AUTHOR REPLY

We are grateful for the comment on our article “A multinational study of the impact of COVID-19 on Urology surgery residency and wellbeing.” Dr. Hoogenes raises excellent points in evaluating the results of our study and appreciating the context of participants’ year of training and home region. We agree that regional variability in pandemic-related experiences can be significant relative to volume, leadership response, and community perspective. This varied both among countries and within countries on regional and institutional levels. Part of our goal within the United States was to ensure we appropriately assessed regional variability by sampling one third of randomly chosen programs. Contextual factors are influential in mediating COVID-19 related occupational stressors and their resulting psychological distress.¹ Interval reports of burnout, trauma, post-traumatic stress and the mental health sequelae resulting from the pandemic reinforce the need to focus on mitigating this risk for our future providers.?>1, 2

Blanchard et al's 2-year survey of over 500 residents at University of Chicago showed stable burnout rates in spite of the pandemic.² While limited to 1 institution, these results are consistent with ours. Despite Chicago experiencing a high COVID-19 case load, the authors hypothesized that the institution's response to the pandemic by reducing work hours and prioritizing mental health care and well-being. This is in line with the model proposed by Hendrickson et al in their conclusion that risk of COVID-19 itself was not the sole mitigator of occupational stress or mental health symptoms of healthcare providers during the pandemic.¹ They present an explanation of direct and contextual factors for occupational stressors, as well as strategies that programs can employ to reduce their effect on healthcare providers. Using this framework, one can think of our study as primarily an examination of how direct volume dependent factors changed for urology residents during the pandemic.

Of critical importance is the 12% of healthcare workers in Hendrickson's study who expressed thoughts of suicide or self-harm. This is in line with a growing body of data demonstrating high rates of distress and post-traumatic stress among healthcare providers around the world. Post-traumatic stress disorder symptoms (PTSD) were not fully evaluated in our study; however, as many as one half of healthcare providers reported acute stress or PTSD in surveys of Turkey³, New York⁴, and Italy⁵ during the respective peaks of their pandemics. However, this data is cross-sectional, and the pandemic continues to carry on. The long-term impact of the acute stress and its evolution into PTSD is highly concerning.?>3, 4, 5?> Rising post-traumatic stress, anxiety and depression appear to represent a “second wave” of the pandemic that we anticipate will have a significant impact on future healthcare providers. Institutions must not only focus on burnout and environmental stressors, but should proactively initiate interventions to support physicians and their mental health. The long-term impact of traumatic stress and mental distress on urology residents are critical for programs to understand and address as the pandemic continues.