Hello. Good day, everyone. Good morning for our friends in America, the ASPS members. Good evening for my friends in Indonesia. Today, it is an honor for me to moderate the first ever joint webinar between INAPRAS and ASPS. This pandemic of COVID-19 is the first time for all of us around the world to experience. We have seen so many webinars about plastic surgeries in all aspects, but we should not forget that plastic surgery education with students are our future is not an easy thing to do. It takes time, sweat, tears, and many sacrifices to make the science of plastic surgery like this today. So let's hear our webinar today about plastic surgery education during pandemic COVID-19, and let's discuss later about the future of our science. Please submit your questions throughout the presentation using the chat feature. We will answer as many questions as possible at the end of the webinar. And please note that today's webinar will be recorded and posted to ASPS website. Let me introduce ourselves. My name is Dona Sahwiti. I'm a plastic surgeon, consultant inborn in Central Police Hospital in Jakarta. Right now, I'm the secretary general of INAPRAS. Our speakers or panelists today is Greg Evans. He's our friends and member of ASPS. I'm sure that you all know him very well. He will talk about COVID and academic medical standards. And second is Professor David Perdanakusunga, our head of Indonesian College of Plastic reconstructive and aesthetic surgery, who has the responsibility of Indonesian plastic surgery education. He is a professor in University of Erlangen, and he will talk about overview in the plastic surgery study program in Indonesia. And another speaker is Dr. Prasetya Nugraheni Kresanti. She is a secretary of postgraduate program of plastic surgery in Universitas Indonesia. She was also an international scholar of the PSF, American Society of Maxillofacial Surgeons in 2013 with Dr. Arun Gosain, Dr. Mims Kohen, Franky Petal, and others. She will talk about teaching and learning adaptation during COVID-19 pandemic in plastic surgery postgraduate program. And now, let our president, Dr. Gudiman, a plastic surgeon and an army general, that will give an introduction to this webinar. Thank you, Dr. Rona. Good day to all my colleagues, plastic surgeons around the world. My name is Gudiman, the current president of INAPRAS. On behalf of all INAPRAS members, I would like to send my gratitude to all of you, especially to organizing committee from SPS, Laura and Romina, that have this Zoom meeting. And also to all of the speakers, Professor Greg Evans from SPS, and from INAPRAS, Professor David Perdanakusuma, and Dr. Prasetya Nugraheni, and also to our moderator, Dr. Rona Savitri. I would like to present a series of talks with the topic of plastic surgery education during COVID-19 pandemic in Indonesia. Currently, there are six established post-secondary residency programs in Indonesia. We have 127 residents, and we have 234 plastic surgeons for 270 million citizens. Which means one plastic surgeon for one million population. And around 76% of our member residents reside in Java, while 11 provinces have zero plastic surgeons. The fact that Indonesia has a small number of plastic surgeons has caused several reconstructive anaesthetic cases handled by other professionals, which is inevitably different in result in terms of quality. In COVID-19 pandemic situation, Indonesia has more than 118,000 confirmed cases today, and with more than 5,500 deaths due to COVID-19. So we are the fourth most populous country in the world, but we are currently ranked at 23rd for confirmed cases across the world. As we can see, we have big problem with COVID-19, and the curve is not declining in any way. We don't know if the peak is yet to come. From March to August, our associations had issued several policies to guide our members during these hard times. What seems worse for us is that Indonesia ranked number one for countries with medical personnel deaths due to COVID-19. This number pushed us to create regulations and policies to protect our members, also to protect our future members, the plastic surgery residents. And so, the new challenges in education for an intrapandemic era in Indonesia are first maintain clinical services with commitment that all plastic surgery practices in pandemic area have to follow strict safety guidelines. And second, maintain ongoing education with utilities, teleconferences, and strategic bridges during daily shifts between residents to reduce access issues to all residents. Third, maintain residence recruitment. We always consider to accept more residents even during COVID-19 era. And fourth, maintain quality in practice and education with adjustment era pandemic education methods, including attitude, cognitive, and also psychomotor aspects. And five, we have to maintain safety in practice and education. We apply strict safety guidelines for all our residents and faculties. And about regulation in conference and meeting, we postpone our public gathering delay to next year. That's all. Thank you for your attention. And we would like to present to you our list of esteemed expert speakers to cover in details the topic of plastic surgery education in COVID-19 pandemic. Thank you for your attention and appreciation. That's all for now. Thank you. Good evening and good morning, dear colleagues and my dear mentors. Thank you very much for this opportunity. Before I start my presentation, I just want to make a quick introduction of my colleagues. We call ourselves the Flash Squad. This is kind of a rapid response team, but in fact, we're just a bunch of friends who help each other out during this difficult time, especially in adapting our plastic surgery training program during the COVID-19 pandemic. Inri is one of the attendees who is completing a master's degree in medical education, and Lanita is the secretary to the training program, and Arutama is the newest addition in the faculty who is energetic and helpful. So the first section of this presentation is the pandemic period. We had our first case of COVID-19 in Indonesia on March 2nd, and at the end of the following two weeks, we had several new cases. So the government decided to limit people mobility, and we started working from home and school from home since March 16th. At the beginning of the pandemic, it required at least two weeks to get the PCR results. That's why we didn't see any spike of positive cases until the end of March. So according to an article in AME, residency will be affected during this pandemic in academic site as well as clinical services. The training program must pay attention to the exhausting shifts that residents used to, and we also need to provide closer supervision and support. We also need to recognize how this pandemic impacted residency education. To manage the exhausting shifts and to make sure the residents had enough time to rest, we split our residents into three teams. One team consisted of six residents were on duty each day, and they will have a two-day off afterwards. While they're off duty, they're still obliged to follow academic activities from home and finish some of the administrative works from home. The training program also implemented closer monitoring. Before pandemic, we took attendance to see who was absent, but during the pandemic, it is more of a checking up on their health condition every day. We also had a WhatsApp group to monitor anyone who was in close contact with the suspected COVID patients. We also made sure the residents followed the recommendations from the infection control committee of the hospital regarding work attires. No more white coats and lanyard, and everyone must wear masks and covered shoes. Our residents also had abundant support of PPA and nutrition supplements from the alumni, the dean's office, and other sources. They really helped at the beginning of the pandemic where the PPA supply is scarce everywhere in the world. The pandemic had impacted residents' teaching and evaluation process. We had to make adaptation for our academic meetings and evaluation. Due to the government instruction to stay at home, we saw a decrease in hospital visits and surgeries. As we can see here, only CMF and burn units were still scheduled surgeries. Also, other procedures related to complicated wound and joint surgery for malignancy cases, which could not be delayed. All electives were canceled. This impacted residents in terms of losing teaching materials to master surgery skills. With the increase of clinical works, we had to make sure the residents had enough academic meetings or coaching to make sure they still got the knowledge. The academic meetings and coaching online through Zoom platform. The advantages of these online meetings were more engagement from the students and the faculties as well. But the downsides were the meetings tended to be long. Also, there were connection problems and application technical error. Mostly because most of us were young and forced to master the online technology as fast as possible. Other academic activities to compensate of the decrease of clinical works for coaching. This was an active learning, which the resident presented self-learned topics and received feedbacks from the attendings. Due to the flexibility of time from the attendings and the residents, the positive side was students could have more additional knowledge transfer. But sometimes it may be time consuming when it was performed after working hours. For the evaluation process, especially for the psychomotor evaluation, we had to modify the evaluation due to decreased number of patients and due to the work from home shifts of the attendings during the pandemic. We performed the Mini-CX online through the Zoom platform. We did role playing. The attendings would play as the patient for history checking and physical exam was limited to only inspection, just the description of the clinical presentation. Other modification was we performed blended Mini-CX evaluation where the resident performed history checking and physical exam on site while supervised by attendings through Zoom. Direct observed procedural skills evaluation was not possible due to the decreased number of surgeries. So we decided to make sure the residents acquired the knowledge parts of procedures based on their models during the pandemic. And we will catch up the psychomotor parts when number of surgeries started. So the modification was we asked them to rescind the procedure as a formative evaluation. And for the summative evaluation, we asked them to submit the written version to the online learning platform provided by our university. And in this platform, we could check whether all residents had submitted the assignments before the due date. We could click their assignments to see the PDF documents and it would show in the window their written task. Afterward, we could give grading and feedback to the residents. So this modified DOPS is maybe ideal only for cognitive aspect, but not really ideal for psychomotor dominated profession. And we should prepare for a technical issue when we are online. For written exams, such as end of rotation exam or level assessments, we use the classic DOPS model. For written exams, such as end of rotation exam or level assessments, we use the class marker application. It's great for MCQ and open-ended questions. We could set time limits for each questions, but it has limitation for drawing the surgery designs or other aspects that needs to be explained by drawing. So we still perform onsite exam for this type of written test. We just made sure that only certain numbers of residents who came for onsite written exam making possible for physical distancing. From March to May, we saw the result of large-scale social restrictions implemented by the governor. We saw a steady number of confirmed COVID patients in Jakarta. This made us confident to step into the transition period in June. So the university and the teaching hospital had prepared online modules to enrich residents' knowledge on COVID to make sure they were ready to work in the transition period. During this transition period, we also had a more established policy regarding hospital zonation, which impacted on patient screening, PPA, and staff assignments. Every resident, including attendings who didn't have any comorbidities and under 50 years old, had a two-week tour of duty in the COVID wing, followed by a two-week period of self-isolation. This policy separated the healthcare workers who worked in the COVID and non-COVID zone, making sure we were not in contact. During this transition period, we split the residents into two teams as anticipation to increasing numbers of elective surgeries while still making sure residents had enough rest. Every resident had alternative days of working at the hospital and working from home. We can see here the number of surgeries started to increase. Electives were scheduled. It was a good thing for residents to get back on track in terms of skill acquisition. This impacted our resident education. We could start the on-site evaluation for direct observed surgery skills and mini-CX. Meanwhile, the online meetings, which we were getting more and more comfortable with, were continued for academic meetings, such as duty report and journal club. During this transition period, we had to organize entry exam because it was approaching the start of a new academic calendar. Besides from Jakarta, our candidates also came from other cities on the same island of Jakarta and from other islands. With the domestic travel restrictions still implemented, these two became a challenge. We had to organize online entry exam for two candidates who came from other islands. For candidates who came from Java Island, we asked them to come to the hospital to do on-site written and skill tests. Meanwhile, for the candidates from outside Java Island, we organized online written and skill tests. We asked them to get online through two gadgets with both cameras on. One gadget, a laptop, to do the written test through class marker, and they shared their screen through Zoom. Another gadget, a mobile phone with camera on from the back showing their laptop screen and their working area. For the suturing skill exam, both on-site and online candidates were observed through Zoom to eliminate the bias of having been supervised directly. Interview process were a blended process. Some of the candidates and attendings were on-site and some of them were also online. When we saw the confirmed cases number in June were steady, the government started the new normal period gradually. So in July, we started the new normal period. In preparation for the 100 load of surgeries, all the residents were asked to go to the hospital every day. Except for those who were on duty the day before in the emergency room, they were requested to take a day off. As you can see here, elective surgeries were increasing in July Sorry. Which was expected since our hospital is a national referral hospital with 1,080 beds and our elective surgeries were put on hold for almost four months. So the impact on residents' education, more teaching materials for the residents to acquire their surgery skills, but at the same time, their schedule was also very tight. Another thing that we could anticipate in this new normal period was if there were residents who were infected with COVID-19, then they had to have self-isolation for two weeks. So the training program would make sure that they could follow the academic activities from home and they would complete their modules later on, which is possible with the open module system in our curriculum. For the patient to other hospitals, we would make sure the safety of our residents in terms of the zonation in the designated hospital and the availability of PPE and screening for our residents. During this normal period, our last year residents had the opportunity to complete their national board exam, which took place blended. The candidates were at the hospital and the national board examiners were online. We faced several challenges during this normal period. We had only a limited number of residents. There were seven residents rotating in plastic surgery, while the other five residents were already in their final years and having their rotation aesthetic surgeries, which are also a challenge of itself due to decreased number of aesthetic procedures. Due to this limitation of human resources, we adapted the clinical services provided by our residents. They still have their rotation in the majorings for academic purposes based on our curriculum, but clinical services are not based on majorings. They will have assignments in outpatient clinics, ODs, unit, et cetera, regardless their academic majoring rotation. Other challenges are the increasing number of confirmed case in Jakarta. As we can see here, the number are still going up until November. As we can see here, the number are still going up until now, since of July. Not to mention the possibility rate, which climbs back to above 5% after the government decided to start the new normal period. What does this mean? This means more people with COVID-19 infection who are symptomless might pass the screening in our hospital, then later on were discovered that their PCR results confirm COVID-19 infection. These put us at risk and we needed to perform contact tracing, monitor the health condition of the residents in contact and encourage them to adhere to the hospital policy. With the roller coaster of COVID pandemic, we felt that we needed to evaluate our teaching adaptation. So we needed feedback from the residents and we needed to know how they feel during these past four to five months. So the quality control board, which consisted of two most senior attendings, Professor Paola and Dr. Imam, distributed a questionnaire through the Google form. The questionnaire covered the aspects might be affected, which were the academics, the clinical services, the safety, the well-being, and we also provided open question, which the residents could try to feel. The quality control board of our training program would then give recommendation to the training program based on the responses to this questionnaire. So we felt that the COVID pandemic is far from over. So the best thing to do is to adapt to the new normal. One of our residents, Felicia, made this safety induction video, which we played every time before our academic meetings so that the residents are reminded and adapted these new norms. So far, we're doing the right thing, we hope. The most recent PCR screening of our residents were on July the 25th and the results were all negative. So... Terima kasih. Thank you for your attention. Thank you, Dr. Haney. We'll proceed with Professor David. The time is yours. okay okay thank you Dr. Dona as moderator for your introduction and good day for everyone. Greetings from Indonesia to all participants around the world and dear distinguished colleague Professor George Evans from HPS, the Honorable Dr. Budiman, President of INAPRAS, the Honorable Dr. Prasetya Nugraheni, all participants in this meeting and also Ms. Romina Valadez and Ms. Laura, my best wishes to all of you. First of all I would like to express my gratefulness for this opportunity to participate in this event with topic plastic surgery education during pandemic COVID-19. I would like to present the overview of plastic surgery study program in Indonesia. The following data shows the distribution of plastic surgeon in Indonesia. Up to present day Indonesia has, as Dr. Budiman said, we have 234 plastic surgeon, 61 out of 234 specialist practice in Jakarta as the capital of Indonesia. This is of followed by East Java where the second largest number of specialist practice with 41 plastic surgeon and this is marked in this slide we can see the red circle and that is larger number of plastic surgeon practice in Indonesia. The yellow circle indicate 5 to 15 plastic surgeon in that area and there is green circle indicate an area with less than 5 plastic surgeon. Indonesia have five center for plastic surgery study program which are Universitas Indonesia in Jakarta since year 1990, then Universitas Erlangga Surabaya since 1998, followed by Universitas Pajajaram Bandung and Universitas Udayana Denpasar since 2016 and Universitas Syakwala Aceh which is recently added in 2018. There are five potential center for plastic surgery study program in Indonesia which are Universitas Prawijaya Malang still in process and then Universitas Sumatra Utara Medan, Universitas Kejamada Yogyakarta, Universitas Diponegoro Semarang and Universitas Hasanuddin Makassar. This is a general picture of plastic surgery study program in Indonesia with total 42 teaching staff and 125 resident. So presently Indonesia has 234 plastic surgeon and 125 resident. And this shows the plastic surgery study program at Universitas Indonesia. This is the picture of staff and resident. The current study program coordinator is Dr. Prasetya Nugraheni as the speaker before. And this picture of study program plastic surgery in Universitas Erlangga Surabaya, Dr. Siti Rizaliana is study program coordinator. And then this picture shows the plastic surgery study program at Universitas Panjajaran Bandung, Dr. Lisa Hasibuan is the study program coordinator. And this picture study program at Universitas Udayana in Pasar Bali, Dr. Hendra is study program coordinator. And last, this is the plastic surgery study program at Universitas Syakwa La'aceh with staff and resident, Dr. Jalani is the study program coordinator. The COVID-19 pandemic is not yet under control. This graph demonstrates the progression of the number of cases within the last few months. We can see the red line, high increase of total amount. However, there is hope considering the number of those who have recovered have also increased even to the point that it has surpassed the number of the active case that we can see in the green line. It gives us optimism that we are heading to an improvement. This pandemic situation is an abnormal situation. Medical attention and facilities are largely located for COVID-19 cases, whereas non-COVID cases are given a reduced portion or even neglected. Non-COVID case may actually be carrier with or without symptom. This become a risk of transmission and infection. There is the decreased number of case available for reaching, fulfilling the competency level target from the training. This may lead to the reduction in the acquired competency. The training period is extended and even indefinite because of the present situation. We need protect ourselves and our workplace, applying with new protocol for various activity. In pandemic condition, there's so many limitation not allowing physical interaction. This significantly affect both medical service and training in the plastic surgical specialty. In response to this, we divide the pandemic period into three phase. There are a pandemic phase transition and new normal or post-pandemic phase. In pandemic situation, all concentrate on COVID case. Only the management of emergency case is priority. Active case have significantly decreased even to the point that aesthetic surgery service is stopped. Interaction is fully by online. In the transition phase, emergency case are still priority with limited elective care under strict health protocol, especially for those case associated with low and moderate risk. Interaction is still mostly done online, but limited offline activity in the form of physical interaction already take days. In the new normal phase, things are expected to return as previously, but adjustment to the condition have to be continuously maintained such as health protocol as the new norm. This is training strategy which is carried out on divided into three phase, pandemic transition and new normal or post-pandemic. It cover aspect concerning the resident and workplace. For resident, there are factor of proficient knowledge, delegating and determining the training level, supervision type and method of training. Also supplying personal protective equipment and mapping at regular interval. Regarding workplace, the main teaching hospital should properly arrange their territory into zone with direction of patient flow and identification of possible exposure to COVID-19. There is also the factor of taking advantage of satellite teaching hospital or affiliation which are safe from COVID. The same applies to the phase of transition and new normal where adjustment have to be made to the current situation. The same factor are taken into account involving aspect concerning the resident and hospital condition. In this photo, we see the various activity followed by the resident before COVID-19 pandemic. We can see the activity morning report, weekly report, textbook reading, research proposal, multidisciplinary case discussion, grand round, operating theater activity and outpatient clinic. These are different activity during the pandemic condition. Due to the limited physical interaction, various activity are carried out via online such as daily and weekly report and scientific meeting. Patient care is provided under strict health protocol. This was the situation during the national board exam before the pandemic compared to during the pandemic which took place online. We can see very different situation. This photo shows all staff and resident examinees at the end of the national board examination. As a conclusion, in the face of the pandemic condition, we need to make the necessary adjustment to sustain the education program. Competency has now been achieved to meet the established education standard. With promotion of the pandemic, reassessment need to be made concerning renewed training model and strategy. Also taking into consideration the current standard of education. Should there be renewed competency standard, there are many changes occurring. The question is, are these changes temporary or permanent? Let us take this precious time and opportunity to contribute providing solution to overcome the situation. Thank you very much for your attention. Thank you, Professor. It is your turn, Greg. Hold on. Can you hear me? Yes, of course. Donna, how are you? I'm trying to share my screen here, and I'm having a little difficulty. For some reason, it's not allowing me access. You have allowed me access to share my screen? Yes, everything on my end says you should be able to. Dr. Evans, let me see. For some reason, it says I don't have access. Sometimes you have to grant access. Can you share your screen? I can. Let me get that up for you. While we wait, if any of the participants have questions, you can type it in the chat box. I'm sorry for the glitch. I'm actually in a hotel on vacation. We'll go ahead and do it this way. For some reason, usually my screen can share without any problems, but it's having an issue today. Why don't we go ahead and advance? What I thought I'd give you is maybe a perspective from an academic institution. Next slide. I just want to thank everybody. Go ahead and advance. There we go, right there. I want to thank the Indonesian Society and ASPS for allowing us to hold this webinar. I think it's a very exciting issue. What's interesting is that as we hear the response, it's very similar across, obviously, countries. I would like to give you a little perspective, at least in California. The difficult part in the United States is that we don't really have a national regulation on the illness itself. We don't have really a lot of national guidelines. We just have some recommendations, and then each state is allowed to do what they think is best. I think that makes it a little bit more difficult than, let's say, having one country and being able to have a little bit more oversight. In California, in March of this last year, Governor Newsom ordered all Californians to stay at home. Next slide. I think this was an evolutionary process, right? At first, we were very concerned about PPE. We basically said hand-washing is necessary. But we really had no mandate in regards to wearing a mask until the CDC required it. It was interesting is that from our standpoint of view, we actually were looked at sort of negatively or reprimanded a little bit if we used PPE and wore a mask. We are still not testing anybody unless they're symptomatic. But we went very similar to Indonesia with a master trauma plan, with sort of what we call a green and red section in the ER. Green is obviously non-COVID positive. Red is COVID positive, at least initially. And then all physicians were put on call. Students were suspended from all clinical activities. And then the residents entered into kind of what we call a trench warfare, in which you basically rotate two residents at a time, and then the next two are rotated, and then there's a third set. So we had sort of three levels of depth of the residents in case there were issues. And then the faculty volunteered for other jobs. So even though I couldn't do plastic surgery per se, I did volunteer for other aspects in the emergency room. Obviously, I'm not a critical care doctor, but I could certainly push patients around and move things around and help out just from a general overall medical standpoint of view. Next slide. So we went down on all elective cases on March 18th, and then we had a priority list. You know, cases with cancer that needed to be done within a month were still being done. Trauma cases were still being done. But then we looked at a priority two elective cases that need to be done within three months, priority three within six months, and then priority four elective cases with no immediate medical necessity. And actually, even the governor said no cosmetic surgery, which was kind of interesting. And then physicians basically determined the priority, and if there were any issues, there was a committee and the department chair that then would have to assign a priority. Next slide. We, like everybody else, went on to Zoom calls. You know, I think I have about 19 Zoom calls a day. We had a week where my administrative staff was working from home, and it's interesting. It looks like they'll probably still be working from home until January 1st of 2021. We have one staff member comes in one day a week. We have basically five, so it kind of covers every five days, and they only come in for a couple of hours. Now, my clinical staff all came in every day, and I came in every day just to kind of support everybody. We had weekly faculty meetings and daily email updates. This is some of the daily updates that came out, basically, and it kind of went through all of the statistics, kind of what was happening. We had town halls twice a week. Next slide. So the more information that we could get out there, the better. All resident education went online. One resident covered a particular service at a time. If we had a resident exposed, we had one resident that was exposed, but there were no positive tests. And so far, no positive tests in our residents, so knock on wood. The written exam was technically scheduled in 2020, but it was delayed primarily because of prometric centers in which all the residents take their written plastic surgery exams, couldn't figure out how to isolate people. And the oral exam this year will actually be virtual instead of sitting down and interacting with the candidates, so we'll see how that works. All medical student rotations were suspended except within 100 miles of UCI, and those programs did not have any plastic surgery programs. Next slide. All resident interviews this year will be online. Both the ACAPs have oversight to this as well as the ACGME. It's interesting, all faculty hires were suspended and all chair searches went online, and anybody that was in that process, that whole process got suspended as well. And every faculty hire has been delayed. Next slide. This is just kind of one of our Zoom meetings. Next slide. We actually did have a couple of Zoom happy hours, so that was actually fun. We tried to make it a little fun as well. We were testing asymptomatic patients with airway issues, primarily because the anesthesia staff was concerned. All the private offices in our area basically closed. They should have closed. A lot of employees were laid off. And as you know, there was a push for small business loans to maintain staff, but the problem was a lot of these did not get pushed out to private practice plastic surgery offices. They continued to operate, but I think they were in the small minority, and certainly it wasn't supported by our national society. Next slide. We went to more telehealth visits. So it's interesting. When I'll show a slide on this, we went to more video visits, and the Department of Health and Human Services distributed about $1 million in support. And basically what they did is that they took whatever you received from Medicare last year, 2019, and they took 7.3% of that. So we got an extra $21,000 for not seeing anybody, and it was basically a distribution by HHS to individual academic centers and also individual practices in order to try to maintain them. Our institution received about $5 million for that. There was another $9 million in, quote, loans that we did not have to borrow. So, you know, at least we got some reimbursement from the government for the downturn of not operating, so to speak, for a two-month period. Next slide. This is just ‑‑ it's interesting. Medicare would not pay for any video visits at all, but they changed the rules on that. Next slide. And these are just some of the criteria in the rules. It's really too small to read, but basically what you needed to do in order to get reimbursed at the same level as if seeing a Medicare patient in your office. So now at least we get reimbursed for at least another couple of months or so through video visits at the same level. So about 50% as an institution, about 50% of our visits actually went to video conferencing. It's a little bit difficult, more difficult than plastic surgery, but certainly in psychiatry and family practice, it actually really kind of helps support the clinic. Next slide. This is just ‑‑ we were all tested. This is at our VA hospital. Next slide. Every time we came into the hospital, we needed not only to have a mask and ID, but all of our temperatures are taken and then we get a special tag that lasts for that day and the color keeps changing on a day‑to‑day basis. Next slide. We set up a tent outside our emergency room. Thank goodness we didn't have to use this for any overflow patients. Next slide. And at the end of April, the governor again said elective surgery can proceed, but no plastic surgery. So May 4th, we started to do our priority one and two cases, and then because of wrap‑up, we started to look at priority three and four, and by May 11th, we were at 110% of volume. We looked at no block time in order to get more cases on, and we had a 1,200 case block backlog. It just our institution alone, because people really were afraid to come into the hospital, but there were a lot of people that, you know, just unfortunately didn't treat their illnesses. And then we extended release time to one to two weeks and extended time on weekends. Next slide. So now all patients coming to surgery are screened. Tests are done 24 to 48 hours ahead of time. Emergent cases are not delayed but can be tested in the OR. And then sometimes if you get tested with an outside lab, we can accept some of those. And we're running about one, at least we were running about one positive test in 500 that's probably gone up recently with our recent surge. Next slide. This is just kind of an ambulatory flow on how to go ahead and get ordered testing in all of our patients. Next slide. This is one of our testing centers. It's actually right outside our clinic office. So you can get through, stay in your car, and the tests are done. Next slide. So on a restart, we tried to preserve as much PPE as possible. You know, we have packaged gowns, and those have a backlog of about, well, we have about six weeks' supply of those. So we wanted to make sure that we maintained as many gowns as possible. If a pack is missing an item, we don't open an additional pack. We tried to limit the number of essential personnel from scrubbing, like no med students scrubbing. And then we looked at even looking at some of the old cloth gowns, but we couldn't find a company to have them sterilized. And then the distribution of P3 and P4 cases all over those that do cancer. So we looked at even trying to get some of those, perhaps even pushing some of those cases back a little bit. Next slide. So now in our ambulatory restart, all patients wore a mask. All the physicians wore a mask. We have not gone to IgG testing of employees. I think it's probably due to an expense issue, but it's something to think about. I actually have had my antibodies tested. They're negative. So we'll see. But, you know, at this point, nobody knows what that really means. So I don't know whether I've been exposed at some point in testing negative or have not been exposed at all. Next slide. This has been a huge financial impact on the health care system. You know, there's been a tremendous reduction in income, reduction in collections. The economic impact in the U.S. in employment is over 20% a couple months ago. It's now dropped about 13%. We normally had about a $21 to $22 million a month collection. We dropped down to $14 million in April and May. But fascinating, when we opened up in June, we actually bounced back quite quickly. And what I thought wouldn't happen would be cosmetic surgery and disposable income. I'm actually busier now from a cosmetic standpoint than I was even before COVID-19. Next slide. This is just a consent form from ASPS. We do not use this about maybe consenting patients for COVID-19. Next slide. And what you basically are saying is that you take on the responsibility of maybe catching COVID-19 by coming to the hospital. I can tell you, though, now that's probably safer for me, next slide, to come into the hospital every day than it is to go to the grocery store. So we resumed. And these are just some comments from ASPS on resuming elective surgery. We've kind of taken some of these and modified them. But basically, you know, you want to follow your local hospital, regional, and regulatory bodies' practices. Next slide. We want to obviously follow the CDC guidelines as much as possible. We want to understand our prevalence and incidence. You know, we have cities that have a very high prevalence of COVID-19 now and other cities that are very small. We want to make sure testing is available. That's still an issue in the United States in regards to testing. Next slide. And then, you know, you want to look at what our national regulations are and our local regulations. But we don't have a whole lot of national regulations. But what we really try to do is, like everybody, social distancing. In the waiting room, we have social distancing. We actually have a temporal component that, you know, the patients have to be there at, let's say, 3.30 in the afternoon. If they're not there, then they don't get seen because we have other patients coming in. So we really try to do that. Everybody wears masks. The clinic is wiped down every hour and is, we do a deep clean every evening. Next slide. So we have cleaning plans. If somebody is, you know, we have now overall good supplies of PPE and we want to make sure we have adequate anesthesia supplies. Next slide. We've never had an issue with having ventilator issues. What was interesting is that during the height of the COVID component, when we were really shut down, we had a maximum of 19 patients in-house. So we were actually very quiet and we were actually not doing anything. It's only recently that we've had, we've seen more spikes in our institutions. Next slide. And then, you know, we want to just make sure all the staff isn't, is safe and secure. And, you know, we have a little hand cleaning protocols and so forth, but that's the reason why I came in every day, just to make sure the staff was doing well. And now if somebody does test positive, we've gone from 14 days to 10 days. So that person needs to quarantine for 10 days and we've gone away from two negative tests, especially if they're asymptomatic. If they're symptomatic, that's a whole nother issue. No medical student or elective rotators, but they just started recently from, just from our own institution. And again, depending on the amount of gowns that we have in the room, they either scrub or non-scrub, but all of our international rotators, you know, are not able to come into the United States and not able to come into our institution. Next slide. And let's go to the next slide. So recently, I think all of you know that we've had a resurgence. Governor Newsom has closed bars, any restaurants inside, hair salons, but, you know, it's interesting all of this has moved outside. Fortunately, we live in California so that we can still eat outside even in the winter. I don't know what's going to happen in other states, especially back east in the winter, whether they're going to be able to eat outside or not. So we've even gone to blocking streets in order for restaurants to survive. I think we all realize that closing down is not an option. And we as an institution will not close elective surgery again. But we're monitoring PPE, and more importantly, we're monitoring ICU bed capacity. So we have four different ICUs, half of which are COVID-designated, the other half are not. So if we know we're going to need an ICU bed following surgery, we need to ensure that anesthesia and the critical care team know that. Our numbers went up to 64 in-house COVID patients. They've now dropped back down to 50. But we've also had a local psychiatric hospital, which we reopened. It's about five miles away and has 150 bed, and we were sending more stable trach patients to this hospital to try to get them out of our facility in order to kind of keep the engine running. We still do daily testings of temperatures and asking for symptoms. We haven't got to the point of testing everybody on a weekly basis. One of the other hospitals in the area where one of my faculty is gets tested twice a week. So I don't know where we're going to go with that. I think the problem is we still have an issue with reagents and the number of tests that we have. Next slide. And these are just a little bands that we color-coded that you don't know what color you're going to get that day, but you have to wear on your badge in order to get into the hospital. Next slide. So it's been a challenge. It's been a challenge, I think, for all of us. I, you know, I'm very proud of both the residents and my faculty and staff. We're continuing to put ourselves on the front line during this process. And, you know, we'll see where this goes. I think probably this, unfortunately, is going to hang around until we get some type of vaccine in order to deal with it. So unfortunately in the United States, we're not, there are still people that don't believe in wearing masks and it becomes an issue. And there are other people are still having large parties and, you know, it's hard to control a virus when those things still happen. So thank you very much. Next slide. And I think we're in the Q&A session at the moment. And it's been a great pleasure to be a part of this webinar this morning. Thank you. Thank you, Greg. Excellent presentation. So it's time for a question and answer. I will see the chat box first. There is a question from Andrew Wexler. What are resident testing protocols? Are asymptomatic residents tested? I think there is in the presentation, but maybe you can, this is for all panelists. Just a brief question. Dr. Haney? Thank you, Dr. Donna. Dr. Wexler, in our hospital, the protocols are only for the ones who are exposed to confirm positive COVID-19 patients or colleagues. So when any residents are exposed to a positive case, then we need to file a report to the hospital management and to the dean's office. And then they will screen, they will see the personal protective equipment that's being used at the time. And then they will score the risk. And if it's, it fall into high risk condition, then they will be scheduled for PCR testing in the maybe three to four days or up to one week after exposure. Okay. Professor David, do you have addition information maybe? Yes. Thank you. In Indonesia, we have the variation of policy for resident protocol safety. In our center, we have a policy on-off activity. On for one month and off for one month. Before activity, on activity, we check a swab for resident. And after activity, one month, we check again. And we check also for resident when come to on activity. We have a policy on-off activity for one month. And before and after activity, we check with a swab test. For all residents, right? Yes. Resident who is want to activity for study. We have the the choice for resident. If he think or feel afraid with the situation, they can choose to stop the study for temporary. For all students, yes. Okay. How about you, Greg? How about you, Greg, in the UCI? We are not, you know, if somebody is symptomatic, they get tested. That was a question, correct? They ask, are asymptomatic residents tested? Asymptomatic. No, not at all. Asymptomatic. No. Matter of fact, we even had a clinic, what we call medical worker, test positive. She quarantined and none of the other staff were tested. So no asymptomatic person is being tested. Okay. Okay. I hope it answer your questions. And I also want to ask all the panelists. So we see that there's changes in education, right? There is a new competency standard due to the increasing amount of patients. There is a new standard of evaluation by more or more online activities. And do the life of education will change also or not? What do you think? Can you give me your comments about that? And how about aesthetic? Because we are plastic surgeon needs skill. You know, we have to have some skills and that skill cannot be obtained by the online study. Can you please comment? Maybe from Greg? Yeah. So I don't think we will go, at least there's no thought process right now of lengthening any of the programs. I can tell you that where we are at now, we are busier than we've ever been pre COVID. So actually our residents are getting much, even though we were limited for two months, they're getting a huge amount of numbers now. And as I said before, you know, with the economy and everything, I thought disposable income would be a little more difficult, but I don't know whether it's a stimulus checks that everybody's getting, or it's because nobody's going anywhere because they've been looking in the mirror for the last two months, two and a half months at themselves, but our, but our cosmetic cases have skyrocketed. And I've never been busier from a cosmetic standpoint of view. It's really, it's, it's contrary to where, where I thought we would be at. I can't, I can't explain it. Okay. As we know in this situation, in pandemic situation, the learning model only in online facility. And for pandemic situation, we allocation the time only for cognitive or knowledge. And we allocation the skill interaction with patient. We allocation in the normal, new normal, but maybe we have, we think about, about the possibility to use the colleague in hospital safe from COVID maybe for, for join with us for education. Okay. Thank you. How about you Dr. Henning? Our training program is a university-based training program. So the policy in our university is we would not lengthen the training period for our residents. So we were a bit worried at the beginning of the pandemic because the cases are really, really down the number of cases. But now since July, the number of cases is like Dr. Gregg said that the we're busier than before the pandemic and the residents are also maybe a little bit tired or very tight schedule. So I think we're optimistic that the number of cases is enough in the future for the residents to train their surgery skills. And for the aesthetic surgeries, I think we have an agreement with the association of plastic surgeons in Indonesia that we would be able to put them as maybe kind of interns in the aesthetic surgery practice with the senior colleagues. Maybe Dr. Budiman can comment on that. Dr. Budiman, do you want to comment? Don't forget to unmute yourself. Yes, of course. I think the aesthetic case can be done in this transition period with the strict of the protocol to COVID because the demand of the aesthetic is still high, especially in the big city like Jakarta. Okay. Thank you, Dr. Budiman. I see that there's no other question in the chat box. So I think we have passed our time to do this webinar and I really hope that this pandemic will get over soon and we have much more better education for the residents, not only for treating the COVID patients, but also for the education because they are indeed our future. So thank you all for the opportunity to do this webinar together, ASPS and INAPLAST. And I hope that we can meet soon not in online platform and stay safe and stay healthy, everyone. Thank you. Good night. Thank you, Greg. It's my pleasure. Thank you. Hope to see you in March in person. We'll see. I hope so. Thank you. Thank you.

plastic surgery education

COVID-19 pandemic

INAPRAS

ASPS

teleconferences

training adaptations

logistical challenges

virtual education

healthcare safety

financial impact

hands-on skills

webinar

telehealth

safety protocols

elective surgeries

online platforms

clinical evaluations

resource allocation