Introduction
The novel coronavirus (COVID-19) pandemic has affected the lives of many health care
workers (HCW), including resident physicians. Residents comprise a large portion of
the workforce in many academic centers and have become critical in the front-line
response for COVID-19 patients. As hospitals experience surges in admissions, residents
in many disciplines, including urology, have been asked to function outside their
specialty training to join COVID-19 treatment units. As the pandemic unfolds, urology
residents will face challenges regarding personal safety and well-being, disruptions
in their urology training, and relationship strain. Given the uncertain duration of
the COVID-19 pandemic, and the possibility of multiple waves of infection,[1] long-term
action plans can help prepare training programs and residents during these unprecedented
times. In this commentary, we discuss different elements affecting urology resident
training during the COVID-19 pandemic and strategies to minimize the impact of these
factors. We recognize urology programs are heterogeneously affected by the COVID-19
pandemic; these suggestions should be adapted to programs' individual needs and capabilities.
Personal and Workplace Safety
Access to personal protective equipment and COVID-19 testing
The large number of HCW infections and deaths from COVID-19 has underscored the importance
of access to personal protective equipment (PPE). As a result of PPE shortages, many
institutions have encouraged employees to reuse single-use PPE items for several days
or longer, in accordance with Centers for Disease Control and Prevention (CDC) guidance.[2]
The Accreditation Council for Graduate Medical Education (ACGME) has acknowledged
the national PPE shortage, but maintains that resident physicians are to only participate
in clinical environments if they have appropriate PPE.[3,4] Proper fit-testing and
training, especially when multiple types/brands of PPE are being utilized, are also
critical safety factors. These PPE lessons will be especially important for the PGY-1
class of 2020, as well as some early medical school graduates,[4] as any errors in
technique or judgment can have significant consequences.
Many HCW are asymptomatic carriers of COVID-19 and can spread the virus to others.
Access to COVID-19 testing for both HCW and patients is variable, and testing policies
differ by region and institution. It is critical that residents who experience symptoms
suggestive of a COVID-19 infection self-quarantine, only return to work after cessation
of symptoms, and obtain testing if available. Until access to testing increases, clinicians
should assume patients requiring an operation have COVID-19 until proven otherwise
and take the proper precautions. Urology residents should exercise precautions in
the operating room, as bag mask ventilation, endotracheal intubation, and laparoscopic
surgery are aerosol-generating procedures that carry an increased risk of airborne
viral transmission. Resident surgeons should leave the room during intubation when
possible, wear proper PPE, avoid excessive use of electrocautery, and suction surgical
smoke liberally.[5] Hospitals should develop protocols for testing patients going
to the operating room (OR) based on testing availability and speed of result acquisition.[5]
COVID-related precautions should be integrated into standard surgical time outs to
ensure that all OR staff are properly protected.
Temporary residency restructuring
Many residency programs have responded to the pandemic by assembling rotating teams
to cover their urology services, reducing the risk of COVID-19 exposure to patients
and residents alike.[6] Through such a strategy, urology teams maintain a "healthy
reserve" of residents who are available to fill in if a co-resident falls ill. Teams
should consider virtual handoffs and assigning individual residents to round on patients,
rather than traditional team rounds.[7] We encourage urology residents to refer non-urgent
consults directly to telemedicine outpatient appointments to minimize patient exposure
to hospitals and clinics.[6]
Additionally, some institutions are running under ACGME Stage 3 surge protocols, which
temporarily lift common program and specialty-specific requirements, thereby allowing
the deployment of urology residents to the emergency room, intensive care units (ICUs),
and other areas of heightened need.[3,7,8] Urology residents rotating outside of their
specialty must have adequate supervision in these new environments, as is mandated
by the ACGME.[3,9] Many urology residents have not rotated on medical or ICU services
since medical school or intern year. Therefore, trainee experience should be considered
when deploying residents to COVID-19 units. Residents should also undergo training
regarding COVID-19 treatment, complications, assessment/management algorithms, airway
and ventilator management, palliative care resources, PPE conservation, and ongoing
clinical trials at their respective institutions.
Clinical Training
With the deployment of urology team members to non-urologic services, many questions
exist concerning the future of urology training.[6] During this time, the American
Board of Urology (ABU) is actively examining the impact of the COVID-19 pandemic on
trainees and will aim to provide fair alternatives for residents who require extended
time away from work. The ABU also indefinitely postponed the qualifying exam for graduating
urology residents.[10] With the unclear natural history of COVID-19 and potential
for future epidemic waves, the development of sustainable alternatives to traditional
resident educational activities is paramount.
Telemedicine
One way to supplement clinical training is through active participation in telemedicine
clinics. As of March 17, 2020, the Centers for Medicare and Medicaid Services (CMS)
temporarily expanded telehealth coverage for Medicare patients as part of the Coronavirus
Preparedness and Response Supplemental Appropriations Act.[11,12] With this policy,
many hospital have encouraged clinicians to transition their clinics to telemedicine
platforms for patients who do not require physical exams or procedures.12
We encourage residents to partake in telehealth initiatives, as permitted by their
institutions. By participating in these virtual visits, residents can review charts
and engage in patient counseling under the supervision of an attending urologist.
A number of studies have demonstrated the feasibility and success of telemedicine
clinics for urologic conditions, both in pediatrics and adults.[13,14] To our knowledge,
no studies have examined the incorporation of telemedicine into urology residency
curricula. However, telemedicine clinics have been effectively implemented in other
specialties.[15], [16], [17]
Surgical simulation
In order to preserve PPE and decrease transmission of COVID-19, the American College
of Surgeons issued a statement recommending that surgeons curtail elective surgeries.[18]
While what constitutes an elective case is left to the discretion of the surgeon,
many institutions have published protocols for surgical priority levels,[19,20] although
there is some heterogeneity among the recommendations. With a dearth of cases in which
residents can participate, there may be a role for at-home surgical simulation.
Simulations have been used to train residents in fundamental surgical skills: open
surgery, endourology, laparoscopic, and robotic procedures.[21,22] While some high-fidelity
urologic simulations use equipment not readily available for use at home,[22] some
low-fidelity models can be constructed from household items.[21] Additionally, many
surgery residency programs support the use of home laparoscopy box trainers, which
may be a suitable replacement for virtual reality simulators only available at the
hospital.[23] Several groups have described makeshift laparoscopic trainers that can
be used at home.[21,[23], [24], [25]] While these simulations are not substitutes
for live surgeries, they may allow residents to maintain their skillset. To further
simulate the surgical environment, we suggest experienced surgeons hold interactive
virtual review sessions of surgical videos to discuss operative techniques and procedural
nuances.
Training outside of urology
As urology residents are reassigned to the emergency room, medical floors, and ICUs,
trainees have the unique opportunity to gain exposure to other disciplines that can
enhance their medical knowledgebase and interoperability with other services. Residency
programs should encourage learning opportunities outside of urology in fields such
as clinical ethics, health policy, and global health, all of which have direct applications
to the COVID-19 pandemic.[1,26] Residents should share with each other how their institutions
are handling surgical triaging, resource allocation, and patient care management innovation.
Ensuring we have an adaptable, resilient surgical workforce will benefit us now and
when we inevitably face future crises.
Didactics
The COVID-19 pandemic has stimulated worldwide educational collaboration within the
urology community. The American Urological Association (AUA) and other organizations
continue to offer a multitude of online didactic resources including the AUA core
curriculum and virtual courses (Table 1
). Most residency programs have transitioned their tumor boards and didactic lectures
to digital platforms.[6] Select centers have extended access to their virtual lectures
on social media permitting hundreds of resident viewers in their audiences. For example,
the University of California at San Francisco founded the Urology Collaborative Online
Video Didactics (COViD), a series of daily online lectures given by urologic educators
across the country covering a variety of topics.[27] Participants have the opportunity
to engage in discussion and ask questions, thereby receiving state-of-the-art education
and gaining exposure to how urology is practiced outside their institutions.[27] These
digital lectures also promote networking and resident camaraderie. Urology residents
working on a flexible clinical schedule should maintain a daily log of their educational
activities that can be monitored by their program directors. Ultimately, virtual platforms
could lead to the implementation of a standardized national urology resident curriculum
with interactive modules, where trainees have access to expert faculty in all areas
of urology, regardless of their program size, location, or faculty composition.Table
2
.
Table 1
Summary of select online educational materials for urology residents
Table 1
Didactic Resources
AUA Core Curriculum
https://auau.auanet.org/core
AUA Course Catalog
https://auau.auanet.org/courses
Urology Collaborative Online Video Didactics (COViD)
https://urologycovid.ucsf.edu/
USC Masters of Urology
Webinar with registration
Educational Multi-Institutional Program for Instructing Residents (EMPIRE)
Webinar with registration with NY AUA section
Evidence-based Decisions in Surgery
http://www.ebds.facs.org/
Research: Resources and Online Courses
AUA Research Overview
https://www.auanet.org/research/research-overview
Writing A Successful Career Development Award Application (2018)
https://auau.auanet.org/content/writing-successful-career-development-award-application-2018
Big Data and 'Omics' Analysis in Urology (2020)
https://auau.auanet.org/content/big-data-and-omics-analysis-urology-2020
Introduction to the Principles and Practice of Clinical Research (IPPCR)
https://ocr.od.nih.gov/courses/ippcr.html
Table 2
Summary of factors affecting urology residents and action items during the COVID-19
pandemic
Table 2
Personal & Workplace Safety
Factors Affecting Urology Residents
Action Items
Access to PPE & COVID-19 testing
Ensure proper fit-testing
Practice donning and doffing PPE
Exercise caution in the operating room: leave OR during intubation, avoid excessive
electrocautery, suction surgical smoke
Assume all patients requiring an emergent operation have COVID-19 until proven otherwise,
and take proper precautions
Incorporate COVID-19 precautions into OR time outs
Temporary residency restructuring
Assemble rotating skeleton crews
Perform virtual patient handoffs
Assign individual residents to patient rounds; forego traditional team rounds
Refer non-urgent consults to telehealth visits
Residents deployed to COVID-19 services should complete training in institutional
algorithms for COVID-19 management, clinical trials, etc.
Education
Clinical training
Enable resident participation in telehealth clinics
Encourage residents to engage in surgical simulation exercises and guided virtual
surgery lectures
Supplement urology curriculum with education in medical ethics, health policy, global
health, and other surgical disciplines
Didactics
Continue departmental education using virtual platforms
Attend publicly available virtual lectures given by providers at outside institutions
Maintain detailed log of daily educational activities
Research
Continue ongoing research projects, if permitted by institution and clinical demands;
encourage inter-institutional collaborations
Participate in online research-focused courses by AUA/NIH
Virtually present at and attend national conferences
Personal Wellness
Social Relationships
Practice social distancing
Maintain close social relationships with family and friends despite physical isolation
Mental health
Educate residents about mental health challenges they may face in a pandemic
Hold forums for residents to express their concerns
Consider periodic screenings for psychological conditions
Establish readily accessible mental health services, including 24-hour hotlines
Research
The COVID-19 pandemic has drastically changed many research practices. Some institutions
have limited their laboratory staff, and many institutional review boards are not
approving non-COVID-19 studies for the foreseeable future,[9] while others continue
to maintain their portfolios of therapeutic clinical trials. These delays are likely
to have consequences for both clinical and basic science research, but faculty mentorship
and many current projects can continue.[9,28] We encourage urology residents to enhance
their knowledge of research design and analysis by participating in free online courses
offered by the AUA, American College of Surgeons, and National Institutes of Health
(NIH) (Table 1).
Personal Wellness
During the COVID-19 pandemic, many urology residents have been deployed to unfamiliar
clinical environments, faced with challenges that may threaten their physical and
mental health. Many trainees are living separately from their families to reduce the
risk of viral transmission. During this time of physical separation, it is essential
that residents attempt to maintain their social relationships despite physical isolation.[9]
Trainees should be briefed on the possibility of moral injury, anxiety, and depression.
Program leaders are encouraged to hold recurring forums for residents to acknowledge
and discuss their daily challenges. Health care systems should consider regular housestaff
screenings for psychiatric conditions including anxiety, depression, insomnia, and
distress; mental health services, including emergency hotlines, should be readily
available to those in need.
Conclusions
The timeline for resolution and the long-term effects of COVID-19 on our patients
and health systems are still unknown. Therefore, urology training programs must respond
in innovative and dynamic ways. It is critical to ensure safety via adequate PPE and
COVID-19 testing and provide adequate mental health assessment for urology trainees.
While this pandemic has altered clinical duties, urology residents are encouraged
to continue ongoing academic endeavors through digital medical education and research.
Ultimately, the challenges created by COVID-19 pandemic will be overcome through novel
solutions that can empower the next-generation of urologists.
Declaration of Competing Interests
None