The Effect of COVID-19 Pandemic on the Training of Dental Postgraduate Students – A Questionnaire-Based Survey

Introduction

The outbreak of the novel corona virus disease (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) started in Wuhan, China, towards the end of 2019 and due to its contagiousness, it spread widely across the globe in less than a year causing a serious public health crisis. Coronavirus, a family of Coronaviridae which is a single-stranded RNA virus is transmitted mainly through sneezing, cough, droplet inhalation (airway) or by direct contact with the infected person.¹ The spread of novel coronavirus disease was so deadly that it extended over the whole of China and other East Asian countries and this was predicted as the risk for a rapid spread globally by various health organisations.² Though unsure, in an attempt to restrain the spread of the disease and to avoid an overwhelming aftermath on the healthcare systems, governments around the globe instigated a number of preventive measures.³ These measures involved social distancing, lockdown/curfew, voluntary and sometimes imposed quarantine, prohibition of mass gatherings, closing down of educational institutions and dental clinics.³ Government of India too declared numerous measures on travel advisoty and countrywide lockdown on March 25, 2020.^4,5

Dental clinics and institutions were either closed or had their clinical activities and elective procedures rescheduled to minimize the transmission of virus, which in turn reduced the patient influx impacting dental education worldwide, including the postgraduate dental training program.⁶ Following the worldwide spread of corona virus disease, COVID-19 was declared as a pandemic by the World Health Organization (WHO) on 12 March 2020, encouraging social distancing and infection control guidelines such as use of facemasks, and personal protective equipment (PPE).⁷ The World Health Organization recommended that dental clinics and institutions perform a routine pre-appointment triaging and checking for COVID-19 risk factors such as temperature measurement, detailed health status investigation, including recent history of travel and contact with an infected person.⁸ All offline academic training activities were substituted with various online teaching programs which put the dental postgraduates under higher pressure leading to even higher stress and anxiety.⁹ All these affected postgraduate teaching and learning in an unprecedented manner. Therefore, the present study was conducted to assess the impact of COVID-19 on postgraduate dental training programme in two different states. Difficulties and problems faced by postgraduate students throughout the COVID-19 pandemic in teaching and training, particularly in terms of the progress in dissertation, lectures, seminars, clinical case discussions, surgical training, re-deployment challenges and the impact on mental health were investigated.

Materials and Methods

Questionnaire design

The cross-sectional research design was approved by the Ethics Committee (IRB protocol number 2021/8/3) of the institution. The survey was conducted among the dental postgraduates (PG’s) from ten different institutions located in the states of Karnataka and Kerala after the second wave of COVID -19 and the data were collected to assess the difficulties faced by the dental PG’s during COVID-19 pandemic. A 26- item questionnaire survey form was constructed. The participants included all postgraduate students from ten dental institutions chosen randomly from two states. A recruitment E-mail or WhatsApp link for the study was sent to the randomly chosen dental residents.

The questionnaire comprised of two sections. The first section included informed consent of the participating postgraduates followed by six questions regarding participant’s demographics such as age, gender, specialty, location, year of the course and the state of the institution. The second section comprised of twenty questions referring to different aspects of their post-graduation training including their study situation, psychological status during lockdown, the effect of COVID-19 on the post-graduation career and clinical practice, outpatient turn out and the infection control measures followed at the resumption of clinical activities.

Sample size determination

Considering 80% power, 95% confidence level and 5% margin of error and a total population size of 434 postgraduate students studying in dental colleges in Kerala and Karnataka, the sample size was estimated to be 205 participants for the online survey.

Questionnaire distribution

Of the total 434 postgraduates, randomly chosen 204 postgraduate residents in the selected colleges were sent a pre-tested questionnaire as Google form to their mobile phone numbers or E-mail ids. Information about the survey and invitation to participate were sent to the postgraduate residents weekly once for four to five times. Anonymity of the participants was maintained to facilitate collection of unbiased data.

Statistical analysis

The data from the completed forms were transferred to Excel sheet, imported into SPSS version 22 and analysed. Univariate and bivariate analyses were performed to calculate proportion. Chi-square test was used to compare the difference in proportions between the groups categorised by age, gender, year of course and state.

Results

Out of 204 questionnaires sent online via WhatsApp and E-mail, 146 were completed and returned. The response rate was 72%, which is within the acceptable range for online survey responses. All the answers were mainly based on the following variables: demographics, the student’s emotional status, impact on outpatient statistics, infection control methods, and the impact of postgraduate anxiety on performing clinical treatments during the lockdown.

Table 1 shows the overall impact of COVID-19 on postgraduate training in terms of their training experience, problems and difficulties faced in attaining necessary clinical and academic skills and factors which induced stress amongst the postgraduate residents. About 87% of postgraduate students agreed that they were anxious about COVID-19 pandemic condition and about 81% were stressed regarding their clinical work during COVID time. Precautionary measures like checking the temperature and oxygen saturation of the patient were strictly followed by 68% of PG’s and more than 84% of them stated that they recorded proper travel, medical and vaccination history of the patients. Around 84% of students opined that they were deprived of adequate clinical training and 86% felt that routine academic activities were affected during the pandemic. According to 82% PG’s, pandemic affected their clinical skills and knowledge. About 89% reported that they received less clinical exposure or working schedule during the pandemic. About 78% of postgraduate students stated that due to COVID-19, clinical working days were reduced and 94% of participants also reported that the number of patients visiting the department reduced.

Table 3 depicts the distribution of responses according to the year of course. Regarding the change in working schedule, majority of second year postgraduate residents (48%) stated that the pandemic affected their work schedule, while very few (21%) final year postgraduates reported the change. A greater proportion of residents (46.5%) in second year of their postgraduate training reported decreased patient inflow after the pandemic. They also reported decreased clinical skills and knowledge (82.2%) during COVID-19.

Table 4 depicts state-wise comparison of the impact of COVID-19 on PG training in two different states, Karnataka and Kerala. In Kerala, almost 68% of residents followed proper precautionary measures such as checking the temperature and oxygen saturation and the residents from Kerala (69.2%) also recorded a proper travel, medical and vaccination history of the patients they treated. Meanwhile, only a fewer number of residents from Karnataka followed proper precautionary measures (32%) and recorded proper patient history (35.8%). Furthermore, only 54.3% residents from Kerala and 45.7% from Karnataka enquired for reverse transcription- polymerase chain reaction (RTPCR) report from the patient during the treatment phase. Larger proportion of residents (65.9%) from Kerala than from Karnataka (34.1%) felt there was difference in patient’s point of view regarding the dental treatment during the COVID pandemic phases, whereas only 43.1% reported that they haven’t noticed any changes. Around 67.1% of postgraduates from Kerala and 32.8% of postgraduates from Karnataka reported a decrease in patient inflow during the pandemic time. Difficulty in the completion and submission of thesis dissertation was also reported by 66.7% of postgraduates from Kerala.

Discussion

Dental postgraduation in India is a three year course devised to build expertise related to oral structures and their diseases and it hones the professionals to provide high quality and specialized oral health care services. The pandemic resulted in a unprecedented effect on the academic as well as clinical training of the dental residents exposing them to unquestionable challenges affecting their day-to-day personal health, raising long-term questions about their training experience.⁶ Based on numerous previous studies conducted among dental residents, it was recognized that fewer aspects of their educational experience were enormously divergent from pre pandemic learning.¹⁰ The current survey evaluated the impact of the pandemic on the postgraduate training, mainly the perceptions, concerns, problems and difficulties faced by residents during the period and also provided suggestions for the alleviation of the said issues in the former epicentre of COVID-19.¹⁰

The total number of postgraduate residents who responded to the survey was 146. Out of this, 59.6% were females and 40.4% were males from different colleges in the states of Karnataka and Kerala. Most of the respondents in this survey were third year postgraduates followed by second year residents, while the first year dental residents were least in number as they had not joined the course during the time of the study (Table 3).

The survey also addressed state wise difficulties faced by the residents in two different states, Karnataka and Kerala. In Kerala, almost 68% of residents followed proper precautionary measures including checking the temperature and oxygen saturation. Around 69.2% of students recorded proper travel, medical and vaccination history of the patients they treated. Meanwhile, only a few postgraduate residents from Karnataka followed proper precautionary measures (32%) and recorded proper patient history (35.8%). During the treatment phase, 54.3% residents from Kerala and 45.7% from Karnataka reported to have asked for RTPCR report from the patients. Larger number of residents from Kerala (65.9%) and 34.1% from Karnataka felt there was difference in patient’s point of view regarding the dental treatment during the COVID pandemic phases. However, 43.1% reported that they have not noticed any change. This change in turn could have caused a decrease in outpatient flow according to the residents (Table 4). Regarding the change in work schedule, majority of second year postgraduate residents (48%) opined that pandemic affected their work schedule, while very few (21%) final year residents reported the change (Table 3).

To confine the contagious spread of COVID-19, all offline classes and academic activities had been cancelled and were replaced with virtual classes in the educational institutions which caused a profound effect on the training of dental students, especially for dental postgraduates. Due to the transition to virtual classes, inter-departmental academic meetings to discuss important and special cases have also been cancelled. Virtual video platforms such as Zoom, Cisco Webex, and Microsoft teams etc., were used to present clinical cases.¹¹ Virtual learning was appreciated by numerous students and professors in academic institutions as it was the only mode for attending postgraduate training throughout the pandemic, owing to the requirement of social distancing.¹⁰ However, only 55.5% of the respondents were very satisfied with the compensatory virtual classes conducted by the institutions (Table 1). This may be due to lack of stability of the internet network, surrounding environment affecting the concentration of residents and also the bond between postgraduates and teaching staff could have weakened compared to face to face teaching activities.¹⁰ These results displayed the crucial role of faculty-student relationship which is an integral part in ensuring an easy and effortless transition to virtual learning with adequate support to cut down student anxiety and distress and overall psychological health of dental residents during pre-COVID-19, in the midst of the COVID-19 and during post-COVID-19.³

The inadequacy of clinical training during a nationwide lockdown in any medical field is an inevitable concern.10 Greater percentage of respondents (84.1%) agreed to the fact that they were deprived of adequate clinical training during the pandemic time which had direct impact on their clinical skill and knowledge. This is mainly due to a sharp decline in the number of patients showing up in the department for treatment during the pandemic according to 94.5% respondents and during the time of survey (59.3%) (Table 1). This could be due to the nationwide lockdown in India, and due to apprehension regarding the spread of infection. Another issue faced during the pandemic was change in the work schedule (89.7%) of the postgraduates as interim changes were made in the operatory field to reduce production of aerosols and exposure in accordance to Centers for Disease Control and Prevention (CDC) guidelines mainly formulated to curb the spread of infection.¹² Nevertheless, with the introduction of new, improved and advanced learning tools and strategies, entire virtual reality may be attainable in the future with fewer issues. Nonetheless, it is important to remember that no replacement could be equivalent to unmediated supervision and immediate feedback for improving and enhancing clinical expertise.¹³ The dental PG curriculum requires compulsory participation of postgraduates in national conferences, conventions, workshops and continued dental education (CDE) programs during their tenure. Most of the residents expressed that even though online conferences were held by different specialities and associations, there were no hands-on courses and workshops that could have helped to improve their clinical skills and values. Interactive online lectures and e-learning does not recreate the outcome of face-to-face interaction and thus PG residents lose their opportunity to associate and make contact with experts in the desired field in virtual meetings.⁹

Postgraduates also expressed their concern regarding the career opportunities post COVID-19. A greater proportion of residents (46.5%) who were in the second year of their post-graduation training responded that decreased patient inflow after the pandemic had a detrimental impact on their clinical skills and knowledge (82.2%) (Table 3) and they expressed their concern if this deficiency in clinical exposure would make them less competent to work as a specialist without achieving proficiency in the essential procedures. The potential recession caused due to the pandemic and its influence in securing a job in the field of dentistry post COVID-19 is another major apprehension for graduating residents.¹⁴

The submission of dissertation in the third year is critical for clearing the MDS degree examination. Final year PG residents who have to submit the dissertation were finding themselves in a dilemma. Over 67% postgraduates from Kerala and 32.8% residents from Karnataka stated that there was a decrease in patient inflow during the pandemic which had an impact on thesis dissertation completion and according to 66.7% postgraduates from Kerala, thesis completion is critical for clearing the MDS examination. The most affected were the ones whose studies were in vivo, ex-vivo or randomised controlled trials because of the decrease in OPDs (59.3%) and significant reduction in follow up cases during the time due to lockdown, travel restrictions and fear of contracting COVID-19 (Table 4).

The COVID-19 pandemic caused extreme stress and anxiety among the dental postgraduate students both personally and professionally.⁶ Overall, 87.7% of survey participants felt apprehensive during nationwide lockdown, while more than half of second year and third year participants disclosed that their disquiet and worry lessened later when they returned to clinical training. One of the major reason for stress among the residents was the spread of infection as all the dentists work in close proximity with the patients and in almost all the procedures in dentistry, production of aerosols is extensive. Another reason for stress and anxiety especially among the final year residents was the submission of dissertation as they had lost considerable number of clinical working days due to the national lockdown. The reduced clinical time, inflow of patients and in person examination of patients had resulted in a feeling of ineptitude, decreased confidence in diagnosis, examination and clinical skills and inability to provide evidence-based treatment. All these factors resulted in a profound uncertainty about their professional life.⁶ Thus, this survey provided evidence that COVID-19 had unfavourable impact on the emotional well-being of dental postgraduates which should be taken into serious consideration by dental education institutions and faculty members and they should focus on the psychological well-being of students amidst and post COVID.¹⁰

As the study was conducted during the COVID-19 pandemic, there were many limitations. Firstly, COVID-19 had majorly affected the academics of all the postgraduates. Predominantly, the first year graduates whose admission process was delayed for a prolonged period. Thus, first year PGs were unable to participate in the study even though the survey form was sent to all the colleges. This resulted in probability for bias because the study majorly included second and third year PG students. Even the second year graduates who had just finished their pre-clinicals were anticipating a lot from the clinical exposure they were about to receive, but were left disappointed and indecisive about their future. This may have led them to be more discontent and could have caused a certain level of variation in their responses. Not to forget about all the pressure and uncertainty about the future that all the students had to undergo during the pandemic which could have affected the overall survey.

The COVID-19 pandemic took the lives of many loved ones which influenced the emotional status of individuals in those situations. This could have caused a certain amount of variation in the number of participants as well as their responses.

Lastly, COVID-19 pandemic was indeed a turning point for everyone and has undoubtedly resulted in distinctive troubles for individuals, thereby varying their state of mind and situations which might result in variability in participation of survey and may also influence the reactions and responses.

COVID-19 has definitely reduced the opportunities that were available for PG’s to learn and enhance their knowledge. The faculties and responsible council must acknowledge the fact that the PG’s have faced isolation, anxiety about the deadly virus and uncertainty about the future. They must continue to provide learning assistance as well as guidance to deliver additional support or go at a slower pace as it is already challenging for the PG’s to cope with the situation. The institutions must provide assistance to have an open conversation about the issues faced by the PG’s and try not to avoid addressing their concerns. Respective supervisors and faculty staff must support each of their PGS to maintain mental and physical health and guide them in their academics so that the PG’s are confident. Furthermore, PG’s must be calm and demonstrate a positive attitude. One should remember to seek support on experiencing a significant feeling of distress.

Conclusion

COVID-19 had an unprecedented impact and critically interrupted the education and training of postgraduates in all the branches of dentistry from both the states. Significant reduction in the number of clinical working days and patient inflow made the situation worse by affecting academic curriculum, clinical skills and knowledge of the residents. This in turn affected their mental well-being and decreased their confidence in handling cases and to practice independently after residency. These factors can result in an unpredicted future of the postgraduates if the responsible teaching organizations and councils do not critically consider the difficulties of the residents and implement effective, appropriate techniques for providing sensible solutions to overthrow their enigmas.

Conflict of Interest

Nil

Acknowledgments

We thank dental residents of the first year, the second year, and the third year for their participation.