Anaesthesia trainees are our current inspiration, our future colleagues and our replacements.
Training in anaesthesia and intensive care, with a degree of overlap that varies on a country by country basis, has evolved from a time-serving apprenticeship to structured programs with bespoke models of learning, reflection and assessment. The pandemic crisis prioritises critical care for those COVID-19 patients who have been most profoundly affected, and hospitals, staffing, and working practices have been radically adjusted to accommodate this. Recent experience with elective surgery suggests the impact of COVID-19 may extend far beyond an ICU capacity and staffing problem 1 with as yet unknown implications for training. Selection into the speciality, placements, workplace-based assessments, examinations, and career progression have all been disrupted. America, and Australia. Contributors were identified as current or recent Council members of the partner organisations and through personal contacts. They were asked to describe the impacts of the pandemic on themselves and their colleagues including: change of case mix, altered experiential learning opportunities, senior staff taking the lead on procedures, deferral or cancellation of teaching, workplace based assessments and exams, impacted rotations, anxiety and mental health.
Local, national and international innovations in practice and support were identified.
We present a (necessarily) selective overview of the impact of COVID-19 on anaesthesia training through the lens of our partner bodies and contacts on six continents. This small sample is not comprehensive but does allow a partial snapshot of the pandemic's impact. From these contributions and the outputs of public bodies we have identified recurrent themes that we present with reference to the UK system supplemented by notes from other countries. Trainees in other specialties are also impacted by the pandemic. We attempt to identify and learn from their experiences 2 as well as our own and to look ahead. Finally, we recognise a duty to document contemporary experiences and present the individual vernacular contributions online (Supplementary Appendix 1).
Guidance on social distancing has prevented face-to-face interviews. In the UK, training posts are allocated by competitive national recruitment. Trainees compete again to progress into year three of training. These processes have continued without interviews on the basis of portfolio self-scores, precipitating concerns of unfairness. Successful applicants now have their training number and will be monitored by enhanced review during training. However, those unsuccessful feel they have only been able to present half of themselves and perhaps in different times their story would have been different. Continuing recruitment allows scheduled rotations and progression through training.
When each contact with a patient becomes a potential health risk, supervised procedures performed by a trainee may seem unnecessary. Aerosol generating procedures such as bag and mask ventilation, tracheal intubation and tracheostomy appear to carry the greatest risks 3 and there is understandable pressure for the most experienced practitioner to perform the procedure swiftly and efficiently. This diminishes the experience gained by the trainee and the opportunity to be signed off for a workplace-based assessment.
Mindful of patient safety, initial anaesthesia training typically focuses on a limited range of techniques learned whilst caring for low-risk patients. In Houston, the introductory month is highly structured with emphasis on bag and mask ventilation and direct laryngoscopy. This has been replaced by two weeks of simulation then a fortnight to learn intubation using a videolaryngoscope and extubation under deep anaesthesia to avoid coughing and droplet exposure. Out of theatre rotations to surgery, medicine and the blood-bank were cancelled. In Hong Kong, rapid or modified rapid sequence induction with videolaryngoscopy has become universal to avoid bag and mask ventilation. Use of laryngeal masks is minimised. Some hospitals have set up airway management teams, which intubate and extubate most of the general anaesthesia patients, limiting staff exposure but excluding junior trainees. Other cases are diverted to regional techniques, with patients continuing to wear surgical facemasks whilst in-theatre. In Chile, some centres chose to keep firstyear trainees away from clinical activity, prioritizing their safety. This group promoted theoretical teaching, especially online. Inequalities in resource were recognised with the provision of internet scholarships and laptops for trainees and teachers. However, trainees asked to be included in the clinical work and are now being reincorporated.
Worldwide, most elective surgery was halted and the few cases undertaken prioritise cancer procedures, emergencies and obstetrics. Accordingly, the less complex workload comprising the basis of early anaesthesia training has become scarce. UK trainees report lost opportunities for solo lists. Only senior trainees have access to emergency procedures and usually at night or the weekend.
Worldwide shortages of Personal Protective Equipment (PPE) have compromised safety and induced anxiety. In some South African hospitals these shortages precipitated poor practice. Since activating COVID-19 protocols has implications for the amount PPE used and where the patient will be managed, labelling of a patient as a COVID-19 suspect becomes contentious. Protective N95 mask respirators must be reused (if not directly contaminated) for at least one week before replacement. inadequate PPE. This received a swift trade union response but remains a threat. By contrast, in Houston every anaesthetist has a fresh (re-sterilised) N95 or fitted P100 mask daily. Training in full PPE challenges communication between trainee and trainer.
In Plymouth, weekly trainee meetings have increased in importance. Combining on-site with remote access increases participation and enables issues to be raised and dealt with in a timely manner.
Socially distanced tutorials can be accessed in person or virtually and saved for access on demand.
This flexibility can be a positive and permanent development.
The experience across the different academic institutions in South Africa is far from uniform.
Examination preparation and structured teaching were drastically reduced and, in some instances, fell away completely. Some universities have embraced the virtual platforms to give tutorials and webinars to postgraduate students and have managed to keep to a regular schedule from the start of the lockdown. These are usually attended after normal work hours and have shown a high level of dedication and professionalism from teachers and registrars. Other institutions have offered little teaching once the university closed, highlighting discrepancies in training across the country. This crisis may well usher in the next revolution in postgraduate education with online teaching becoming the new normal.
Anaesthesia is a craft (hands-on) speciality and on-line study may be a poor substitute for part-task simulators and supervised procedures performed on patients. Loss of training opportunities also impacts surgical disciplines. 4, 5 Reconfiguring obstetric anaesthesia training in Singapore involved experimentation, some failures and some compromises. 6 US directors of pain programmes have developed detailed guidance on adapting training. 7, 8 Many countries have redeployed non-anaesthesia trainees to ICU, an unsettling and challenging time for those affected. 9 In Dublin, anaesthesia trainees supported redeployed peers from surgery and psychiatry introducing them to ICU in a safe and controlled manner.
On a positive note, reduced time in theatre has focussed the minds of both trainees and trainers since every moment counts. Training objectives are identified for each list and both parties are more engaged than previously.
Medical regulators and national training bodies specify learning outcomes and the curricula to deliver them, in increasing detail. Inevitably (and properly) training programs focus on using trainees time well to route them through the curriculum with progressive completion of assessments and "time served" requirements. This inevitably diminishes flexibility whilst arguably increasing the quality and efficiency of training. The pandemic has disrupted the structure and content of curriculum compliant training programmes. Social distancing and logistics have impacted the assessments whose completion permit progression and evidence the completion of training.
Adjustments to lessen the impact to medical training are being agreed and implemented very quickly. Nevertheless, concerns remain that changes in exams and recruitment may tip trainees into other specialties or leaving the profession altogether.
Temporary flexibility within the UK anaesthesia curriculum facilitates progress within training.
Specifically, progression that is exam success dependent will not be automatically halted, with the expectation that the exam is successfully completed at a future sitting. Patient safety considerations preclude complete omission of mandatory components although they may be rescheduled. Control of progression by Annual Review of Competency Progression (ARCP) panels will continue, using new COVID-19 specific learning outcomes to incorporate experiences and learning from the disrupted workplace into training. 10 South African training programmes have opted to continue the rotation of trainees to different departments and hospitals, a decision supported by a survey of registrars. Whether these rotations will need to be supplemented with extra time is yet to be determined. 
The impact of the pandemic on trainees adds to existing challenges to morale, mental and physical health. 12 Professional and personal pressures in the workplace coincide with derangement of private lives. Loss of personal support due to social distancing measures has left many doctors struggling to juggle childcare and work commitments. Finances have become stretched with households dropping to a single income. Difficult clinical decisions and compromises in care may generate moral injury. 13 Trainees have expressed heightened anxiety at home and at work. Anaesthetists have responded with innovation and adaptation using measures shown to be effective in previous viral epidemics. 14 
Other specialties 15 are also reporting impacts on the mental health of staff with trainees more affected than faculty. 16 Internationally, anaesthesia departments have recognised these stressors and responded. 16a Training on stress recognition, peer support and access to resources is variably implemented but universally understood. 17 
UK undergraduate programmes are all to some degree 'integrated' with exposure to patients in all years and often within weeks of starting. The total or near total withdrawal of clinical placements turned the clock back with a focus on basic science and self-directed learning. 19 Problem-based learning groups function well by video-link but the context-setting patient encounters with which they might have been bracketed have disappeared. The set-piece lecture may be a dinosaur to educationalists, but it is easy to provide remotely. Innovative small-group techniques are harder to replicate if they depend on anatomical models, surface anatomy or part-task simulation.
The greatest impact is undoubtedly on senior students who should be concentrating on maximising clinical encounters, building consultant and diagnostic skills, and progressively integrating into clinical teams as they prepare for the transition from student to care-providing trainee. Temporary arrangements whereby patient contact is minimal or non-existent are not sustainable and feel inconsistent with the production of patient-focussed and clinically skilled medical graduates. 19a
Looking ahead, exclusion of medical students from the operating rooms may impair recruitment to the specialty even if a temporary fillip is provided by current media exposure. For Hong Kong medical students, all patient contact has been suspended. Didactic components of the program have been moved and grouped together, with all teaching material, including lectures and small-group discussions, delivered on-line. Clinical components were moved to later in the program. If patient examination is required in the medical school exam, patients would be tested for SARS-CoV-2 and wear N95 masks. Final year medical students are expected to graduate as scheduled.
COVID-19 will not go away any time soon and therefore the new balance between service provision and training needs to be agreed in a sensitive way to avoid further frustration amongst trainees.
Adaptations to these circumstances have delivered new forms of teaching and supervision and the pandemic has provided a brutal laboratory to test them. Video-calls, electronic learning and computer-based exams are probably here to stay. So too is the video-aryngoscope whose promotion from fall-back option to instrument of choice 20 has been accelerated.
Variation in national responses and possibly unknown epidemiological factors have produced dramatically different COVID-19 burdens on health services. In Australia, case numbers remained low and elective surgery escalated until recently. New Zealand had no active cases and all restrictions were removed. Other countries remain greatly disrupted with the pandemic worsening.
In consequence the impacts on trainees are increasingly heterogenous.
Our ability to work effectively in teams and to support each other through crises was already well developed 21 but has been pre-eminent of late. As one trainee commented "this sense of community is a welcome silver lining and will be paramount in helping our health service transition smoothly out of crisis mode into the new normal". Trainees and their supervisors have made pastoral and professional innovations and their departments have the opportunity to make them permanent.
They are improvements just as important as teleconferences and videolaryngoscopes.