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Effect of COVID-19 on Urology Residency Training: A Nationwide Survey of Program Directors by the Society of Academic Urologists

2020; Lippincott Williams & Wilkins; Volume: 204; Issue: 5 Linguagem: Inglês

10.1097/ju.0000000000001155

1527-3792

Geoffrey H. Rosen, Katie S. Murray, Kirsten L. Greene, Raj S. Pruthi, Lee Richstone, Moben Mirza,

Healthcare cost, quality, practices

You have accessJournal of UrologyAdult Urology1 Nov 2020Effect of COVID-19 on Urology Residency Training: A Nationwide Survey of Program Directors by the Society of Academic UrologistsThis article is commented on by the following:Editorial Comment Geoffrey H. Rosen, Katie S. Murray, Kirsten L. Greene, Raj S. Pruthi, Lee Richstone, and Moben Mirza Geoffrey H. RosenGeoffrey H. Rosen Division of Urology, Department of Surgery, University of Missouri, Columbia, Missouri , Katie S. MurrayKatie S. Murray *Correspondence: 1 Hospital Dr., MC 304, Columbia, Missouri 65212 telephone: 573-884-4057; E-mail Address: [email protected] Division of Urology, Department of Surgery, University of Missouri, Columbia, Missouri , Kirsten L. GreeneKirsten L. Greene Department of Urology, University of Virginia, Charlottesville, Virginia , Raj S. PruthiRaj S. Pruthi Department of Urology, University of California, San Francisco, San Francisco, California , Lee RichstoneLee Richstone Department of Urology, Hofstra-Northwell School of Medicine, New York, New York , and Moben MirzaMoben Mirza Department of Urology, University of Kansas, Kansas City, Kansas View All Author Informationhttps://doi.org/10.1097/JU.0000000000001155AboutAbstractPDF Cite Export CitationSelect Citation formatNLMAMAIEEEACMAPAChicagoMLAHarvardTips on citation downloadDownload citationCopy citation ToolsAdd to favoritesTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail Abstract Purpose: Coronavirus disease (COVID-19) has profoundly impacted residency training and education. To date, there has not been any broad assessment of urological surgery residency changes and concerns during the COVID-19 pandemic. Materials and Methods: The Society of Academic Urologists distributed a questionnaire to urology residency program directors on March 30, 2020 exploring residency program changes related to the COVID-19 pandemic. Descriptive statistics are presented. A qualitative analysis of free response questions was undertaken. A post hoc analysis of differences related to local COVID-19 incidence is described. Results: The survey was distributed to 144 residency programs with 65 responses for a 45% response rate. Reserve staffing had started in 80% of programs. Patient contact time had decreased significantly from 4.7 to 2.1 days per week (p <0.001). Redeployment was reported by 26% of programs. Sixty percent of programs reported concern that residents will not meet case minimums due to COVID-19. Wellness activities centered on increased communication. All programs had begun to use videoconferencing and the majority planned to continue. Programs in states with a higher incidence of COVID-19 were more likely to report resident redeployment (48% vs 11%, p=0.002) and exposure to COVID-19 positive patients (70% vs 40%, p=0.03), and were less likely to report concerns regarding exposure (78% vs 97%, p=0.02) and personal protective equipment availability (62% vs 89%, p=0.02). Conclusions: As of April 1, 2020 the COVID-19 pandemic had resulted in significant changes in urology residency programs. These findings inform a rapidly changing landscape and aid in the development of best practices. Abbreviations and Acronyms ACGME Accreditation Council for Graduate Medical Education COVID-19 Coronavirus disease GME graduate medical education M&M morbidity and mortality OR operating room PPE personal protective equipment In The Graduate Education of Physicians, one of the seminal reports in the development of current North American graduate medical education, the authors outline the goal of residency training, as "The general goal of medical education is the same now as it was a decade or a century ago: to educate physicians who will have the desire and the qualifications to offer excellent health care to their patients."1 They continue, "The demands, expectations, and the resources of society change, and so do medical capabilities and the concept of what constitutes excellent health care." Coronavirus disease has profoundly impacted demands, expectations and resources as well as the concept of superb care. We studied how the COVID-19 pandemic has affected urological surgery training. Previous examples of pandemic effects on GME relate to HIV and Ebolavirus.2–6 As with those pandemics, some medical specialties will be primarily charged with treating patients with COVID-19, while others, like urology, will likely be subject to secondary effects. International locations faced COVID-19 outbreaks before the United States. A group from Italy has described some of the challenges related to urology training in the time of COVID-19, including decreased elective case volume, supervision and in-person teaching.7 There are sparse reports of how North American residency programs are responding. In radiology 3 programs described cohorting of residents and changes aimed at minimizing personal protective equipment use.8 General surgery programs have described siloing with increased team sizes (for illness related absence), socially distanced hospital workstations,9 electronic systems to track those at risk for exposure, elimination of resident presence in clinics,10 and pooling of residents and advanced practice providers.11 One urology program has published their plans related to the pandemic,12 moving two-thirds of residents to reserve coverage and changing weekly conference to daily meetings. While sporadic reports exist, there is no nationwide evaluation of changes to urology residency programs related to COVID-19. Here, we use a survey to explore adaptations and examine ongoing concerns of program directors. Materials and Methods A questionnaire was developed and distributed to urology program directors at member institutions of the Society of Academic Urology (SAU). The SAU board approved and distributed the final survey, with 35 questions including 3 free-response prompts. Unique hyperlinks were used to allow geographic linkage. For several questions respondents subjectively answered relative to before, during and after COVID-19, as localities had varied timing of pandemic related changes.13 PPE availability was also subjectively defined. Inductive methods were used to identify patterns and themes in open responses. We ranked states by their incidence of COVID-19 through April 1, 2020 (the last day of survey responses) and dichotomized at the 90th percentile. We then divided programs by presence in high or low COVID-19 incidence states. States and territories in the 90th percentile or above for COVID-19 incidence up to April 1, 2020 were Illinois, Massachusetts, Michigan, California, New Jersey and New York. Numerical and categorical data were analyzed using tableone14 in python 3.7 and descriptive statistics are provided. Chi-squared or Fisher's exact tests were used to compare responses between high and low incidence states. Days per week spent in clinic/OR before and after COVID-19 were compared using paired t-tests. We did not correct for multiple testing in this exploratory analysis. Results Survey invitations were sent to 144 programs and there were 65 unique program responses collected between March 30 and April 1, 2020 for a response rate of 45%. A majority of questionnaire responses were from programs in low COVID-19 incidence states (58%). Staffing Formal reduction of resident presence in the workplace was reported by 92% of programs, with 83% of programs reporting reduced work hours overall. There was a statistically significant (p 0.99 No. intend to comply with redeployment request (%) 25 (96) 35 (92) 0.64 No. increased remote resident clinical work (%) 21 (78) 30 (88) 0.32 No. remote resident clinical work (%) 21 (78) 29 (76) 0.87 No. resident televisits (%) 12 (44) 22 (58) 0.41 No. resident research (%): Decreased 8 (30) 6 (16) 0.25 Increased 8 (30) 9 (24) Same 11 (41) 23 (61) No. cause that residents will not meet case min (%): COVID 20 (74) 19 (50) 0.09 Increase case requirements 3 (11) 3 (8) 0.67 No. reduced double-scrubbing (%) 23 (85) 33 (87) >0.99 No. overall work hrs (%): Reduced 22 (82) 31 (84) >0.99 Same 5 (19) 6 (16) No. changes in clinical work proportion (%): Increased clerical 3 (12) 4 (11) 0.6 Increased educational 10 (40) 11 (29) None 12 (48) 23 (61) Resident health No. resident concern for general workplace exposure (%) 21 (78) 37 (97) 0.02 No. resident concern for OR exposure (%) 11 (41) 20 (53) 0.49 No. resident concern for PPE availability (%) 16 (62) 33 (89) 0.02 No. residents exposed to COVID pos pts (%) 19 (70) 15 (40) 0.03 No. residents tested for COVID (%) 14 (52) 20 (53) 0.85 No. residents COVID pos (%) 2 (7) 0 (0) 0.17 No residents under quarantine (%) 15 (56) 21 (55) 0.82 No. changes for pregnant/high risk residents (%): No pt care 6 (30) 14 (42) 0.58 No suspected or pos COVID care 10 (50) 15 (46) None 4 (20) 4 (12) Resident wellness No. additional resident wellness programs (%): Special leave 5 (19) 3 (8) 0.34 Special hospital provided resources 17 (65) 26 (68) None 4 (15) 9 (24) No. residents needed leave for psychological stress (%) 0 (0) 1 (3) >0.99 No. resident-only meetings/meetups (%) 23 (85) 29 (76) 0.57 Didactics/meetings No. reduced didactics/negatively impacted didactics (%) 12 (44) 19 (50) 0.85 No. didactics in small groups (%) 12 (44) 14 (37) 0.72 No. use of teleconferencing (%): Conferences 27 (100) 38 (100) >0.99 Lectures 26 (96) 37 (97) >0.99 M&M 23 (85) 31 (82) 0.75 No. plan continued use of teleconferencing (%): Conferences 13 (48) 26 (68) 0.17 Lectures 16 (59) 21 (55) 0.95 M&M 7 (26) 11 (29) 0.99 No. video based learning/conferences/wk (%): 1–2 16 (59) 21 (55) 0.72 3–4 8 (30) 10 (26) 5 or More 3 (11) 7 (18) Discussion COVID-19 and related societal changes have greatly affected GME. In the sporadic reports of individual programs in urology12 and other specialties,8–11 an emphasis has been placed on reserve staffing, with up to two-thirds of trainees on reserve at any time. In this report 80% of respondents reported creating teams to limit intermingling and to keep residents on reserve for subsequent deployment in urological surgery or redeployment outside of the specialty. In Italy 8% of residents were redeployed outside of urology.15 In this survey of United States training programs 26% reported being asked to redeploy residents, with a higher percentage in high COVID-19 incidence states than in low incidence states (48% vs 11%, respectively). Nearly all urology programs are willing to send residents for redeployment if needed and have discussed this possibility with trainees. One program specifically described an "Airway 101" course developed by their residents in preparation. Eighty-five percent of urology residents surveyed in Italy reported having significant free time each day, likely related to decreased clinical responsibilities.15 In our study resident presence in the workplace had decreased overall in the vast majority of programs. Programs reported significant decreases in clinic/OR time for residents (down from nearly 5 days to 2 days), with increased clerical work, administrative work and research reported. There was no significant difference in the proportion of programs reporting decreased research time between those in high and low COVID-19 incidence states. Additional free time and increased academic time were themes encountered in free text discussions of wellness and beneficial changes. It is too early to assess the impact of these changes on resident abilities and productivity. Regarding education efforts during the COVID-19 pandemic, reports from individual programs involve making most, if not all, meetings virtual.8–12 For a majority of programs in our sample, weekly conferences, M&M, didactics and check-ins (one-on-one or group) are now offered virtually. Around half of all programs plan to continue video learning after restrictions are lifted, while only a quarter plan to continue specifically with M&M. Virtual didactics, specifically nationwide urology video didactics,16 were a theme featured in the best changes program directors reported. Resident health and wellness are important priorities. During the HIV epidemic, before effective treatments were available, the Association of American Medical Colleges emphasized the importance of medical students and residents in patient care.17 Presently, some recommend that only experienced individuals participate in some aspects of COVID-19 positive patient care.18,19 People with comorbidities have been shown to have higher risk of severe illness from infection with SARS-CoV-2.20 Trainees with comorbidities are restricted from contact with COVID-19 positive patients in 85% of programs. Although not explored here, high risk providers could be used for noncontact activities such as responding to patient calls.11 Program directors reported frequent resident concern for workplace exposure and appropriate PPE. Only 3% of programs reported residents testing positive for COVID-19, although this must be interpreted in the appropriate context, with limited availability of testing21 modified by location and time. Of note, reported resident concern for exposure and PPE availability was significantly higher in states with low COVID-19 incidence while resident exposure to known COVID-19 positive patients was reported to be higher in high COVID-19 incidence states, perhaps suggesting a mismatch between assessed and true risk. There may also be interaction with the ability to curtail resident involvement in direct patient care, which may be more feasible in low COVID-19 incidence states. To assist with resident wellness, programs reported use of direct communication between faculty and residents, increased free time and university supported initiatives such as childcare, counseling and improved PPE availability. The Accreditation Council for Graduate Medical Education has reaffirmed previous policies for work hours and appropriate supervision.22,23 The ACGME recently increased case minimums in urology beginning with the class of 2021.24 Changes include a 25% increase in general urology and endourology, a 67% increase in reconstruction, a 30% increase in oncology and a 60% increase in robotic cases. Program directors reported less concern about these ACGME mandated increases and were much more concerned about the impact of COVID-19 on the ability to fulfill the requirements. Acknowledging similar concerns across specialties, the ACGME recently reiterated that requirements are not absolute. A resident meeting minimums may not be allowed to graduate while one who does not may graduate, pursuant to the judgement of their program director.25 Despite some historical attempts to define trainee roles in epidemics,2–6 many programs had no established plan before COVID-19. The Millis report states, "New knowledge, new medical opportunities and possibilities, new social demands come at such a pace as to require continuing review and continuous efforts to improve graduate medical education."1 While at that time they were referencing the need for establishment of national accrediting bodies, these words are applicable to the present COVID-19 pandemic. Here, we offer a snapshot of American urology program adaptations and concerns as COVID-19 related changes were progressing rapidly. Independently, this should inform residency programs in urological surgery and other specialties of current perceptions and practices. Subsequent work should assess changes longitudinally, eventually providing an opportunity for programs to develop thought-out, stepwise plans should a similar situation develop in the future. How changes impact resident academic productivity and clinical skills remains to be seen. As for limitations and strengths, this is a survey of residency program directors regarding circumstances that are in flux. There are 144 urology programs that participate in the match.26 With 65 responses the generalizability of our findings is limited. Statistically significant results from this work should be interpreted as hypothesis generating given the sample size and lack of correction for multiple testing. The survey was only open for 3 days. There may have been nonresponse bias for program directors in places with many COVID-19 cases who may not have had time to reply within that time period. Running counter to this is the likelihood that these program directors might respond at higher rates due to increased interest. There is some risk of social desirability bias given that the population of urology residency program directors is small and this survey was administered by a urological society. Geographic areas had different timing of pandemic onset, legal changes related to COVID-19 and availability of testing. There may be recall bias related to questions asking about resident workload before COVID-19 related changes, although estimates seem in line with prior reports of surgical residency work hours.27 Results potentially related to COVID-19 testing should be interpreted with caution. Subjective definitions of PPE availability and pandemic timing limit comparability, although geotemporal context is important and precludes standardization. Resident concerns and time were reported by the program directors whose perceptions do not necessarily accurately reflect the feelings or experiences of the residents. This is the first national survey of residency program changes related to COVID-19. To our knowledge, this is the first systematic nationwide accounting of such adaptations in any specialty in any epidemic. Despite limitations, it can serve as an important first representation of changes in this ever evolving situation and a harbinger of future needs. Conclusion This is an exploratory analysis of residency program changes made in response to the COVID-19 pandemic as of April 1, 2020 with responses from 65 of 144 programs. Residents may have more time away from urology related clinical duties, although this may be replaced with clerical duties or redeployment outside of urology. There is widespread use of technology to continue clinical and academic tasks, and many plan to continue use of such technology after COVID-19 restrictions have been lifted. Program directors in low COVID-19 incidence states reported more frequent resident concern for safety than did those in high COVID-19 incidence states, although geographical differences in accuracy of prevalence estimates limit interpretation. Wellness remains a priority for program directors and most are relying on regular communication. National accreditation agencies have provided some guidance on how to handle resident staffing and case minimums, although concern with meeting these minimums remains prevalent. References 1. : The Graduate Education of Physicians. Chicago, Illinois: American Medical Association 1966. Google Scholar 2. : A national study of AIDS and residency training: experiences, concerns, and consequences. Ann Intern Med 1991; 114: 23. Google Scholar 3. : Concerns of medical and pediatric house officers about acquiring AIDS from their patients. Am J Public Health 1988; 78: 455. Google Scholar 4. : A national survey of surgeons' attitudes about patients with human immunodeficiency virus infections and acquired immunodeficiency syndrome. Arch Surg 1992; 127: 206. Google Scholar 5. : Ebola, physicians in training, and the duty to treat. Acad Emerg Med 2015; 22: 88. Google Scholar 6. Accreditation Council for Graduate Medical Education: ACGME Guidance Statement on Ebola Virus Infection and Resident/Fellow Training in the United States. Accreditation Council for Graduate Medical Education 2014. Available at http://www.acgme.org/Portals/0/PDFs/Nasca-Community/ACGME-GME-Ebola-Final1.pdf. Google Scholar 7. : Slowdown of urology residents' learning curve during COVID-19 emergency. BJU Int 2020; 125: E15. Google Scholar 8. : Radiology residency preparedness and response to the COVID-19 pandemic. Acad Radiol 2020; 27: 856. Google Scholar 9. : Emergency restructuring of a general surgery residency program during the coronavirus disease 2019 pandemic: the University of Washington experience. JAMA Surg 2020; doi: 10.1001/jamasurg.2020.1219. Crossref, Google Scholar 10. : Rapid response of an academic surgical department to the COVID-19 pandemic: implications for patients, surgeons, and the community. J Am Coll Surg 2020; 230: 1064. Google Scholar 11. : Blueprint for restructuring a department of surgery in concert with the health care system during a pandemic: the University of Wisconsin Experience. JAMA Surg 2020; doi: 10.1001/jamasurg.2020.1386. Crossref, Google Scholar 12. : Cleveland Clinic Akron General Urology Residency Program's COVID-19 Experience. Urology 2020; 140: 1. Google Scholar 13. : An interactive web-based dashboard to track COVID-19 in real time. Lancet Infect Dis 2020; 20: 533. Google Scholar 14. : Tableone: an open source python package for producing summary statistics for research papers. JAMIA Open 2018; 1: 26. Google Scholar 15. : Impact of the COVID-19 pandemic on urology residency training in Italy. Minerva Urol Nefrol 2020; 72: 505. Google Scholar 16. University of California San Francisco: Urology Collaborative Online Video Didactics (COViD). University of California San Francisco 2020. Available at https://urologycovid.ucsf.edu/. Google Scholar 17. Association of American Medical Colleges: Professional responsibility in treating AIDS patients. Statement of the Association of American Medical Colleges. J Med Educ 1988; 63: 587. Google Scholar 18. : Staff safety during emergency airway management for COVID-19 in Hong Kong. Lancet Respir Med 2020; 8: e19. Google Scholar 19. : Urology practice during COVID-19 pandemic. Minerva Urol Nefrol 2020; 72: 369. Google Scholar 20. : Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet 2020; 395: 1054. Google Scholar 21. : Why only test symptomatic patients? Consider random screening for COVID-19. Appl Health Econ Health Pol 2020; 18: 333. Google Scholar 22. : ACGME Resident/Fellow Education and Training Considerations related to Coronavirus (COVID-19). Accreditation Council for Graduate Medical Education 2020. Available at https://acgme.org/Newsroom/Newsroom-Details/ArticleID/10085/ACGME-Resident-Fellow-Education-and-Training-Considerations-related-to-Coronavirus-COVID-19. Google Scholar 23. Accreditation Council for Graduate Medical Education: Stage 3: Pandemic Emergency Status Guidance. Accreditation Council for Graduate Medical Education 2020. Available at https://acgme.org/Stage-3-Pandemic-Emergency-Status-Guidance. Google Scholar 24. Quinn-Leering K and Review Committee for Urology: New Urology Case Log Minimums: Effective 2021 Graduates. Accreditation Council for Graduate Medical Education 2020. Available at https://www.acgme.org/Portals/0/PFAssets/ProgramResources/480-Uro-Case-Log-Mins2021.pdf?ver=2020-02-24-161557-147. Google Scholar 25. : COVID-19: Special Communication to Surgical Program Directors, including Case Log Guidance. Accreditation Council for Graduate Medical Education 2020. Available at https://www.acgme.org/Portals/0/Documents/COVID-19/SurgCOVID19LTC.pdf. Google Scholar 26. American Urological Association: 2020 Urology Residency Match Statistics. American Urological Association 2020. Available at https://www.auanet.org/education/auauniversity/for-residents/urology-and-specialty-matches/urology-match-results. Google Scholar 27. : The value of surgical graduate medical education (GME) programs within an integrated health care system. J Surg Educ 2019; 76: e173. Google Scholar No direct or indirect commercial, personal, academic, political, religious or ethical incentive is associated with publishing this article. © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsCited byCallegari M, Maclean J, Rhodes S, Piyevsky B, Prunty M, Jesse E, Tay K, Abou-Ghayda R, Zell M and Scarberry K (2022) Impact and Implications of the COVID-19 Pandemic on Urological TrainingUrology Practice, VOL. 9, NO. 5, (474-480), Online publication date: 1-Sep-2022.Wang R, Daignault-Newton S, Ambani S, Hafez K, George B and Kraft K (2021) SIMPLifying Urology Residency Operative Assessments: A Pilot Study in Urology TrainingJournal of Urology, VOL. 206, NO. 4, (1009-1019), Online publication date: 1-Oct-2021.Related articlesJournal of Urology28 Aug 2020Editorial Comment Volume 204Issue 5November 2020Page: 1039-1045Supplementary Materials Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.Keywordsinternship and residencyCOVID-19pandemicsurologyMetrics Author Information Geoffrey H. Rosen Division of Urology, Department of Surgery, University of Missouri, Columbia, Missouri More articles by this author Katie S. Murray Division of Urology, Department of Surgery, University of Missouri, Columbia, Missouri *Correspondence: 1 Hospital Dr., MC 304, Columbia, Missouri 65212 telephone: 573-884-4057; E-mail Address: [email protected] More articles by this author Kirsten L. Greene Department of Urology, University of Virginia, Charlottesville, Virginia More articles by this author Raj S. Pruthi Department of Urology, University of California, San Francisco, San Francisco, California More articles by this author Lee Richstone Department of Urology, Hofstra-Northwell School of Medicine, New York, New York More articles by this author Moben Mirza Department of Urology, University of Kansas, Kansas City, Kansas More articles by this author Expand All No direct or indirect commercial, personal, academic, political, religious or ethical incentive is associated with publishing this article. Advertisement Advertisement PDF downloadLoading ...