**4. Resident education during COVID**

The 2020 COVID-19 pandemic has had an impact on all aspects of general surgery training. Residency conferences and didactics moved to online platforms, rotations were canceled to reduce viral exposure, and non-urgent elective cases were delayed or rescheduled [7, 8, 27]. A concern for skills decay with the decrease in opportunities for procedural training emerged as a result.

There has been a significant reduction in surgical case volumes among all surgical specialties throughout the COVID 19 pandemic. For example, Aziz et al. found a significant reduction in operative case volume among 1,102 general surgery trainees in the United States [8]. Reduction in case volume has caused concern among both residents and directors as minimum case requirements are increasingly difficult to obtain. Rosen et al. demonstrated these results among the urological community as 60% of urology program directors were concerned that residents would not reach required operative volumes secondary to the COVID pandemic [28]. Similarly, there has been a shift to nonoperative management among previously emergent presentations like appendicitis [27]. The pandemic has shed light on an evident shift in surgical management that has been occurring over the past 50 years. Even before the emergence of COVID-19, the introduction of new data and technologies for certain disease processes, that were managed with complex surgical procedures in the past, has led to treatment with less invasive methods. For example, in surgical oncology the advent of the sentinel lymph node biopsy has drastically decreased the amount of completion lymph node dissections for melanoma and breast cancer [29, 30]. The advent of endovascular surgical techniques in vascular and cardiothoracic surgery has decreased trainee's exposure to a variety of open surgical cases. Smith et al. demonstrated a significant decrease in the amount of open abdominal aortic aneurysm repairs. Over a five-year study period from 2010 to 2014 trainees demonstrated a 38% decrease in open repairs, with one half of trainees in 2014 having exposure to less than five open repairs [31].

The obvious concern among surgical residents is inadequate operative skills secondary to decreased case volumes. Simulation training is now as important as ever to develop surgical skills among trainees. Doulias et al. argues that to prevent deterioration of operative skills, programs need to expand simulation training [32]. To improve surgical skills, online video conferencing platforms are now used to provide real time feedback from experts to surgical trainees undergoing laparoscopic and robotic training.

Despite many negative impacts from COVID on training Hope et al. argues for some positive implications. The authors argue that the adaptation of online learning has allowed greater access to educational material. Electronic-learning has now become a staple within surgical education [27]. Focus has shifted from in person lectures to a variety on online tools like podcasts, social media, YouTube videos, virtual peer reviewed libraries, and video conferencing platforms. Video conference platforms like Microsoft Teams and Zoom have provided an outlet for remote didactics, conferences, and virtual rounding [32]. Future studies will investigate the effectiveness of these new learning modalities on surgical education, but they will likely continue to have an impact in the post COVID era.

#### **5. Conclusion**

Surgical education over the last 50 years has proven to be a constantly evolving process. No longer is the Hasteadian "see one, do one, teach one" the sole maxim in training. With a growing emphasis on both patient safety and resident well-being,

### *Surgical Education in the 21st Century DOI: http://dx.doi.org/10.5772/intechopen.99406*

there has been a development of novel training paradigms. Greater emphasis has been placed on surgical simulation as a means for increasing operative skills. Training today also places an emphasis on didactics, conferences, and research as protected time is set aside for during the 80-hour work week for residents to develop their skills outside of the operating room. The lasting effects of the COVID-19 pandemic on surgical education are unknown, but the use of simulation and online training will likely continue to increase throughout the remainder of the 21st century to ensure stable and consistent training.
