EDITORIAL

Burnout and the Ancient Greek Definition of Happiness

It occurred during a long forgotten Presidential press conference on 10/31/63. President Kennedy was conducting a press conference and during the Q and A, a female reporter rose and said, “Mr. President, just shortly after the Bay of Pigs, I asked you how you liked being President and, as I remember, you said you liked it better before the event. Now you have had a chance to appraise your job, and why do you like it and why do you want to stay in office for 4 more years?” The President replied, “Well, I find the work rewarding. Whether I am going to stay, and what my intentions are, and all the rest, it seems to me it is still a good many months away, but as far as the job of President goes, it is rewarding and I have given before to this group the definition of happiness by the Greeks, and I will define it again. It is the full use of your powers along lines of excellence. I find, therefore, the Presidency provides some happiness.”

The lesson from this interchange during a presidential press conference is, I think, that whether you are a president or a urologist, stress is part of the job. Government and insurance regulations are not going to disappear, patient expectations will not decrease and the economic exigencies will remain a reality. Therefore, what can a urologist do to manage burnout?

The 2016 AUA census reported a 36.2% incidence of burnout in those responding to the survey.1 In addition, it has been noted that burnout among urologists and physicians in general seems to be increasing.2 Multiple causes of burnout have been suggested including work hours, regulatory burdens, EHR and decreased reimbursement. These external forces are unlikely to dissipate, so what can urologists do about burnout?

Exercise and Physical Fitness

Christopher Weight and others have provided evidence that physical activity and healthy exercise habits can ameliorate the effects of burnout.3,4 Certainly there are numerous exercise options and the urologist should select those that are most appealing to him/her personally. Clearly, physical fitness, regardless of which activity is selected, requires the self-discipline that comes naturally to most surgeons.

Pursue Hobbies

Most urologists have numerous interests outside of medicine. The pursuit and development of these non-medical hobbies can serve as a valuable outlet to unwind and debrief from the exigencies of urologic practice. Music, in particular, has been mentioned, as an effective vehicle for physicians to escape from the demands of urologic practice. Danielle Ofri has described her personal journey to learn how to play the cello and the benefits she has accrued.5 Nonetheless, whatever non-medical passion appeals to the urologist, it should be pursued, nurtured and developed.

Subspecialization and Proficiency

Malcolm Gladwell proposed that to become highly skilled and proficient in any human activity takes time and practice, which he refers to as the 10,000 hour rule. In the past several decades, the trend in urologic practice has been toward subspecialization. This has occurred for a variety of reasons, but an unexpected benefit of subspecialization is the likelihood of achieving significant proficiency. Part of the human condition is that generally the more one practices something, the better one gets at it. The advent of fellowship training and the evolution of large group practices has allowed many urologists to focus on relatively narrow areas of urologic practice. With focus comes proficiency and with proficiency comes enjoyment. We like things that we are good at and emphasizing discreet portions of urology can often result in greater job satisfaction and less stress. This enables one to achieve Kennedy’s exhortation, to apply “the full use of your powers along lines of excellence.”

Delegate

It is no surprise that urologists have embraced the increasing role of advanced practice providers (APPs) in urologic practice. Aside from many other benefits, APPs provide the opportunity for the urologist to offload some tasks that, although necessary, are not particularly satisfying. The urologists in a group practice should reach a consensus as to how their APPs can best be utilized to reduce some of the practice demands which can alleviate some degree of burnout.

Humor

The old bromide, “Laughter is the best medicine” has its origins in the Bible and should not be forgotten for either our patients or ourselves.6 Fatigue and tension can often be abrogated by humor. Humor engenders an atmosphere
of teamwork and collegiality in the clinic and the operating room. Humor should not be overlooked as a burnout antidote.

The Role of Organized Medicine

Only recently has organized medicine recognized and confronted the issue of burnout. In September 2017, Doctor Tait Shanafelt was appointed the first Chief Wellness Officer for Stanford Medical School. The American Medical Association (AMA) has expressed strong support for the Charter on Physician Well Being as a catalyst to address the growing problem of physician burnout. The AMA provides a resource, AMA’s STEPS Forward, which is a collection of practice improvement strategies to help physicians make practice changes to rekindle a joy of medicine.7,8

The Future

Ariely and Lanier have provided a cogent analysis of the underpinning for the rise of physician burnout.9 They ascribe the burnout phenomena to three underlying causes: 1) asymmetrical rewards, where physicians are far more likely to receive a strong rebuke for a mistake, but much less likely to be praised for a successful outcome; 2) loss of autonomy, where physicians feel that they have less and less authority over the decisions that impact patient care; 3) cognitive scarcity, where the increasing demands on time and clinical productivity vitiate the opportunity to think or reflect on clinical issues. They describe the perception of a “fixing-people production line”.9

In recent decades, the practice of American health care has changed dramatically and many of these changes have profoundly impacted the job satisfaction of urologists and other physicians. A reasonable response to confront these changes is to proactively take greater control of our immediate practice environment and how we spend our off hours with family and friends. We should not relinquish the unique job satisfaction that accrues from being a urologic surgeon.

Kevin R. Loughlin, MD, Associate Editor

Harvard Medical School

Boston, MA, USA

References

1. 2016 AUA Census. The American Urological Association, Linthicum, Maryland.

2. Shanafelt TD, Hasan O, Dyrbye LN et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clin Proc 2015;90(12):1600-1613.

3. Weight CJ, Sellan JL, Lessard-Andeson CR. Physical activity, quality of life and burnout among physician trainees: the effect of a team-based, incentivized exercise program. Mayo Clin Proc 2013;88(12):1435-1442.

4. Liselotte D, Satele D, Shanafelt T. Healthy exercise habits are associated with lower risk of burnout and higher quality of life among US medical students. Acad Med 2017;92(7):1006-1011.

5. Ofri D. Thoughts on a G string. Lancet 2009;373(9658):116-117.

6. Proverbs 17:22 A heart doeth good like medicine.

7. Thomas LR, Ripp JA, West CP. Charter on physician well-being. JAMA 2018;139(15):1541-1542.

8. Press release-AMA strongly supports the charter on physician well-being. 3/29/18 https://www.ama-assn. org/press-releases/ama-strongly-supports-charter on-physician-well-being. Accessed 1/15/2019.

9. Ariely D, Lanier WL. Disturbing trends in physician burnout and satisfaction with work-life balance: dealing with malady among the nation’s healers. Mayo Clin Proc 2015;90(12):1593-1596.

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© The Canadian Journal of Urology™; 26(3); June 2019