Impact of the COVID-19 pandemic in Mexican residency programs: Implications and Experiences for the Continuing Professional Development of Residents


 Introduction: The COVID-19 pandemic has forever changed the way to evaluate and teach residents, fellows, and medical students by means of new demanding learning modalities and alternatives to leverage from this new lifestyle without affecting our training as medical specialists. As of January, 24 2021, the number of confirmed cases and deaths by COVID-19 both in Mexico and around the world have been continuously growing (1,752,347 and 149,084 vs. 99,596,451 and 2,135,068, respectively). Mexico registers the world’s highest number of deaths from coronavirus among health workers, with 1,320 deaths confirmed. Methods: Four residents of different specialties analyzed and described how the pandemic affected and benefited the ongoing residency program and exposed some recommendations for each specialty. Results/Discussion: In Mexico, residents from all specialties are rotating in the COVID-designated area working as general practitioners exclusively for hospitalized COVID-19 patients. Our residency program has had to put a stop to routine activities such as academic sessions, specialty consultations, practices, and surgeries. Conclusion: Nothing will replace the insights of the training from real surgical practices, but new and forgotten resources can be used to help assess surgical proficiency.


Impact of the COVID-19 pandemic in
What's new?
After nding a study reporting up to 31.6% of ocular manifestations in COVID-19 patients, we decided to start a protocol of ocular manifestations in the same hospitalized patients. 5 Our program designed one weekly virtual clinical case session for residents and medical students to compensate for the lack of clinical experience at the moment. Nevertheless, 2020 has also had its bright side as the year of ophthalmology with more virtual resources being used.

Internal Medicine
How the practice changed: Internal medicine residents were called immediately to the front line of the COVID-19 pandemic. Initially, it was unclear our role in the attention of patients; when the rst cases arose in our state, we were kept out for our protection. However, when the cases exponentially increased, we became an important factor needed. Our clinical rotations continued in the hospitals that comprise our academic health center including the attention of non-COVID-19 and COVID-19 patients.
What stopped?
To ensure and enhance residents' preparation in this emerging topic, academic coursework had to focus on its pathogenesis, management innovations, and mechanical ventilation. Therefore, both clinical and academic practice had to change and became COVID-19-focused.
What's new?
It has been reported in several articles that burnout, anxiety, and stress had increased signi cantly in residents. 6-8 The most relevant reasons are the increasing workload, the reduced sense of accomplishment, and particularly an unsafe feeling due to the risk from the exposure to transmit the virus to our families. Besides that, the pandemic has represented a big challenge to internal medicine residents because it forced us to boost our knowledge in related topics to SARS-COV-2; while, at the same time, try to continue our integral training. 6 General Surgery How the practice changed: Our general surgery program oversees 2 hospitals that comprise our health system. One of these hospitals had to become a hospital for COVID-19 patients, so all surgical activity was stopped, and all non-COVID-19 was sent to a single hospital. Nonetheless, in the non-COVID-19 hospital was a considerable decrease on surgical activity, probably due to society's fear of contagion.
What stopped?
In the COVID-19 era, with the risk of infection and the overload of healthcare systems, we were forced to suspend elective surgeries and gradually reduce the number of admissions for surgical diseases, referring these patients to tertiary care centers. As reported, surgery residents had to join the team of residents caring for COVID-19 patients and became the main force for the placement of central venous accesses and thoracostomy. 9 What's new?
Our program increased the number of online sessions of clinical cases, discussion, and research activities. The uncertainty about practical learning is vast and understandable due to the lower exposure to surgical pathologies and procedures. It is a medical specialty in which the experience and practice is essential to develop the needed skills for each procedure. 10 However, we believe that with a reorganization of our learning competence systems in the following years, surgical residents will be able to recoup and achieve an adequate formation.

Anesthesiology
How the practice changed: The pandemic has affected anesthesiology residency, in particular for not having almost any elective surgery scheduled, prioritizing obstetric, emergency, and COVID-19 related surgeries. 11 This leads to very low practice and training involving general anesthesia and increasing risks of contagion.
Until now, one of the highlights during the pandemic is the importance of airway management, and as we know, anesthesiology is a key part of the team that manages endotracheal intubation and airway procedures. 12,13 What stopped?
Considering this, guidelines have stated that only the most experienced personnel available should manage the airway of a patient with COVID-19 to minimize exposure and risks of infection 13 leading anesthesiology trainees, especially rst year residents, to miss the opportunity of intervention during these procedures as well as losing practice experience for endotracheal intubation.
What's new?
As well as the other specialties, we also had to join rotations in COVID-19-designated areas as general physicians. Additionally, our program supported us with training simulators and online certi cations for airway management for COVID-19 patients. Worldwide adaptation to online academic sessions has also been an important part of our "new normal". 14

Conclusion
The COVID-19 pandemic affected residency program differently, for better or for worse. Surgical programs decreased their surgical practice, especially for the last-year residents. For the clinical residencies they focused on analyzing pathologies with COVID-19, decreasing the academy for other pathologies. No program was prepared for this situation, these unprecedented events represented a real challenge for everyone including program managers to rst-year residents. The challenge of being able to support the COVID-19 area without neglecting the main pathologies that occur by specialty and without abandoning the academic preparation of the residents, was the di cult thing the organization had to deal with.
In most specialties, the academic load increased, and all were provided with training to care for COVID-19 patients. Likewise, research and the number of publications by specialty increased considerably.
Although we have already reactivated medical consultations the protection measures are maintained.
The coronavirus outbreak signi cantly altered and transformed medical specialty education in Mexico and accelerated the adoption of innovative virtual learning resources for trainees. These changes are here to stay and that is why new virtual learning strategies and a new way to evaluate residents´ performance using virtual media are required. Residency program educators need to restructure the curricula taking in consideration that each medical specialty was affected differently. Undoubtedly, nothing will replace true surgical practices. Nonetheless, surgical skills laboratories and proctoring residents to independently performing procedures would de nitely help assess surgical pro ciency.
Finally, yet importantly, the pandemic has taught us and other medical schools that we need to pay more attention to innovation and adaptation of new ways of learning. 15 Using for example, simulators and technologic resources so as not to delay our training and experience.