Lighting the candle at both ends: Burnout in urologists.

Burnout was initially described by Freudenberger in 1980 in his book. 'Burn-out: The High Cost of High Achievement'as the “extinction of motivation or incentive.”[1] It has been subsequently expanded to include poor physical, mental, and emotional well-being. The concept was further developed by Christina Maslach who invented the Maslach burnout inventory which assesses three major areas – emotional exhaustion (a feeling of complete exhaustion by one's everyday work with nothing left in reserve), depersonalization (an impersonal treatment of patients as objects without empathy), and reduced sense of personal achievement (lack of feelings of competence in one's own work).[2] Burnout is a distinct entity, separate from fatigue, depression, and unhappiness with the current job or position.

While burnout has been documented in all major specialties across all major regions, it seems to have a greater prevalence among urologists. In 2020, a survey involving more than 15,000 doctors reported a burnout rate of 54% in urologists, the highest among surveyed specialties.[3]

In the 2016 annual census of the American Urological Association, 39% of urologists met the criteria for burnout.[4] These findings have been corroborated by multiple studies which have consistently shown urologists to have high burnout and low work–life satisfaction.[5]

Burnout results in reduced productivity, affects the quality of patient care, and affects physician health leading to substance abuse, depression/suicidal ideation, poor self-care, and potentially earlier retirement. It is, however, the elephant in the room that no one wants to see or talk about.

There are many reasons why urology is more affected. Traditionally, doctors choosing to be urologists are more ambitious and driven. The dissonance between expectation versus reality starts most often during training with up to 25% of residents experiencing burnout. It also tends to affect younger urologists disproportionally. The factors that most often cited include administrative responsibilities, increased volume of work, lack of institutional and management support, high patient expectations, and low salary/financial compensation. Very few seek professional support preferring to self-medicate or increase alcohol intake.[6]

There is a negative association between burnout and patient care. Emotional exhaustion and depersonalization results in less-than-optimal patient care practices and increased risk of medical errors. Burnout resulted in greater chances of reporting a major medical error in the next 3 months; additionally, adverse patient outcomes and longer recovery times for hospitalized patients post discharge have been reported.[7]

The direct impact on the health of the physician is significant. A 25% increased dependence on alcohol and substance abuse with a doubled risk of suicidal ideation has been reported in surgeons.[8] There is also a greater risk of motor vehicle accidents that is independent of fatigue.[9]

Urology practice in India is unique from other specialties in many ways. In the majority of cases, it is an individual practice by a single urologist. The unregulated evolution of health care and the lack of knowledge and training in managing a private practice places unusual stresses on the young urologist. The advantage of more autonomy in private practice is often negated by the increased pressure to meet revenue obligations.

The inequitable distribution of health care in India has resulted in the location of most health-care facilities in urban areas. This results in urologists competing for patients and being forced to freelance in poorly equipped centers. The consequent increased workload, longer working hours, reduced family and social time contribute to chronic fatigue and emotional exhaustion.

Additionally, the level of training in cloistered environments is in most cases not adequate to treat the complexity of urological and social issues in the real world. As the practice and workload increases, the lack of support to handle the stress leads to emotional exhaustion.

The lack of personal and family time often leads to emotional distress. In India, societal pressures and responsibilities toward one's extended family can result in an additional stressor that is not found in the west. Additionally, the breakdown of the doctor–patient relationship, the lack of trust, and increased patient expectations can only be addressed with focusing an extraordinary amount of energy on a single patient which is unsustainable in the long run.

STRATEGIES TO PREVENT BURNOUT

Since burnout tends to affect younger urologists and trainees more than the established urologist, it is imperative to mentor our junior colleagues in this vulnerable period of their careers. There is insufficient literature on the efficacy of intervention for burnout in general and for urologists in particular, however certain approaches appear reasonable.[10]

Interventions at the level of the individual:

A focus on recognizing the symptoms,

Committing to a level of workload that can be comfortably done without overreach

Schedules that maintain work–life balance

Having an extracurricular hobby

Encourage regular exercise.

Interventions at the organizational level:

Collaborative practice with increased teamwork

Adequate staffing to optimize the workload

A positive work environment

Effective and clear decision-making

Emphasis on improved communication at the workplace

Recognition of efforts

Personal wellness as a quality indicator at the workplace

Professional and personal development programs specifically tailored for preventing burnout

Wellness surveys for early recognition of warning signs

Departmental heads should set limits on workload, encourage skill development and mutual support.

The role of the urological societies both at a local and national level is crucial in this regard. The interventions, if properly implemented, are likely to result in a generation of happy urologists who commit lesser medical errors, provide better quality of patient care with improved patient satisfaction.