key: cord-0774235-u0lbh7t6
authors: Hanson, Kate A.; Borofsky, Michael S.; Lindsay, A. Hampson; Breyer, Benjamin N.; Kern, Nora G.; Conti, Simon L.; Kielb, Stephanie J.; Sorensen, Mathew D.
title: Capturing the Perspective of Prospective Urology Applicants: Impacts of COVID-19 on Medical Education
date: 2020-09-30
journal: Urology
DOI: 10.1016/j.urology.2020.09.027
sha: f481e7bff7badcfe8eb6209ddd6b180d7d8451c0
doc_id: 774235
cord_uid: u0lbh7t6

OBJECTIVE: To capture the perspective of prospective urology applicants experiencing unique challenges in the context of COVID-19. METHODS: A voluntary, anonymous survey was distributed online, assessing the impact of COVID-19 on a large sample of US medical students planning to apply to urology residencies. Themes of (1) specialty discernment, (2) alterations to medical education, and (3) the residency application process were explored. RESULTS: A total of 238 medical students, 87% third- and fourth- years, responded to the survey. While 85% indicated that the pandemic had not deterred their specialty choice, they noted substantial impacts on education, including 82% reporting decreased exposure to urology. Nearly half of students reported changes to required rotations and 35% reported changes to urology-specific rotations at their home institutions. Students shared concerns about suspending in-person experiences, including the impact on letters of recommendation (68% “very concerned) and program choice (73% “very concerned”). Looking to the possibility of virtual interactions, students identified the importance of small group and one-on-one communication with residents (83% “very important”) and opportunities to learn about hospital facilities (72% “very important”). CONCLUSIONS: Despite the impacts of COVID-19 on medical education, prospective urology applicants appear to remain confident in their specialty choice. Students’ biggest concerns involve disruption of away rotations, including impacts on obtaining letters of recommendation and choosing a residency program.

MeSH Terms : " U ro logy , " " Educa t ion , Med ica l , " " I n t e rnsh ip and res idency , " " COVID-19 " Th is wo rk was in i t i a l l y ga the red to i n f o rm the Soc ie t y o f Academic Uro log i s t s (SAU) Execu t i ve Commi t tee as they made dec is io ns re la ted to a l t e ra t i ons in ex te rna l ro t a t ions , rec ru i tmen t , i n te rv iews , and the r es idency ma tch p r ocess f o r t h i s yea r due to t he COVID-19 pandemi c . I t was a l so used by seve ra l o f t h e V i r t ua l Sub-In te rnsh ips i n Uro logy SAU Work ing G roups to he lp c rea te a gu idebook .

Objec t i ve To cap tu re the pe rspec t i ve o f p rospec t i ve u ro logy app l i can ts exper ienc ing un ique cha l l enges in t he con tex t o f COVID -19.

A vo lun ta ry , anonymous su rvey was d i s t r i bu ted on l i ne , assess ing the impac t o f COVID-19 on a l a rge samp le of US med ica l s tudent s p lann ing to app ly t o u ro logy res idenc ies . Themes of (1 ) spec ia l t y d i s ce rnmen t , (2 ) a l te ra t i ons to med i ca l educa t ion , and (3 ) t he res idency app l i ca t i on process were exp lo r ed .

Resu l t s A to ta l o f 238 med i ca l s tuden ts , 87% t h i rd -and fou r th -y ears , responded t o t he su rvey . Wh i l e 85% ind i ca ted that t he pandemic had no t de te r red t he i r spec ia l t y choi ce , t hey no ted subs tan t ia l impac ts on educa t ion , i nc lud ing 82% repo r t i ng dec reased exposu re to u ro logy . Near l y ha l f o f s tuden ts repo r ted changes to requ i red ro ta t i ons and 35% r epor ted changes t o u ro logy -spec i f i c r o ta t i ons a t t he i r home ins t i t u t i ons . S tuden ts shared conce rns abou t suspend ing i n -per son expe r iences , i nc lud ing the impac t on l e t t e rs of recommenda t ion (68% " ve ry conce rned) and p rog ram cho ice (73% " ve ry conce rned " ) . Look i ng to t he poss ib i l i t y o f v i r t ua l i n te rac t ions , s tuden ts i den t i f i ed the impor tance o f sma l l g roup and oneon -one commun ica t i o n w i th res iden ts (83% " ve ry impor tan t " ) and oppor tun i t i es t o l e arn abou t hosp i ta l f ac i l i t i es (72% " v ery impor tan t " ) .

Desp i te the impac ts o f COVID-19 on medi ca l educa t ion , p rospec t i ve uro logy app l i can ts appear t o rema in con f iden t i n t he i r spec ia l t y cho ice . Studen ts ' b igges t c once rns invo l ve d i s rup t i on o f away ro t a t ions , i nc lud ing impac ts on ob ta in ing l e t t e rs o f recommenda t ion and choos ing a res idency p rog ram.

MeSH Terms : " U ro logy , " " Educa t ion , Med ica l , " " I n t e rnsh ip and res idency , " " COVID-19 " I n t roduc t ion

The COVID-19 pandemic has resul t ed in w ide -reach ing and un fo reseeab le changes to med ica l educa t ion . As a resu l t o f c ruc ia l hea l th and sa fe t y precau t ions , med ica l s tuden t s were t empora r i l y removed f rom the c l i n i ca l env i ronmen t , resul t i ng in de lays and a l te ra t i ons o f co re requ i remen ts and spec ia l t y exper i ences . S tuden ts have been tak ing c l i n i ca l sub jec t exams remote l y , and na t iona l l i cens ing exams have been suspended . Changes w i l l con t inue in to the 2020-2021 res idency app l i ca t ion cyc le, s ta r t i ng w i th the Coa l i t i on fo r Phys ic ian Accoun tab i l i t y ' s r ecommenda t ions agai ns t away ro ta t i o ns and in -pe rson i n te rv iews . 1 The Assoc ia t i on o f Ameri can Med ica l Co l le ges de layed the app l i ca t ion dead l i ne fo r the E lec t r on ic Res idency Appl i ca t i on Serv ice . For med ica l s tuden ts in te res ted in app ly ing t o u ro logy res idenc ies , these changes p resen t un ique cha l lenges . The Amer ican Uro log i ca l Assoc iat i on match is consi s ten t l y compe t i t i ve and ear l i e r in t he yea r than the genera l Na t iona l Res iden t Match ing Prog ram. Med ica l s tuden ts have l imi t ed exposu re to uro logy , as ha l f o f U.S . schoo ls prov ide no fo rma l cou rsework i n uro logy be fo r e th i rd year . 2 His to r i ca l l y , mos t p rospec t i ve app l i can ts have used the i r fou r th yea r to comp le te mu l t i p le uro logy -spec i f i c r o ta t i ons a t d i f f e r en t ins t i t u t i ons , a l low ing s tuden ts t o ga in add i t i ona l exposu re , con f i rm the i r in te res t in uro logy as a ca r eer cho ice , demons t ra te geograph ic f lex ib i l i t y , and ob ta in le t t e rs o f recommenda t ion . In the cu r ren t con tex t , s tuden ts ' inperson expe r iences wi l l be res t r i c ted to the i r home ins t i t u t i on w i th the Ken isbe rg e t a l . used the mos t r ecen t c lass as a proxy fo r these ques t ions , f i nd ing tha t those who have a l ready undergone the app l i ca t i on process fee l ce r t a in componen ts canno t be rep l i c a ted v i r tua l l y . 4 However , the issue rema ins tha t so lu t i ons and adap ta t ions shou l d cons ide r the perspec t i ve o f d i rec t st akeho lde rs , the 2020 -2021 app l i can t c lass . We sough t to cap tu re the i r v iewpo in t th rough a su rvey -based ques t ionna i re . We focused on how the pandemic has impac ted th ree doma ins o f the t rad i t i ona l s t uden t expe r ience :

(1 ) spec ia l t y d isce rnmen t , (2 ) al t e ra t i ons to t radi t i ona l med ica l educa t ion , and (3 ) t he u ro logy res idency app l i ca t i on p r ocess . We an t i c i pa te tha t such i n fo rma t ion may prove use fu l to u ro l ogy t ra in ing p rograms as rap id and

widesp read e f fo r t s a re be ing made to deve lop new educat i ona l expe r iences and in te rac t i ons w i t h med ica l s tuden ts i n te res ted i n u ro l ogy .

A Goog le Forms survey was deve loped wi th med ica l s tuden t and prog ram d i rec to r ove rs igh t f rom s i x Un i ted S ta tes uro logy res idency prog rams. Survey ques t ions were rev i ewed fo r con ten t , qua l i t y , c la r i t y ,

and e f f ec t i veness . Par t i c ipa t i on was anonymous and vo lun t ary . One ques t ion was in tab le fo rma t wi th a l i s t o f t rad i t i ona l cu r r i cu la r e lemen t s ( requ i red th i rd -yea r co re ro ta t i on, gene ra l su rge ry co re ro ta t i on , u rol ogy ro ta t i on a t home ins t i t u t i on , uro logy ro ta t i on a t o the r ins t i t u t i on , USMLE Step 1 exam, USMLE Step 2 exam) and a l lowed s tuden ts to se lec t app l i cab le a l t e rat i ons tha t they had exper ienced due t o COVID-19 (cance led , a l t e red f rom t rad i t i ona l fo r m, pos tponed , no t a f fec ted , unsu re ) .

Three ques t ions asked s tuden ts to iden t i f y the leve l of p r io r i t y o f spec i f i c i ssues . Regard ing changes to the i r cu r r i cu lum and match process , the sca le ranged f rom " no t a conce rn , " " so me conce rn , " to

" v e r y conce rned . " For poss ib le feat u res o f v i r t ua l i n te r ac t ions wi th prog rams, the range was " no t impor tan t , " somewha t impor tan t , " to

" v e r y impor tan t . "

The survey was d i s t r i bu ted by each o f the 6 uro logy res idency prog rams , u t i l i z i n g a l i nk th rough Uro logy Co l labo ra t i ve On l ine V ideo Didac t i cs (COViD) eva lua t i on fo rm. COViD is a mu l t i -i n s t i t u t i ona l e f fo r t t o p rov ide lec tu res fo r res iden ts dur ing COVID tha t i s hos ted by the UCSF webs i te . 5 It p rov ides an eva l ua t ion fo rm fo r vi ewers to assess l ec tu res . V iewers who comp le ted an eva lua t i on form and se lec ted " med ica l s tuden t " as the i r eva lua t or demograph ics were then d i rec ted Spec ia l t y D isce rnmen t Most s tuden ts repor ted COVID-19 has had " no change" on the i r dec is ion to app ly to u ro logy (86%, n=201 ) . Overa l l , 9% (n=21) were " l e ss l i ke l y to app ly " to u ro logy and 3% (n=6) were "mo re l i ke l y to app ly . " Fo r s tuden ts who repor ted be ing less l i ke l y t o app ly , the most common con t r i bu t i n g fac to rs were " i n ab i l i t y to rot a t i on a t o the r i ns t i t u t i ons " (76%, n=16) and " i nsuf f i c i en t exposu re t o u ro logy to be con f iden t in spec i a l t y cho ice " (67%, n=14) . S tuden ts who were "more l i ke l y to app ly " repo r ted tha t they had add i t i ona l t i me to lea rn abou t uro logy (50%, n=3) ) and cons ide red uro logy a t rad i t i ona l l y h igh -ea rn ing spec ia l t y (50%, n=3). An add i t i ona l 3% (n=6) repo r ted p lann ing to de fe r t he i r app l i ca t i on, c i t i ng the " i n ab i l i t y to r o ta te a t o the r i ns t i t u t i ons " (100%, n=6) as we l l as the " i nab i l i t y t o ge t le t t e rs o f recommenda t ion " ( 8 3%, n=5 ).

I n the subgroup o f s tuden ts " de f i n i t e ly app ly ing to u ro logy , " 93% (n=163) repo r ted no change due to COVID-19 and 3% (n= 5) repor ted they were less l i ke l y t o app ly . In con t ras t , fo r those t ha t se lec ted any l e ve l s o f ce r ta in t y be low " de f in i t e l y app ly ing " ( n=60) , a h ighe r por t i on (27%, n=16 ) repo r ted they were " l ess l i k e ly to app ly to uro logy " due to COVID-19 .

Al te ra t i ons to Studen ts were mos t l i ke l y to repo r t be ing ve ry conce rned regard ing " f ewe r oppor tun i t i es to ob ta in mean ing fu l le t t e rs o f recommenda t ion "

(68%, n=161 ) , " f ewer oppor tun i t i es to see uro log ic procedures and su rge r ies " (55%, n=131) , and " f ewer oppor tun i t i es t o in te rac t w i th uro logy pa t ien ts " (48%, n=115) (F i gure 2 ) . Less than 12% of s tuden ts des igna ted each of these th ree cat ego r ies as " no t a concern . " In con t ras t , a ma jo r i t y o f s tuden ts were no t conce rned abou t the impac t on t he i r dec i s ion to pursue u ro logy ( 61% , n=144) o r changes in grad ing sys tems (50%,n=119). Las t l y , s tuden ts were asked to i den t i f y the i r conce rns abou t t he uro logy ma tch p rocess . The la rges t conce rn was " P rog ram cho ice : I am conce rned tha t i nabi l i t y t o comp le te away ro ta t i ons w i l l make i t more 

Our f ind ings sugges t tha t COVID-19 has min ima l l y impac ted spec ia l t y d isce rnmen t , w i th mos t par t i c i pan ts ind i ca t i ng the re was no change in the i r commi tmen t to u ro logy desp i te the pandemic . However , s tuden ts who were l ess con f iden t in uro logy ove ra l l were more l i ke l y to i nd i ca te tha t COVID-19 had nega t i ve l y impac ted the i r speci a l t y cho ice .

These resu l t s a re cons is ten t w i th l i t e ra tu re sugges t in g tha t wh i le c l i n i ca l ro ta t i ons tend to have a pos i t i ve impac t on s tuden ts '

cons ide ra t i on o f t ha t spec ia l t y , the ro ta t i ons themse l ves don ' t o f ten change s tuden ts ' minds bu t more l i ke l y re in fo rce t he i r op in ions . 7 However , o the r s t ud ies have shown poss ib le in f l uence o f c le rksh ip exper ience , fo r examp le , s tuden ts wi th p r io r u r o logy c le rksh ip exper ience a re more l i ke l y to cons ider a ca ree r in u rol ogy . 8 I t may be more impor tan t to t a rge t s tuden ts who are less con f iden t in u ro logy in orde r to enhance spec ia l t y d i sce rnmen t . As a f ie ld , we may need to be prepa red fo r f ewer app l i can ts t o u ro logy th i s yea r .

Decreased exposu re to u ro logy is po t en t ia l l y a ma jo r concern bo th f o r the log i s t i cs o f s tuden ts ' c l i n ica l ro ta t i on schedu l i ng and fo r res idency p repa redness . i den t i f y ing the mos t p re fe rab le forma t o f these int e rac t ions . 9 Our f i nd ings sugges t t ha t sma l l g roups and one -on-one conversa t ions wi l l be most impor tan t . As s tuden ts seek ou t the i r bes t " f i t , " i t w i l l be essen t ia l to c rea t e env i ronmen ts where res iden ts may speak f ree ly and answer app l i can ts ' ques t ions . S tudent s a l so ind ica ted i n te res t to lea rn more abou t the hosp i ta l s and fac i l i t i es wh ich may be accomp l i shed wi th v i r t ua l t ou rs and di s cuss ion o f p rac t i ca l l og i s t i cs .

Programs wi l l be f orced to f ind a l te rna t i ve means to commun ica te wi th app l i can ts , mak ing on l ine con ten t more impor tan t t han ever . Some prog rams have a l ready reached ou t to s tuden ts w i th v i r t ua l town ha l l s , i n fo rma t ion sess ions , and soc ia l med ia accoun ts . I t wi l l be essen t ia l f o r p rog rams to harness webs i tes as access ib le and st ab le sou rces o f i n fo rma t ion to wh i ch s tuden ts can ref e r , espec ia l l y as s tuden ts t ry to ba lance the i r schedu les w i th f requen t on l i ne sess ions . Webs i tes may h igh l i gh t p rog ram s t reng ths and speak to recogn ized s t uden t in te res t s in f acu l t y members and a lumn i f e l l owsh ips. 11 L im i ta t i ons o f th i s s tudy inc lude tha t d is t r i bu t ion v i a the COViD l ec tu re se r ies and soc ia l med ia may have in t roduced a se lec t i on b ias fo r i n te res ted app l i can ts who have a l ready sough t ou t lec tu res and made pro fess iona l connec t ions on Twi t t e r . The re fe rence map fo r s tuden ts ' demograph ics on ly i nc luded the con t i nen ta l Un i ted S ta t es . Par t i c ipan t demograph ics were se l f -repo r ted . The evo lv ing na tu re o f the impac t o f COVID-19 on med ical educa t ion means t ha t changes have a l ready occu r red s ince the su rvey was d is t r i bu ted. Fo r examp le , t he su rvey was d is t r i bu ted p r io r to the Coa l i t i on fo r Phys ic ian Accoun tab i l i t y ' s re lease o f recommenda t ions. Because t he re was no denomi na to r , we canno t know the su rvey r esponse ra te . None the less , the inf o rma t ion in the su rvey is po ten t i a l l y va luab le f or d i v in ing s tuden ts ' mos t acu te conce rns and p rov idi ng i ns igh ts i n to wha t t hey va lue mos t .

Med ica l educa t ion dur ing a pandemic i s a nove l mat te r , presen t ing unan t i c ipa ted chal l enges fo r bo th s tuden ts and med ica l educa t ion prog rams. Prog rams mus t cons ide r t he perspec t i ve o f those d i rec t l y impac ted , and our su rvey demons t ra tes w idesp read concerns regard ing the absence o f away rot a t i ons and in -pe r son in te rac t i ons . Open commun ica t ion be tween s tuden ts and prog rams wi l l be an essen t ia l componen t fo r equ i tab le and success fu l adap t ions .

The Coa l i t i on f o r Phys ic ian Accoun tab i l i t y ' s Work Group on Med ica l Studen ts i n t he C lass o f 2021 Mov ing Ac ross Ins t i t u t i ons f o r Pos t Gradua te T ra in ing . F ina l Repor t and Recommenda t ions f o r Med ica l Educa t ion Ins t i t u t i ons o f LCME-Acc red i t ed . 2020

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