Urology in the Time of COVID19

Adapting Urology Residency Training

in the COVID-19 Era
Young Suk Kwon*, Alexandra L. Tabakin*, Hiren V. Patel*, Jeffrey R. Backstrand,
Thomas L. Jang, Isaac Y. Kim, and Eric A. Singer

The novel coronavirus (COVID-19) pandemic has accordance with Centers for Disease Control and Preven-
affected the lives of many health care workers (HCW), tion guidance.2 The Accreditation Council for Graduate
including resident physicians. Residents comprise a large Medical Education (ACGME) has acknowledged the
portion of the workforce in many academic centers and national PPE shortage, but maintains that resident physi-
have become critical in the front-line response for cians are to only participate in clinical environments if
COVID-19 patients. As hospitals experience surges in they have appropriate PPE.3,4 Proper fit-testing and train-
admissions, residents in many disciplines, including urol- ing, especially when multiple types/brands of PPE are
ogy, have been asked to function outside their specialty being utilized, are also critical safety factors. These PPE
training to join COVID-19 treatment units. As the pan- lessons will be especially important for the PGY-1 class of
demic unfolds, urology residents will face challenges 2020, as well as some early medical school graduates,4 as
regarding personal safety and well-being, disruptions in any errors in technique or judgment can have significant
their urology training, and relationship strain. Given the consequences.
uncertain duration of the COVID-19 pandemic, and the Many HCW are asymptomatic carriers of COVID-19
possibility of multiple waves of infection,1 long-term and can spread the virus to others. Access to COVID-19
action plans can help prepare training programs and resi- testing for both HCW and patients is variable, and testing
dents during these unprecedented times. In this commen- policies differ by region and institution. It is critical that
tary, we discuss different elements affecting urology residents who experience symptoms suggestive of a
resident training during the COVID-19 pandemic and COVID-19 infection self-quarantine, only return to work
strategies to minimize the impact of these factors. We rec- after cessation of symptoms, and obtain testing if avail-
ognize urology programs are heterogeneously affected by able. Until access to testing increases, clinicians should
the COVID-19 pandemic; these suggestions should be assume patients requiring an operation have COVID-19
adapted to programs’ individual needs and capabilities. until proven otherwise and take the proper precautions.
Urology residents should exercise precautions in the oper-
ating room, as bag mask ventilation, endotracheal intuba-
tion, and laparoscopic surgery are aerosol-generating
PERSONAL AND WORKPLACE SAFETY procedures that carry an increased risk of airborne viral
Access to Personal Protective Equipment and transmission. Resident surgeons should leave the room
COVID-19 Testing during intubation when possible, wear proper PPE, avoid
The large number of HCW infections and deaths from excessive use of electrocautery, and suction surgical smoke
COVID-19 has underscored the importance of access to liberally.5 Hospitals should develop protocols for testing
personal protective equipment (PPE). As a result of PPE patients going to the operating room (OR) based on
shortages, many institutions have encouraged employees testing availability and speed of result acquisition.5
to reuse single-use PPE items for several days or longer, in COVID-19-related precautions should be integrated into
standard surgical time outs to ensure that all OR staff are
* These authors contributed equally to the work in this manuscript. properly protected.
Disclosure: None.
Funding Support: This work is supported by a grant from the National Cancer Institute
(P30CA072720).
IYK receives research support from US Department of Defense (W81XWH-17-1- Temporary Residency Restructuring
0359). Many residency programs have responded to the pan-
EAS receives research support from Astellas/Medivation. demic by assembling rotating teams to cover their urology
From the Division of Urology, Rutgers Robert Wood Johnson Medical School and
Rutgers Cancer Institute of New Jersey, New Brunswick, NJ; and the Rutgers School of services, reducing the risk of COVID-19 exposure to
Public Health, Newark, NJ patients and residents alike.6 Through such a strategy,
Corresponding author: Eric A. Singer, M.D., M.A., M.S., F.A.C.S., Rutgers Can- urology teams maintain a “healthy reserve” of residents
cer Institute of New Jersey, 195 Little Albany Street, New Brunswick, NJ 08903.
E-mail: [email protected] who are available to fill in if a co-resident falls ill. Teams
Submitted: April 16, 2020, accepted (with revisions): April 17, 2020 should consider virtual handoffs and assigning individual
© 2020 Elsevier Inc. https://doi.org/10.1016/j.urology.2020.04.065 15
All rights reserved. UROLOGY 141: 15−19, 2020  0090-4295
residents to round on patients, rather than traditional Telemedicine
team rounds.7 We encourage urology residents to refer One way to supplement clinical training is through active
nonurgent consults directly to telemedicine outpatient participation in telemedicine clinics. As of March 17,
appointments to minimize patient exposure to hospitals 2020, the Centers for Medicare and Medicaid Services
and clinics.6 (CMS) temporarily expanded telehealth coverage for
Additionally, some institutions are running under Medicare patients as part of the Coronavirus Preparedness
ACGME Stage 3 surge protocols, which temporarily lift and Response Supplemental Appropriations Act.11,12 With
common program- and specialty-specific requirements, this policy, many hospitals have encouraged clinicians to
thereby allowing the deployment of urology residents to the transition their clinics to telemedicine platforms for
emergency room, intensive care units (ICUs), and other patients who do not require physical exams or procedures.12
areas of heightened need.3,7,8 Urology residents rotating out- We encourage residents to partake in telehealth initia-
side of their specialty must have adequate supervision in tives, as permitted by their institutions. By participating
these new environments, as is mandated by the ACGME.3,9 in these virtual visits, residents can review charts and
Many urology residents have not rotated on medical or ICU engage in patient counseling under the supervision of an
services since medical school or internship. Therefore, attending urologist. A number of studies have demon-
trainee experience should be considered when deploying strated the feasibility and success of telemedicine clinics
residents to COVID-19 units. Residents should also undergo for urologic conditions, both in pediatrics and adults.13,14
training regarding COVID-19 treatment, complications, To our knowledge, no studies have examined the incorpo-
assessment/management algorithms, airway and ventilator ration of telemedicine into urology residency curricula.
management, palliative care resources, PPE conservation, However, telemedicine clinics have been effectively
and ongoing clinical trials at their respective institutions. implemented in other specialties.15-17

Surgical Simulation
In order to preserve PPE and decrease transmission of
CLINICAL TRAINING COVID-19, the American College of Surgeons issued a
With the deployment of urology team members to non- statement recommending that surgeons curtail elective sur-
urologic services, many questions exist concerning the geries.18 While what constitutes an “elective” case is often
future of urology training.6 During this time, the Ameri- left to the discretion of the surgeon, many institutions have
can Board of Urology (ABU) is actively examining the published protocols for surgical triage, although there is
impact of the COVID-19 pandemic on trainees and will heterogeneity among the recommendations.19,20 With a
aim to provide fair alternatives for residents who require dearth of cases in which residents can participate, there
extended time away from work. The ABU also indefi- may be a role for at-home surgical simulation.
nitely postponed the qualifying exam for graduating urol- Simulations have been used to train residents in funda-
ogy residents.10 With the unclear natural history of mental surgical skills foropen, endoscopic, laparoscopic, and
COVID-19 and potential for future epidemic waves, the robotic procedures.21,22 While some high-fidelity urologic
development of sustainable alternatives to traditional resi- simulations use equipment not readily available for use at
dent educational activities is paramount. home,22 some low-fidelity models can be constructed from

Table 1. Summary of select online educational materials for urology residents

Didactic resources AUA Core Curriculum https://auau.auanet.org/core
AUA Course Catalog https://auau.auanet.org/courses
Urology Collaborative Online Video https://urologycovid.ucsf.edu/
Didactics (COViD)
USC Urology 60 Minutes Youtube channel: Urology 60 minutes
Educational Multi-Institutional https://nyaua.com/empire/
Program for Instructing Residents
(EMPIRE)
Evidence-based Decisions in Surgery http://www.ebds.facs.org/
Research resources AUA Research Overview https://www.auanet.org/research/research-
and online courses overview
Writing A Successful Career https://auau.auanet.org/content/writing-
Development Award Application successful-career-development-award-
(2018) application-2018
Big Data and ’Omics’ Analysis in https://auau.auanet.org/content/big-data-
Urology (2020) and-omics-analysis-urology-2020
Introduction to the Principles and https://ocr.od.nih.gov/courses/ippcr.html
Practice of Clinical Research
(IPPCR)

16 UROLOGY 141, 2020

Table 2. Summary of factors affecting urology residents and action items during the COVID-19 pandemic
Factors Affecting Urology
Residents Action Items
Personal and Access to PPE and
workplace safety COVID-19 testing  Ensure proper fit-testing

 Practice donning and doffing PPE

 Exercise caution in the operating room: leave OR during intuba-

tion, avoid excessive electrocautery, and 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 nonurgent consults to telehealth visits

 Residents deployed to COVID-19 services should complete train-

ing 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 out-

side 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 or 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

UROLOGY 141, 2020 17

household items.21 Additionally, many surgery residency all areas of urology, regardless of their program size, loca-
programs support the use of home laparoscopy box trainers, tion, or faculty composition.
which may be a suitable replacement for virtual reality simu-
lators only available at the hospital.23 Several groups have RESEARCH
described makeshift laparoscopic trainers that can be used at The COVID-19 pandemic has drastically changed many
home.21,23-25 While these simulations are not substitutes for research practices. Some institutions have limited their
live surgeries, they may allow residents to maintain their laboratory staff, and many institutional review boards are
skill set. To further approximate the surgical environment, not approving non-COVID-19 studies for the foreseeable
we suggest experienced surgeons hold interactive virtual future,9 while others continue to maintain their portfolios
review sessions of surgical videos to discuss operative techni- of therapeutic clinical trials. These delays are likely to
ques and procedural nuances. have consequences for both clinical and basic science
research, but faculty mentorship and many current proj-
Training Outside of Urology ects can continue.9,28 We encourage urology residents to
As urology residents are reassigned to the emergency enhance their knowledge of research design and analysis
room, medical floors, and ICUs, trainees have the unique by participating in free online courses offered by the
opportunity to gain exposure to other disciplines that can AUA, American College of Surgeons, and National Insti-
enhance their medical knowledgebase and interoperabil- tutes of Health (NIH) (Table 1).
ity with other services. Residency programs should
encourage learning opportunities outside of urology in
fields such as clinical ethics, health policy, and global PERSONAL WELLNESS
health, all of which have direct applications to the During the COVID-19 pandemic, many urology residents
COVID-19 pandemic.1,26 Residents should share with have been deployed to unfamiliar clinical environments,
each other how their institutions are handling surgical tri- faced with challenges that may threaten their physical
aging, resource allocation, and patient care management and mental health. Many trainees are living separately
innovation. Ensuring we have an adaptable, resilient sur- from their families to reduce the risk of viral transmission.
gical workforce will benefit us now and when we inevita- During this time of physical separation, it is essential that
bly face future crises. 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 encour-
DIDACTICS
aged to hold recurring forums for residents to acknowledge
The COVID-19 pandemic has stimulated worldwide edu- and discuss their daily challenges. Health care systems
cational collaboration within the urology community. should consider regular housestaff screenings for psychiatric
The American Urological Association (AUA) and other conditions including anxiety, depression, insomnia, and dis-
organizations continue to offer a multitude of online tress; mental health services, including emergency hotlines,
didactic resources including the AUA core curriculum should be readily available to those in need.
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 CONCLUSIONS
to their virtual lectures on social media permitting hun-
The timeline for resolution and the long-term effects of
dreds of resident viewers in their audiences. For example,
COVID-19 on our patients and health systems are still
the University of California at San Francisco founded the
unknown. Therefore, urology training programs must
Urology Collaborative Online Video Didactics (COViD),
respond in innovative and dynamic ways. It is critical to
a series of daily online lectures given by urologic educators
ensure safety via adequate PPE and COVID-19 testing and
across the country covering a variety of topics.27 Partici-
provide adequate mental health assessment for urology
pants have the opportunity to engage in discussion and
trainees. While this pandemic has altered clinical duties,
ask questions, thereby receiving state-of-the-art education
urology residents are encouraged to continue ongoing aca-
and gaining exposure to how urology is practiced outside
demic endeavors through digital medical education and
their institutions.27 These digital lectures also promote
research. Ultimately, the challenges created by COVID-19
networking and resident camaraderie. Urology residents
pandemic will be overcome through novel solutions that
working on a flexible clinical schedule should maintain a
can empower the next generation of urologists.
daily log of their educational activities that can be moni-
tored by their program directors. Ultimately, virtual plat-
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