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You have accessUrology Practicethe Specialty1 Jan 2022

Addressing Burnout in Urology: A Qualitative Assessment of Interventions

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Abstract

Introduction:

We characterized physician burnout among urologists to determine the prevalence and efficacy of specific burnout interventions utilized and to determine involvement of workplaces in effective burnout interventions.

Methods:

The Western Section of the American Urological Association created an electronic, 29 question workforce survey. Several questions focused on assessing the level of urologist burnout, prevalence of work sponsored burnout interventions and efficacy of specific interventions.

Results:

A total of 440 responses were received (25.9% response rate); 82.2% of responders were male. The majority of urologists noted some level of burnout (79.5%) with no significant difference between those who reported no burnout vs some level of burnout (p=0.30). The most commonly tried interventions to reduce burnout were participating in regular physical exercise (76.6%), reading nonmedical literature (67.1%) and decreasing or modifying work hours (52.3%). The interventions most frequently cited as “very effective” were hiring a scribe (62.5%), regular exercise (56.1%) and participating in 1-on-1 gatherings with colleagues outside of work (44.6%). There were no significant differences noted when comparing “very effective” interventions by gender. The interventions most frequently cited as not effective were stress or burnout seminars (26.9%) and meditation/mindfulness training (11.5%); 42.5% reported workplace interventions to help prevent or reduce burnout.

Conclusions:

Certain practice-changing and personal burnout interventions were noted to be “very effective” in decreasing burnout. Fewer than half of responders noted workplace sponsorship of interventions. Organizational support may lead to increased participation and effectiveness of burnout interventions.

Abbreviations and Acronyms

WSAUA

Western Section of the American Urological Association

Urologist burnout has been well documented.1,2 This condition is defined as a psychological syndrome consisting of depersonalization, low personal accomplishment and emotional exhaustion that can occur among individuals working with people.3 Stressors that contribute to physician burnout in the modern era include but are not limited to: increased nondirect patient care, clerical burden related to the electronic medical record, longer work hours, and decreased work–life balance.2,4–7 There is also an increasing awareness of the negative patient-related outcomes of burnout including medical errors.8

Prior studies in health care have shown that interventions targeted at both the personal and institutional levels can result in meaningful reductions in burnout. However, the most effective strategies are implemented at the organizational level.9–11 Unfortunately, there is a paucity of data in the field of urology evaluating specific interventions to prevent or decrease burnout.

The primary objective of this study was to evaluate the effectiveness of various burnout interventions among the members of the Western Section of the American Urological Association (WSAUA). The secondary objectives were to evaluate the prevalence of workplace interventions and the level of burnout among practicing urologists.

Methods

This was an institutional review board exempt study. The WSAUA created an electronic, 29 question general workforce survey. This was distributed to members of the section via email during the COVID-19 pandemic (2020). Two additional reminder emails were sent along with 1 postcard announcement/reminder via mail.

To assess the level of physician burnout, we posed the following question: Using the following definition of burnout, how would you define your current level of burnout? (Burnout definition: “Burnout is a long-term stress reaction characterized by depersonalization, including cynical or negative attitudes towards patients, emotional exhaustion and a feeling of decreased personal achievement”). We used the American Medical Association STEPS Forward definition of burnout.12 Please see supplementary material (https://www.urologypracticejournal.com) for a list of all questions included in the workforce survey.

To evaluate the effectiveness of specific burnout interventions, responders could choose one of the following options: “not applicable,” “mildly effective,” “moderately effective” and “very effective.” Only those who tried the intervention were included in the data collection and analysis.

Chi-square analysis was utilized to assess associations between gender and level of burnout, as well as gender and “very effective” interventions used to address burnout. Fischer’s exact test was employed to assess the association between gender and those “very effective” interventions which were utilized by fewer responders (ie hired a scribe, physician/employee counseling services, and burnout or stress management seminars); 95% confidence intervals were estimated for proportions of responders who noted interventions as “very effective.” All statistical analyses were conducted using SAS® 9.4 (SAS Institute Inc., Cary, North Carolina). Tests of statistical significance were determined using 2-sided tests, and a p value ≤0.05 was considered statistically significant.

Results

There were 1,700 urologists in the WSAUA who were eligible to participate in the survey. A total of 440 responses were received for a 25.9% response rate. Of those who responded to the questions, 352 were male (82.2%). The most common practice types were private practice, single specialty group/network (124) and employee of a teaching hospital/academic medical center (79). Most urology practices had 2–5 urologists (146), followed by 6–10 (103) and 11–20 (86).

Table 1 describes the level of burnout among responders. While the majority of urologists noted some level of burnout (349/439, 79.5%), only 31% noted moderate to severe levels (136). Chi-square analysis showed no difference among different levels of burnout and gender (p=0.78). Among all responders, there was no statistically significant difference between those who reported no burnout versus those who reported some level of burnout (mild, moderate, or severe; p=0.30).

Table 1. Level of burnout

Level of Burnout No. (%) No. Male (%) No. Female (%) No. Gender Not Specified
Total respondents 439 (100) 351 (100) 76 (100) 12
None 90 (20.5) 74 (21.0) 12 (15.8) 4
Mild 213 (48.5) 171 (48.6) 39 (51.3) 3
Moderate 113 (25.7) 89 (25.3) 21 (27.6) 3
Severe 23 (5.2) 17 (4.8) 4 (5.3) 2

Table 2 demonstrates the various interventions utilized by urologists to prevent or reduce burnout and if they were work sponsored. Less than half of responders noted these were work sponsored interventions (185/440, 42.5%). The figure shows the interventions that were rated “very effective.” Lastly, table 3 shows “very effective” interventions stratified by gender. When comparing “very effective” interventions by gender, there was no statistically significant difference noted with any of the interventions (p=0.08–1.00).

Table 2. Type of burnout intervention performed and work sponsored status organized from most common intervention to least common

Type of Intervention No. (%) No. Work Sponsored (%)
Participate(d) in regular physical exercise (≥ 3 d/wk) 337 (76.6) 2 (0.6)
Read nonmedical literature (fiction, nonfiction) 295 (67.1) 0 (0)
Decreased or modified work hrs 233 (52.3) 3 (1.3)
Hired an advanced practice provider 137 (31.1) 25 (18.2)
Participate(d) in recreational 1-on-1 or small group gatherings with colleagues (eg happy hour, dinner) 130 (29.6) 6 (4.6)
Participate(d) in meditation/mindfulness interventions 122 (27.7) 11 (9.0)
Participate(d) in burnout or stress management seminar(s) 52 (11.8) 11 (21.2)
Hired a scribe 48 (10.9) 10 (20.8)
Participate(d) in physician/employee counseling services 28 (6.4) 4 (14.3)
Figure.Percentage and 95% confidence intervals of responders who noted “very effective” for interventions.

Figure. Percentage and 95% confidence intervals of responders who noted “very effective” for interventions.

Table 3. Number of responders by gender who noted “very effective” for interventions

Type of Intervention No./Total No. Male (%) No./Total No. Female (%) p Value
Hired a scribe 23/38 (60.5) 4/7 (57.1) 1.00*
Regular exercise (≥3 d/wk) 148/277 (53.4) 34/51 (66.7) 0.08
1-on-1 or small group gathering with colleagues 44/100 (44.0) 10/23 (43.5) 0.96
Decreased or modified work hours 83/192 (43.2) 16/31 (51.6) 0.38
Hired an advanced practice provider 39/117 (33.3) 7/15 (46.7) 0.31
Physician/employee counseling services 7/22 (31.8) 1/5 (20) 1.00*
Reading nonmedical literature 56/237 (23.6) 14/49 (28.6) 0.46
Meditation/mindfulness interventions 18/94 (19.1) 6/20 (30.0) 0.36
Burnout or stress management seminars 7/39 (17.9) 2/12 (16.7) 1.00*

Fisher’s exact test.

Chi-square test.

Discussion

In this study, almost a third of urologists noted moderate to severe levels of burnout. The most effective interventions to prevent or reduce burnout varied from practice changing to personal/collegial. Despite the high prevalence of urologist burnout, less than half of burnout interventions tried were work sponsored.

Degree of Burnout

Previously reported rates of urologist burnout vary from 38.8%–78%.1,2 Our evaluation noted a similarly high percentage. The authors are aware that we did not use a validated instrument to assess burnout in this population. The primary reason for this was wanting to focus on our primary objective, which was to assess burnout interventions and their effectiveness. As this survey included dozens of other general workforce questions, there was also a need to limit the overall number of questions in order to maximize the response rate and decrease “survey fatigue.”

In this study, the percentage of females noting burnout was slightly higher than males which is consistent with other published studies. However, this difference was not statistically significant in our study. In general, reasons for higher levels of female urologist burnout can include: reporting more stress from lack of time at work, lack of control at work and lack of personal time.2 Along this point, data have shown that patients of female physicians speak more during office visits and reveal more medical and psychosocial issues. This was shown to increase appointment duration by 10% for female vs male physicians.13 This may lead to burnout among women as their clinic schedule may fall behind and/or they may not be able to see as many patients in a day as their male counterparts.

Other reasons for gender differences can include the presence of children at home, caring for someone with a serious health program and/or discriminatory practices that can revolve around maternal leave and/or breastfeeding needs.14 In addition, at least among primary care physicians, women were less likely to believe they had sufficient time to see patients during office visits and less control over their workload. A review article evaluating surgeon burnout across specialties found that gender was a risk factor with women reporting generally higher rates of burnout.15 However, they did note some conflicting data among included studies.

Effective Interventions

The interventions cited most often as “very effective” were hiring a scribe (30/48, 62.5%), regular exercise (189/337, 56.1%) and participating in 1-on-1 gatherings with colleagues outside of work (58/130, 44.6%). This correlates with prior research that found exercise and socializing to be protective against burnout in practicing urologists as well as trainees.16 Unfortunately, due to the COVID-19 pandemic, lack of socialization and in-person gatherings may further exacerbate burnout. Our survey was sent out during the pandemic and therefore may be influenced by some of these factors.

Implementation of scribes had the highest percentage “very effective” responses (30/48 who hired a scribe, 62.5%). The utilization of scribes has been previously suggested as a method to combat organizational burnout.11 Furthermore, any intervention to increase electronic health record efficiency has been shown to be beneficial.17 Not only do scribes reduce the workload for physicians, but they also have been shown to be financially effective as well. McCormick et al investigated the cost and outcomes of utilizing medical scribes in a urology office environment.18 Not only did providers report increased efficiency and satisfaction, they also found they could see more patients and increase overall revenue. The effectiveness of scribes found in our survey likely further speaks to the significant burden physicians experience with the electronic health record system. It will be interesting to see how the new 2021 Centers for Medicare and Medicaid Services outpatient coding changes will alter burnout symptoms in urologists who do not utilize scribes, as certain history and physical examination components will no longer be required for billing purposes.

Participating in regular exercise and recreational 1-on-1 or small group gatherings with colleagues were also frequently cited to be “very effective.” The literature reports some institutional experiences to create initiatives to combat burnout by paying for gym memberships and promoting regular exercise.19 In another example, the Mayo Clinic created COMPASS groups (Colleagues Meeting to Promote and Sustain Satisfaction) in an attempt to cultivate community at work.11 Participating physicians met with a group of 6–7 colleagues and ate a meal together once every 2 weeks. During these meals, they spent the first 20 minutes discussing a question that explored the benefits and issues of being a physician. These meals were reimbursed by the Mayo Clinic. At the close of their study, the data showed an improvement in burnout and an increase in work meaning.

In our study, 53.1% of urologists decreased or modified work hours in order to manage burnout; 44.6% of these individuals reported that this was “very effective” in reducing burnout but only 1.3% of those who tried this intervention noted it was work sponsored (3/233). In addition, decreased or modified work hours was one of the top 3 interventions noted by female urologists to be “very effective.” The 2019 AUA Census reported that approximately a third of urologists work more than 60 hours/week with 44% spending ≥5 hours/week at home performing nonclinical work.20 Our findings corroborate other published work that notes a reduction in work hours as a way to manage burnout. Shanafelt et al found that increasing emotional exhaustion and/or decreased satisfaction increased the odds of decreasing one’s full time employment status.21 However, one limitation of our survey is that it did not seek to understand the number of baseline hours worked, the types of hours worked (clinical vs nonclinical) and the degree of modification or decrease in hours.

For surgeons, there are conflicting data regarding the effect of work hours and burnout by specialty and country.22–25 However, noted benefits of decreased work hours include improved symptoms of depression, decreased rates of major medical errors, and a lower likelihood of experiencing work or home conflict.23 While a large proportion of WSAUA urologists changed their work schedule to combat burnout, this was completed without the formal support or sponsorship of their practice. One wonders if workplace sponsorship would have allowed for more urologists to try this themselves. In addition, sponsorship may have increased the options available to modify one’s practice and may have increased the percentage of urologists who found this intervention effective.

Studies present mixed findings concerning the role of work hours and burnout when stratified by gender.2,24,25 The results of our study indicate that more female than male urologists found reducing work hours to be “very effective” in addressing burnout (51.6% vs 43.2%, respectively). A recent survey of urologists belonging to the American Urological Association revealed that female urologists reported a significantly higher level of severe burnout than male urologists, identifying lack of personal time as the most common reason for burnout.2

Ineffective Interventions

Through our evaluation, we found that burnout/stress management seminars and meditation/mindfulness interventions were least effective (26.99% and 11.5%, respectively). These are often typical offerings by practices/organizations. Unfortunately, reasons that these were least effective were not elucidated in our study. One possible reason may be due to the belief that each individual physician should be in charge of their own professional satisfaction and burnout.11 Unfortunately, the 2 above-noted interventions do not directly address the underlying practice issues contributing to burnout. In addition, multisession courses on either burnout or mindfulness may not be practical with a busy clinical schedule and outside responsibilities.

While the Mayo Clinic noted improvements in depersonalization that were sustained after 19 biweekly facilitated physician mindfulness and shared experience discussion groups, this was protected time with 1 hour of paid time every other week.9 It is unlikely that such protected time is available in many practices. As an example, it has been noted that 44% of health care professionals randomized to an 8-week mindfulness-based stress reduction intervention could not finish it for a variety of reasons including a “lack of time.”26 However, protected time for burnout interventions should certainly be a consideration to support physicians. Newer modalities, such as app-delivered mindfulness training, may prove to be an additional means to reach physicians with busy schedules.27

Work Sponsored Interventions

A systematic review of controlled interventions found improved effects for organization-directed interventions.10 However, we need to differentiate organization-directed interventions into 2 categories: 1) organizational interventions that alter the current work environment in order to make it a better place to work and 2) interventions that put the onus on the physician to change their work environment (ie a “physician heal thyself” attitude).

At this time, our study shows that less than half of interventions are work sponsored. It is unknown if more urologists would have participated in these interventions if they were work sponsored and/or if they would have been more effective with organizational support. Our data show that both institutional and personal interventions can be effective, and we believe that practices should consider both in tandem when creating a multipronged effort to decrease urologist burnout as it is not a “one size fits all” issue. In addition, practices/organizations should be thoughtful in both their practice models and burnout interventions due to the known consequences of burnout (eg medical errors, depression, substance abuse, premature turnover). However, as seen in our study, certain independent efforts (eg regular exercise) should continue to be used as they were “very effective” in a large percentage of urologists who tried it.

Strengths and Limitations

Strengths of the survey included responses from a variety of practice settings. Of note, 49.6% of responders work in private practice. This is similar to the national prevalence of 53.2% private practice urologists.20 In addition, 17.8% of responders were female. This is above the national average of practicing female urologists (9.9%).

Limitations of the survey include a response rate of 25.9%, selection bias, response bias and data collection from only 1 region of the United States. Future studies will be needed to evaluate whether burnout rates and intervention effectiveness are similar in other sections of the United States. While we sought to evaluate the effectiveness of previously published burnout interventions, there may be others that need to be assessed. In addition, we did not use a validated burnout inventory to assess the degree of burnout due to the length of the survey and the need to assess multiple aspects of the current work force. However, the American Medical Association STEPS Forward definition of burnout does include the 3 main domains encompassed by the Maslach Burnout Inventory (depersonalization, emotional exhaustion and low personal accomplishment).

Conclusion

In conclusion, the most effective burnout interventions varied from practice altering to personal/collegial interventions. Increased institutional support and offering several different types of burnout interventions allows urologists to choose the one(s) that best fit their work–life goals.

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This study was deemed exempt from IRB review.

Funding: Not applicable.

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