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      Adapting urology residency training in the COVID-19 era

      , MD a , # , , MD a , # , , MD PhD a , # , , PhD b , , MD MPH,FACS a , , MD PhD MBA FACS a , , MD MA MS FACS a , *

      Urology

      Elsevier Inc.

      Urology, residents, Residency, COVID-19, Medical education

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          Abstract

          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

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          Most cited references 19

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          Minimally Invasive Surgery and the Novel Coronavirus Outbreak: Lessons Learned in China and Italy

          As elective operations are being cancelled, and surgeons are called upon to perform only emergency or carcinological surgery, the precautions to take when operating on patients who are potentially or proven COVID-19 positive are of utmost importance. The novel coronavirus (2019-nCoV) outbreak hit China in the beginning of December 2019, and ignited the headlines a few days later. Unexpected, unprecedented, and radical modifications have profoundly shaken the world since then. The economic shutdown in China cleared the map of China viewed from the sky, the halt in travel, counseled first within the country, then internationally, was too late to stop the diffusion outside of China, and meanwhile has destroyed enterprises such as Flybe, while changing the economy of airlines and airports the world over. Hospitals and medical structures, in China, then Korea, and now Italy and France, abound with people either infected, or afraid of being so. The stock of respiratory machines has never been used so prominently, while facial masks, visors of all sorts and handkerchiefs, wipes and tissues have never been expended more often, and are even depleted in certain regions. First in China, then in Europe, and in particular, in Italy, the sudden and rapidly exponential afflux of patients in need of management, simple or intensive care, or simply advice to stay where they were, became the omnipresent and urgent preoccupation of health care workers, essentially those based in hospitals. In China, make-shift neo-hospitals were built in unparalleled record-braking time spans, and in Europe, external triage tents, internal reshuffling of beds and usage radically modified the architecture of existing health facilities. Surgery has also evolved and changed radically, but over a 30-year span. How has the novel coronavirus (2019-nCoV) outbreak affected surgery in China and Italy and will affect the future of surgery tomorrow is the question of today. The Centers for Disease Control and Prevention recently published recommendations that were upgraded by the American College of Surgeons. 1 Both recommended to stop elective surgery and to take general precautions, but there was little on the pragmatic aspects of surgery. In laparoscopic surgery, an essential part of the technique is the establishment and maintenance of an artificial pneumoperitoneum; with this comes the risk of aerosol exposure for the operation team. Ultrasonic scalpels or electrical equipment commonly used in laparoscopic surgery can easily produce large amounts of surgical smoke, and in particular, the low-temperature aerosol from ultrasonic scalpels cannot effectively deactivate the cellular components of virus in patients. In previous studies, activated corynebacterium, papillomavirus, and HIV have been detected in surgical smoke 2–4 and several doctors contracted a rare papillomavirus 5 suspected to be connected to surgical smoke exposure. The risk of 2019-ncov infection aerosol should not be any exception. One study found that after using electrical or ultrasonic equipment for 10 minutes, the particle concentration of the smoke in laparoscopic surgery was significantly higher than that in traditional open surgery. 6 The reason may be that due to the low gas mobility in the pneumoperitoneum, the aerosol formed during the operation tends to concentrate in the abdominal cavity. Sudden release of trocar valves, non-air-tight exchange of instruments, or even small abdominal extraction incisions can potentially expose the health care team to the pneumoperitoneum aerosol; the risk is definitely higher in laparoscopic than in traditional open surgery. This outbreak thus poses a great challenge to the clinical work of surgeons who practice MIS. As the epidemic spreads and pandemics, we surgeons have the responsibility of raising the level of awareness, prevention, and control of transmission, not only for the current epidemic, but also, in general, as a principal for all surgeries. 7 Even if all elective surgery has been curtailed if not stopped in countries of the current pandemic, the risk is present for patients who require emergency surgery or operations for malignancy, and above all, for the surgeons and operating room staff who undertake these operations. We would like to share the following, based on our recent experience in Shanghai and Milan. 1) General protection: all surgery patients must complete preoperative health screening, whether they are symptomatic or not. As operating staffs might become infected, and therefore reduced in number, all medical personnel have to comply with the tertiary protection regulations. 8,9 2) Prevention and management of aerosol dispersal: during operations, whether laparoscopic or via laparotomy, instruments should be kept clean of blood and other body fluids. Special attention should be paid to the establishment of pneumoperitoneum, hemostasis, and cleaning at trocar sites or incisions to prevent any gush of body fluid caused by air leakage or uncontained laparotomy incisions. Liberal use of suction devices to remove smoke and aerosol during operations, and especially, before converting from laparoscopy to open surgery or any extra-peritoneal maneuver. Avoid using 2-way pneumoperitoneum insufflators to prevent pathogens colonization of circulating aerosol in pneumoperitoneum circuit or the insufflator. 3) Management of artificial pneumoperitoneum: keep intraoperative pneumoperitoneum pressure and CO2 ventilation at the lowest possible levels without compromising the surgical field exposure. Reduce the Trendelenburg position time as much as possible. This minimizes the effect of pneumoperitoneum on lung function and circulation, in an effort to reduce pathogen susceptibility. 4) Operation techniques: The power settings of electrocautery should be as low as possible. Avoid long dissecting times on the same spot by electrocautery or ultrasonic scalpels to reduce the surgical smoke. Special attention is warranted to avoid sharp injury or damage of protective equipment, in particular gloves and body protection. 5) Postoperative operating room and equipment management: all protocols involving postoperative cleaning and disinfection should comply with governmental and learned society instructions. 1,8,9 Devices used on infection-suspected or proven patients should undergo separate disinfection followed by proper labeling. It is mandatory to specifically label and dispose clinical wastes separately. 6) Ideally, hospitals should be immediately divided into 2 main categories: dedicated hubs for positive COVID-19 patients (with limited surgical staff and ORs, for those infected patients requiring surgery) and other both for emergency surgery and urgent oncological procedures in negative COVID 19 patients. Health authorities should allow surgical teams to move from one hospital to another. 7) Teaching and future recommendations: strengthen the awareness on the hazards caused by surgical smoke and the management of intraoperative aerosol. Strict protocols must be established for the creation and maintenance of laparoscopic pneumoperitoneum to reduce the occupation hazard caused by aerosol exposure. 8) Operating staff protection: efforts must be made to raise awareness of the occupation protection on operating staffs, including surgeons, anesthetists, and nurses and all possible transiting persons in the OR. Correct 2-way protective apparel (goggles, visor, mask, and body protective garb) should be routine. When engaging a suspected or diagnosed patient, tertiary dress code should be applied according to the protocols which also include strengthening OR ventilation and installing air purification equipment. 9) Preoperative health screening: to effectively battle against the possibility of prolonged 2019-nCOV outbreak, it is imperative to establish new standards of practice for admitting patients in the future. This should range from preoperative health screening to final differential diagnosis, including epidemiology investigation and adequate imaging. This outbreak not only raises challenges to MIS in terms of disease control today but also should remind surgeons that we need stronger occupational protection in the future. We must raise the level of awareness and protection measures for the risk of occupational exposure in laparoscopic but also traditional open surgery. There is an urgent need of a strict protocol to accurately manage the artificial pneumoperitoneum and the hazards of aerosol diffusion for surgeons.
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            Considerations in the Triage of Urologic Surgeries During the COVID-19 Pandemic

            Take Home Message We present a suggested list of urologic surgeries that should be prioritized if COVID-19 surges warrant cancellation of elective surgeries to free up health care resources. The recommendations should be tailored to locally available resources and situations and can be used as a framework for other specialties.
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              COVID-19 and Urology: A Comprehensive Review of the Literature

              To discuss the impact of COVID-19 on global health, particularly on urological practice and to review some of the available recommendations reported in the literature.
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                Author and article information

                Contributors
                Journal
                Urology
                Urology
                Urology
                Elsevier Inc.
                0090-4295
                1527-9995
                24 April 2020
                24 April 2020
                Affiliations
                [a ]Division of Urology, Rutgers Robert Wood Johnson Medical School and Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
                [b ]Rutgers School of Public Health, Newark, NJ
                Author notes
                [* ]Corresponding author: Eric A. Singer MD, MA, MS, FACS, Associate Chief of Urology and Urologic Oncology, Associate Professor of Surgery and Radiology, Rutgers Cancer Institute of New Jersey, 195 Little Albany Street New Brunswick, NJ 08903, USA, Phone: (732) 235-2043, Fax: (732) 235-6596 eric.singer@ 123456rutgers.edu
                [#]

                These authors contributed equally to the work in this manuscript.

                Article
                S0090-4295(20)30452-0
                10.1016/j.urology.2020.04.065
                7194676
                32339555
                © 2020 Elsevier Inc. All rights reserved.

                Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

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                Urology

                urology, residents, residency, covid-19, medical education

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