Assessing Goals of Urology Residency Program in TASH, A.A.U, Addis Ababa Ethiopia

10/09/2021
Assessing Goals Of Urology Residency Program

In Tikur Anbessa Tertiary Hospital
Department of Surgery , Urology Unit , AAU, A.A, Ethiopia 2021
By – Mekbeb Chere (M.D, PGY-5 Urology Resident)

Advisor – Wondossen Ergete (M.D, MSc Urology)
Goals of Urology Residency

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10/09/2021
Outline
• Introduction
• Statement of the problem
• Objectives
• Methodology
• Results
• Discussion

• Conclusion
• Recommendation
• Limitations
• References
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Introduction
Goals of Urology Residency 10/09/2021

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Background
• In 2010 G.C the first two residents joined the training, graduated in 2015.
• By 2020 , a total of 31 Urologists have graduated from the program.
 26 were residents who completed a five year program.
• Currently there are 10 PGY-5, 6 PGY-4 and 2 PGY 3 residents.

• The training includes a 2 year General Surgery and 3 year Urology stay.
• The main center is at TASH which has 26 Urology beds. 5 days per week Endourology
OR table and 3 days per week Open surgery OR table.

• There are three affiliate hospitals, Yekatit 12, Menilik II and Hamlin Fistula Hospital.
All located in A.A.
• There are 8 Consultant Urologists who provide the training program
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Curriculum Goals
Specific Objectives
Graduate Profile
1. Knowledge and Understanding 1. Accelerate the development of a Urology department in all
 Comprehensive and thorough knowledge of urology basic science, teaching hospitals
anatomy, physiology, disorders ,Endourology and Laparoscopic surgery
 Knowledge base in Nephrology , Transplant, General surgery, radiology 2. Produce competent Urologists to address urological problems
and Oncology of the country
2. Skills –expert in
3. Contribute to capacity building in modern urologic surgery

 Diagnosis ,Ix ,interpretation of results and management of urological
disorders 4. Reduce the national disease burden

 All aspects of Operative Urology including endoscope and
laparoscopic surgery. 5. Introduce cost effective and modern Minimally invasive
Urological services in all referral hospitals

3. Attitude
 Collaborator, communicator, manager, scholar , ethical, punctual,
responsible 5
The selection of candidates;
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• faculty interviews and letters of recommendation
The goals of the program
The requirements for good • Future medical and personal demands of the trainee
training in urology • provide a motivating environment

• provide enough flexibility for the resident, permitting an individualized personal
To make a ‘Modern day’ Urologist, the development

• up-to-date and kept at an internationally competitive level
program needs a design fitting to
1. Its respective region

Supplementary training and international exchange;
2. with a vision of universality in
• European Association of Urology
knowledge creation and sharing . • Endourological Society

Implementation strategy;
• fixed times for lectures, clinical parts and a (self)-monitoring system.

• opportunity to develop a personal clinical profile within urology.
Miernik et al., 2014 Environmental considerations
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• flexible working hours and periods; to enable personal life and work balance
10/09/2021
Models Of Urology Residency
RCPSC ACGME
• tried to standardize the expectations at different

Six Core Components
levels of training.

 Practice-Based Learning and Improvement.
 Patient Care and Procedural Skills.
 Systems-Based Practice.
 Medical Knowledge.
 Interpersonal and Communication Skills.
 Professionalism.
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Simulation Lab Activities
• Placement of transobturator slings, retropubic and fascial

pubovaginal slings
• Vascular anatomy of the pelvis and anatomic lymph
nodes
• Anatomic approach for radical cystectomy/pelvic
exenteration
• Prolapse repair surgeries

• Artificial urinary sphincter and prosthesis placement
• Retroperitoneal anatomy and laparoscopic procedures
(nephrectomy and pyeloplasty)
• Open abdominal surgery, bowel handling, stapled bowel
anastomosis and formation of complex urinary reservoirs
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Definition
• Long term, unresolvable job stress that leads to exhaustion and feeling overwhelmed,
cynical , detached from the job , and lacking a sense of personal accomplishment.

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• Urology training is a relatively new specialty in Ethiopia.
• It is a sophisticated field with unique components of diagnostic and therapeutic

principles which are intertwined with technological advancements.
• The current curriculum goals are vaguely set and the competence of residents not
known in relation to the local demand and infrastructure as well as internationally
Statement of the accepted standards.
problem
• ‘professional Burnout’ is an important factor in achieving personal goals of trainees
and in provision of efficient health care.

• Yet , the magnitude of this problem has not been studied in TASH – Urology
residents and graduates.
• Understand the current state of the program, residents proficiency level , working
condition of graduated Urologists and assessing the effect of the program on
trainees will help in guide the training for the future.
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Objectives
General Objective Specific Objectives
• Asses the current urology training components

• Evaluate the Urology residency
program goals in • Asses Competence level of trainees as perceived by
TASH/AAU/Addis Ababa/Ethiopia themselves
• Asses ‘Professional burnout’ level among trainees and

• Asses ‘Professional burnout’ level among ‘new’
graduates
• Asses the relevance of the different components of the
training in clinical practice of recent graduate
Urologists.
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Methodology

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Study Participants
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• 2 PGY 3, 6 PGY 4 and 9 PGY 5 residents – response rate of 100%
• 15 Urologists graduated between 2018-2020 – response rate of 88%
Materials
• Google Form
• MBI-HSS(MP)
• Microsoft Excel 2016
• SPSS v26
Procedure
• Google Form was used to structure a 36 structured question survey sent via mail and telegram to
all urology residents and a 20 structured question survey sent via mail and telegram to all
urologists graduated between 2018 and 2020

• MBI-HSS(MP) tool was sent via mail/telegram to both residents and recent graduates.
• Cronbach’s Alpha was measured for Linkert scale questions – 0.87
• Linkert questions were transformed to positive and negative dichotomous variables
Study Design
• Cross sectional descriptive study

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Result

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Demographics
• Mean age for residents was 30.3 while the mean age of Urologists was 33.
• There was only one female resident and one female Urologist

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Prerequisites to joining the program

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Career Choice

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Duration of General Surgery and total Length of training
General Surgery Training Duration
3%
32%

65%
1 Year 2 Years 3 Years 18

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Skill lab
• All of the residents spent only two months in ‘skill lab’. It consisted of
Laparoscopy Simulation and Endo-Urology simulation.

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How do you rate your level of Count
Stone disease Unsatisfactory 5 29.4%
exposure to the following sub- Satisfactory 12 70.6%
specialities of urology? Urologic Oncology Satisfactory 12 70.6%
Unsatisfactory 5 29.4%
• Overall average Pediatric Urology Satisfactory 7 41.2%
satisfaction rate was Unsatisfactory 10 58.8%
Satisfactory 3 17.6%
22.2%
Satisfactory 0 0.0%

Satisfactory 0 0.0%
Renal Transplant Satisfactory 0 0.0%
Satisfactory 0 0.0%
Satisfactory
Unsatisfactory
0
17
0.0%
100.0%
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Residents perceived proficiency level to
RCSPC Category A procedures

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Catagory A Catagory B Catagory C
Row N % Row N % Row N %
Hydrocelectomy 100.0% 0.0% 0.0%
Open pyeloplasty 100.0% 0.0% 0.0%
Open suprapubic cystostomy 100.0% 0.0% 0.0%
Orchidopexy for inguinal testis 100.0% 0.0% 0.0%
Open prostatectomy 88.9% 11.1% 0.0%
Open uretero-ureterostomy 88.9% 11.1% 0.0%
Repair of testicular torsion 88.9% 11.1% 0.0%
88.9% 11.1% 0.0%
Radical inguinal orchiectomy 77.8% 22.2% 0.0%

Urethral meatotomy, meatoplasty 77.8% 22.2% 0.0%
Open Varicocelectomy 66.7% 33.3% 0.0%
Ileal conduit diversion 55.6% 44.4% 0.0%
Meatal repair for glanular hypospadias 55.6% 33.3% 11.1%
Open radical nephrectomy 55.6% 44.4% 0.0%
Open uretero-neocystostomy 55.6% 44.4% 0.0%
Pediatric indirect hernia repair 55.6% 33.3% 11.1%

Vasectomy 55.6% 33.3% 11.1%
Nephro-Ureterectomy 33.3% 66.7% 0.0%
22.2% 44.4% 33.3%
Open partial nephrectomy 22.2% 77.8% 0.0%

11.1% 44.4% 44.4%
Open pelvic lymphadenectomy 0.0% 44.4% 55.6%

0.0% 0.0% 100.0%
Radical Cystectomy (Female) 0.0% 44.4% 55.6%

Radical Cystectomy (male)
Table Caption
0.0% 55.6% 22
44.4%
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Urologists
Recently Graduated

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Recently Graduated Urologists

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Equipment Availability
• 8 of the 15 Urologists have instruments for Cystoscopy
• 7 of the 15 Urologists have equipment for DVIU in their institution.
• Only 3(20%) of the Urologists have URS + Lithotripter
• Only 4 Urologists have TUR instruments
• None of the respondents had Urodynamic Machine, ESWL, PNL equipment,
RIRS equipment or laparoscope

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How useful are the following clinical
components Urology training to your
current practice?

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Rate how the residency training prepared you
to the following aspects of your practice?

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Research and Academic activity
• Though all of the Urologists were required to conduct research as part of
fulfillment of training, only two respondents were able to publish their paper.
• Lack of effort and not having enough knowledge about the process were the
commonest reasons stated.
• Almost all of the respondents didn’t publish any scientific paper since

graduation. “Lack of interest” was the most common reason for not doing so.
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“Burnout” in Urology

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Discussion

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Achievements of the program
• The graduated Urologists are mostly serving in an academic institution, which has enabled
the establishment of a Urology Unit in many of the countries teaching institutions.
• St. paul’s millennium medical college , one of the biggest tertiary teaching hospitals in
Ethiopia has started Urology residency training since 2019G.C. Two of its Urology faculty
members are graduates of the TASH/A.A.U urology residency program.
• Bahir Dar University which is located in the Amhara region of Ethiopia has started its own

Urology residency program accepting its first residents in 2021. Most of its faculty members
are graduates of the TASH/A.A.U urology program.
• With the current residents being mostly from academic institutions , many more are likely to
follow in starting their own Urology residency programs.
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General Surgery
• 65% of respondents said the duration of General Surgery attachment should be
reduced to one year.
• The most chosen duration for residency duration was five years including a one
year general surgery attachment.
• This finding may reflect the fact that residents found their General Surgery

training to be “Very Poor” and there was no involvement with the Urology unit.
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Knowledge and understanding
• All of the residents were not ‘Unsatisfied’ with their training in Laparoscopy, female pelvic medicine, Renal
Transplant , Neurourology and andrology.
 Laparoscopy and Neurourology are not being practiced currently.
• Among the components of Urological clinical training, the highest satisfaction rate was for “stone disease and
Minimally invasive Rx” and “Urologic Oncology”. Each scoring ‘Satisfactory’ form 70% of the residents based on
exposure. Both components were rated as “Useful” to clinical practice by most of the recent graduates.
• Only 41% of residents found exposure to pediatric Urology as “satisfactory”
While most of recent graduates rated it as “Useful” to their clinical practice.

•
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Knowledge Sharing and Research
• A good residency program must balance meeting international standards with its resources. An isolated program
hinders its own improvement. There were no International exchange programs available for current residents and
recent graduates.
• Although residents are required to do at least one research before graduation. There was no dedicated time given for
research and none of the residents received any formal training.
• This may reflect the fact that only one of such researches done on a mandatory bases was published. The main
reasons for not publishing were lack of knowledge and interest.

• The lack of attention to knowledge sharing through conducting research and understanding scientific papers has been
shown by the fact that more than 90% of researches conducted by final year residents over the past three years have
not been published. And the fact that most 66%(2/3 rd) of Urologist were ‘unprepared’ to conduct research on their own.
• This is in contrary to international standards set by CanMEDs. Research is given a dedicated time of 6 months to a
whole year to trainees in experienced centers like Egypt , Saudi Arabia, U.S.A and Canada.
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Skills and Procedures
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• Skill lab courses were given only once for a two months period. It included Endourology and Laparoscopy. Most of the residents
rated the skill lab as ‘Unsatisfactory’ . Individual practice time were not available for regular practice. This contradicts the fact
that the curriculum is on a fixed time bases, leaving residents training of skill to ‘chance’. Many of the centers which follow a
fixed timeline for training , like Egypt and many centers in USA use simulation based training to bridge the gap in skills. A paper
published in U.K (Gohil et al., 2011) , noted that the future of training in Urology has shifted from volume based to proficiency
based competence. Hence simulation training of critical steps of procedures is vital to attain proficiency in a time limited training.
• Majority of the residents perceived that they were able to perform common endourological procedures independently.
• Among the recent graduates, only half (53%) of the respondents had Cystoscope, 33% had Equipment for DVIU and 26% had

Instruments for TUR.
• None of the respondents had equipments for Laparoscopy, Ureteroscopy, PCNL, ESWL or Urodynamics.
• The lack of access to these minimally invasive equipment contradicts the trainees main competence area which is Endourology.
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Cont’d
• The perceived ability to perform Open surgical procedures was low, specially the more
complicated procedures like Radical Cystectomy, Radical nephrectomy and
Nephroureterectomy. Similar study done in Canada showed a much higher rate for more
complicated open surgical procedures. Our finding contradicts the fact that there is no
Laparoscopic or Robotics, and all such procedures are done with open surgery.

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Professional Attitude
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 The Graduate is expected to have skills as a Collaborator, communicator, manager, scholar , and is expected to
be ethical, punctual, responsible.
1. Most of the recent graduates rated “prepared” for ‘communication with patients and colleagues’, ‘Accept ultimate
responsibility for a patient’ and ‘providing care in a financially constrained setup’
2. while only half were ‘prepared’ in making ‘Ethical Decision’.
3. Almost all of the recent graduates were ‘Unprepared’ for ‘Hospital Administration’ and half of them were
‘unprepared’ in time management skill.
4. A similar study in Canada showed a similarly lower rates preparation in “Administrative skills’ and ‘Time

Management’. The study also showed only 40% were ‘prepared’ in ‘Providing care in financially constrained
setup’ in contrast to our finding of 80%. The higher rates may be a reflection of a training done in poor financial
setup.
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‘Burnout’
• There was a high level Emotional Exhaustion, Depersonalization and a Low
sense of Achievement among residents overall but Urologists had relatively
lower rates of burnout in all categories. Medscape 2021 report found that
Urology had the highest burnout rate (54%) among physicians. The sample size
of our findings was small and limited to a single institution to asses for reasons
of burnout. But similar studies done in USA and Canada found that institutional

factors like work hours, structured mentorship and access to mental health were
significant factors in Urology residents burnout.
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Conclusion
• There is a an alarming discrepancy between the curriculum expectations and actual practice patterns.
• Residents perception of competence to perform major open surgical procedures was very low
• Most of the senior residents feel more competent to perform endourological procedures but recent graduates have little
to no access of endourological setup.
• Most of the residents are unsatisfied with their exposure to many areas of Urology clinical practice.
• Majority of the Urologists didn’t have most of the basic Endourologic, equipments at their institution.

• There is a poor preparation of residents to do research independently, critical appraisal of scientific paper, time
management and hospital administration.
• There is a High level emotional burnout, High level cynicism and low level of feeling of accomplishment among residents.
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Recommendations

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1. International exchange program
 Serve as a quality control
 Better exposure to Subspecialties not practiced in Ethiopia.
2. Restructure the curriculum to meet the financial constraints and feasibility.

 Provide a detailed structure breaking down the major components for residents to follow at each stage
of the training.
 Residents performance should be followed regularly and attachments arranged based on deficiencies.

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3. Have a dedicated time for research conduction. And publishing a paper should
be mandatory before graduating for those who come from academic
institutions. If possible , have a separate training for research.
4. Conduct research for reasons of burnout, have a support system for residents
who are on the verge of Burnout. Provide access to mental health of
professionals.
5. Decrease the General surgery duration to one year, to increase exposure of

residents to Urologic procedures.

6. Increase awareness about the need minimally invasive procedures
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Limitations
• Small sample size
• Factors for Burnout Not assessed
• Lack of access to subscription Urology journals
• MBI-HSS(MD)-tool not available for free, institutional subscription not available.

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References
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• AAU (2020) TASH; Background Information. Available at: http://www.aau.edu.et/chs/tikur-anbessa-specialized-hospital/background-of-tikur-anbessa-hospital/ (Accessed: 13 October 2020).
• ACGME (2020) Urology Milestones, https://www.acgme.org/Portals/0/PDFs/Milestones/UrologyMilestones.pdf?ver=2020-09-01-153021-157 . Available at: https://www.acgme.org/Portals/0/PDFs/Milestones/UrologyMilestones.pdf?

ver=2020-09-01-153021-157.
• Addis Standard (2017) ANALYSIS: THE AILING STATE OF HEALTH CARE IN ETHIOPIA’S STATE-RUN HOSPITALS: WHO TAKES THE BLAME? Available at: https://addisstandard.com/analysis-ailing-state-health-care-ethiopias-
state-run-hospitals-takes-blame/ (Accessed: 23 September 2020).
• Alebachew, A. and Waddington, C. (2015) ‘Improving health system efficiency: Ethiopia: human resources for health reforms’, Who, pp. 1–28. Available at:
https://apps.who.int/iris/bitstream/handle/10665/187240/WHO_HIS_HGF_CaseStudy_15.6_eng.pdf?sequence=1&isAllowed=y.
• Bachir, B. G., Aprikian, A. G. and Kassouf, W. (2014) ‘Are Canadian urology residency programs fulfilling the Royal College expectations?: A survey of graduated chief residents’, Journal of the Canadian Urological Association,
8(3-4 APR), pp. 109–115. doi: 10.5489/cuaj.1339.
• Bhandari, M. (2009) ‘Guest Editorial Urology training : From schelp to jaunt’, (June), pp. 215–216. doi: 10.4103/0970-1591.52922.
• Binsaleh, S. et al. (2015) ‘Evaluation of urology residents’ perception of surgical theater educational environment’, Journal of Surgical Education, 72(1), pp. 73–79. doi: 10.1016/j.jsurg.2014.08.002.
• Cadotte, D. W. et al. (2013) ‘Establishing a surgical partnership between Addis’, 56(3), pp. 19–23. doi: 10.1503/cjs.027011.
• Cheng, J. W. et al. (2020) ‘Stressors and Coping Mechanisms Related to Burnout Within Urology’, Urology, 139, pp. 27–36. doi: 10.1016/j.urology.2019.11.072.
• Gohil, R. et al. (2011) ‘BJUI Urology training : past , present and future’, pp. 1444–1448. doi: 10.1111/j.1464-410X.2011.10653.x.
• J. Rickard1, R. Ssebuufu2, P. Kyamanywa2, G. N. (2016) ‘Scaling up a Surgical Residency Program in Rwanda’, East Cent. Afr. J. surg, 21(3), pp. 28–35.

• Marchalik, D. et al. (2019) ‘The Impact of Institutional Factors on Physician Burnout: A National Study of Urology Trainees’, Urology, 131, pp. 27–35. doi: 10.1016/j.urology.2019.04.042.
• Miernik, A. et al. (2014) ‘Bringing excellence into urology: How to improve the future training of residents?’, Arab Journal of Urology, 12(1), pp. 15–20. doi: 10.1016/j.aju.2013.06.001.
• Monsalve, D. M. C. et al. (2018) ‘Current status of urological training in Europe’, (January).
• Moore, T. D. (1923) ‘A History of the Development of Urology as a Specialty’, Journal of Urology, 10(2), pp. 99–120. doi: 10.1016/s0022-5347(17)73718-4.
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10/09/2021

Assessing Goals Of Urology Residency Program

By – Mekbeb Chere (M.D, PGY-5 Urology Resident)

Goals of Urology Residency

Goals of Urology Residency

Goals of Urology Residency 10/09/2021

• Currently there are 10 PGY-5, 6 PGY-4 and 2 PGY 3 residents.

Goals of Urology Residency

Goals of Urology Residency

disorders 4. Reduce the national disease burden

laparoscopic surgery. 5. Introduce cost effective and modern Minimally invasive

Urological services in all referral hospitals

The goals of the program

training in urology • provide a motivating environment

To make a ‘Modern day’ Urologist, the development

1. Its respective region

Goals of Urology Residency

• fixed times for lectures, clinical parts and a (self)-monitoring system.

Miernik et al., 2014 Environmental considerations

• tried to standardize the expectations at different

Goals of Urology Residency

 Patient Care and Procedural Skills.

• Placement of transobturator slings, retropubic and fascial

Goals of Urology Residency

Goals of Urology Residency

• It is a sophisticated field with unique components of diagnostic and therapeutic

Goals of Urology Residency

• Asses the current urology training components

Goals of Urology Residency

Goals of Urology Residency 10/09/2021

Goals of Urology Residency

• Cross sectional descriptive study

Goals of Urology Residency 10/09/2021

Goals of Urology Residency

Goals of Urology Residency

Goals of Urology Residency 10/09/2021

General Surgery Training Duration

Goals of Urology Residency

1 Year 2 Years 3 Years 18

Goals of Urology Residency

Goals of Urology Residency

Goals of Urology Residency

Radical inguinal orchiectomy 77.8% 22.2% 0.0%

Goals of Urology Residency

Open partial nephrectomy 22.2% 77.8% 0.0%

Open pelvic lymphadenectomy 0.0% 44.4% 55.6%

Radical Cystectomy (Female) 0.0% 44.4% 55.6%

Goals of Urology Residency 10/09/2021

Goals of Urology Residency 10/09/2021

Goals of Urology Residency

Goals of Urology Residency

Goals of Urology Residency

Goals of Urology Residency

Goals of Urology Residency 10/09/2021

Goals of Urology Residency 10/09/2021

Goals of Urology Residency

Goals of Urology Residency

• Only 41% of residents found exposure to pediatric Urology as “satisfactory”

While most of recent graduates rated it as “Useful” to their clinical practice.

Goals of Urology Residency

Goals of Urology Residency

Goals of Urology Residency