Impact of the COVID-19 pandemic on teaching and research activities in obstetrics and gynecology: a national two-stage, stratified, cluster sampling survey in China
The emergence of COVID-19 in early 2020 marked a seismic shift across global sectors. In response to the burgeoning epidemic, strict public health measures were swiftly implemented, including travel restrictions and the suspension of in-person educational activities. While these measures were essential in containing viral transmission, they also posed unprecedented challenges to medical education and research activities. To reduce the risk of infection, hospitals had to restrict student access to clinical environments, impeding essential hands-on training opportunities for aspiring healthcare professionals. Concurrently, laboratory closures and research personnel isolation resulted in the suspension or postponement of numerous scientific projects. However, amidst these obstacles, the pandemic catalyzed innovation and transformation in both medical education and research. As highlighted by Semaan et al. , significant knowledge gaps persist in managing maternal cases, with or without COVID-19. Several reports shared experiences of adapting continuing medical education in maternal care amidst the pandemic . Moreover, recommendations and strategies have been proposed for the reformation of medical education , resident training , research , and education  in obstetrics and gynecology during these unprecedented times. One study conducted in Italy has investigated the impact of the COVID-19 pandemic on a surgical residency program . Despite these insights, scant attention has been given to assessing the tangible impact of the pandemic on teaching and research activities. To address this gap, we conducted a comprehensive national survey among obstetricians and gynecologists in China. To our knowledge, this is the first nationally representative survey of its kind on this topic. Our investigation specifically examines variations in these impacts across different municipal and hospital settings, providing valuable insights for future planning and adaptation in the face of similar crises.   Patient and public involvement The formulation of research inquiries and the selection of outcome metrics were endorsed by all respondents through questionnaires. However, respondents were not directly engaged in the study's design, recruitment, or implementation. The dissemination of findings to study respondents will occur via published papers and social media channels. Gratitude is extended to all respondents, acknowledged in the designated section. Sampling design and participants In this study, a stratified two-stage random cluster sampling methodology was employed to ensure the acquisition of a representative sample. The study encompassed all 22 provinces, 5 municipalities, and 4 autonomous regions within mainland China (all of them have the same administrative status, collectively referred to as "provinces" herein). Cities within each province were categorized into three groups based on the number of hospital beds available in 2019: Category 1 (fewer than 10,000 beds), Category 2 (10,000 to 30,000 beds), and Category 3 (more than 30,000 beds). Two cities were randomly selected from each category, employing a selection ratio of 1:2 or 1:3, as determined by the city numbers in each province. In the second stage, two hospitals were randomly chosen from each hospital-type stratum (primary, secondary, and tertiary hospitals) within each selected city, utilizing 2019 data. All actively practicing obstetricians and gynecologists in the selected hospitals were invited to participate via a questionnaire link ( https://www.wjx.cn ). The response rates were subsequently documented by hospital directors from the selected institutions. Completed questionnaires were collected, and the data were stored in a centralized online database. Further elaboration on the sampling methods and outcomes is provided in the Supplementary Appendix. Eligible participants consisted of registered physicians actively engaged in obstetrics and gynecology practice who consented to partake in the survey. Those registered as assistant physicians or midwives, as well as those retired from routine medical practice, were not solicited to complete the questionnaire. The Institutional Review Board of Peking Union Medical College Hospital approved the study (No. S-K1291). This study was registered with clinicaltrials.gov on July 27, 2020 (NCT04491201). Before participation, electronically signed informed consent was obtained alongside the completion of the questionnaire. Data collection The questionnaire was developed based on foundational teaching and research activities in China, comprising 31 items in total. These items encompassed various domains: 10 items elucidated respondents' sociodemographic characteristics, one item inquired about the months during which physicians encountered the most pronounced impact from the pandemic (with options ranging from January to June 2020), 1 item addressed overall teaching and research activities, while 5 items delved into specific teaching activities (such as resident training, graduate education (In mainland China, medical students undergo a 5-year university program. The first four years are focused on learning medical knowledge in the classroom. The term "graduate education" specifically refers to the fifth year, during which students complete internships and gain practical experience by rotating through different clinical departments.), patient education, visiting scholar programs, and participation in online seminars). Additionally, 5 items were dedicated to specific research activities (including clinical trials, laboratory studies, academic writing, publication endeavors, and fund applications). For each item, the responder was asked to select the options that best described the changes during the pandemic from January to June 2020 as follows: irrelevant to his/her specialty, completely stopped, decreased by > 50%, decreased by 25% to 50%, decreased by < 25%, or no change or increased. For each item, the respondents were also asked to evaluate the changes after July 1, 2020, as follows: same, less than, or more than the level in 2019. Statistical analysis The unweighted demographic characteristics of all respondents were stratified by city category, hospital level, hospital type (general versus specialized hospitals), and province (Hubei Province versus other provinces). Continuous variables were presented as means with standard deviations, and categorical variables were described as percentages. All the calculations were weighted to represent all obstetricians and gynecologists nationwide and analyzed with the “survey data analysis” module in Stata (version 15.0, StataCorp, TX, USA). The weights incorporated sampling probabilities, nonresponse adjustments, and poststratification adjustments. The weighted percentages of teaching and research activities were compared between the various municipal and hospital characteristics mentioned above by the χ 2 test. Multinomial logistic analysis was used to examine the associations of city category, hospital level, and hospital type with changes in teaching and research activities. The results were presented as relative risk ratios (RRRs) with 95% confidence intervals (95% CIs). In this study, reference subgroups in this model were defined as category 1 city, primary hospital, and specialized hospital in city category, hospital level, and hospital type, respectively. RRRs indicated the relative differences between subgroups about their experiences and opinions, rather than their practical changes. Unless otherwise stated, all analyses were performed with a two-sided significance level of 0.05 by Stata.   The formulation of research inquiries and the selection of outcome metrics were endorsed by all respondents through questionnaires. However, respondents were not directly engaged in the study's design, recruitment, or implementation. The dissemination of findings to study respondents will occur via published papers and social media channels. Gratitude is extended to all respondents, acknowledged in the designated section.   In this study, a stratified two-stage random cluster sampling methodology was employed to ensure the acquisition of a representative sample. The study encompassed all 22 provinces, 5 municipalities, and 4 autonomous regions within mainland China (all of them have the same administrative status, collectively referred to as "provinces" herein). Cities within each province were categorized into three groups based on the number of hospital beds available in 2019: Category 1 (fewer than 10,000 beds), Category 2 (10,000 to 30,000 beds), and Category 3 (more than 30,000 beds). Two cities were randomly selected from each category, employing a selection ratio of 1:2 or 1:3, as determined by the city numbers in each province. In the second stage, two hospitals were randomly chosen from each hospital-type stratum (primary, secondary, and tertiary hospitals) within each selected city, utilizing 2019 data. All actively practicing obstetricians and gynecologists in the selected hospitals were invited to participate via a questionnaire link ( https://www.wjx.cn ). The response rates were subsequently documented by hospital directors from the selected institutions. Completed questionnaires were collected, and the data were stored in a centralized online database. Further elaboration on the sampling methods and outcomes is provided in the Supplementary Appendix. Eligible participants consisted of registered physicians actively engaged in obstetrics and gynecology practice who consented to partake in the survey. Those registered as assistant physicians or midwives, as well as those retired from routine medical practice, were not solicited to complete the questionnaire. The Institutional Review Board of Peking Union Medical College Hospital approved the study (No. S-K1291). This study was registered with clinicaltrials.gov on July 27, 2020 (NCT04491201). Before participation, electronically signed informed consent was obtained alongside the completion of the questionnaire.   The questionnaire was developed based on foundational teaching and research activities in China, comprising 31 items in total. These items encompassed various domains: 10 items elucidated respondents' sociodemographic characteristics, one item inquired about the months during which physicians encountered the most pronounced impact from the pandemic (with options ranging from January to June 2020), 1 item addressed overall teaching and research activities, while 5 items delved into specific teaching activities (such as resident training, graduate education (In mainland China, medical students undergo a 5-year university program. The first four years are focused on learning medical knowledge in the classroom. The term "graduate education" specifically refers to the fifth year, during which students complete internships and gain practical experience by rotating through different clinical departments.), patient education, visiting scholar programs, and participation in online seminars). Additionally, 5 items were dedicated to specific research activities (including clinical trials, laboratory studies, academic writing, publication endeavors, and fund applications). For each item, the responder was asked to select the options that best described the changes during the pandemic from January to June 2020 as follows: irrelevant to his/her specialty, completely stopped, decreased by > 50%, decreased by 25% to 50%, decreased by < 25%, or no change or increased. For each item, the respondents were also asked to evaluate the changes after July 1, 2020, as follows: same, less than, or more than the level in 2019.   The unweighted demographic characteristics of all respondents were stratified by city category, hospital level, hospital type (general versus specialized hospitals), and province (Hubei Province versus other provinces). Continuous variables were presented as means with standard deviations, and categorical variables were described as percentages. All the calculations were weighted to represent all obstetricians and gynecologists nationwide and analyzed with the “survey data analysis” module in Stata (version 15.0, StataCorp, TX, USA). The weights incorporated sampling probabilities, nonresponse adjustments, and poststratification adjustments. The weighted percentages of teaching and research activities were compared between the various municipal and hospital characteristics mentioned above by the χ 2 test. Multinomial logistic analysis was used to examine the associations of city category, hospital level, and hospital type with changes in teaching and research activities. The results were presented as relative risk ratios (RRRs) with 95% confidence intervals (95% CIs). In this study, reference subgroups in this model were defined as category 1 city, primary hospital, and specialized hospital in city category, hospital level, and hospital type, respectively. RRRs indicated the relative differences between subgroups about their experiences and opinions, rather than their practical changes. Unless otherwise stated, all analyses were performed with a two-sided significance level of 0.05 by Stata.   Sampling design and participating results From August 1 to August 10, 2020, a comprehensive survey was conducted among obstetricians and gynecologists in China, encompassing 11,806 respondents hailing from 779 hospitals across 157 cities within 31 provinces. Notably, this cohort represented 7.6% of the total 155,787 registered and actively practicing professionals within this medical specialty nationwide. The response rates of physicians and hospitals were 93.8% and 82.0%, respectively. The demographic characteristics of the respondents are detailed in Table . Significantly, 35.9% of physicians had previous involvement in healthcare services directly addressing the challenges posed by the COVID-19 pandemic. Analysis of geographic distribution revealed that 17.8%, 51.2%, and 20.9% of respondents originated from category 1, 2, and 3 cities, respectively. Moreover, 16.2%, 31.1%, and 52.7% were affiliated with primary, secondary, and tertiary healthcare facilities, while 78.3% and 21.7% were associated with general and specialized hospitals, respectively. Noteworthy was the representation of 376 physicians (3.2%) from Hubei Province, the epicenter of the initial COVID-19 outbreak in China. Regarding the temporal impact of the pandemic on medical practices, the survey elucidated that physicians predominantly identified February as the month during which their professional activities were most severely affected, with 87.1% of respondents concurring. Subsequently, March was cited by 58.8% of respondents, followed by January and April, each noted by 21.7% of respondents. A lesser impact was reported for the subsequent months of May (6.3%) and June (4.9%), as illustrated in the accompanying figure (Fig. ). Changes across city categories and hospital levels These results are presented in Tables and Supplementary Tables 1–3. From January to June 2020, except for online seminar participation, physicians reported a minimum 20% reduction in all teaching and research activities. Notably, resident training experienced the most significant decline, with 61.7% of physicians reporting either a complete cessation or a reduction exceeding 50%. Total and specific activities, that were completely terminated or reduced by > 50% differed significantly according to city category and hospital level (all p values < 0.05). Cities or hospitals with greater resources or higher tiers experienced more pronounced reductions in overall activities and teaching endeavors, excluding patient education. Conversely, cities or hospitals with greater resources or higher tiers experienced relatively milder declines in publications and funding applications. As depicted in Supplementary Table 3, the multivariable regression analysis indicated that category 3 cities and tertiary hospitals experienced more pronounced reductions in various activities, including total activities, resident training, graduate education, visiting scholar programs, clinical trials, and laboratory studies, compared to category 1 cities and primary hospitals (all adjusted p values < 0.05). These differences persisted even after July 1, 2020 (adjusted p values < 0.05). Conversely, no significant disparities were observed among city categories or hospital levels in terms of online seminar participation, patient education, academic writing, publications, and fund applications (adjusted p values > 0.05). Notably, physicians from category 3 cities and tertiary hospitals reported increases in online seminar participation (adjusted p values of 0.002 and < 0.001, respectively). Changes across hospital types The results are presented in Supplementary Table 3 and Supplementary Table 4. Across total and specific activities, except for graduate education and laboratory studies, significant disparities were observed in the proportions of physicians reporting either a complete cessation or a reduction exceeding 50%, stratified by hospital type (all p values < 0.05). Notably, general hospitals exhibited the most pronounced reductions, as evidenced by multivariable regression analysis (adjusted p values < 0.05). However, these discrepancies dissipated after July 1, 2020. Regarding the complete termination or > 50% reduction in graduate education and laboratory studies, no significant differences were detected between general and specialized hospitals in either univariate or multivariate analysis (adjusted p values < 0.05). Changes across various provinces These results are listed in Supplementary Table 5. For teaching activities except resident training ( p = 0.027), physicians from Hubei Province reported similar rates of complete termination or a > 50% reduction compared with physicians from other provinces (all p values > 0.05). However, for research activities except for laboratory studies ( p = 0.251), Hubei Province suffered a more severe reduction than other provinces (all p values < 0.05). These differences still existed after July 1, 2020.   From August 1 to August 10, 2020, a comprehensive survey was conducted among obstetricians and gynecologists in China, encompassing 11,806 respondents hailing from 779 hospitals across 157 cities within 31 provinces. Notably, this cohort represented 7.6% of the total 155,787 registered and actively practicing professionals within this medical specialty nationwide. The response rates of physicians and hospitals were 93.8% and 82.0%, respectively. The demographic characteristics of the respondents are detailed in Table . Significantly, 35.9% of physicians had previous involvement in healthcare services directly addressing the challenges posed by the COVID-19 pandemic. Analysis of geographic distribution revealed that 17.8%, 51.2%, and 20.9% of respondents originated from category 1, 2, and 3 cities, respectively. Moreover, 16.2%, 31.1%, and 52.7% were affiliated with primary, secondary, and tertiary healthcare facilities, while 78.3% and 21.7% were associated with general and specialized hospitals, respectively. Noteworthy was the representation of 376 physicians (3.2%) from Hubei Province, the epicenter of the initial COVID-19 outbreak in China. Regarding the temporal impact of the pandemic on medical practices, the survey elucidated that physicians predominantly identified February as the month during which their professional activities were most severely affected, with 87.1% of respondents concurring. Subsequently, March was cited by 58.8% of respondents, followed by January and April, each noted by 21.7% of respondents. A lesser impact was reported for the subsequent months of May (6.3%) and June (4.9%), as illustrated in the accompanying figure (Fig. ).   These results are presented in Tables and Supplementary Tables 1–3. From January to June 2020, except for online seminar participation, physicians reported a minimum 20% reduction in all teaching and research activities. Notably, resident training experienced the most significant decline, with 61.7% of physicians reporting either a complete cessation or a reduction exceeding 50%. Total and specific activities, that were completely terminated or reduced by > 50% differed significantly according to city category and hospital level (all p values < 0.05). Cities or hospitals with greater resources or higher tiers experienced more pronounced reductions in overall activities and teaching endeavors, excluding patient education. Conversely, cities or hospitals with greater resources or higher tiers experienced relatively milder declines in publications and funding applications. As depicted in Supplementary Table 3, the multivariable regression analysis indicated that category 3 cities and tertiary hospitals experienced more pronounced reductions in various activities, including total activities, resident training, graduate education, visiting scholar programs, clinical trials, and laboratory studies, compared to category 1 cities and primary hospitals (all adjusted p values < 0.05). These differences persisted even after July 1, 2020 (adjusted p values < 0.05). Conversely, no significant disparities were observed among city categories or hospital levels in terms of online seminar participation, patient education, academic writing, publications, and fund applications (adjusted p values > 0.05). Notably, physicians from category 3 cities and tertiary hospitals reported increases in online seminar participation (adjusted p values of 0.002 and < 0.001, respectively).   The results are presented in Supplementary Table 3 and Supplementary Table 4. Across total and specific activities, except for graduate education and laboratory studies, significant disparities were observed in the proportions of physicians reporting either a complete cessation or a reduction exceeding 50%, stratified by hospital type (all p values < 0.05). Notably, general hospitals exhibited the most pronounced reductions, as evidenced by multivariable regression analysis (adjusted p values < 0.05). However, these discrepancies dissipated after July 1, 2020. Regarding the complete termination or > 50% reduction in graduate education and laboratory studies, no significant differences were detected between general and specialized hospitals in either univariate or multivariate analysis (adjusted p values < 0.05).   These results are listed in Supplementary Table 5. For teaching activities except resident training ( p = 0.027), physicians from Hubei Province reported similar rates of complete termination or a > 50% reduction compared with physicians from other provinces (all p values > 0.05). However, for research activities except for laboratory studies ( p = 0.251), Hubei Province suffered a more severe reduction than other provinces (all p values < 0.05). These differences still existed after July 1, 2020.   In this national survey conducted among obstetricians and gynecologists in China, all teaching and research activities except online seminar participation substantially decreased. Cities with more hospital beds and hospitals with more resources exhibited more pronounced decreases in activities necessitating face-to-face interaction, such as staff and student training, visiting scholar programs, clinical trials, and laboratory research. Nonetheless, these regions demonstrated a notable increase in online seminar engagement. Consequently, a comprehensive analysis of overall activities may not yield meaningful insights into the determinants of teaching and research pursuits. Compared with physicians from specialized hospitals or from provinces in which the pandemic was less severe, physicians from general hospitals and from Hubei Province suffered greater reductions in most teaching and research activities. The differences may have potential explanations. Larger, densely populated cities have a greater risk of epidemic diseases such as COVID-19 than smaller, sparsely populated cities. Hence, most activities requiring direct contact and communication were voluntarily restricted either actively or passively. Moreover, physicians from regions or hospitals boasting ample healthcare resources are more inclined to participate in online seminars, leveraging their extensive teaching and research backgrounds. Conversely, general hospitals or regions disproportionately affected by the pandemic, such as Hubei Province, dedicated more resources and time to the diagnosis and treatment of COVID-19 patients, diverting attention and resources from other academic pursuits. This phenomenon underscores the dynamic nature of healthcare resource allocation during times of crisis, as exemplified by our findings. The significant reduction in teaching and research activities, particularly in subspecialties such as obstetrics and gynecology, incurs considerable costs. The reallocation of resources and personnel to address emerging crises lacks indefinite sustainability . This is evident in a surgical residency program, where the lack of strategic planning during the COVID-19 pandemic was highlighted . The pandemic-induced disruptions prompt a reevaluation of educational resource allocation, as the substantial decrease in patient volumes and the need for social distancing hinder experiential learning . Kanneganti et al.  reported strategies to maintain continuing medical education during the pandemic in Singapore. Additionally, an institution in Jordan implemented measures to sustain services while facilitating the training and education of trainees and medical students . Although suspending clinical rotations protects students , specialty organization programs have been suggested to mitigate the deficits in clinical education . Baecher-Lind et al.  and other authors  have argued that medical students should be considered as physicians-in-training, even during surges in COVID-19 cases and potential future pandemics. These methods warrant further validation and adaptation to different cultural and socio-economic contexts. In our study, clinical trials and laboratory research experienced a significant decline. According to Zhu et al. , the foremost priority for clinical trials during the pandemic is ensuring the safety of both subjects and researchers, reflecting the current research conditions in China. However, establishing a successful research environment requires substantial effort, and the long-term consequences of these adjustments necessitate ongoing follow-up in related studies. Conversely, online seminar participation increased sharply during the pandemic, as observed in our study and previously reported in the literature . The transition of nearly all teaching activities to a virtual environment has been challenging, yet it may offer more interaction than traditional readout sessions or didactic lectures . Numerous authors  have suggested that residency programs should develop the infrastructure to conduct video-based interviews and engage students through virtual networking events. Furthermore, several strategies for designing remote surgical training curricula have been proposed during this unprecedented time. These developments underscore the potential for enhancing educational methodologies in response to crisis situations . The COVID-19 pandemic has profoundly altered global dynamics and public activities, leading to significant economic recession and societal shutdowns. Similar to other countries and regions, the intensive demands have physically and emotionally exhausted Chinese healthcare providers . Despite these challenges, targeted research and teaching activities are essential to help mitigate the potential burden of COVID-19 without diverting limited human resources, funding, or medical supplies from response activities . The trends, differences, and experiences identified in this study can contribute to the improvement of future healthcare reforms in China and other countries to better cope with pandemics like COVID-19. Despite the significant impact of the pandemic on teaching and research activities, many students successfully completed their training and transitioned into clinical practice. The differences in clinical competence and future development between doctors who completed their training during the pandemic and those who did so under normal conditions warrant further investigation. It is crucial that advancements in medical education and research continue uninterrupted, even in the face of pandemic threats . Our study's strengths include the use of a large, nationally representative sample and a comprehensive assessment of the impact of the COVID-19 pandemic on teaching and research activities. Notably, the pandemic's impact varied significantly across different municipalities, hospital levels, and types. However, several limitations must be acknowledged. Firstly, we did not evaluate the learning, implementation, and outcomes of specific guidelines or consensus recommendations in obstetrics and gynecology for the prevention and treatment of COVID-19. These issues are integral to teaching activities and warrant further individualized investigation. Secondly, our study did not account for national and local policies and interventions, which significantly influence the resumption of medical services and the recovery of the social economy. As with other societal systems, the temporal trends in the decrease or increase of teaching and research activities are strongly affected by the restrictions, measures, and actions taken by federal and local governments and organizations in response to the pandemic. Lastly, graduates and interns were not included in the survey. Their perspectives and experiences could provide valuable insights into the overall impact of the pandemic on the educational landscape.   In this national survey, which utilized a stratified, two-stage, random cluster sampling design, teaching and research activities in obstetrics and gynecology were significantly reduced during the COVID-19 pandemic in China. Activities requiring direct, face-to-face communication were more affected in resource-rich cities and general hospitals compared to resource-limited areas and specialized hospitals. Residency training experienced the most substantial decrease. Conversely, participation in online seminars increased, offering additional opportunities for continuing medical education.   Supplementary Material 1: Supplementary Appendix.   