Urology residency is a competitive period for physicians, due to long working schedules and demands to master many different surgical fields. In Europe, recent studies revealed mediocre results regarding satisfaction of training in several European countries. Meanwhile, as we already know, in Greece, there is no minimum surgical case log or specific training program, that needs to be accomplished to be appointed as urologist after succeeding in the residency board examinations. In consequence, the staff of Urology departments along with residents is responsible for the educational program under the supervision and advisory of each department's director.
Another main issue is the lack of feedback from the residents' point of view regarding the accredited training centers. The main objective of this study is to assess the level of confidence and perception of Greek Urology residents regarding their educational program and detect areas that necessitate improvement.
Materials and Methods
The study was approved by the Ethics Committee of the National and Kapodistrian University of Athens, located in Athens, Greece. The study complied with the principles of the Declaration of Helsinki for the protection of human rights.
All participants were informed in detail for inclusion in the study and signed informed consent before participation.
Selection and description of participants
In Greece, the training program of urology residents consists of a 5-year period, with the 1st year devoted to learning General Surgery skills and the remaining 4 years to General Urology. In this study postgraduate years (PGY) 1–4 refers to the relevant year of the Urology training period. In addition, we decided to further include fellow Urologists in the survey, as they actively participate in Urology Departments' daily program.
A 51-question survey was developed using the electronic platform http://www.free online surveys.com, according to the Checklist for Reporting Results of Internet Surveys. The survey was sent initially via E-mail to all Greek Residents, who were members of HUA in March 2019, and the survey collector was operational between March 2019 and May 2019. The questions were in Greek language and the completion of the questionnaire was anonymous and voluntary. Several parameters of residents' training program were examined such as quality of surgical and theoretical training and subjects related to research involvement as well as trainees' quality of life. A committee of Greek Urology experts further reviewed the quality of the survey, which was evaluated for usability and functionality before further distribution.
Categorical variables are described as proportions. Fisher's exact test and Chi-square test were used to compare categorical variables. Kruskal–Wallis test was conducted to determine if there were differences in the several areas describing the quality of education and potential predictive factors, such as belonging to a University Department, the proportion of bureaucracy to daily workload, the PGY, working hours per day, possession of an MSc or PhD and age group. Pairwise comparisons were performed whenever a statistical significance was detected, using Dunn's procedure. Statistical significance was set at P = 0.05. All analyses were performed with IBM SPSS Statistics 25.0 software (SPSS Inc., Chicago, IL, USA).
A total of 91 out of 104 (87.5%) Urology residents responded to the survey. Among them 28 (30.8%) were 25–30 years/old, 43 (47.3%) 30–35 years/old, 14 (15.4%) 35–40 years/old and 6 (6.6%) ≥40 years/old while 77 (84.6%) were men and 14 (15.4%) were women. Regarding the year of residency, 21 (23.1%) were PGY1, 19 (20.9%) PGY2, 18 (19.8%) PGY3 and the same rate were PGY4, while fellow urologists were 15 (16.5%), showing an equal distribution among categories. Among responders, 42 (46.2%) worked at a University Department and 49 (53.8%) to a Community Hospital. The questionnaire revealed that a proportion of 34.1% and 28.6% worked for 8–10 and 10–12 h daily, respectively, while 41 (45.1%) of the participants were obliged to undergo 6–8 24-h shifts monthly. Altogether, most residents surpass the limit of 50 h/week. Finally, bureaucracy seems to represent a major issue for daily practice since 64 (70.4%) report more than 50% of daily workload to be related to it.
In Table 1, the number of diagnostic procedures per PGY is shown. Among them, cystoscopy and kidney-ureter-bladder ultrasound seem to be common procedures for residents, since most of the participants reported to perform more than 50. Concerning transrectal ultrasound (TRUS) the majority of residents responded to perform 11–50 except PGY4 and fellow Urologists who seem to be more experienced with more than 50 procedures. Similarly, trainees become more confident to perform TRUS-guided biopsy in the last years of residency programs, since PGY3–4 and fellow Urologists performed more than 50 cases in contrast to PGY2 and PGY1 with 11–50 and <10, respectively. Finally, most residents have not performed any scrotal ultrasound or pressure-flow studies, except PGY4 and fellow Urologists.
In Figures 1 and 2, the number of endourological procedures [Figure 1] and surgeries [Figure 2] performed or involved as a first assistant who completed some steps of the procedure, is graphically depicted. Double-J stent insertion is a common procedure done by residents since most of them have placed more than 11–50 stents. The 52.7% and 60.4% of the responders performed 1–10 varicocele and hydrocele corrections, respectively. The majority (80.2%) have not performed any ESWL, while 53 (58.2%) residents performed <10 ureteroscopies. Transurethral resection of bladder tumors (TURBT) was reported to be performed rarely by PGY1–2 residents, while PGY3–4 trainees performed more than 10 TURBTs in the majority of them (67% and 100%, respectively). Similarly, transurethral resection of prostate adenomas was rarely performed by PGY1–3 residents, in contrast with all PGY4 trainees who reported completing more than 10 cases. Finally, most residents mentioned to rarely perform basic steps of the following procedures more than 10 times: Percutaneous nephrolithotripsy (98.9%), open radical nephrectomy (86.9%), laparoscopic nephrectomy (98.9%), open transvesical (Freyer's) prostatectomy (78.1%), and open radical prostatectomy (89%). The median overall satisfaction from surgical training is 6/10, which seems to be independent of working schedule, working in a University Department, PGY or number of residents in the clinic [Tables 2–5].
Surprisingly, 54 (59.3%) of residents have not published any study in peer-reviewed journals, while as a reasonable consequence, the vast majority of them reported a very low level of confidence in leading a research project (75.8%) or writing a scientific manuscript (68.1%). The vast majority of participants (74.8%) reported no educational courses during residency programs or in the best case 1–2 monthly. Interestingly, working at a University Department didnot affect positively neither the confidence level for leading a project or writing a paper nor the number of publications or congresses attended, although these clinics seem to occupy more residents and for a significantly larger amount of time [P < 0.001, [Table 3]]. Moreover, the level of confidence and number of publications did not differ according to bureaucracy workload, PGY, working hours, possession of MSc/PhD, or age group [Tables 2–8].
Quality of life
Most residents who participated in the survey rated their QoL during residency as moderate (5/10) and most of them reported to rarely feel satisfied (44%). 46 residents (50.5%) stated that they rarely manage to meet family or friends due to heavy programs. Despite adequate hours of daily sleep of 6–7/day in 39.6% and 5–6/day in 36.3%, 54 of the participants (59.3%) suffer from burnout sometimes. Level of satisfaction and burnout frequency does not seem to be affected by parameters such as bureaucracy workload, PGY, residency at a University Department, age and number of residents in the department [Tables 3, 5–8]. On the other hand, working hours per day have a significant and negative impact, since residents who work >12 h daily, reported to suffer from burnout often [P = 0.028, [Table 2]].
In Europe, in contrast with the US, residency programs vary significantly regarding organization and content, sometimes even across the same country. Carrion et al. reported a 14% of satisfied last-year trainees coming from several European countries, regarding their surgical exposure. This lack of training implicates a direct impact on confidence level to operate independently as shown by recent studies, where 38% of General Surgery residents do not feel confident after completing 5-year training program. As a reasonable consequence, nearly 80% of European Urology Residents seek a future fellowship program. Possible reasons for these findings are pressure to minimize operative time, increased working hours, and the high proportion of bureaucratic work, as well as lack of organized and structured curriculum of clinical and surgical education. Our study confirms this trend since most of Greek Urology Residents' level of satisfaction for their surgical education is moderate.
One of the most important tools that trainees should gain during their training is the ability to criticize before adopting new concepts. Research training time, besides providing the opportunity for critical thinking, will also render residents more competitive candidates for fellowship positions abroad and follow an academic, rather than private practice career. Even though academic activity is commonly accepted as important part of residency training programs, many studies demonstrate low academic activity and scientific production among residents. In Greece, academic scholarship is greatly underestimated, depicted by the fact that no Urology residency program offers a protected and dedicated block time for research involvement. Since according to our findings, confidence level to lead a research project or publish a scientific paper does not differ between University and Community Hospitals, there is the risk of future lack in physician-researchers and academicians in our field. Possible reasons to explain this phenomenon are the lack of funding, constricted time and absence of facilities, as well as the lack of research-oriented med-schools and minimal training during undergraduate years, which inevitably leads to an imbalance between academic career and private practice, forcing urologists to the second aim. Bench differs from clinical research and needs more time and skills to be mastered during a limited block of training, thus clinical research skills such as data gathering, scientific, and grant writing and biostatistics should be highlighted at least initially.
Laparoscopic surgery is currently utilized worldwide, despite the dominance of robotic surgery in many centers. Since in most countries, there is a lack of robotic training simulators, residency programs should at least provide to young trainees the chance to expose themselves to basic laparoscopy via dry-lab training, a relatively inexpensive form of hands-on exercise. According to our findings, only 36.7% of community programs and 23.8% of University Departments offer a training box (P = 0.183), lying in alliance with findings across Europe. In 2007, European Urology Residents Education Program was initiated, during which last year trainees accessed a laparoscopy course. Initially, during the first 2 years, only 4.2% passed the examination based on both time and quality criteria, with an improved pass-rate of 55% overall have been reported by Somani et al. in 2019. Higher rates of success were accompanied by more hours of training on box trainers and assisting in a larger number of laparoscopic operations. Therefore, regulatory authorities across every European country should pay special attention and provide residency programs with the necessary equipment and tutors toward fulfilling this aim.
Marchalik et al. detected a 40% rate of burnout, with the highest rates among Portuguese residents. In this study, Greek residents reported feeling burnout sometimes, which was associated significantly with working >12 h/day. Dissatisfaction and unmet expectations from training are also major drives for burnout. Potential solutions like structured mentorship during residency, access to health-care advisors and relaxing activities, along with improvements in the program structure may alleviate this problem and should be implemented in European Residency programs.
This unprecedented COVID-19 pandemic has resulted in significant changes in urology residency programs worldwide, with a negative impact on matters such as surgical training and academic activities. A slowdown in the learning curve of urology residents is noticed, as many scheduled surgeries were postponed and congresses/courses were delayed or even cancelled. In this era, the adoption of smart learning modalities in the form of webinars, podcasts, prerecorded sessions, and social media is fundamental tool for continuous training. These educational and healthcare resources challenge urology residents to reinvent themselves during the pandemic, especially in the de-escalation phase. Theoretical training could be approached via telemedicine and virtual courses offered by EAU and AUA, along with distant learning organized by the faculty of each Department. Surgical training via laparoscopy boxes, along with watching video surgeries or courses for operative techniques could blunt the slow-down of the learning curve. Research activities are also limited due to prioritization given by institutional review boards to trials related to the management of COVID-19 patients.
The main strength of our study is that it is only assessing the quality of education of Greek Urology Residents. The great interest from the residents' part, is revealed by the high proportion of responders. As all surveys, this study suffers from the subjectivity of the responders. We did not perform a comparison between men and women trainees, due to the small number of women who completed the questionnaire.
This is the first national survey assessing Greek Urology residency programs. Based on the results, residency programs are marked by the low level of satisfaction mainly regarding surgical education, low confidence level for performing clinical research, and risk of burnout due to increased working hours. As these findings allies from studies coming from other European countries, regulatory authorities should join forces to establish a structured curriculum of clinical, surgical, and research training in Urology across Europe.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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