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
