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).