DISCUSSION
The COVID-19 pandemic has placed significant strain on the American healthcare system. In response, major efforts have been made to divert healthcare resources for the treatment of COVID-19 patients. These include cancelling of elective surgery, redeployment of physician specialists to “frontline services,” and the increased use of telemedicine. Additionally, in-person academic meetings and conferences have been cancelled to comply with social distancing recommendations. We sought to characterize urology resident education, clinical practice, and well-being with a national survey, and identified several important trends.
We identified several significant predictors of perceived anxiety and depression, both at work and home. Perceived adequacy of access to PPE was inversely related to all four mental health outcomes. That is, urology residents who reported adequate access to PPE reported lower levels of anxiety and depression. Similarly, a previous study of 1557 healthcare workers during the 2003 Severe Acute Respiratory Distress Syndrome pandemic found that lower stress levels were associated with PPE availability10.
The relationship between PPE availability and mental health during a pandemic may be related to fear of becoming ill and/or spreading the illness to loved ones. Indeed, urology residents who reported the presence of a household member (including themselves) who was susceptible to COVID-19 reported higher levels of anxiety at work, anxiety at home, and depression at work scores. This notion of self-protection is supported by a study of 169 healthcare workers during the avian flu epidemic in which 83% of respondents cited confidence in the hospital’s ability to protect them as the most important factor influencing their willingness to report to work11. These findings suggest that ensuring adequacy of PPE availability is important for urology resident well-being during the COVID-19 pandemic.
Another potentially modifiable predictor of urology resident anxiety and depression was perception of support by the residency program. Residents who reported higher levels of program support had lower anxiety at work and depression at work scores. Furthermore, previous literature has described the importance of perceived support and appreciation by faculty in mitigating burnout amongst general surgery residents under regular circumstances12. Thus, it is important for program directors and faculty to regularly engage with residents and offer support and appreciation as this may improve well-being at work.
Performing surgery is a key component of routine urology practice. However, with the onset of the pandemic, there has been a precipitous decline in operative volume with 94% of urology residents reporting that non-oncologic cases have been cancelled and 37% reporting that oncologic cases have been cancelled. The sharp decline is further illustrated by the decrease in percentage of residents reporting participation in 6 or more operations per week since the onset of the pandemic (89% vs. 5%). This significant decrease in operative volume raises questions about disruption of surgical education. Urology residents tend to be the most active in the operating room during their senior and chief years and accordingly PGY-4 and PGY-5 residents reported higher levels of concerns regarding comfort with operative autonomy at the conclusion of training.
Routine urology practice also encompasses outpatient clinic visits. There has been a radical increase in the reported use of telehealth by urology services since the onset of the pandemic (10% vs. 95%). However, 82% of urology residents report that they have not been trained on how to perform effective telehealth visits. Given the reasonable possibility that increased telehealth usage will persist beyond the pandemic, urology residents would likely benefit from formal telehealth training.
Another major change to routine urology practice has been “redeployment” to a “frontline” COVID-19 service. Approximately one fifth of the urology residents surveyed have been redeployed, most commonly to the intensive care unit, medical wards, and emergency room. Of the redeployed residents, 77% report that their redeployment was mandatory. For all respondents, we assessed perception of declination of voluntary redeployment. Modifiable negative predictors of declination score were perception of institutional support and perception of shared responsibility for pandemic related activities with attendings. That is, urology residents who felt supported by their institution and that additional responsibilities were not being solely placed on the residents would be more likely to agree to voluntary redeployment. It may be helpful for hospital administrators to reach out to residents and inquire what resources they need to feel a greater sense of support (e.g. hazard pay, complementary lodging for self-quarantine, food subsidy). Additionally, responsibility for the care of COVID-19 patients should be shared between attendings and residents. Implementing these changes may improve morale by making redeployment feel more voluntary than mandatory.
Our study had several notable limitations. Our respondent rate was 20% and therefore not necessarily indicative of the entire population of urology residents. This may be an inherent limitation of using an optional survey in this population given that by comparison, the AUA-sanctioned resident survey conducted over three years from 2016-2018 had a respondent rate of only 26%13. Additionally, the survey was predominantly distributed through secondary means (i.e. residency program directors and AUA section secretaries) rather than directly to respondents which may result in sampling error. Furthermore, a simple 1-5 scale was used for assessing depression and anxiety rather than a validated questionnaire such as the Patient Health Questionnaire 9. The use of a validated questionnaire may have provided more insight into the surveyed population. For example, in our study men reported lower depression and anxiety scores. Previous research has found that men tend to underreport anxiety and depression14,15. Without the use of a validated questionnaire, it is unclear if our findings are due to this known underreporting phenomenon or have another explanation.
Despite limitations, we have identified several important interventions which could potentially be undertaken by hospital administrators and urology programs to optimize urology resident well-being, education, and morale during the course of a pandemic. In summary these are: advocating for adequate access to PPE, providing support at both the residency program and institutional levels, instituting telehealth education programs, and fostering a sense of shared responsibility for COVID-19 patients. Interestingly, all of these findings are relatively general in nature and could potentially be applied to all specialties. Thus, we believe it is imperative to perform a follow up study across all specialties to assess the generalizability and validity of our findings. Furthermore, our study provides a unique and timely prospective, as it was conducted during a critical period of the pandemic in the US, capturing the days leading up to and including April 11th, 2020 (the date that the USA became the nation with the most total COVID-19 mortalities).