Karen Nash

Karen Nash is a medical reporter and media consultant based in Monroeville, PA.

Urology Times® reached to three urologists (selected randomly) and asked them each: Do you ever face feelings of burnout? How do you cope?


“I don’t feel burned out. One reason people do is they feel they don’t have value to the system, their voices aren’t heard or their job is less gratifying.

The dehumanizing aspects of medicine are something I was born into. I trained on electronic medical records and in a multispecialty group practice. Many things people point to as sources of burnout have been there throughout the entirety of my experience.

I find incredible gratification in the perfection of my craft and the ability to provide care I find meaningful to patients.

Burnout is a nebulous concept. I’m the first physician in my family, so I’m grateful for being able to do what I do. So gratitude is part of it.

That being said, I exercise. I meditate. I spend time with family and try to cultivate hobbies and other things that provide meaning in my life, things you’re supposed to do to avoid burnout. It’s hard to know whether I’m refractory to burnout or whether I’m just in the honeymoon phase. I don’t know how I’ll feel in 15 years when somebody enacts a completely meaningless policy with no evidentiary basis and makes me comply.

People who’ve been practicing a while are the ones who struggle the most—midcareer, late career, especially those in private practice. Anyone who had so much control of their surroundings where they were boss—a lot of those folks struggle the most.”

“I‘ve done general surgery, urology, pediatric urology. I’ve been in academics most my life. For the past 7 years--primarily by myself, I’ve covered call 24 hours a day. Sometimes I get tired, but at Nemours, we have a medical school with med students and residents. The teaching component and patients from wonderful families keep me going.

I can have a long day, then a student sends a note, ‘My paper got accepted,’ and you just know how excited they are. I also write books, primarily geared to the layperson. That keeps me feeling engaged.

You may think that would make me more tired, but just sitting around, not getting involved would be more discouraging than trying to find new ways of doing things. Getting up at 8 o’clock, going to work, and doing the same thing every day would be harder for me.

There are also personal things. I tell my residents you’ve got to laugh each day. Even if it’s the worst day ever, you have to find something stupid you can laugh at.

Also, I got home last night so tired, but my Grinch needlepoint was staring at me—I had to do a little more before I went to sleep. I have to carve out something each day that is selfish and totally for me.

You have to prioritize things that must get done and realize you won’t get everything done all the time.”

“I’ve often wondered if I’m just frustrated; the feeling of burnout waxes and wanes. Within the past year, I’ve felt things escalating.

Burnout comes from the added stresses of the increasingly complex business of medicine in America. Negotiating health insurance gets more complicated, government accreditations more complex, EMRs add to the workload, and health care systems merge and increase in size and complexity while physicians play a smaller role and administrators a bigger role in determining health care. Physicians lose a sense of autonomy.

I struggle with fighting burnout because I don’t think I’ve done it as well as some people. People advised me to establish a better work-life balance. You see fewer patients, but you can’t cut back on bureaucracy. You sacrifice the part of medicine you love most, but still have to do work that contributes to burnout.

What I found that energized me were opportunities to collaborate with other physicians. When I started working with other surgeons on things I traditionally did alone, the job was much more fun. There was more communal responsibility; I benefited from the collective wisdom of my colleagues, and beyond that, from friendships with them.

I’ve even extended the idea of collaboration to the administration. I don’t know if I can make changes, but I feel they’re listening.

At times, I found it helped to say the Serenity Prayer multiple times a day. That little prayer helped me step away from frustrating situations and empowered me to make changes.”

Articles

"I struggle with fighting burnout because I don’t think I’ve done it as well as some people. People advised me to establish a better work-life balance," says one urologist.

Do you ever face feelings of burnout? How do you cope?

 reached to three urologists (selected randomly) and asked them each the following question: How has the FDA's mesh guidance affected POP treatment?

"It didn’t change my treatment. I never used transvaginal mesh for prolapse, maybe because I’m old. I trained in an era that didn’t really use it for prolapse. It became popular after I was already in practice.

I used mesh for recurrent prolapse through abdominal sacrocolpopexy. I adopted the new technology of robotics, but it was still placement of mesh from a transabdominal route. It was the same procedure I already did, just less invasive access.

I prefer doing transvaginal prolapse surgery with native tissue and always have. So I was not affected when mesh was restricted.

It wasn’t just that transvaginal mesh came along after I trained. We all adopt new technologies and advancements to some degree. I just wasn’t comfortable with transvaginal mesh because of the exposure to the outside environment required to place it. Data might have swayed me, but there was never a study that changed how I wanted to approach prolapse.

I have 2 smart partners who used transvaginal mesh. Of course, they’re a different generation, and their training experience was different. They’re doing mostly transvaginal native tissue repairs now, with occasional robotic abdominal sacrocolpopexies or biologic graft material. Neither did a fellowship, and my additional training probably influenced my thinking.

A lot of people did very good transvaginal prolapse surgeries using mesh, and some didn’t; then there are people who just didn’t adopt it, like me.”

“I do more robotic sacrocolpopexies than I used to. I did more vaginally with mesh kits, because I never really had a problem. They were great; my patients loved them, and they lasted longer.

Prior to mesh, I did native tissue repairs, which didn’t last long. Anecdotally, for the average woman, a native repair would last 3 to 5 years, while mesh could easily go 8 to 10. I trained with transvaginal mesh and used it for about 15 years. Now, I’m doing native tissue repairs, if the patient wants it done vaginally, over the past 6 to 8 months. We’ll see how long they last.

I don’t do as much vaginally as I used to. For severe prolapse, I do robotic sacrocolpopexies using the mesh that’s still available, and patients do well, but it’s more invasive.

It was a knee-jerk reaction by the FDA to pull those products off the market. There are issues with mesh, but a lot had to do with technique and experience. With mesh, I had some complications, but nothing major. The FDA should have considered how many cases surgeons were doing and what their complication rates were prior to taking the product off market. They could have told surgeons they needed more training or that patient selection needed to change, but that would’ve been a lot more work…for the government.

Kit manufacturers actually shot themselves in the foot. When kits were developed, they took them out to every surgeon and said, ‘This is great! Just do it this way.’ Some surgeons adapted, were able to do it efficiently, incorporated it into their practices, and had few complications. Other surgeons did it infrequently and therefore had more complications.”

“I’m fortunate. I trained more recently and do a lot of robotic surgery. From that sense, it hasn’t changed things for me except reinforce my training in a better surgery. I wasn’t doing much transvaginal mesh anyway, because the writing was on the wall. Plus, results weren’t as good. I’m in a big group, and it seems to have affected older surgeons more than me.

It’s a more fellowship-driven field now. Instead of doing certain vaginal surgeries or one specific aspect of the surgery well, now you have to address it in a variety of ways.

From that standpoint, fewer urologists are willing to operate in that space. A number of my older partners trained at Mayo Clinic and used a lot of Xenform. Technically, it’s not “synthetic mesh” but was included in the FDA warning. A lot of my partners have completely stopped doing that surgery. That makes somebody like me busier.

When it initially happened, there were a lot of questions. People wanted things removed that were done 10 years earlier that weren’t hurting them. They wanted the mesh removed because of the warnings. But that’s kind of slacked off.

Transvaginal mesh came in kits; doctors trained in weekend courses. Mesh kits weren’t terrible if the patient was chosen correctly and doctors knew what they were doing. But there was a mixture of doctors who didn’t do many procedures and on people who shouldn’t have had that particular surgery. That’s probably where we got ourselves in trouble.”

"I prefer doing transvaginal prolapse surgery with native tissue and always have. So I was not affected when mesh was restricted," says one urologist.

How has the FDA’s mesh guidance affected POP treatment?

Urology Times reached out to three urologists (selected randomly) and asked them each the following question: 

What has been the pandemic’s main effect on your practice?

“It’s had a dramatic impact since we can’t do elective surgeries and probably can’t for most of April.

I’m only seeing 2-3 patients a day in the office. I’m doing FaceTime visits, and audio visits with patients without technology. I’m only seeing patients I absolutely have to see, like a catheter change or a stent removal. We’ve postponed things like vasectomies.

We’re temporizing a lot of problems. We’re giving antibiotics more easily, without cultures like we normally do, to keep our patients home and safe.

We’re struggling to reschedule 6-8 weeks out, particularly elderly and frail patients. We’re anticipating very little productivity this month. Staff members are struggling to make ends meet with significantly cut hours.

Patients we can’t reschedule, we do with telemedicine visits. I’ve never done telehealth before, but the Shannon Medical Center has really helped us figure out what we need. We’re learning new telemedicine codes. My understanding is that the governor has decreed that insurance companies honor telemedicine visits. There’s a lot of hearsay, but we don’t expect a lot of denials we might’ve had previously with telemedicine.

I brought my iPad in and I see patients in their living rooms. I just saw a guy out building a fence in West Texas, so it’s different.

I don’t like it is much as patients coming into the office. But we can do things with telemedicine, particularly for patients who live far away. It may be something that becomes a part of our practice going forward.

Right now, we’re just treading water.”

“Some docs are pretty busy; some would like to be busier."

“Some docs are pretty busy; some would like to be busier.

We have 150 physicians in Maryland, Tennessee, Colorado, and Arizona.

Although in office, we’re only seeing urgent and emergent cases, we have a large telehealth operation. We’re fortunate. We had started a small telehealth pilot program, planning to roll it out gradually. But this crisis was a call to action. We had the infrastructure, so we could quickly scale up to meet our patients’ needs.

With the government relaxing telehealth rules, especially for Medicare recipients, it opened the door for our entire population. This week, it wouldn’t be surprising if we see 400-500 patients a day via televideo, across all four states.

In office, our patient volume is dramatically reduced. We don’t keep significant numbers of physicians or staff in the office. In most facilities, we have patients come in, check in, give us their cell phone number, then wait in their cars so they’re not congregating in the waiting rooms.

We’ve closed probably half our offices and furloughed a number of staff because we can’t afford to keep all of our facilities open when we’re seeing 20% of our usual patients. Ultimately, we have to be able to see patients who need help.

We haven’t furloughed any doctors at this juncture. They’ve been extraordinarily flexible in making sure we can continue seeing patients, whether in the office or via telehealth.

Getting supplies and equipment is difficult. There were a lot of things we used to take for granted that now require a lot of effort.”

"We are open and taking all the precautions."

“I work part-time in a federally qualified health center for the underprivileged with no insurance, but we also see patients with insurance or Medicare.

We are open and taking all the precautions. Nobody stays in the waiting room. They come in, check in, then we tell them to stay in their car, and we’ll call them and pick them up when it’s their turn.

We haven’t had to take any other precautions because we have no virus in our county yet. But we are in pretty cautionary mode. Things are going pretty good. It hasn’t affected us yet, but I don’t think it will continue like that.

Most of the patients are nonemergency. So it hasn’t started affecting our patient load yet. I’ve only had a few patients not show up for appointments.

We’re very comfortable here. It’s a small town, but we draw from a large area. I can’t say it will continue because we have coronavirus occurring just a few miles south of us in another county.

Also, in urology a lot of patients, being older, are hearing impaired. Before, staff would be a couple feet away and speak loudly. Now, the distance is quite substantial, so I can actually hear them yelling. It’s funny how you see the difference.

Personally, we haven’t had contact with our grandkids for two weeks, because we’re elderly and our son doesn’t want to put us in jeopardy.”

"I’m only seeing patients I absolutely have to see, like a catheter change or a stent removal. We’ve postponed things like vasectomies," says one urologist.

Is MRI fusion Bx the new gold standard for diagnosing PCa?

“It hasn’t become the gold standard yet. There are still a lot of inter-reader reliability issues. The same MRI scans, read by different radiologists, may be read differently. That’s going to limit its broad application across the country as a whole and is a major issue.

Anecdotally, within our own practice we’ve seen that when a scan done in one facility needs to be translated for the fusion biopsy machine we utilize, we’ll get a different reading from the radiologist here than from the original radiologist. There’s a discrepancy between what the two radiologists see on the scan. That issue definitely needs to be worked out.

I expect some interesting data on that in the future. The PI-RADS system tries to standardize the readings, but there are still discrepancies between the different readers.

Working out the readability issue will make a difference. There will be patients who have a false-negative MRI but still have significant prostate cancer present. The data isn’t there yet that MRI fusion biopsy can be used as a rule-out test for someone with a very high suspicion of prostate cancer. It’s another data point as to whether someone needs a biopsy.

The gold standard is still a positive traditional biopsy, but that could evolve over the next few years.

The other issue is whether it gets broad acceptance from insurance companies. Some insurers approve it in the initial biopsy setting, but many do not. So that’s going to be the next point for broad applicability.

Still, I would say we’re definitely seeing an increased utilization of MRI for additional diagnosis of prostate cancer within our practice as a whole.”

"I don’t think they’re necessary for everybody"

“We don’t have MRI fusion biopsy available in our community, in our hospital, or in our office, so for an initial biopsy, we still do standard transrectal ultrasound biopsy in the office with ultrasound guidance. We may refer patients who need a second biopsy to a university center for MRI fusion for a second biopsy if they have persisting elevated PSA or other factors that are suspicious. It’s just not feasible for everybody to do MRI fusion yet. For the majority of urologists, it’s still not even commercially available.

Even if it were available, I’m not sure it would be our first choice yet. The yield is a little bit better, but our percentage yield of positive biopsies is pretty close to MRI fusion biopsies, at least in our practice. Our results differ by just 5% to 10%-not much.

I don’t think they’re necessary for everybody. As I said, we use them when we’re puzzled, when men have already had two or three biopsies, and we see them for consultations. In those situations, MRI fusion is a good next step.”

"I am still skeptical about MRI fusion because MRI quality varies so much nationwide"

“That’s a great question. At our center, probably 80% of biopsies are done the traditional way with a transrectal ultrasound-guided approach.

Practice patterns in our area and insurance coverage usually dictate that the patient with an elevated PSA who needs a first-time biopsy is not able to get an MRI covered by insurance. That may change over the next couple years, but now most initial biopsies are done the standard way.

I am still skeptical about MRI fusion because MRI quality varies so much nationwide.

A regular biopsy certainly is more efficient, less expensive, and takes less time in the urologist’s office. Fusion biopsy generally takes about twice as long as a standard biopsy. Fusion biopsies could easily create issues of having enough providers, nurses, and rooms to do all biopsies in a fusion manner on every patient with an elevated PSA. It’s resource intensive and expensive.

We initiated an important program with our primary care doctors to do a better job identifying younger men with elevated PSA, high-risk men, such as African-American men, and men with a family history of prostate cancer. That’s increased the number of men who need biopsies at our center.

I’d rather focus on reaching underserved men and not be totally swept away by the MRI craze, especially since some recent data shows that results from initial MRI fusion biopsies can vary greatly, even in clearly high-grade cases.

The other thing is, no one just does fusion biopsy. Every single fusion biopsy is associated with a regular biopsy. Why do all the doctors advocating fusion biopsy do fusion plus regular biopsy in everybody?”

“It hasn’t become the gold standard yet. There are still a lot of inter-reader reliability issues. The same MRI scans, read by different radiologists, may be read differently," says one urologist.

Author | Karen Nash

Articles

Do you ever face feelings of burnout? How do you cope?

How has the FDA’s mesh guidance affected POP treatment?

What has been the pandemic’s main effect on your practice?

Is MRI fusion Bx the new gold standard for diagnosing PCa?