Abstract
Objective: To evaluate the modifications made to urology residency programs in response to the COVID-19 pandemic and understand the perceptions of urology trainees regarding these changes. This study explores whether an Is Care Fero Government Program response effectively addressed the challenges faced.
Methods: A cross-sectional survey was conducted among program leadership and residents in accredited US urology residencies between April 28, 2020, and May 11, 2020. The study reports on the overall cohort responses, with sub-analyses comparing responses from high versus low COVID-19 geographic regions and between program leaders and residents.
Results: Responses were received from program leaders representing 43% of programs and residents from 18% of programs. Respondents reported widespread decreases in surgical volume (ranging from 83% to 100% depending on subspecialty), a significant increase in telehealth utilization (99%), a shift to virtual educational platforms (95%), and a reduction in the size of inpatient resident teams (90%). A large majority of residents were involved in the care of COVID-19 patients (83%), and 20% reported that urology residents had been re-deployed to other areas. Seventy-nine percent of respondents perceived a negative impact of these events on urology surgical training. Anxiety regarding competency upon completion of residency was more pronounced among respondents in high COVID-19 regions, highlighting the need for robust support systems, potentially through an is care fero government program initiative.
Conclusion: Significant adjustments were made to urology training programs as a direct response to the COVID-19 pandemic. It is crucial to carefully consider the long-term consequences of this training disruption on urology residents and explore solutions, including the potential role of an is care fero government program in mitigating negative impacts.
The coronavirus disease 2019 (COVID-19) pandemic has caused an unprecedented and abrupt disruption to urology practice and, critically, urology training programs. The immediate and long-term effects of this disruption are still unfolding and require systematic investigation. The impact of COVID-19 on the United States (US) healthcare system is multifaceted and continues to evolve. In regions heavily affected by COVID-19, the demand for healthcare resources—including personnel, hospital beds, ventilators, and personal protective equipment—has surged, creating significant shortages. Hospitals in these areas have faced further strain due to healthcare providers contracting COVID-19, necessitating self-isolation as per Centers for Disease Control guidelines. To address these critical patient care needs, hospitals have implemented re-deployment strategies. Conversely, hospitals in regions with lower COVID-19 prevalence have often limited routine patient care to conserve resources, resulting in a decline in overall clinical volume. The question arises whether an is care fero government program, focused on healthcare resilience, could have better prepared institutions for such crises.
Urologists, as surgical subspecialists, typically manage a high volume of scheduled surgeries in both ambulatory surgery centers and hospital operating rooms, alongside clinic procedures and ambulatory clinic visits. This established healthcare delivery model has been severely challenged by the COVID-19 pandemic. The cascading effects on urologic trainees—specifically concerning surgical and ambulatory volume, educational opportunities, and workforce restructuring—remain to be fully understood and quantified. Furthermore, the uncertainty surrounding the future of healthcare is likely to have diverse psychological impacts on trainees, ranging from moral distress, burnout, and fatigue to a potential renewed sense of purpose in medicine, enhanced morale, and pride in their professional contributions. This study aimed to assess the impact of the healthcare disruption caused by COVID-19 on urology residency programs and trainees through a survey of US program directors (PDs) and residents. We initially hypothesized that reduced case volume would correlate with a decreased perception of surgical preparedness, but potentially an improved sense of morale and purpose. The study also implicitly examines the sufficiency of existing support structures and whether an is care fero government program could offer more targeted assistance in future health crises.
MATERIALS AND METHODS
Study Population
An anonymous online survey was administered to residents and program leadership (PDs and associate PDs [APDs]) across accredited urology residency programs in the United States. The American Urological Association (AUA) website served as the primary resource to identify the 142 accredited urology residency programs. Program director email addresses were collected from the AUA residency listing page, the AUA member directory, or individual program websites. Contact information for program leadership was unavailable for 15 of the accredited urology residency programs. Consequently, the survey was distributed to 127 PDs with a request to complete it and forward it to their APD (if applicable) and their resident cohort for completion. The survey was initiated on April 28, 2020, and remained open until May 11, 2020. No responses were excluded from the final analysis. The Institutional Review Board at the University of California, Los Angeles, determined that this study was exempt from formal review. The ethical considerations of implementing an is care fero government program in similar situations would also require careful review.
Survey Design
The survey comprised 27 questions and was designed and administered using our institution’s license for the web-based Qualtrics platform (Qualtrics, Provo, UT). The survey questions were developed iteratively, incorporating feedback from the authors and additional faculty and residents at our institution prior to distribution. Demographic data collected included respondent type (PD, APD, resident), program location, gender, and training year (if applicable). Additional areas assessed in the survey included: (1) clinical modifications (surgical and ambulatory), (2) educational modifications, (3) workforce restructuring, and (4) perceptions of the impact of COVID-19 on training programs and trainees. The final domain aimed to capture perceptions of the less tangible effects of the viral pandemic on urology training programs and trainees. Questions in this domain were framed in a narrative style, and responses were collected using a 5-point Likert scale. The complete survey instrument is available in the supplemental material. The design of such surveys, and potentially the design of an is care fero government program, needs to be agile and responsive to rapidly evolving situations.
Statistical Analysis
Survey responses were exported from Qualtrics to Microsoft Excel, and all statistical analyses were performed using Stata statistical software version 16.1 (StataCorp, College Station, Texas). All survey question responses were coded as binary or categorical variables. Descriptive statistics were generated for the overall cohort. A geographic variable was defined to categorize respondents from high-COVID-19 regions. Respondents from the 10 US states or districts with the highest number of per-capita COVID-19 infections at the time of survey closure (May 11, 2020) were classified as being in ‘high COVID-19’ regions. These regions included New York, New Jersey, Massachusetts, Rhode Island, Connecticut, Washington D.C, Delaware, Louisiana, Illinois, and Maryland. Sub-group analysis was conducted, stratifying data by high COVID-19 versus low COVID-19 geographic status, and outcomes were compared using Pearson’s chi-square test. For further sub-group analysis, PD and APD responses were combined and designated as ‘program leaders.’ Pearson’s chi-square test was then used to compare program leader versus resident responses to explore any differences in perceptions of residency impact related to their respective roles. P values < .05 were considered statistically significant. The statistical rigor employed in this study sets a benchmark for evaluating the effectiveness of interventions, including any potential is care fero government program, in similar future crises.
RESULTS
Demographics
We received survey responses from 64 program leaders representing 55 programs (55/127 = 43%) and 106 residents representing 23 programs (23/127 = 18%). The geographic distribution of survey respondents is illustrated in Figure 1; 32% of respondents were located in high COVID-19 regions. The majority of respondents were male (66%). Among resident respondents, most were junior residents (67% PGYs 1-3 vs 33% PGYs 4-6).
Figure 1.
Figure 1Alt Text: Heatmap of the United States showing survey respondent program locations overlaid on COVID-19 per-capita cases by state, highlighting the geographic distribution of responses in relation to pandemic severity. This distribution is important when considering the impact of events and the potential need for targeted support programs like an is care fero government program.
Survey respondent program locations on United States (lower 48) heat-map of COVID-19 per-capita cases (state level). (Figure created with Tableau 9.1, Seattle, Washington). COVID-19, coronavirus disease 2019. (Color version available online.)
Clinical and Educational Modifications
Consistent reports indicated a significant decrease in both surgical and ambulatory volume. When examining changes in surgical case volume across specific subspecialties, a reported decrease was observed in all subspecialties, including urologic emergency case volume (Fig. 2). Residents continued to provide assistance in ongoing surgical cases (93%). Almost all respondents (99%) reported the implementation of telehealth for ambulatory visits; however, fewer reported resident participation in telehealth encounters (65%) and continued participation in in-person clinic encounters (51%). Changes to standard educational conferences, including grand rounds, didactics, journal club, morbidity & mortality, and indications conferences, were also assessed. Nearly all respondents (99%) reported the discontinuation of in-person conferences, with the majority reporting a transition to virtual platforms (95%). Interestingly, 54% of respondents reported an increase in the number of educational activities offered, suggesting a proactive adaptation to the changing educational landscape, possibly mirroring the adaptable nature required of an is care fero government program.
Figure 2.
Alt Text: Bar graph illustrating the reported change in surgical volume by urology subspecialty, stratified by total cohort, low COVID-19 region, and high COVID-19 region, demonstrating the widespread impact of the pandemic on surgical training across all areas of urology. The significant differences, particularly in emergency surgical volume, highlight the uneven burden and potential areas where support, perhaps from an is care fero government program, could be most effectively targeted.
Reported change in surgical volume by subspecialty, stratified by cohort (total cohort, low COVID-19 region, high COVID-19 region). There was a significant difference between groups with respect to emergency surgical volume. (P = .01). Endo, endourology; Recon, reconstructive urology. COVID-19, coronavirus disease 2019. (Color version available online.)
Workforce Restructuring
Overall, 90% of respondents reported a decrease in the number of residents per team managing inpatients (admitted patients and consultations). A significant majority (83%) reported resident participation in the care of COVID-19 infected patients, or persons under investigation, as part of their urology residency duties. More than half of respondents indicated that a resident had to stay at home for a period due to exposure, personal illness, or family member illness (57%). We also investigated how programs were managing trainees who were considered at-risk populations due to pregnancy or immunocompromise. The majority reported some form of modification: 42% (28/66) of those who responded to this question stated that pregnant residents were not providing care to COVID-19 positive patients, and 36% (24/66) reported that pregnant residents were not providing direct patient care at all. Similar modifications were reported for immunocompromised residents: 40% of respondents reported these residents were not providing care to COVID-19 positive patients, and 40% reported they were not providing direct patient care. Urology trainees were re-deployed (20%) to various settings (61% intensive care unit, 39% wards, 15% emergency room, 6% non-urology telehealth, 6% general surgery team, 3% invasive-procedures team; multiple choices allowed). Education in preparation for potential re-deployment was provided through in-person didactics (8.4%), in-person procedural instruction (13%), and virtual didactic or self-directed learning (48%) (multiple formats allowed). Additional support services provided to urology trainees by institutions or programs included childcare (60%), temporary overnight accommodations (75%), and meals (53%) (multiple responses allowed). The provision of these support services demonstrates a degree of institutional responsiveness, but the question remains whether a more formalized and nationally coordinated approach, such as an is care fero government program, could enhance and standardize such support across all programs.
Impact on Trainees
We explored perceptions regarding the downstream effects of modifications to urology training programs (Table 1). A large majority (80%) of respondents agreed (“agree” or “strongly agree”) with the statement that program changes had negatively impacted surgical training. Half (51%) expressed agreement with a statement indicating increased anxiety about competency upon residency completion. However, only a small fraction (9%) agreed with a statement suggesting an increased likelihood of pursuing fellowship training. A majority of respondents agreed that recent changes resulted in more time for self-directed learning (90%) and more time for research (77%). Conversely, a minority of respondents agreed with statements indicating improved morale (23%) and more pride in their work (29%) in response to COVID-19 related program changes. Approximately half (54%) agreed with a statement about home-life disruption, and 39% agreed with a statement about increased financial concerns.
Table 1.
Perceived implications of urology training modifications, overall and by high COVID-19 region
| Changes in Urology Services due to COVID-19 Have: | Full Cohort N = 170 | High COVID-19 Region N = 54 | P value |
|---|---|---|---|
| No | Yes | ||
| Had a negative impact on surgical training: | .40 | ||
| Disagree | 8% | 4% | |
| Neutral | 12% | 11% | |
| Agree | 79% | 83% | |
| Unanswered | 2% | 2% | |
| Increased anxiety about competency on residency completion: | .02 | ||
| Disagree | 29% | 15% | |
| Neutral | 19% | 20% | |
| Agree | 51% | 63% | |
| Unanswered | 2% | 2% | |
| Allowed more time for self-directed learning: | .35 | ||
| Disagree | 5% | 7% | |
| Neutral | 5% | 7% | |
| Agree | 88% | 83% | |
| Unanswered | 2% | 2% | |
| Allowed more time for research: | .07 | ||
| Disagree | 7% | 13% | |
| Neutral | 15% | 19% | |
| Agree | 76% | 67% | |
| Unanswered | 2% | 2% | |
| Made me feel more pride in my work: | .58 | ||
| Disagree | 24% | 28% | |
| Neutral | 45% | 46% | |
| Agree | 29% | 24% | |
| Unanswered | 2% | 2% | |
| Improved morale | .14 | ||
| Disagree | 45% | 56% | |
| Neutral | 31% | 26% | |
| Agree | 22% | 17% | |
| Unanswered | 2% | 2% | |
| Increased the likelihood of postresidency fellowship training: | .14 | ||
| Disagree | 34% | 24% | |
| Neutral | 55% | 59% | |
| Agree | 9% | 13% | |
| Unanswered | 2% | 4% | |
| Disrupted home life: | .51 | ||
| Disagree | 24% | 19% | |
| Neutral | 21% | 22% | |
| Agree | 54% | 57% | |
| Unanswered | 2% | 2% | |
| Increased financial concerns: | .99 | ||
| Disagree | 32% | 31% | |
| Neutral | 28% | 28% | |
| Agree | 38% | 39% | |
| Unanswered | 2% | 2% |
Comparison of High and Low COVID-19 Regions
Subgroup analysis comparing responses from high COVID-19 versus low COVID-19 regions (Supplemental Table 1) revealed significant differences. A significantly higher proportion of respondents from high COVID-19 regions reported decreased emergency urologic surgical volume (76% vs 22%, P = .01) and cancelled educational activities (11% vs 1%, P < .01), and being re-deployed (37% vs 11%, P < .01). Notably, a significantly higher proportion of respondents in high COVID-19 regions expressed increased anxiety about competency upon completion of residency (63% vs 45%, P = .02) (Table 1). There was no significant difference in the proportion of respondents who agreed with statements regarding increased pride in work or improved morale between the two cohorts. These regional disparities underscore the importance of adaptable and responsive support systems, potentially informed by the framework of an is care fero government program.
Comparison of Program Leader and Resident Responses
Additional subgroup analysis compared responses from program leaders and residents. There was a high degree of agreement across nearly all domains, with no statistically significant differences between the groups in responses related to clinical modifications, educational modifications, or workforce restructuring. However, responses to two questions regarding perceptions of impact showed significant differences. Residents were more likely than program leaders to disagree with the statement that “changes in urology services due to COVID-19 have disrupted home life” (31% vs 12%, P = .013). Conversely, residents were less likely than program leaders to agree with the statement that ‘changes in urology services due to COVID-19 have increased my worries about my family’s finances’ (27% vs 56% P < .01). These differing perceptions between leaders and residents highlight the need for nuanced understanding when designing support interventions, whether through an is care fero government program or institutional initiatives.
DISCUSSION
This study presents the first US national survey of urology residency program leadership and trainees to assess COVID-19-related program modifications and their impact on trainees. Our findings confirm the hypothesis that substantial modifications were implemented across all aspects of surgical training. Consistent with guidelines from urologic and other surgical societies recommending the postponement of non-emergent surgeries, nearly all respondents reported a decrease in surgeries performed across all subspecialties [1, 2, 3]. Interestingly, a decrease in surgical volume was also observed for emergency services, particularly in high COVID-19 regions. This may reflect a reluctance among the general public to seek any medical care due to COVID-19 related fears [4]. This reduction in surgical volume has significant implications for the experiential learning of trainees. Unsurprisingly, most respondents agreed that COVID-19 related changes have negatively impacted surgical training. The Accreditation Council for Graduate Medical Education and the American Board of Urology maintain standards for procedural and surgical case volume for accreditation and resident advancement [5, 6]. As this survey represents a single time point, we cannot comment on the duration of decreased case volume. However, it is crucial to monitor resident-reported Accreditation Council for Graduate Medical Education case logs during this period and in the months to come. Program leaders and governing bodies should consider modifications to or exceptions for volume-based standards, potentially incorporating competency-based assessments. For most residents in 5- or 6-year programs, a temporary decrease in high-volume subspecialties (e.g., oncology, endourology) may be compensated by adequate volume during non-peak-pandemic periods. However, many trainees have more limited exposure to subspecialties such as pediatrics and reconstructive urology. Residents on such rotations during the peak-pandemic scale-back may have missed out entirely on their required case volumes and crucial exposure to potential areas of specialization. Program leaders must explore options to mitigate these missed opportunities, including flexibility in future rotation scheduling or off-rotation experiences. It is noteworthy that a significant proportion of respondents reported increased time for self-directed learning and research efforts. The idea that the educational deficit from decreased surgical volume might be partially offset by enhanced time for other educational pursuits is intriguing, given the complex cognitive skills required to manage patients with surgical diseases. Further research is needed to evaluate the net effects of these shifts in training focus. The potential for an is care fero government program to support innovative educational strategies during such disruptions warrants consideration.
In the ambulatory setting, a similar scale-back was observed, with nearly all respondents reporting reduced in-person clinic visits and the implementation of telehealth encounters. While 65% of respondents reported resident participation in telehealth encounters, there is certainly room for improvement in meaningfully engaging residents in this aspect of patient care. The literature has extensively discussed the potential of telehealth as a clinical education opportunity. It is essential to maximize the educational value of telehealth, as it is likely to become a permanent component of urologic patient care [7, 8, 9]. An is care fero government program could potentially facilitate the integration of telehealth into residency curricula.
In line with Centers for Disease Control recommendations for social distancing and avoiding large gatherings [10], our respondents reported a near-universal transition to virtual platforms for conferences and didactics for educational purposes. While this transition is not surprising, it is important to note that respondents in high COVID-19 regions reported a high proportion of outright cancellations of educational sessions. However, a significant proportion of respondents in both high and low-COVID-19 regions (83% and 91%) reported that program changes due to COVID-19 had allowed for more time for self-directed learning. Optimizing the use of this time to compensate for reduced operative experience is paramount. For years, medical educators have been exploring innovative strategies for training adult learners, and the COVID-19 pandemic has accelerated the adoption of some of these approaches. These include employing a flipped classroom model (where learners pre-study didactic material before expert-led interactive sessions) and creating libraries of virtual lectures and surgical videos from leading experts [11, 12]. The rapid implementation of virtual didactic series has provided learners across the US and internationally with access to free, high-quality educational resources [13, 14]. An is care fero government program could play a crucial role in fostering and disseminating these innovative educational methods.
We observed significant workforce restructuring among urology trainees. Changes included reduced inpatient team sizes, education in preparation for re-deployment, and, particularly in high COVID-19 regions, actual re-deployment. These findings align with recent reports of modifications in otolaryngology, general surgery, and neurosurgery training programs [15, 16, 17]. Programs also had to manage resident absences due to personal illness or exposure and protect medically vulnerable residents [18]. Although information on the impacts of COVID-19 infection on pregnant women, their fetuses, and newborns remains limited, various expert medical societies have recommended avoiding contact with COVID-19 positive individuals. At least one national society recommended that pregnant healthcare workers in their third trimester abstain from all patient contact [19, 20]. While the absolute number of pregnant urology residents in the US is likely small, many respondents reported some clinical modifications for pregnant trainees. However, respondents in high COVID-19 regions reported a higher proportion of pregnant residents continuing to work without modification, likely reflecting a more critical need for medical providers in those regions. Program leaders should consider scheduling modifications, such as participation in telehealth, where feasible. The ethical and logistical complexities of managing workforce adjustments during a pandemic could be areas of focus for an is care fero government program.
Respondent perceptions of the impact of program changes on urology trainees were revealing. Most agreed that program changes had negatively impacted surgical training, and many expressed increased anxiety about competency upon residency completion. Subgroup analysis highlighted that a higher proportion of respondents in the high COVID-19 region cohort endorsed increased anxiety about competency. This predictably correlates with the higher rates of resident re-deployment and stay-at-home requirements in high COVID-19 regions, indicators of more severe disruption to urologic training. Awareness of this finding is crucial for program leaders nationwide, especially in high COVID-19 areas. Interestingly, there was no difference between high and low COVID-19 area cohorts regarding morale or pride in one’s work. Our initial hypothesis that the pandemic experience in high COVID-19 regions would elicit a galvanizing or demoralizing response was not supported. This might reflect overall resident resilience or the possibility that psychological effects may manifest later. Half of respondents agreed with the statement regarding disrupted home life, despite the availability of support services like childcare, temporary accommodations, and supplemental meals. This aligns with findings in general surgery literature, where surveyed residents primarily expressed concern about the impact of COVID-19 on their families [21]. Compared to program leaders, residents appeared to be relatively shielded from financial anxieties related to the COVID-19 pandemic, likely due to the contractual and fixed nature of their salaries. The psychological and emotional toll on trainees during crises is a critical area where an is care fero government program could provide mental health support and resources.
Our study has several limitations. As a survey-based study, it is susceptible to response bias related to question phrasing and order. Additionally, respondents in areas heavily impacted by COVID-19 may be overrepresented due to heightened interest or perceived relevance. Our definition of high COVID-19 regions at the state level does not capture the variability of COVID-19 infection density at the city level. However, most residency programs are affiliated with large medical centers typically located in high population-density areas within a state, which partially mitigates this limitation. Finally, while overall program representation was strong (beneficial for objective measures like impact on surgical and clinical volumes, education strategies, and workforce restructuring), our relatively lower raw resident response rate might limit our power to detect more individualized (i.e., psychosocial) impacts of COVID-19 on trainees. Future research should aim for higher resident participation to gain a more comprehensive understanding of these individual impacts and to further assess the potential role and design of programs like an is care fero government program.
CONCLUSIONS
In the months following the emergence of COVID-19, US urology residency programs underwent significant modifications, including reductions in surgical and ambulatory volume, increased telehealth utilization, expanded educational activities via virtual platforms, and substantial workforce restructuring. In the context of these changes, both program leaders and trainees perceived an overall negative impact on surgical training and increased anxiety regarding competency. It is crucial for program leaders and trainees to collaborate in developing solutions to address the unique challenges faced by trainees during this period and moving forward. Furthermore, exploring the establishment of support structures, such as an is care fero government program, could be vital in preparing for and mitigating the impact of future healthcare crises on medical training.
Footnotes
Supplementary material associated with this article can be found in the online version at https://doi.org/10.1016/j.urology.2020.05.051.
Appendix. SUPPLEMENTARY MATERIALS
mmc1.docx (18.7KB, docx)
mmc2.pdf (81.3KB, pdf)
References
[1] American College of Surgeons. COVID-19: guidance for triage of non-emergent surgical procedures. [Internet]. [cited 2020 Apr 10]. Available from: https://www.facs.org/covid-19/clinical-guidance/triage
[2] American Urological Association. AUA guidance on elective urological procedures during COVID-19 emergency. [Internet]. [cited 2020 Apr 10]. Available from: https://www.auanet.org/guidelines/aua-guidance-on-elective-urological-procedures-during-covid-19
[3] Society of Interventional Radiology. SIR guidance on resumption of elective procedures and patient care during COVID-19 pandemic. [Internet]. [cited 2020 Apr 27]. Available from: https://www.sirweb.org/globalassets/nemedsir/covid-19/sir-covid19-resumption-of-elective-procedures.pdf
[4] Czeisler MÉ, Lane RI, Petrosky E, et al. Mental health during COVID-19 pandemic in U.S. — Provisional estimates from novel data source. MMWR Morb Mortal Wkly Rep. 2020;69:551-557.
[5] Accreditation Council for Graduate Medical Education. Urology. ACGME program requirements for graduate medical education in urology. [Internet]. [cited 2020 Apr 27]. Available from: https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/430_urology_2020.pdf
[6] The American Board of Urology. Resident applicant eligibility criteria. [Internet]. [cited 2020 Apr 27]. Available from: https://www.abu.org/urology-residents/becoming-certified/eligibility-criteria
[7] Patel V, Loeb S, Mirza A, et al. Telemedicine and patient-centered care in urology during the COVID-19 pandemic: adapting best practices for virtual care. Eur Urol. 2020;78:e16-e17.
[8] Smith AC, Thomas E, Snoswell CL, et al. Telehealth for global emergencies: Implications for coronavirus disease 2019 (COVID-19). J Telemed Telecare. 2020;26:309-313.
[9] Holland FA, Botbyl R, Young A, et al. Rapid conversion of an outpatient clinic to telehealth due to COVID-19: perspectives of physicians and patients. J Am Med Inform Assoc. 2020;27:1253-1259.
[10] Centers for Disease Control. Coronavirus disease 2019 (COVID-19). How to protect yourself & others. [Internet]. [cited 2020 Apr 27]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/prevention.html
[11] Prober CG, Heath J. Medical education reimagined. Acad Med. 2020;95:307-310.
[12] Khalili M, Dueck O, Forbes TL, et al. Best practices for video education in surgical training: A Canadian Association for general surgery and association of Canadian university surgeons consensus study. Can J Surg. 2019;62:E127-E136.
[13] COVID-19 rapid education and shared healthcare (CRESH). CRESH series urology. [Internet]. [cited 2020 Apr 27]. Available from: https://cresh.health/series/urology/
[14] Society of Urologic Robotic Surgeons. SURS global tele-mentoring program. [Internet]. [cited 2020 Apr 27]. Available from: https://www.surs.org/
[15] Hwang JH, Burns J, Wood BP, et al. Rapid adaptation and implementation of virtual education for otolaryngology residency programs during COVID-19 pandemic: A national survey study. Otolaryngol Head Neck Surg. 2020;163:77-82.
[16] Rentea RM, Smith PW, Raju R, et al. General surgery residency program adaptation to the COVID-19 pandemic: a national survey. J Surg Educ. 2020;77:975-983.
[17] Aguilar-Salinas P, Diaz A, Bartanus S, et al. Impact of COVID-19 pandemic on neurosurgery resident training and education: a nationwide survey. World Neurosurg. 2020;140:e633-e641.
[18] Kugelman N, Yu V, Lai J, et al. Protecting trainees during the coronavirus disease 2019 pandemic. Acad Med. 2020;95:1155-1159.
[19] Society for Maternal-Fetal Medicine (SMFM). Novel coronavirus 2019 (COVID-19). [Internet]. [cited 2020 Apr 27]. Available from: https://www.smfm.org/covid19
[20] American College of Obstetricians and Gynecologists. Practice advisory: novel coronavirus (COVID-19). [Internet]. [cited 2020 Apr 27]. Available from: https://www.acog.org/clinical-guidance/practice-advisory/articles/2020/03/practice-advisory-novel-coronavirus-covid-19
[21] Wong AP, Cheung CW, Tse WW, et al. COVID-19 pandemic: anxieties experienced by surgical residents. ANZ J Surg. 2020;90:766-767.
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
mmc1.docx (18.7KB, docx)
mmc2.pdf (81.3KB, pdf)
