EDITORIAL

Burnout in Urology and the Hidden Workplace Dangers

Recently, the AMA and Medscape each published data indicating that the specialty of Urology has the highest burnout rate among all specialties. Although definitions vary, the WHO has defined burnout as a “syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed”. Key symptoms of burnout include feelings of energy depletion or exhaustion; increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job; and reduced professional productivity. Burnout is now formally defined in International Classification of Diseases (ICD-10 and ICD-11).

In 2019 the National Academy of Medicine published a consensus paper “Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being”.1 They called for immediate action from the health care system to combat physician burnout and improve professional well-being. In their report they cite 12 key factors that contribute to physician burnout and stress. These included many administrative factors such as health care reform and payment policies, EHR and coding requirements, quality measurements and reporting to name a few.

The question is why does urology have such a high burnout rate, even higher than other surgical disciplines? Similar surgical disciplines such as ENT and General Surgery have burnout rates of 35% each compared to 54% for urology. Is it possible there are other factors involved in the practice of urology that are contributing to stress and burnout beyond the commonly identified administrative burdens?

The American Urological Association (AUA) has found that working more clinical hours per week, working more overall hours per week or seeing more patients per week increased burnout.2 This is true for both residents and attendings. Mid-career urologists (those in practice 10 to 25 years) have more burnout than early career urologists. This data is not surprising and speaks to administrative demands to spend more time involved in patient care activities. The AUA assessed burnout by using the Maslach Burnout Inventory in the 2016 AUA Census. Some factors identified that worsen burnout for urologists: government regulations, administrative burdens, reimbursements, physician autonomy, work hours and work life balance.2 On the surface these factors do not appear to be unique to the specialty of Urology.

In August 2019 Urology Times published survey data on hazards urologists face in the in the workplace.3 They identified two major stressors: violence against urologists and work-related pain and injury. These had not been previously assessed in the context of these stressors contributing to burnout. A shocking finding was that 62% of urologists reported being threatened by a patient with nearly 25% having suffered a physical attack or abuse at the hands of a patient. Urology often deals with sensitive areas of patients’ lives. Since urologists tend to care for a male dominated patient population, law enforcement statistics suggest men are more likely to be involved in violent acts. Some news stories that highlight violence against urologists:
• “Suspect in urologist killing had prostate surgery” (USA Today)
• “Reno shooter gunned down two doctors, patient at urology clinic” (LA Times)
• “Sheriff’s deputies continue to investigate the shooting death of a 75-year-old Metairie urologist” (Washington Times)

Nearly 75% of all assaults in the workplace occur in health care, according to the Occupational Safety and Health Administration (OSHA). Workplace violence against health care workers often goes unreported by up to 70 percent. There are certainly higher risk areas in medicine such as emergency departments and psychiatric units but the 25% report of attacks by patients on urologists is noteworthy. Between 2013 and 2015 there were 33 physician homicides in the US with several urologists as victims in the news stories noted.

Work related pain or discomfort is experienced by 90% of urologists in the Urology Times survey. Awkward positioning in the OR, repetitive motion injuries, extended periods standing and wearing loupes and heavy lead aprons are cited as common causes. Lumbosacral and cervical spine diseases were the most commonly reported work-related conditions. These occurrences appear to be similar to other surgical disciplines.

Any 2020 discission of workplace dangers would be incomplete without noting the impact of CVOID-19 on all aspects of health care. Like many other providers, the main danger to urologists has been the financial impact on the practices. Urologist’s direct patient care risks appear to be lower when compared to our colleagues who deal with the upper respiratory tract for example with documented viral shedding from these areas. The reports of corona virus in the urine thus far are limited and suggest the rate of shedding is low with the level of infectivity unknown. Regardless, there is still a surprise work place risk to urologists who perform robotic and laparoscopic procedures. The aerosolization from cautery and ultrasonic scalpels is contained within the pneumoperitoneum. These aerosolized particles and surgical smoke plume may contain active COVID-19 virus which places all surgical team members at risk. Recommendations are in place including corona virus pre op patient testing, use of appropriate personal protective equipment and the use of add-on trocar vent filters (passive filtration).4 Doctor burnout is a major consideration during the corona virus pandemic, and it’s one that’s largely been absent from most discussions thus far.

I have been fortunate to have never experienced burnout. I credit my very supportive team at work and a very supportive family at home. However, I have received major threats from a patient that were so significant my hospital took corrective action. Some of you are old enough to remember laparoscopy circa 1991. There was only one monitor at the foot of the bed and the procedures were often long and difficult. My once painful herniated disk is now just a remote memory of the poor ergonomics of that early operating room set up. You can check me off as a “yes” for both of the Urology Times survey items attesting to these hidden workplace dangers.

Organizations such as the AUA, Accreditation Council for Graduate Medical Education (ACGME) and the American Medical Association (AMA) have all taken a major interest in addressing physician burnout. There is clearly something different about the practice of urology causing the higher degrees of burnout. It is possible that workplace violence and physical injuries may be unrecognized contributing factors to burnout and others likely exist. More research is needed to identify the specialty specific contributors to physician burnout beyond the well documented and growing administrative burdens of medical practice. Once these unique factors are identified, specialty specific programs need to be developed to mitigate burnout. This research may reveal hidden issues such as unrecognized workplace dangers that may be impacting burnout in specialty practices including Urology that have not been previously identified.

Leonard G. Gomella, MD
Thomas Jefferson University
Philadelphia, PA, USA
Editor-in-Chief

References

1. https://www.nap.edu/catalog/25521/taking-action-against-clinician-burnout-a-systems-approach-to-professional. Accessed May 30, 2020.
2. North AC. Burnout in Urology, AUA Update Series Lesson 25, Volume 37, 2018.
3. https://www.urologytimes.com/sites/default/files/legacy/mm/digital/media/ut0819_ezine.pdf. Accessed May 30, 2020.
4. Zheng MH, Boni L, Fingerhut A. Minimally Invasive Surgery and the Novel Coronavirus Outbreak: Lessons Learned in China and Italy.
   Ann Surg 2020 Mar 26:10.1097/SLA.0000000000003924. Online ahead of print.

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© The Canadian Journal of Urology™; 27(3); June 2020