Urology trainee burnout and strategies to mitigate it, with Andrew M. Harris, MD

In this interview, Andrew M. Harris, MD, discusses the study, “Burnout in Urological Education: An In-Depth Study of Residents and Fellows in the 2021 AUA Census,” for which he served as the lead author.¹ Harris is the chief of urology at the Lexington VA Health System, an associate professor at the University of Kentucky, and the chair of the Workforce Task Force and a member of the Quality Improvement and Patient Safety Committee for the American Urological Association (AUA).

This transcription has been edited for clarity.

Andrew M. Harris, MD

Could you describe the background/rationale for this study?

I appreciate the opportunity to talk about a topic very important to the AUA's Workforce Task Force, and that is burnout. [One of] our more recent papers was in the Journal of Urology in the practicing work force post-residency, and we saw a decent amount of burnout. Some of the trends we saw in the most recent burnout paper compared with 2016 is that the gender gap has widened quite a bit. We also see burnout more in our younger urologists. So, we wanted to take a look at the trainee population, which is a more vulnerable population. They don't have a lot of control over their schedule. We wanted to understand, are the risk factors for burnout and the burnout percentages similar among trainees compared to post-trainee urologists? And also, is the risk the same for all trainees? Is it different if they're younger, different if they're older, if they’re earlier in training, later in training? Does it matter based on their sex? Does it matter if we have call rooms or meal plans or if they have kids during residency? Anything that we could figure out, we wanted to take a shot at learning to see how we can fight burnout if indeed the percentages were similar among trainees as they are in post-trainee urologists, where we know burnout is an issue.

What were the key findings from this study?

Interestingly, the trainees, when you look at residents as a conglomerate, experienced burnout at a higher rate than post-trainee urologists. Our post-training urologists are in the mid-30% range of burnout. Among trainees, specifically residents, about 48% of them met the criteria for burnout, and about 33% of fellows. What is interesting about that 48% is it's much higher than in our post-trainee, practicing urologists. But even when you break it down by year, we start to see some differences. Our PGY-2s and PGY-3s are at a higher risk of burnout compared with the other years. We can see them have up to 60% to 70% burnout compared with, say, PGY-4s, in which it is much lower.

Why might PGY-2 and PGY-3 residents have a higher rate of burnout?

We don't have answers to that particular question in this dataset, but I think future studies will take a look [at this]. It likely has to do with the amount of learning and the amount of work involved in that younger population of residents––and by younger I mean PGY-2 and PGY-3, not necessarily age. There's a lot more learning going on as compared to a PGY-4 or PGY-5. When you get to your later years in residency, you have more of a foundational urological knowledge base. You've seen more aspects of urology, and you're more comfortable taking care of complex patients and consults. It's a very steep learning curve at the beginning of residency. One thing that was interesting when you look at the Maslach Burnout Inventory is that depersonalization is what we saw a lot of. That's when you start to have emotional detachment and cynicism toward what we're doing every day. We saw that being a very high contributor in the resident or the trainee population. That is very concerning because instead of thinking, "Mr. Harris, who is having his prostate out today," it just becomes "the prostate for today," or "the prostate from yesterday is in room 242," instead of "Mr. Harris." That detachment is not good for patient care, and it's also not good for the trainees to experience.

The study also highlights a few factors that might be a risk for or protective against burnout. Could you highlight those findings?

We want to know what the contributing factors to burnout are, especially if those are influenceable, where we can work on mitigating those factors. For trainees, not having access to a call room was associated with burnout. When you think about it, that makes sense. Sleep is a basic human need, and when we don't get enough sleep, stress tends to be worse. So, when we don't provide our trainees access to a place to sleep, and they're in the hospital all night long, or say they get a consult at 2 am and they have to be back at 6 am, going home an extra 15 to 20 minutes each way, getting in your bed, and those things, that's wasting time. If we could have a call room for them, you're looking at 3 or 4 hours of sleep vs 2 hours of sleep. When the residents or the trainees don't have access to those call rooms, they are more likely to be burned out. Also, if they can't make health care appointments. Again, that’s a basic human need. We want to practice more preventive health care. When our trainees can't get to health care to take care of themselves, or if they have an issue where they need active treatment or active care that's not preventive, when they can't make those appointments, that makes the job harder. It makes the job worse. That stress on them then is not only the learning volume and the patients for which they have to care, but it's also themselves. If we can help them have time for those appointments, that may help them experience less burnout.

Interestingly, we also saw that having a child during residency or during training seems to be somewhat protective against burnout. I don't think we really anticipated that going in. That was very interesting. Then, when you talk about choosing medicine as your career, choosing urology, those that were more burned out were less likely to want to do medicine again or less likely to choose urology as their career. So, some very concerning things when you talk about decisional regret among career choices of those that are burned out.

What advice do you have for mitigating burnout in this population?

First is recognition. Our data suggest that those in leadership positions are among the least burnt out. So, when you look at the post-trainee work force, those who are older tend to be less burned out, and those people also tend to be more in the leadership positions. We need those folks to realize that our trainees may be having some burnout. What I experience in my everyday life is not going to be the same as what the trainees experience in their everyday life, so I should not take my assumptions into their world. I should talk to them. Some advice would be talk to the residents. Have them take the Maslach Burnout Inventory and see where they're sitting, have that conversation. Then really, [understand] what it is that is important to those trainees that can help them fight burnout. For that specific population, is it a call room, are you missing that? Is it a meal plan? That was something else they mentioned in the study that they would like to have. Is there time for their appointments?

Other things that have been done that have shown positivity toward mitigation of burnout are mentorship programs. Having that discussion, "hey, what's going on today?" and really an individualized approach for each specific resident [is important], because we're all different, and we all experience the workplace differently. Our stressors are all different. We all have different things going on in our personal lives that may make our work difficult. Taking time to elucidate those things from a mentor-mentee perspective, and then figuring out how you can help [can fight burnout]. Some studies also suggest having good access to mental health care at the institution and making time to get to those mental health appointments [can help]. A lot of universities do that very well. Those opportunities are phenomenal for all of us, not just the trainees. But specifically to the trainees, that's tough. I mean, they're seeing people die and have bad complications for the first few times in their career. That never gets easier, even as you get older––it's really tough on all of us, but especially a learning population. Or when you're having to miss other things outside of the hospital because we have to work, sometimes those things can be really tough. Life also happens. Having access to mental health appointments and a good mental health infrastructure has also been shown to help against burnout.

What is the key take-home message based on these findings?

Burnout is dangerous. Not necessarily because it's burnout, but because burnout is a risk factor for depression and suicide. If we don't take the time to speak to trainees, an already vulnerable population, we're missing an opportunity to help them early. There are some studies that suggest the second leading cause of death in residency is suicide.² If we don't take the opportunity to get on that individual level with our trainees and speak with them about what their struggles are and how we can help them, we're missing an opportunity. I would encourage any residents or trainees that are [seeing] this, if you're having struggles, reach out to somebody. We love you, you're doing great, we want to help you. If you're in a position where you are a mentor or in a leadership position at a program with trainees, please make it a priority to reach out to those trainees to make sure that their health needs are being met. Not only their physical health needs, but also their mental health needs, whether that be call rooms, meal plans, time for your appointments, or just a check in on how they're doing. [It’s also helpful to] make sure people are aware of the resources at those training institutions to help with those issues and problems that we all run into.

Is there anything else you’d like to add?

The Workforce Task Force is a great group of humans all just wanting to try to make our work easier to do so that we can show up to work and do what we love every day. I really appreciate the opportunity to work with the Workforce Task Force and appreciate the opportunity to be with you today to talk about a topic that we're very passionate about.

References

1. Harris A, Golan R, Kraft K. Burnout in urological education: An in-depth study of residents and fellows in the 2021 AUA Census. J Urol. 2024;212(1):205-212. doi: 10.1097/JU.0000000000003949

2. Yaghmour NA, Brigham TP, Richter T, et al. Causes of death of residents in ACGME-accredited programs 2000 through 2014: Implications for the learning environment. Acad Med. 2017;92(7):976-983. doi:10.1097/ACM.0000000000001736.