, all educational facilities stopped face-to-face lectures, and distance education began on state television for primary, secondary, and high school students [4]. Council of Higher Education also followed the regulations and announced the suspension of in-class training and all academic meetings for universities including medical schools, and residency training programs [5]. Total cases of COVID-19 reached almost 15 million by March 2022, and the burden on the healthcare system increased accordingly [6] (Fig. 1).

Fig. 1
A line graph of total corona virus cases versus dates from February 15, 2020 to march 06, 2022 plots a gradually increasing line.

Total coronavirus cases in Turkey

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1.2 Medical Education During Pandemics

Previous pandemics introduced new challenges for medical education. Especially during the 2003 SARS outbreak, some countries implemented online teaching modalities for medical students [7]. Residency training programs for emergency medicine have been developed by specialty societies and regulated by the Ministry of Health (MOH). Residency programs were also affected by the pandemic. Especially, emergency medicine residency training was uniquely disturbed because the medical care provided by the hospitals during pandemics was restricted to only emergency admissions [2].

1.3 Emergency Medicine Residency Training in Turkey

Emergency medicine training started in 1994 at some of the university hospitals in Turkey. In 2006, state-owned public hospitals started their own emergency medicine residency training programs. Two emergency medicine specialty societies support academic facilities for a standard residency education system. The duration of the emergency medicine residency is planned as a four-year training at accredited facilities. At the end of the residency training, every resident is expected to finish an academic research project following an oral exam in front of a jury of academics. Regular scientific conferences and postgraduate training courses are organized by both societies to support scientific improvement within the field [8].

1.4 Study Aim

We aimed to describe the challenges of residency training during COVID restrictions and reflect the opinions of the emergency medicine residents through an online survey study.

2 Methods

A questionnaire with 15 questions was administered to the emergency medicine residents that participated in online training sessions and worked at the ED during pandemic restrictions. The questionnaire was prepared by the research team which included a survey specialist with an MPH degree and emergency medicine residency training. Survey topics were selected by the research team and piloted on a group of emergency physicians before distribution. The survey questionnaire was improved based on their responses for measurement accuracy and internal consistency. The survey was implemented using Google Forms and survey results were analyzed accordingly. In 2020, there were 18 attending and 21 resident physicians in the emergency department (ED) [9]. An electronic survey invitation was sent to all 21 residents.

3 Survey Results

The Likert scale was used for the questionnaire, and the data were analyzed. There were 21 responses out of 21 invitations, and the survey response rate was 100%.

3.1 Preferences on Document Sharing

Participants were asked to rate the usefulness of various methods during the restrictions (Fig. 2).

Fig. 2
A horizontally stacked bar graph of email, whatsapp, and printed material versus numbers from 0 to 1. It plots bars for 1 as not useful, 2, 3, 4, and 5 as very useful. The stacks range from 0 to 1. The highest rate for each category is 5, 5, and 4, respectively.

Usefulness of different methods for document sharing during restrictions

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As an important aspect of educational training, sharing the information was questioned in this part of the survey questionnaire, and easily accessible methods were preferred by the participants. More than 80% preferred email and WhatsApp as useful for document sharing in comparison to printed documents.

Participants were asked to rate various tools as a communication method during COVID restrictions (Fig. 3).

Fig. 3
A horizontally stacked bar graph of email, WhatsApp, and online training versus numbers from 0 to 1. It plots bars for 1 as not useful, 2, 3, 4, and 5 as very useful. The stacks range from 0 to 1. The bar for 5 is the highest bar for each category.

The usefulness of various tools as a communication method during restrictions (1 = not useful; 5 = very useful)

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Communication is an important part of medical practice, especially during emergency situations. All three communication tools were found to be useful by the participants, and WhatsApp was described as useful or very useful by 20 of the 21 participants (95.2%).

3.2 Preferences for Online Training

Participants were asked to rate online training during COVID restrictions for various aspects (Figs. 4 and 5).

Fig. 4
A horizontally stacked bar graph of theoretical method and practical method versus numbers from 0 to 1. It plots bars for 1 as not useful, 2, 3, 4, and 5 as very useful. The stacks range from 0 to 1. The highest rate for each method is 4 and 1, respectively.

The usefulness of online training as a practical versus theoretical method (1 = not useful; 5 = very useful)

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Fig. 5
A horizontally stacked bar graph of Ministry of Health and Specialty societies versus numbers from 0 to 1. It plots bars for 1 as strongly disagree, 2, 3, 4, and 5 as strongly agree. The stacks range from 0 to 1. The highest rate for each category is 1 and 4, respectively.

Who should organize online training? (1 = strongly disagree; 5 = strongly agree)

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Online training was evaluated for their usefulness, and as a practical method more than 40% described it as not useful (n = 9). One-on-one sessions were preferred, especially for surgical procedures and ultrasound training.

The residents were asked about the responsible organizer of the online training during the pandemic. More than 50% agreed to specialty societies as the organizing body, while MOH was preferred by only 28% (n = 6). Overall, 80% of the participants agreed that department academic staff should organize online training (n = 17).

3.3 Preferences for Residency Training

The preferences of the residents regarding their residency training are another important aspect. To understand their views on the party responsible for implementing the training during the restrictions, the last part of the questionnaire asked who should organize the required training (Fig. 6).

Fig. 6
A horizontally stacked bar graph of hospital administration and clinical academic staff versus numbers from 0 to 1. It plots bars for 1 as strongly disagree, 2, 3, 4, and 5 as strongly agree. The stacks range from 0 to 1. The highest rate for each category is 3 and 5, respectively.

Who should organize the required training during COVID at the hospital? (1 = strongly disagree; 5 = strongly agree)

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Clinical academic staff was preferred over the hospital administration for the required training. Of the participants, 80% (n = 17) agreed that the clinical department should organize the required training during restrictions.

4 Discussion

4.1 Adaption of the Emergency Department for Residency Training

Our hospital is a state-owned Training and Research Academic facility. Emergency Medicine residency training was established in 2011 at our department. In 2020, there were 18 attending and 19 resident physicians in the emergency department. Educational residency lectures were planned for every academic year starting from September to June. These educational plans included weekly faculty lectures, mortality morbidity meetings, and monthly journal clubs. The academic program also included specialty society training courses throughout the academic calendar including two scientific meetings every year.

Following the countrywide restrictions, residency lectures and meetings were suspended in March 2020. The academic faculty of the emergency department began organizing the upcoming lectures and meetings in accordance with the suggestions of the specialty societies and the ministry of health. But these online teaching programs did not start until the end of May 2020. The organization of these training was preferred to be the departmental staff by our responders. Similarly, a nationwide survey on disaster medicine needs assessment for Turkish emergency physicians from 2016 revealed that physicians prefer these training to be organized by the clinical academic staff [8].

Additionally, hospital-wide meetings and educational programs were also suspended. Medical care within the healthcare system was regulated by the guidelines provided by the scientific committee board meeting [2]. In accordance with the guidelines, all non-emergency procedures and hospital admissions were suspended. Emergency medical care was planned to handle an additional patient load due to the pandemic. Patient care sections within the emergency department were increased and hospital-wide COVID patient guidelines were implemented in accordance with the ministry of health recommendations. The literature review revealed that it is important to follow the guidelines implemented by the governmental organization to manage resident satisfaction and mental health [10, 11].

Our Survey results revealed that WhatsApp Group announcements were preferred to email for rapid information distribution. This is in accordance with the literature; a 2003 study by Maunder et al. emphasizes the requirement of clear communication methods during the 2003 SARS pandemic [10]. To achieve that, additional groups were created among physicians of the emergency medicine department for better management of the pandemic surge.

A survey study on the effects of the COVID pandemic on orthopedic resident education from Romania emphasizes the importance of electronic document sharing tools [12]. Similarly, our responders preferred electronic methods to printed documents for information sharing. Initially, document sharing within the Whatsapp groups was the only educational activity for the department.

According to another survey study on the effects of the COVID pandemic on resident physicians in Jordan, it is important to have mental health support for the residents during these types of crises [13]. Additional online meetings were planned for resident motivation during the first months of the pandemic for improving the mental health of our residents. After the summer break, weekly academic educational meetings were planned online via Google Meet. Additionally, Ministry of Health introduced distance learning programs for COVID management and patient care. Specialty societies also introduced online versions of their regular post-graduation courses. Online-only lectures were practiced until the end of September 2020 after the restrictions were eased within the country. Our survey results revealed that resident physicians prefer online meetings organized by specialty societies. The importance of the adoption of similar smart educational techniques was also emphasized by previous survey studies [8, 12, 13].

4.2 Challenges During the Pandemic

The major challenge during the initial period was following the weekly scientific board meeting guidelines and distributing the updated documents within the department to follow the latest knowledge.

Social interaction was the main aim of the initial online meetings to keep up the morale of the physicians. Adaptation to the online lectures was also challenging for the faculty and residents. Additional video and audio materials were implemented to increase motivation during the online lectures. These were all in accordance with previous survey studies that emphasize the importance of keeping high mental status for physicians during the pandemic [10,11,12,13].

Small online group sessions limited to 5–6 residents were also useful for better interaction within the group. Rapidly developed online courses had also introduced additional problems. Practical sessions were found to be the most challenging and unattainable by the residents. Similarly, the 2016 survey study revealed the same results regarding the lack of effectiveness of practical sessions of online training [8]. One-on-one sessions were preferred especially for surgical procedures and ultrasound training. Online courses prepared by the specialty societies were found to be useful for specialty-focused information sharing.

4.3 Impact of the Pandemic on Residency Training

The importance of communication during the pandemic is well described in the literature. Electronic methods are the preferred tools for information sharing like our survey findings [8, 10, 12]. The emergency department faculty introduced different methods in order to improve communication within the department as well as the hospital. Initially, emergency department physicians and intensive care doctors were the only parts of the hospital serving the entire COVID patients. This put pressure on the department faculty who were also responsible for resident education. Additional online training sessions and improved communication among the doctors were key factors during the initial phases of the pandemic.

4.4 Limitations

This was a single-center study and therefore generalizability of the results is limited. Our study additionally has limitations regarding the online survey methodology.

5 Conclusion

Online education has been used and proved to be effective during pandemics. Our survey revealed that WhatsApp can be used as the preferred way for fast information sharing including educational materials and guidelines, but practical educational sessions are not easy to implement online. Specialty societies are seen as an important stakeholder in improving the up-to-date materials for distance learning within emergency medicine residency training. Additional research implementing this survey questionnaire may improve the generalizability of the results to refine our understanding of the effects of the COVID pandemic on residency training and education.