Burnout: How can it be prevented?

Raj S. Pruthi, MDAre you burned out? If not, you may know someone who is; 40% of respondents to the 2016 AUA ­Annual Census reported burnout. In this interview, Raj S. Pruthi, MD, discusses the factors behind burnout and steps that can be taken to address and prevent it. Dr. Pruthi is Rhodes Distinguished Professor and chair of urology at the University of North Carolina, Chapel Hill. Dr. Pruthi was interviewed by Urology Times Editorial Consultant Stephen Y. Nakada, MD, the ­­Uehling Professor and founding chairman of urology at the University of Wisconsin, Madison.

Please describe the problem of physician burnout.

Burnout in medicine is a national, complex, and systemic issue whose effects go far beyond physicians themselves, impacting our patients and even having far-reaching societal implications. Sadly, across the world, I believe that physician burnout is becoming the norm within our career path.

The term “burnout” was first used in 1974 to describe stress related to one’s occupation. It can affect anybody but seems to have a disproportionate effect on health care providers, police officers, and teachers-those whose work involves constant demands and intense interactions with people with high levels of physical and emotional needs. I think we all realize physicians are often part of or at the top of that short list of those with burnout.

Does burnout affect urologists differently than other physicians?

I think it affects all physicians, as we share common internal characteristics: drive and determination, motivation, and perfectionism, which paradoxically can actually contribute to burnout by giving one’s self until there’s nothing left to give. Other elements shared by all physicians are external stressors that have worsened recently: government regulations, bureaucratic burdens of providing health care, electronic health records, and so forth.

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A group at the Mayo Clinic led by Dr. Tait Shanafelt looked at burnout in 2011 (JAMA 2011; 306:952-60). Despite burnout being described for 40-50 years, it was not until this paper that it was really addressed in a broad way in the physician work force. In a subsequent paper, his group broke down burnout rates by specialty (Mayo Clin Proc 2015; 90:1600-13). The rate in urology was 64% and was the highest of the specialties evaluated, which many of us in the field found rather surprising. It is not what we expected; when we went into urology, we had a perception of it being a specialty of very fulfilled, happy, relaxed surgeons who can make a difference.

Subsequent surveys have suggested different numbers. A 2017 Medscape survey suggested a 52% rate for urologists, which is right in the middle of the specialists surveyed. The AUA Annual Census embedded Maslach Burnout Inventory questions in the survey and showed a rate of about 40%. (Also see, “Burnout rate lower than believed, but still too high") That might be a more accurate number than the Mayo Clinic number as it had a larger sample size than the 2015 Mayo Clinic study. Still, 40% is a high number. It’s something that deserves attention by our field.

Next: Why do you think this is happening, specifically to urologists?

Why do you think this is happening, specifically to urologists?

There are attributes in all surgical specialties that may contribute to burnout. We have an unwritten code: Come in early, stay late, meet multiple deadlines, keep emotional problems at home, never complain, never show weakness.

It begins with our training. We work long hours and don’t have a lot of control over our schedules, and I think this contributes to life imbalance beginning in residency. There are data suggesting that when students enter medical school, the depression and burnout rates are the same or slightly lower than the general population. Sadly, we put them through our educational system and then they come out with burnout rates that are two- or three-fold higher. There is something in our process, obviously, that contributes to that.

We delay gratification in residency. We have the feeling that, well, this is residency and when we get through residency, it’s all going to get better. I think the habits formed in residency persist for many people and they don’t regain their work/life balance and some of their personal pursuits. The thinking becomes: I’ve got to establish my practice or I need to become promoted to associate professor or I need to be on this committee or I need to secure this grant in order to get my funding. It never ends, and after a while it becomes habit-forming to put life on hold, which can be a negative.

When I saw the 64% burnout figure, I thought, why in urology, when studies done by the American College of Surgeons showed that burnout rates for neurosurgery and transplant/vascular were much lower? It made me wonder if in urology, we take the external environment stressors that have come along in medicine-less autonomy, administrative tasks-more severely. Expectations in our field are very high. Our medical students are the best and the brightest, and what they like about urology is the ability to make a big clinical impact. We also look at it as a surgical specialty that provides a little bit of balance; you can have it all. When some of those external burdens are put upon us, it disrupts that balance. Again, maybe we’ve taken the external burdens more severely.

Next: "This is a national issue."

What are some solutions to urologist burnout?

It’s going to take solutions on a lot of levels. This is a national issue. I don’t want to overuse the word “crisis,” but I think it will become a crisis if it’s not addressed in the near future if for no other reason than the work force problem in medicine. It’s estimated we’ll need 90,000 new physicians in the next 10 years. If our ranks are burned out, not performing to their fullest ability, and leaving the work force early, that is going to have implications.

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Governmental regulations interfere with our ability to care for patients, and there are steps the government could take to streamline the process of documentation and regulations and so forth. Those requirements have only been additive or even exponentially grown over the years. There are difficulties in getting paid in terms of coding and billing. I think they are intentionally difficult and a burden to us.

The American Board of Medical Specialties can streamline maintenance of certification. Also, can we use EHRs in a more effective way rather than them being a clerical burden for us? What are the ways we could use them to help our practices? State boards can play a role. Many state boards function in almost a punitive way for physicians, which I think may limit admitting a mental health condition or depression; it needs to be much more private and supportive.

Our institutions play a very, very important role in this. They have long prioritized patient satisfaction and staff satisfaction-very appropriately-but I think there’s been a blind spot to provider satisfaction. A few institutions have taken leads on it, but just as we use patient satisfaction and staff satisfaction as quality measures for how a hospital performs, I think provider satisfaction should be added to that. People call it the “fourth aim” in medicine. As it becomes a priority for the institution then, accordingly, you can allocate the appropriate resources. If patient satisfaction is low, the institution will dedicate financial and other resources to try to improve that. The same could be done for provider satisfaction as well.

Speaking for my own institution, the health care system leadership has to meet their hospital metrics and they get incentivized to do that. If provider satisfaction was part of that, I think they may have some different views on where resources should go and how that should be carried out. It may not even be on their radar, to be honest. If it’s not measured, it doesn’t exist, and people can’t do something about it.

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As more and more of us are becoming part of larger organizations, it goes a long way to have physicians in the trenches involved in participatory management and be a part of the process. Sometimes we feel like there’s a disconnect and that’s a cause of dissatisfaction as well. Ultimately, it falls upon us as physicians to address burnout, discuss it, and develop interventions.

Next: The role of "20% time"

A study illustrated the concept of “20% time” in which companies allow their workers 20% of their time to pursue whatever they want to pursue. Google has adopted this concept, and Gmail actually was discovered in 20% time. It’s very renewing for the workers. In medicine, a group at the Mayo Clinic showed that if you can provide 20% of time to a physician to be engaged in meaningful professional activity, that can alleviate burnout by almost half (Arch Intern Med 2009; 169:990-5). Every individual physician will have a different meaningful activity, whether it be teaching, research, process improvement, or community service, and if each individual can find what that 20% of meaningful professional activity is. If department chairs and other mentors for our faculty can help them find that meaningful activity, that goes a long way.

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Also, when we’re thinking of life outside of work, talking about it and not hiding it is important. Often in medicine, we try to hide the personal side and not talk about it because it’s considered a sign of weakness or lack of dedication, but I think it can be very positive to talk about it and admit we do have lives outside of work.

On a more practical point, there are studies that show exercise can be a very important factor. If physicians follow the Department of Health and Human Services recommendations for exercise and get 75 minutes of vigorous exercise each week or 150 minutes of more sedentary exercise, they can improve quality of life and reduce dissatisfaction and burnout.

What do you think the future holds?

I am optimistic about the future because there is acknowledgement and discussion of burnout. We’re having several discussions on a national stage, including this year’s meeting of the Society of Academic Urologists, an organization of academic urologists, chairs, and program directors who can help to discuss this, open this up, and not treat it as a blind spot-at least on the departmental level. As we become more aware of this in our positions, we can lead from the top down and help our learners and our junior faculty with it. At this year’s AUA annual meeting, there was an international plenary panel on burnout that I participated in to discuss the problem and its international implications. To do this in such a public forum is the first positive step.

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I do think institutions are beginning to address this issue. I’d love for our institution to do more operationally and structurally, which will require big financial investments. At least we’re beginning at institutions to have seminars and discussions about the issue. We’re starting to measure burnout at our institution as well. Until you measure it, you can’t improve it. We have a long way to go, and there are financial hurdles, but from an institution’s perspective and from a department’s perspective, preventing burnout is financially worthwhile. Faculty turnover is very expensive both for a department and an institution. A dissatisfied worker is less productive and a lot more likely to turn over.

Next: "You can recover from burnout, but the best strategy is prevention."

What do you think a young aspiring urologist can do to mitigate the risks of burnout?

You can recover from burnout, but the best strategy is prevention. Actively nurturing personal interests and well-being can help prevent burnout. It helps if you do it early on and if promotion of wellness is openly supported by leadership within a hospital or department or group practice.

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I think a younger individual should try to find what their 20% time is. What is a meaningful activity for them? Younger faculty are so intelligent, driven, motivated, and ready to work hard, and one of my goals in meeting with them is to make sure that they’re finding that 20% time, so that practicing medicine doesn’t become a hamster wheel, where 5 years later they wonder, what have I been doing? Again, they’re very smart, driven people and they deserve to be happy and fulfilled in their lives. People need to be aware early on of life outside of work and prioritize that with time with family, with other interests, with exercise.

Maybe some of this could end up being generational too, although some data suggest that younger workers tend to have more burnout. But, we showed some information indicating that burnout peaks in the 40s and 50s. Perhaps the younger generation are ahead of us in that they’ve already walked into this with a sense of proper work/life balance, which the previous generation may have looked on negatively.

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