A recent study published in Urology described how American Urological Association–accredited urological residency training programs are organized in terms of clinical exposure and teaching of their residents.

First study portrays urology resident clinical experience in the United States

, joined Urology Times® for an interview to explain their finding of a rise in sepsis following ureteroscopies in their study, “Yearly Trends in Sepsis and Mortality After Ureteroscopy". Bhojani is a clinical researcher and associate professor in the division of urological surgery at the University of Montreal, and Chew is an associate professor in the department of urological sciences at the University of British Columbia and a scientist at the Stone Centre at Vancouver General Hospital.

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“Not only, as we've shown, does sepsis cost a lot of money, is very morbid, and can lead to mortality, but it's increasing,” says Naeem Bhojani, MD.

Study finds a rise in sepsis post ureteroscopy over 5-year period

Laura Bukavina, MD, MPH, asks, "Has [kidney cancer] mortality rate dropped off because our incidence has been climbing so high for these incidental, small tumors and mortality is not going to be high in those small renal masses? Or is mortality improving because our therapy is getting better?"

In this interview, Laura Bukavina, MD, MPH; and Sarah P. Psutka, MD, MS, discuss “Epidemiology of Renal Cell Carcinoma: 2022 Update,” which was recently published in 

 Bukavina is a urologic oncology fellow at Fox Chase Cancer Center in Philadelphia, Pennsylvania. Psutka is an assistant professor of urology at University of Washington School of 

"It’s important that we continually reassess the epidemiology and the risk factors for these disease processes," says Sarah P. Psutka, MD, MS.

Medicine and a physician at Fred Hutch Cancer Center in Seattle.

Can you discuss the background and rationale behind this paper?

 Every couple of years, there is a paper about epidemiological risk factors of kidney cancer incidence and mortality, because we know that there are a lot of things that are changing in the world, including risk factors and identification of potential risk factors. So every few years, there’s an update with any new information that…is relevant for any urologist or researcher within kidney cancer.

: Dr Bukavina brings up a really important point, which is that as urologists and scientists we think about epidemiology and these basic risk factors as being somewhat static. But actually, there has been a tremendous amount of work and understanding around environmental exposures that we didn’t even know existed 10 to 15 years ago, which was where a lot of the statistics that I traditionally quoted in patient interviews came from. It’s important that we continually reassess the epidemiology and the risk factors for these disease processes. This paper really highlights our greater understanding of the genetic and genomic backgrounds and risk factors, how those interact with the environment and patients’ own personalized risk factors. Getting to the nuances of that is critical, which is what these updates provide us with an opportunity to highlight.

: Going back 10, 15, 20 years ago, before we had some of the technology that we have available now, clinicians used to think of risk factors as lifestyle risk factors. Now we know that these risk factors are not just lifestyle risk factors, but—whether it’s mutagenic, tumorigenic, or carcinogenic potential in these risk factors—it’s your exposure. Some of these risk factors are hereditary, but a lot of the things that we see in kidney cancer are exposures that you can control, and now we’re getting deeper into the mechanisms. That’s important because you might think of this as an isolated kidney cancer picture, but exposure is exposure, right? Exposure doesn’t predispose you just to kidney cancer. Once we find something that’s potentially relevant to kidney cancer, can we use that information and look at other cancers such as bladder cancer or any genitourinary cancer? Maybe this is a carcinogen that goes well outside the genitourinary space.

What were some of the key points and findings that came out of this paper? Were any a surprise to you?

: We have all known that the incidence of renal cell carcinoma—which is the number of cases reported per year per 100,000 individuals—has been steadily increasing. That’s been reported in the literature. It’s nothing new. What was surprising to me is that the incidence has leveled off over the past 2 years. That’s probably because clinicians are realizing not everyone needs a CT scan for every small abdominal pain or hiccup.

Also, the mortality rate has dropped off. There are 2 schools of thought here. Has mortality rate dropped off because our incidence has been climbing so high for these incidental, small tumors and mortality is not going to be high in those small renal masses? Or is mortality improving because our therapy is getting better? Are we just improving the outcomes in patients with better therapy? Right now, it’s a bit difficult to say. There’s a certain lag in time before these therapies were instituted to what we’re looking at now, so it’s difficult to say.

The second thing I found reassuring is that we see a lot of disparities in care and survival in minorities and women, especially Black patients, and we didn’t see that in kidney cancer. Black patients have almost identical mortality as White patients, even though they have a higher incidence of kidney cancer diagnosis.

: One factor that has become apparent to me and that we really tried to highlight in this paper…is the component or the risk that comes with kidney disease with end-stage renal failure and transplant. There’s increasing understanding of how the immunosuppression that comes with undergoing an organ transplant increases the risk for cancer. That has been previously stated, but it wasn’t strongly acknowledged in the urologic literature.

Also, the association between CKD [chronic kidney disease] and end-stage renal failure and increasing risk of kidney cancer is a striking and important association to be aware of. It’s something that I’m seeing in practice, but it’s a trend that hasn’t been strongly acknowledged in our literature. That was something that I found interesting, and it heightens the awareness, given the increasing prevalence of end-stage renal failure and kidney cancer and CKD globally.

What questions arise out of what you discovered?

The biggest question that arose from this is, “Why is there such a lack of large familial genetic disorder epidemiological studies?” There are only 7 or 8 hereditary familial disorders that we’re basing all of our knowledge on. A lot of these, when you look at the studies, were assessed in 1000 individuals here, 500 individuals there, but there’s not a huge population study looking at these familial risk factors. I’m wondering why no one has looked at this with huge databases, such as UK Biobank and TCGA [The Cancer Genome Atlas]. It’s curious that no one has probed to see what the actual incidences of these familial syndromes are, especially if you have a huge, healthy cohort to go along with it.

: I think that’s incredibly important. In TCGA alone, we identified that somewhere between 6% and 9% of kidney cancer cases appear to have a germline alteration. That’s relatively low. It begs for us to understand more about the genetic underpinnings and their interactions with these environmental exposures and lifestyle risk factors that predispose high sporadic rates of kidney cancer.

There are still a lot of unknowns, such as why is there variability in the age presentation? Why is the average age at diagnosis younger in the United States compared with other developed countries? Granted, there’s certainly going to be the confounding based on the ubiquity of cross-sectional imaging and whether it’s a lead-time bias and we’re just catching them earlier.

There is also substantial variation in these environmental exposures. One of the things we tried to highlight was that although there are germline variants and more well-acknowledged genetic syndromes that include kidney cancer, there’s an increasing number of other variants of kidney cancer that have been identified. If you look at the new [World Health Organization] classification for kidney cancer, there are all of these new histologic variants that we previously did not identify within the greater context of kidney cancer. We are starting to get to the genomic underpinnings of those diseases and understanding the mutations that are different among them. Are we misclassifying some of these tumors? Are we missing them?

I think that as we get better at molecularly understanding and classifying these diseases, we’ll probably get a better understanding of the genetic risks. Then we can get to the nuances of the interaction between those genetic risks and the environmental risks. The holy grail here is—and this is potentially a dangerous comment—when do we start the risk-adapted screening? All the patients that I see come in and say, “Why didn’t we look for this? Why did I only find this because I went in with gallbladder pain?” The truth is, at some point, we may have enough of an understanding to be able to thoughtfully employ a program such as this. We’re far off from that right now.

Overscreening, of course, would be a disservice. Lack of appropriate utilization of active surveillance is something we need to continue to work on because we don’t want to overtreat patients with kidney cancer. Identifying those patients who present with these very large tumors before they come in because of symptoms—if we could figure out ways to start to catch these patients earlier, that’s the holy grail. Hopefully, as we start to understand these genetic nuances, we can get closer to that. That’s what these epidemiological surveys—and to Dr Bukavina’s point, larger, thoughtful genetic surveillance studies—can potentially do to move the needle here and drop mortality rates even lower.

: Unfortunately, I think a lot of patients have heard about these blood screening tests for all kinds of cancers, but they really don’t come close. They use platelet RNAs and ctDNAs. For kidney cancer, especially, [the sensitivity is] notoriously terrible, less than 40%. That’s even at stage IV. So these are not good tests for screening of any population, let alone patients who have hereditary disorders. We’re very far away from it, but we’re slowly making our way.

What would you say is the take-home message for the practicing urologist?

: We need to continue to push the field forward, and the way we do that is to evaluate the risk factors and to stratify patients based on their risk factors and their genetic components. Not every kidney cancer is the same. As we continue to learn about them, every urologist needs to continue to learn with us. We need to be open to the idea that we might have to change our practice, not just based on a patient’s history but also their molecular underpinnings.

: That’s a critical point that Dr Bukavina makes. The other thing that I would say is a take-home message is that there are so many modifiable lifestyle risk factors for kidney cancer that even if we modify them in the context of a diagnosis, we can improve outcomes. Smoking cessation is still a critical modifiable risk factor. If we stop the patient with kidney cancer from smoking at the time of diagnosis, we can improve outcomes for that patient. Similarly, obesity, visceral adiposity, and exercise are key modifiable factors. Patients come to us and we tell them about things such as surgical treatments that we can offer them, immunotherapies, targeted agents, but there are many things that they can work on. They can reclaim some agency in this whole process and control outcomes.

Understanding epidemiologically the impact of things such as obesity, smoking, and hypertension—those are all factors that are very useful to be aware of in our clinical practice. Hopefully, there’s a little something in this paper for everyone. Dr Bukavina did a beautiful job of describing the most up-to-date genetic and genomic understanding of the background of this disease. We also tried to be thoughtful about putting out what’s known about these modifiable risk factors, which is eminently important when you’re counseling a patient before a nephrectomy.

: I anticipate in the next update, which will happen in a couple of years, there are going to be even more things discovered about microbiome and risk factors. The microbiome is a very modifiable factor and potentially so are exposures in the environment, such as microplastics. There are several projects underway and the next update will definitely have more of these available.

Is there anything else you would like to add about the paper?

: It’s a huge team effort. The physicians on this manuscript are experts in their field and it was an honor to be part of it. I hope everyone can learn something from it.

: We’re very fortunate to be in a field where there’s a lot of development in the past couple of years, largely due to the incredible contribution of many of the authors on this paper. It was an absolute honor and a privilege to get to work with Dr Bukavina and the remainder of the team, who all contributed their own expertise in important ways to advance our understanding of the epidemiology of kidney cancer.

1. Bukavina L, Bensalah K, Bray F, et al. Epidemiology of renal cell carcinoma: 2022 update. 

2022;82(5):529-542. doi:10.1016/j.eururo.2022.08.019

Articles

"What was surprising to me is that the incidence [of kidney cancer] has leveled off over the past 2 years," says Laura Bukavina, MD, MPH.

Overview of kidney cancer epidemiology underscores importance of modifiable risk factors

 is the director of Male Reproductive Medicine and Surgery at the University of Miami Desai Sethi Urology Institute in Miami, Florida. In this interview, he discusses his ongoing trial on the combined use of shockwave therapy and platelet-rich plasma (PRP) to treat erectile dysfunction.

“We're trying to see if combining shockwave therapy along with PRP will make an additive impact on the improvement in erectile function in men with erectile dysfunction,” says Ranjith Ramasamy, MD. 

Dr. Ramasamy explains current trial on combined treatment for erectile dysfunction

 highlights the recently released findings from the American Urological Association’s (AUA) 2021 census targeting residents and fellows in urology. North is the AUA Data Committee Chair and an associate professor of urology at Montefiore Medical Center in Bronx, New York.

“There have been a lot of efforts to increase the diversity of the urologic workforce, and I think the fruits of our labor are starting to show themselves when we look at the residents,” says Amanda North, MD.

Dr. North shares 2021 AUA census results on residents and fellows

A retrospective subgroup analysis sharing during the 2022 International Kidney Cancer Symposium, tivozanib (Fotivda) demonstrated anti-tumor activity with an acceptable safety profile in patients with non-clear cell renal cell carcinoma (nccRCC).

The analysis of a phase 2 trial (NCT00502307) focusing on 46 patients with nccRCC histologies showed a best objective response rate (ORR) of 31.6% and a confirmed ORR of 21.1% with tivozanib. The median progression-free survival (PFS) was 6.7 months, which investigators considered comparable to other agents in this setting. Only 2 grade 4 treatment-related adverse events (TRAEs) were reported in this subgroup, with only 1 TRAE leading to discontinuation of tivozanib.

“Due to the rarity and poor molecular characterization of nccRCC, there is an underrepresentation in clinical trials evaluating patients with this type of RCC; because of this, patients are often treated with non-tailored therapies,” the investigators stated in their poster.

Tivozanib is an oral VEGF-receptor tyrosine kinase inhibitor approved for use in advanced RCC following at least 2 prior lines of systemic therapy based on the results of the phase 3 TIVO-3 trial (NCT02627963), which excluded patients with nccRCC histologies.

However, this phase 2 discontinuation trial enrolled 272 patients including 46 (16.9%) who had nccRCC including papillary, chromophobe, collecting duct, and mixed or unclassified histologies. Patients with advanced RCC who had no prior VEGF-targeted therapy received open-label 1.5 mg of tivozanib orally once daily for 3 weeks followed by 1 week off for 4 cycles, totaling 16 weeks. Patients who had a 25% or greater tumor shrinkage continued treatment, whereas those who had a 25% or greater tumor growth stopped treatment.

Patients who had less than a 25% change in tumor size at 16 weeks were randomly assigned 1:1 to receive tivozanib or placebo in a double-blind fashion for 12 more weeks. Afterward, both groups could continue receiving tivozanib.

The primary end point was PFS as assessed by blinded radiological review per RECIST 1.1 criteria. Secondary end points included ORR, overall survival, and duration of response.

Of the 272 total patients, those with nccRCC subtypes included 11 patients with papillary disease, 2 with chromophobe, 2 with collecting duct, and 31 with mixed/unclassified subtypes. Only 26% of them had received prior systemic therapy, which was predominantly interferon therapy. Their ORR at 16 weeks was 15.2%. One patient with collecting duct subtype and 6 with mixed/unclassified subtype had a partial response (PR) at 16 weeks. Twenty-two patients, including patients with all 4 subtypes, had stable disease (SD) at 16 weeks and were randomly assigned to continue tivozanib or receive placebo, with 8 receiving placebo for the next 12 weeks.

Best ORR and confirmed ORR with tivozanib showed lower ORR for mixed/unclassified than all patients with nccRCC, though the number of patients was small. The best ORR for all nccRCC was 31.6% versus 22.6% only the mixed/unclassified subtype, whereas best confirmed ORR was 21.1% for all nccRCC versus 14.8% with mixed/unclassified.

Disease control rate (DCR) for all patients with nccRCC based on best unconfirmed response was 73.7%, 87.5% for the papillary subtype, 100.0% for the chromophobe subtype, 100.0% for the collecting duct subtype, and 66.7% for the mixed/unclassified subtype. The DCR did not count the 8 out of 46 patients who were assigned to receive placebo after 16 weeks.

The median time to best confirmed response was 23.2 weeks (mean, 26.7 weeks), and median time to best unconfirmed response was 19.1 weeks (mean, 27.2 weeks). There were 24 patients (52.2%) who experienced progression events during tivozanib treatment or follow-up for over 2 years.

In terms of safety and tolerability in the nccRCC subgroup, the most common TRAE of any grade was hypertension (46%, n = 21), followed by dysphonia (15%, n = 7), asthenia (13%, n = 6), diarrhea (11%, n = 5), fatigue (9%, n = 4), and rash (7%, n = 3). There were 2 grade 3 cases of hypertension and 1 each of asthenia and diarrhea. There was a single grade 4 duodenal ulcer hemorrhage and a grade 4 hyperbilirubinemia, and no reported grade 5 TRAEs. The single TRAE that led to treatment discontinuation was duodenal ulcer hemorrhage.

Investigators concluded that tivozanib had promising activity in nccRCC subtypes, especially considering that these patients have few effective treatment options compared with those with clear cell histology.

They stated that the results were comparable to the phase 2 ASPEN trial (NCT01108445) of everolimus (Afinitor) versus sunitinib (Sutent), which resulted in an ORR of 9% for everolimus and 18% for sunitinib, and a median PFS of 5.6 months for everolimus versus 8.3 months for sunitinib.

 Considering the low rate of grade 3 or higher TRAEs, tivozanib shows potential to be a viable treatment option in this population.

1. Barata P, Allman KD, Chehrazi-Raffle A, Anis-Alibozek A, Kasturi V, Pal SK. Activity of tivozanib in non-clear cell renal cell carcinoma (nccRCC): subgroup analysis from a phase 2 randomized discontinuation trial. Poster presented at: the International Kidney Cancer Symposium (IKCS): North America; November 4-5, 2022; Austin, TX. Abstract 35.

2. FDA approves tivozanib for relapsed or refractory advanced renal cell carcinoma. FDA. March 10, 2021. Accessed November 8, 2022. https://bit.ly/3tbKdSD

3. Armstrong AJ, Halabi S, Eisen T, et al. Everolimus versus sunitinib for patients with metastatic non-clear cell renal cell carcinoma (ASPEN): a multicentre, open-label, randomised phase 2 trial. 

. 2016;17(3):378-388. doi:10.1016/S1470-2045(15)00515-X

“Due to the rarity and poor molecular characterization of nccRCC, there is an underrepresentation in clinical trials evaluating patients with this type of RCC; because of this, patients are often treated with non-tailored therapies,” the researchers wrote. 

Analysis shows promise of tivozanib in patients with nccRCC

"For patients receiving prostate-only RT, concurrent/adjuvant sequencing is associated with optimal outcomes,” said Amar Kishan, MD

Androgen deprivation therapy (ADT) sequenced during and after radiotherapy (RT) has clinical benefits for patients undergoing treatment for prostate cancer, according to investigators at the University of California, Los Angeles (UCLA) Jonsson Comprehensive Cancer Center.

 The study analyzed ADT in combination with prostate-only radiotherapy (PORT) and whole-pelvis radiotherapy (WPRT).

“To our knowledge, this study represents the first time a significant association has been demonstrated between concurrent and adjuvant ADT sequencing and overall survival rates among prostate cancer patients. For patients receiving prostate-only RT, concurrent/adjuvant sequencing is associated with optimal outcomes,” said Amar Kishan, MD, chief of genitourinary oncology for Radiation Oncology at UCLA, in a news release about the findings.

Although ADT has been shown to improve survival for localized prostate cancer when in combination with RT in past studies, its sequencing has remained controversial. In clinical practice, patients have typically been placed on ADT prior to beginning RT. This study now shows that concurrent/adjuvant sequencing of ADT for RT optimally causes the period of having low testosterone to be “backloaded” after radiation is complete.

The study cohort consisted of 7409 participants across 12 randomized trials who were treated with short-term ADT (4-6 months) with RT for localized prostate cancer. Patient data were obtained from the Meta-Analysis of Randomized trials in Cancer of the Prostate consortium. A total of 6325 patients received ADT before and during RT (neoadjuvant/concurrent) and 1084 received ADT during and after RT (concurrent/adjuvant). The median follow-up period across both groups was 10.2 years.

Findings showed that there was a significant interaction between ADT sequencing and RT field size for all study end points except overall survival (OS). Concurrent/adjuvant ADT sequencing showed improved outcomes for metastasis-free survival (MFS), which was the primary end point of this study (

For men receiving PORT, concurrent/adjuvant ADT sequencing was associated with improvements in multiple oncologic end points, including MFS (

 = .0046), prostate cancer-specific mortality (

 = .0001). For men receiving WPRT, no significant difference was seen in any end point when comparing neoadjuvant/concurrent sequencing with concurrent/adjuvant except for worse DM (

 = .0009) with concurrent/adjuvant sequencing.

According to Kishan, these results should be “considered practice-changing with regards to how ADT is sequenced with radiation for patients getting short courses of ADT with prostate radiation.”

Investigators concluded that when PORT is delivered with short-term ADT (as is recommended for men with intermediate-risk disease), concurrent/adjuvant ADT sequencing should be the standard of care. When WRPT is delivered with short-term ADT, neoadjuvant/concurrent ADT may be better for patients given its DM benefit, although this is less consistent than the benefit seen with concurrent/adjuvant ADT with PORT.

1. Ma TM, Sun Y, Malone S, et al. Sequencing of androgen-deprivation therapy of short duration with radiotherapy for nonmetastatic prostate cancer (SANDSTORM): A pooled analysis of 12 randomized trials. 

 Published online October 21, 2022. Accessed October 25, 2022. doi/full/10.1200/JCO.22.00970

2. News analysis led by UCLA Jonsson Comprehensive Care Center finds timing androgen-deprivation therapy with radiation therapy improves outcomes in localized prostate cancer. News release. University of California, Los Angeles (UCLA). October 21, 2022. Accessed on October 25, 2022. https://www.newswise.com/articles/new-analysis-led-by-ucla-jonsson-comprehensive-cancer-center-finds-timing-androgen-deprivation-therapy-with-radiation-therapy-improves-outcomes-in-localized-prostate-cancer?sc=mwhr&xy=10016681

“To our knowledge, this study represents the first time a significant association has been demonstrated between concurrent and adjuvant ADT sequencing and overall survival rates among prostate cancer patients," says Amar Kishan, MD.

Concurrent/adjuvant ADT sequencing appears optimal in patients receiving prostate-only RT

, highlights key takeaways from the discussion “Appreciating Diversity in Urology Care”, which took place during the 

 in Chicago, Illinois. Lowentritt is a practicing urologist at Chesapeake Urology in Baltimore, Maryland.

“From a patient care standpoint, anything that opens the door and makes the patient feel more secure and open is going to lead to better outcomes for them and allow us to serve their needs best,” says Benjamin Lowentritt, MD, FACS. 

Dr. Lowentritt highlights LUGPA discussion on urologic care for LGBTQ patients

Over half of physicians are experiencing burnout, according to 

 from the American Medical Association. The most common factors include things like physician-patient relationships, regulations, professional liability, and heavy work hours (

 of over 51 hours per week). This lack of work-life balance is destructive to both the physician and to their patients.

For physicians looking to combat feelings of burnout and establish a true work-life balance, here are seven areas of focus to consider.

Many physicians find it difficult to set boundaries, but doing so is an excellent form of self-care. When done correctly, boundaries can improve both your personal and professional lives. Boundaries are meant to protect all of our needs (physical, emotional, mental, and time) so that we can be our best selves and remain productive and energetic.

There are three types of boundaries to consider setting to help keep your personal and professional lives separate:

These are specifically for leisure activities, such as spending time with loved ones or taking part in your favorite forms of exercise. Try to set aside a specific time each day or week to dedicate to these activities.

Physical boundaries create a literal distance between your work life and home life. The idea of turning off your phone or computer may seem laughable to most, but even doing so long enough to enjoy a meal is still a successful boundary.

A cognitive boundary is one that allows you to leave work behind completely (and not turn your phone or computer back on). Like setting a physical boundary, this can be impossible for some, but dedicating some time each week to just yourself is enough.

Don’t forget that the word “no” is a boundary within itself. Saying “yes” and taking on more when your plate is already full leads to more burnout. In turn, more burnout leads to resentment and takes a toll on the psyche. Sometimes, “no” is the best boundary you can set.

Remember that working all day and then binging Netflix or HBO 

It’s entirely common to unwind after a hard shift by turning off your mind and turning on the TV. In a 

, 80% said they choose to relax by doing so. However, binge-watching is actually more likely to increase stress, anxiety, and depression; it can also have negative effects on sleep. Instead, try picking up a new book, get outside, exercise, or socialize with family and friends. Even spending time with your pets can help improve cortisol levels, heart rate, and mental health.

Go old school and use paper and colored pens to create, stick to, and defend what 

 calls a “life calendar.” Once a week, meet with your entire household and have everyone write down what they have going on in pens of different colors. Next, write what 

want to do outside of medicine that week. It could include getting coffee with a friend or family member, going out with your spouse, or exercising – anything but medicine. Whatever it is, put it on the calendar.

The easy part is done; now it’s up to you to defend it.

If someone asks you to do something, such as taking on an extra shift or staying for an extra hour, you must check your life calendar before deciding. If you see there’s a commitment, stick to it and say no. When you use a life calendar, you’ll see your happiness improve and have a better sense of fulfillment. But before creating one, be sure to have a clear idea of your what your values are and the things that are important to you.

Outsourcing your life doesn’t mean handing off everything on your to-do list. Instead, it simply means you take the most mundane tasks and have someone else do them at a low cost. You can outsource almost anything, including cleaning, dog-walking, calendar scheduling, and laundry. You could even have someone on an app like TaskRabbit mount your television. Why pay people to do things you could do for free? Because you’re buying back the rarest of commodities: time. Skipping mundane or unenjoyable tasks leaves you with more time to do what you enjoy.

 that getting your time back improves quality of life and that those who prioritize time over money are happier in the long run. She even came up with a metric to measure that happiness in – called happiness dollars – and found that outsourcing chores can make you as happy as receiving an $18,000 raise.

Sometimes, your work-life balance comes down to work environment. If you’re experiencing burnout, it might be time to consider a new workplace. When interviewing, decide what you want and need for your work-life balance. What’s important to you? What do you want your schedule to look like? What do you need time for each week?

It’s also important to ask questions of a potential employer to better understand the workplace culture and decide if you want to spend your time and energy there. What are workdays like? Why is the position open? What will they expect you to accomplish in the near future? Better yet, take a look at the other employees. If they’re happy and friendly, there’s probably some semblance of work-life balance.

you work. Many medical group practices shifted their workers to hybrid work in 2021 and saw improved performance, productivity, and engagement. Likewise, physicians that have pivoted to a telehealth career noted an increased job satisfaction and timeliness of patient care.

Spend 20% of your work hours doing something that you’re passionate about

 that doctors who spend less than one-fifth of their full-time equivalent (FTE) on things they’re passionate about are far more likely to suffer burnout than others. Spending the equivalent of one half-day per week doing something that you care about will not only help you stay engaged at work but also remind you why you wanted to become a doctor. What you focus on is up to you: it could be researching, working with patients, or managing your team. There are no limits.

You might even pursue a side gig or project to create the feeling of work-life balance. While it doesn’t have to be related to medicine, there are several routes you could go, including life or career coaching, medical writing, MCAT tutoring, and serving as a consultant.

You earned your days off, so why not use them? 

 that one-third of physicians take two weeks or less of vacation each year, but taking that time away is crucial. Not only does it help to reduce work-related stress, but it also helps regulate your emotional and physical states, increases time with loved ones, and improves work performance.

Physicians are constantly telling their patients to go easy, and relax – why aren’t they following their own advice? It’s not easy to actively work to find a work-life balance, and doing so will take time and dedication. Remember, it won’t solve all of your problems – but it’s a great place to start.

Overworking has become the norm, but that doesn’t mean it should be.

Tips for physicians to improve work-life balance

 discuss the take-home messages from the 

study, “Epidemiology of Renal Cell Carcinoma: 2022 Update.” Bukavina is a urologic oncology fellow at Fox Chase Cancer Center in Philadelphia, Pennsylvania, and Psutka is an associate professor of urology at University of Washington Medical Center, Seattle.

“We need to continue to push the field forward, and the way we do that is to evaluate the risk factors and to stratify patients based on their risk factors and their genetic components,” says Laura Bukavina, MD, MPH.

Dr. Bukavina and Dr. Psutka share take-homes from kidney cancer epidemiology paper

 is an attorney in the Columbus, Ohio, office of Reminger Co, LPA. He specializes in malpractice defense and insurance litigation.

"Generally, the occurrence of a never event or a hospital-acquired condition standing alone should not satisfy a medical negligence plaintiff's obligation to demonstrate the applicable standard of care or a breach of that standard," says Kenton H. Steele, Esq.

Standard of care is a concept used in determining whether an individual was negligent and potentially liable for an injury. Although the standard of care may vary in specificity, it often revolves around the concept of what a reasonable individual would have done under similar circumstances. If an individual breaches the standard that applies and their actions cause harm to another individual, they will be liable for negligence.

This concept is carried over to the medical field. However, medical professionals are not asked to meet the standard of a reasonable individual; instead, the medical standard of care refers to the type of care that a reasonably skilled and competent medical provider would have provided to a patient under the same treatment circumstances. These standards are set by medical professionals and are based on scientific evidence. When medical professionals breach the applicable standard and their actions cause harm to a patient, they may be liable for medical malpractice.

How federal regulations could affect the standard of care

The establishment of a set standard of care is a topic of great debate in the medical community. As technology and medical science evolves, so do the standards to which physicians are held. One recognized standard may suggest that a doctor do X, whereas another may state they should do Y. As you can imagine, a plaintiff’s lawyer will always argue for the standard that imposes liability on the doctor. However, in recent years, a new technique has emerged: substituting federal regulations or guidelines for the standard of care. The most common way this is done is by citing federal regulations regarding 

 are derived from federal sources. Hospital-acquired conditions are the subject of federal law enacted in October 2008, which, in order to provide an incentive for hospitals to reduce hospital-acquired conditions, provides for a reduction in the amount of governmental medical benefits payable for inpatient hospital services related to such conditions. The term 

 comes from proposed guidelines issued by the Centers for Medicare & Medicaid Services regarding the payment of benefits. However, the “never event” language was eventually omitted from the rule and the term is no longer used for purposes of Medicare and Medicaid payment policies.

This issue was considered by an Ohio court in a case involving a patient who underwent surgery for recurrence of renal cell carcinoma. The patient remained at the hospital in the days following the surgery and he developed at least 1 pressure ulcer in the area of his buttocks and coccyx. The patient alleged that, as a result of malpractice, he required additional treatment for years after the surgery. The patient alleged that the development and delayed healing of his ulcers was attributable at least in part to a sponge that was left inside his body and caused a chronic infection. In his complaint against the hospital and urologist, the patient alleged that the occurrence of a never event and/or hospital-acquired condition constituted proof that the standard of care was breached.

In this case, the Ohio court ultimately held that nothing in the statutes or the regulations suggests an intent to establish a new standard of care applicable to private lawsuits. Generally, the occurrence of a never event or a hospital-acquired condition standing alone should not satisfy a medical negligence plaintiff's obligation to demonstrate the applicable standard of care or a breach of that standard.

However, it is worth noting that this a rapidly developing area of the law. Regulatory rules are often used as evidence in other areas of law. As such, it is reasonable to anticipate more and more plaintiffs’ lawyers in the years to come will attempt this bait-and-switch to persuade a jury that since a federal regulation was violated, the hospital/physicians must have breached the standard of care.

Plaintiff’s attorneys are substituting regulations for standard of care.

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