Urological Science

: 2022  |  Volume : 33  |  Issue : 3  |  Page : 119--123

Shifting paradigm of urology residency after the COVID-19 pandemic in Indonesia

AH Wisda Kusuma, Raden Danarto, Adryan Kalya Ndraha Khairindra 
 Division of Urology, Department of Surgery, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Dr. Sardjito Hospital, Yogyakarta, Indonesia

Correspondence Address:
Raden Danarto
Jl. Kesehatan No. 1, Yogyakarta 55281


Purpose: World Health Organization has declared coronavirus disease 2019 (COVID-19), a global pandemic in March 2020. Nations around the world enact prevention measures such as lockdowns, quarantines, massive testing, and tracing policies. Prevention measures against the pandemic may result in less opportunities for urology residents to learn. This study aims to investigate the difference in urology residency in Indonesia before and during the COVID-19 pandemic. Materials and Methods: This research is a cross-sectional study. Authors analyzed 147 urology residents across five urology education centers in Indonesia who fulfilled a self-administered online questionnaire. Participants were asked about their objective and subjective experience regarding urology residency, before and during the COVID-19 pandemic. Results: Change in urology education paradigm in Indonesia during the COVID-19 pandemic is agreed upon by 95.91% participants, 57.82% thinks it brings negative causes negative consequences. Anxiety toward competence level is felt by 70.06% of participants. Reduced opportunities to learn, especially surgical skills may lead to this result. Overall mental health condition of participants does not significantly change. Multiple factors may contribute to this result. Conclusion: As changes and adaptations are inevitable, more attention should be brought to residents' competence level while maintaining COVID-19 prevention protocol. This is the first nationwide survey showing the effects of the COVID-19 pandemic on urology education system in Indonesia. Authors suggest a larg-scale study, with more detailed questionnaire to further elaborate the causes and effects of each variable observed.

How to cite this article:
Wisda Kusuma A H, Danarto R, Ndraha Khairindra AK. Shifting paradigm of urology residency after the COVID-19 pandemic in Indonesia.Urol Sci 2022;33:119-123

How to cite this URL:
Wisda Kusuma A H, Danarto R, Ndraha Khairindra AK. Shifting paradigm of urology residency after the COVID-19 pandemic in Indonesia. Urol Sci [serial online] 2022 [cited 2022 Sep 29 ];33:119-123
Available from: https://www.e-urol-sci.com/text.asp?2022/33/3/119/354709

Full Text


Following a cluster of pneumonia cases of unknown etiology in Wuhan City, People's Republic of China, in December 2019, the Chinese Center for Disease Control identified a novel virus, with confirmed human-to-human transmission in January 2020. The novel virus was named severe acute respiratory syndrome novel corona virus-2, and the disease it causes was named corona virus disease 2019 (COVID-19). COVID-19 has spread rapidly around the globe, causing millions of deaths and disabilities,[1],[2],[3],[4],[5],[6] and the pandemic is ongoing during the writing of this manuscript.

The predominant mode of transmission for COVID-19 is direct contact, through coughing, sneezing, inhalation of droplets, and contact with oral, nasal, or eye mucous membranes.[6] Prevention of viral transmission includes the strict limitation of direct human-to-human interactions, leading to area lockdowns, area quarantines, and schooling and working from home.[7] During the pandemic, medical education has been overlooked.[8] Although all specialty residencies are affected by the COVID-19 pandemic, lack of procedural training opportunities means that craft specialties are the most affected.[3]

The pandemic has forced urologists to adapt and innovate. New treatment methods and guidelines are being formulated, elective surgeries are being canceled, surgeries are performed by experienced operators to limit exposure times, rounds, and scientific meetings have been canceled, and urology residents and operating theater teams are being sent to work from home or redeployed into other stations in need.[8],[9],[10],[11] The pandemic has negatively affected and stressed residents across the globe. Changes in learning models are urgently needed to accommodate the pandemic situation.[3],[8],[12],[13] To achieve this goal in Indonesia, information on how the COVID-19 pandemic has changed urology education is needed. To the best of our knowledge, this is the first nationwide survey exploring objective and subjective changes in urology education from the residents' perspective in Indonesia.

 Materials and Methods

A purposive sampling method was employed for this cross-sectional study. Data were collected from September to October 2021 with an online self-administered questionnaire using the Google Forms® platform. The inclusion criteria were active urology residents who started their urology training program before the COVID-19 pandemic and voluntarily completed the questionnaire. The exclusion criteria were inactive urology residents, urology residents who started their urology trainee program after the COVID-19 pandemic began, and residents who were unwilling to complete the questionnaire.

Mood status was measured using the numbered graphic rating scale (NGRS)-depression intensity scale circles (DISCs). The DISC score was quantified using a scale from 0 to 10. A 0 indicated that the subject did not feel depressed, whereas a 10 indicated that the subject was very depressed.[14]

The questionnaire required subjects to give their objective and subjective opinions about changes in urology education during the COVID-19 pandemic. The study aims and data confidentiality were explained to participants before completing the questionnaire. Subjects consented to participate in the study by choosing to proceed to the objective questions section of the form, after clicking a button representing the participant's signature. One author acted as a contact person for the subjects.

Data are reported as frequencies, percentages, means, and medians.

This study was approved by the Medical and Health Research Ethics Committee of the Faculty of Medicine, Nursing and Public Health, Gadjah Mada University (KE/FK/1007/EC/2021). All authors contributed equally to this study. There are no conflicts of interest for this study. This study was funded by the authors, without any involvement of sponsors.


One hundred and fifty-four urology residents from five centers in Indonesia participated in the study. Seven residents were excluded because they did not fulfill the inclusion criteria. Thus, 147 urology residents were included in the analysis. The results of the objective questions are shown in [Table 1], [Table 2], [Table 3]. The results of the subjective portion of the questionnaire are listed in [Table 4].{Table 1}{Table 2}{Table 3}{Table 4}


Public health measures to stop COVID-19 transmission have led to online scientific meetings, morning reports, seminars, and workshops.[3],[10],[11],[12],[13] Furthermore, the pandemic has substantially reduced the opportunities for urology residents to experience both clinical and surgical activities.[8],[10],[12]

Urology residents in Indonesia reported a similar phenomenon across five urology centers. A majority of study participants reported less direct supervision by teaching staff during the outpatient clinic and inpatient ward rounds. Before the pandemic, 75.51% and 77.55% of participants reported no online assessments and morning reports, respectively. Since the pandemic began, the frequency of online assessments and morning reports was relatively unchanged compared with the frequencies before the pandemic, ranging from two times per week to every day. Approximately half (51.02%) of participants stated that they would prefer some routine scientific meetings to be held offline, while 45.57% prefer the current online meetings.

Triage criteria were formulated to guide urology care service during the COVID-19 pandemic.[8] The summary of principles is shown in [Table 5]. The European Association of Urology (EAU) guidelines for urological cases during the COVID-19 pandemic are divided into four priority levels. Low priority cases are defined as cases that are very unlikely to cause clinical harm if postponed for 6 months. Intermediate priority cases are defined as cases posing possible but unlikely clinical harm if postponed for 3–4 months. High-priority cases are those, in which clinical harm is very likely if postponed for >6 weeks, and emergency cases are defined as life-threatening situations. No high-quality evidence is available to support these compromises, and the decision to delay urological procedures should adapt to the current local public health measures and ethical considerations.[8],[9] The EAU recommends only operating on high-priority and emergency cases. Surgeries on COVID-19 positive or suspected patients should be done in specially equipped and dedicated operating rooms. Personal protective equipment (PPE) for operating staff is needed according to local guidelines.[9]{Table 5}

Our study showed that ureteroscopy, transurethral resection of the prostate, and transurethral resection of bladder tumors were the most common endourology operations during both the prepandemic and pandemic periods. Pyelolithotomy and nephrectomy were the most common open surgeries during both periods. Cystectomy replaced hypospadias repair as the third most common surgery during the pandemic period. The total number of surgeries dropped considerably during the pandemic. The average number of endourology surgeries per month in all 5 urology centers was 38.47 before the pandemic and 20.66 during the pandemic. The average number of open surgeries per month also dropped from 21.04 to 11.55 during the pandemic.

The pandemic has been going on for more than 2 years and factors such as COVID-19 trends, local government regulations, and residents' need for surgical experience may play a role in decision-making processes.[5],[9] Furthermore, delayed surgery may increase patients' psychological burden if the delays continue. Thus, patients should be prioritized on a waiting list.[9] Relationships between the most common urologic procedures and surgeries, time, pandemic conditions in Indonesia, and government regulations need to be explored to determine the cause of this phenomenon.

The use of technology may help the learning process for residents.[15] A 2021 study by Campi et al. showed that 455 urology residents out of 501 study participants responded positively to the use of smart learning methods during the COVID-19 pandemic. Prerecorded videos were considered a highly useful smart learning modality by 78.4% of study participants, followed by interactive webinars, podcasts, and social media, at 78.2%, 56.9%, and 51.9%, respectively. Guidelines (84.8%), surgical videos (81.0%), clinical trials (63.9%), frontal lessons (59.5%), journal clubs (55.5%), and clinical cases (45.7%) were preferred by residents. Despite the lack of interactions between speakers and listeners, prerecorded videos were preferred because they enabled residents to independently manage learning time and contents.[12]

A majority of participants reported no webinars before the pandemic hit (63.26%). However, 98.64% of participants reported at least one webinar per month during the COVID-19 pandemic. Webinars help residents pursue their continuing medical education when clinical experience is not available. Webinars also eliminate the need for study leave, along with costs of travel and accommodation.[3] Urology residents and other health-care workers pursuing continuing medical education need to adapt to the increased use of telemedicine and smart learning methods.[8],[10]

Despite the negative impacts of COVID-19 on medical education, some positive aspects should be considered. The shift from offline to online learning methods facilitates the development of theoretical knowledge for residents.[3] This is consistent with our findings that show 67.34% and 65.98% of participants feel that the pandemic has given them more time for pursuing self-study and writing scientific papers, respectively. Resident redeployment to hospital wards in need also gives residents ample opportunities to learn or re-learn skills that may not be closely related to urology.[3]

The internet is the future of continuous medical education (CME) and the most common method used for CME. The free open access medical education movement enables fellow physicians to develop networks of virtual communities and quickly share knowledge.[13] The pandemic may force the development of internet-based CME beyond its current boundaries, hopefully for the better.

Multiple studies reported the negative impact of the COVID-19 pandemic on stress, anxiety, and overall psychological burden among residents.[3],[8],[11] Our study assessed urology residents' depression scores using the NGRS-DISCs scale. The mean scores decreased from 4.10 before the pandemic to 3.93 during the pandemic. This contradictory result may be caused by several factors. The pandemic has been going on for more than 2 years during the sampling period. Thus, the general public's perception of COVID-19 and the new normal way of living may have improved, leading to less stigmatization and discrimination. A study in Hongkong showed that respondents who were bothered by not having enough surgical masks had poorer mental health.[16] In our study, although 72.10% of participants felt that being a urology resident increased exposure to COVID-19, 93.19% of participants had adequate PPE provided by their respective hospitals, possibly helping residents feel more at ease. Participants also disagreed that the COVID-19 pandemic caused financial difficulties (28.57% disagreed, 55.46% stayed neutral).

Six key elements contribute to maintaining mental health among healthcare workers during the COVID-19 pandemic: appropriately thanking health-care workers, looking after colleagues that do not show up to work as scheduled, performing “return-to-normal-work” interviews when a crisis response period has ended to understand what each worker currently feels, paying attention to high-risk workers (juniors, inexperienced staff, and those working beyond their usual roles), monitoring workers who have had traumatic experiences during the pandemic, and managers and superiors should helping workers make sense of their experiences.[17]

In this study, 95.91% of participants agreed that paradigms in the urology education system in Indonesia are shifting. However, feelings about these changes are mixed. Perhaps the most concerning finding is that 70.06% of participants feel anxious about how the new paradigm will affect their competence level. Early during the pandemic, Amparore et al. stated the same result and also showed that residents may be more critically impaired during their last years of training because the majority of surgical exposure happens then.[10] In addition, residents experienced anxiety about the decreased opportunities to learn hands-on surgical skills. Fortunately, no plunge in participants' mental health condition occurred. More attention should be given to ensuring that residents attain an adequate competence level based, while considering COVID-19 prevention measures at every step.

This is the first nationwide study of the effects of the COVID-19 pandemic on urology education in Indonesia. A larg-scale study with a more detailed questionnaire is needed to further elaborate on the causes and effects of each variable observed.


This is the first nationwide study on the effects of COVID-19 pandemic on urology education system in Indonesia. Author would suggest a larger-scale study, with more detailed questionnaire to further elaborate the causes and effects of each variable observed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Fauci AS, Lane HC, Redfield RR. COVID-19 – Navigating the uncharted. N Engl J Med 2020;382:1268-9.
2Khan M, Adil SF, Alkhathlan HZ, Tahir MN, Saif S, Khan M, et al. COVID-19: A global challenge with old history, epidemiology and progress so far. Molecules 2020;26:39.
3Hope C, Reilly JJ, Griffiths G, Lund J, Humes D. The impact of COVID-19 on surgical training: A systematic review. Tech Coloproctol 2021;25:505-20.
4World Health Organization. WHO Coronavirus (COVID-19) Dashboard. Available from: https://covid19.who.int/?gclid=CjwKCAjwmMX4BRAAEiwA-zM4JpqYlZhA3EdyHAWZoc3-2iaZmvAxRKSxhEpq8QqHXyStKHNA1gIO1xoCXp8QAvDBwE. [Last accessed on 2021 Oct 14].
5Gravas S, Bolton D, Gomez R, Klotz L, Kulkarni S, Tanguay S, et al. Impact of COVID-19 on urology practice: A global perspective and snapshot analysis. J Clin Med 2020;9:1730.
6Salian VS, Wright JA, Vedell PT, Nair S, Li C, Kandimalla M, et al. COVID-19 transmission, current treatment, and future therapeutic strategies. Mol Pharm 2021;18:754-71.
7Cipriano M, Giacalone A, Ruberti E. Sexual behaviors during COVID-19: The potential risk of transmission. Arch Sex Behav 2020;49:1431-2.
8Thapa BB, Shrestha D, Bista S, Thapa S, Niranjan V. Urology during COVID-19 pandemic crisis: A systematic review. Surg J (N Y) 2021;7:e3-10.
9Ribal MJ, Cornford P, Briganti A, Knoll T, Gravas S, Babjuk M, et al. European Association of urology guidelines office rapid reaction group: An organisation-wide collaborative effort to adapt the european association of urology guidelines recommendations to the coronavirus disease 2019 era. Eur Urol 2020;78:21-8.
10Amparore D, Claps F, Cacciamani GE, Esperto F, Fiori C, Liguori G, et al. Impact of the COVID-19 pandemic on urology residency training in Italy. Minerva Urol Nefrol 2020;72:505-9.
11Jin P, Park H, Jung S, Kim J. Challenges in urology during the COVID-19 pandemic. Urol Int 2021;105:3-16.
12Campi R, Amparore D, Checcucci E, Claps F, Teoh JY, Serni S, et al. Exploring the residents' perspective on smart learning modalities and contents for virtual urology education: Lesson learned during the COVID-19 pandemic. Actas Urol Esp (Engl Ed) 2021;45:39-48.
13Gravas S, Ahmad M, Hernández-Porras A, Furriel F, Alvarez-Maestro M, Kumar A, et al. Impact of COVID-19 on medical education: Introducing homo digitalis. World J Urol 2021;39:1997-2003.
14Turner-Stokes L, Kalmus M, Hirani D, Clegg F. The Depression Intensity Scale Circles (DISCs): A first evaluation of a simple assessment tool for depression in the context of brain injury. J Neurol Neurosurg Psychiatry 2005;76:1273-8.
15Ali SR, Dobbs TD, Whitaker IS. Webinars in plastic and reconstructive surgery training – A review of the current landscape during the COVID-19 pandemic. J Plastic Reconstr Aesthet Surg 2020;73:1357-404.
16Choi EP, Hui BP, Wan EY. Depression and anxiety in Hong Kong during COVID-19. Int J Environ Res Public Health 2020;17:3740.
17Greenberg N. Mental health of health-care workers in the COVID-19 era. Nat Rev Nephrol 2020;16:425-6.