 is the president of Dowling Medical Director Services, a private health care consulting firm specializing in quality improvement, clinical informatics, and health care policy affecting specialty care. He is the former medical director of a large, metropolitan, single-specialty urology group in Fort Worth, Texas.

Robert A. Dowling, MD

The World Health Organization defines burnout as “a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed. It is characterized by three dimensions: feelings of energy depletion or exhaustion; increased mental distance from one’s job or feelings of negativism or cynicism related to one’s job; and reduced professional efficacy.”

 The contributions to burnout identified by physicians include bureaucratic tasks, time pressure, lack of respect, insufficient compensation, lack of control and autonomy, increased computerization, and government regulation. Much of the energy on this subject is directed at recognizing the symptoms, learning coping skills, and accepting the inevitability of these contributing workplace stresses. In this article, I will take a slightly different approach by challenging the inevitability of some factors and offering a few practical suggestions that may help manage burnout by addressing the root cause.

When physicians complain about bureaucratic tasks, they are probably thinking about processes imposed by government and private insurance companies. Prior authorizations, requests for medical records, drug formulary substitutions, and appeals of denials are examples of the systemic dysfunction in our fee-for-service reimbursement environment that may push work to the physician. Some of these bureaucratic tasks can be prevented, or prevented from requiring physician involvement. For example, most contemporary electronic health records include drug formulary checking as part of the core functionality. It may require a subscription, configuration, or training. A small investment of time on the front end prevents time-consuming tasks later—like answering a call from a pharmacist or patient about a routine substitution.

Prior authorizations and requests from insurance companies for medical records are generally predictable. Most urology practices have 20 common patient types, 20 common surgical procedures, and less than 20 common insurance companies. Your practice can easily track this activity for a month and learn to recognize which combination of activities/companies/diagnoses are generating these requests; armed with that intelligence, you can prevent requests by authorizing or submitting records proactively. Report abuses to your state board of insurance. As a last resort, consider terminating contracts with companies whose bureaucracies are not worth the contribution to your bottom line—and your burnout.

Another type of bureaucratic task that may contribute to physician burnout is low-value documentation to support compliance with coding, reimbursement, or value-based care models. A prime example of this is documenting the review of systems or multisystem examination for a routine office encounter, or citing extraneous information to document medical decision-making. There is usually no good reason to cite a review of systems for an established patient; reimbursement is almost always based on history, medical decision-making, and/or time spent with the patient.

Keeping current with arcane and complex coding rules is in itself a contribution to burnout. Instead of trying to master every possible coding scenario, or coding every single encounter one at a time, simplify: Identify your 20 common visit types that constitute 80% of your encounters and code them the same way every time. Override or turn off the coding engine in your electronic health record (EHR) for these common visits. Be sure your note templates are working for you, not against you, by including only the necessary sections or choices. These simple tactics return valuable hours of time and relieve pressure contributing to burnout.

Documenting for the Merit-Based Incentive Payment System (MIPS) deserves special mention as a potential contributing factor to burnout. There is widespread frustration with the effort required for MIPS participation, the modest rewards, and the perceived lack of benefit to patient care. However, there is no need for most physicians to understand the complexities of the model, the scoring paradigms, or the fee schedule adjustments. Simplification, delegation, repetition, and discipline will relieve the pressure from these bureaucratic tasks. Recent MIPS data reveal that urologists are submitting data for quality measures that are driven entirely by nonphysician documentation.

 In most practices, if the clinical staff take vital signs, update the current medication list, and perform a urinalysis at each visit, and once a year ask about tobacco use, vaccine status, and colonoscopy, they will have optimized performance on quality measures—all with no direct physician documentation. There is a real cost to MIPS: It may contribute to staff burnout, and it may extend the length of patient intake by a few minutes—but it involves bureaucratic tasks that are arguably already being done for other reasons or can be delegated and simplified. If you think MIPS is a cause of your burnout, take a look at your processes and see if they can be simplified.

Burnout is often recognized when the amount or pace of work exceeds the available capacity. There are a finite number of hours in a work week, and once the limit is reached, the only management strategy to relieve time pressure is to work more efficiently, ie, do more work in the same or fewer hours. The first step in addressing this contribution to burnout is to believe that it is possible to be more efficient and understand it will take some work to get there. The next step is to keep a journal of a day in your life. To the extent possible, track everything you do: hospital rounds, travel time, clinic hours (copy a list of your appointments, including patient type), meals, surgeries, consults, phone calls, document review and sign-off, on-call activities, drug rep visits, sleep, etc. Your EHR may have an audit report that can simplify this record, especially for visits and phone calls. If you have a scribe, they can keep your journal.

Next, give your journal to a staff or manager who can transcribe your diary into rows on a spreadsheet with these columns: Category (patient care, admin, personal), task, time spent, required physician (Y/N), notes. You should fill out the column on whether a task required a physician or could have been delegated. A high-level analysis of this journal should tell you how much time is being spent on each category, and what activities do and do not require your involvement. Urologists and practice owners are understandably proud of the ability to “do it yourself”; relieving time pressure requires a fresh look at trade-offs and delegation.

Drilling down into your clinic schedule should identify possible opportunities for scheduling efficiency. Get specific: Is your schedule full of routine visits and going through the motions? Can your scheduling template be refined to prevent high-pressure situations like cancer conferences back to back? Do you have a workable list of patients available to fill empty slots on short notice? Do you program work in spots or pauses in your schedule? If you have been in practice for years, there should be a predictable pattern of patient types (demand) and schedule openings (supply). Rearranging a schedule may return time previously spent on travel, waiting, or switching from clinical to nonclinical activities. Many urologists have come to recognize that doing 4 surgeries on a Friday is far less efficient than doing 1 surgery before clinic 4 days/week because of case turnover time out of their control. You can eliminate some peaks and valleys of activity, and waste.

Be prepared: The vast majority of office visits in a urology practice are elective, common, and predictable. Surprises are stressful and add to time pressure. A clinical staff member reviewing a patient’s chart in advance of the visit is making a deposit in your time bank. Any missing information should be corrected and any questions anticipated and answered before the visit. You are less likely to feel burned out with a predictable schedule and more likely to respond appropriately to surprises.

Learn to recognize and leverage downtime. If you finish with 1 patient before the next one is ready, use the time to do a predictable, short task: review a lab, refill a prescription, return a routine phone call, or get a cup of coffee. Reflect on how often these gaps are occurring and whether it might mean it’s time to review your template again, retrain your staff, or evaluate how much time you are spending with your patient.

Most burned-out physicians have little control over reimbursement and probably believe they are maximally productive. The only remaining lever to address compensation is to decrease expenses. Once again, the first step is a willingness to examine every expense and understand whether it is reasonable and necessary. The major expense categories are recurring and fixed: rent, salaries, insurance, etc. Drugs and supplies are examples of variable expenses. Your accounting software or accountant should be able to provide you with a summary of expenses by category. The next step is to benchmark these expenses to other urology or physician practices. Benchmarks are published by professional associations, private companies and, in some cases, the Centers for Medicare & Medicaid Services. If your expenses are higher than benchmarks in 1 or more categories, it’s time to roll up your sleeves and look at every expense. Small variances in overhead percentage can lead to large changes in the bottom line. Successful businesses are always examining and adjusting their expenses. Finally, consider participation in group purchasing organizations to reduce the cost of supplies or even professional services.

I have some bad news: Computers are here to stay and demand to use them may increase. Resistance is not productive. Contemporary surveys identifying computers as the source of burnout could be reflecting several correctable problems. First, physicians may be using outdated software or systems. First- and second-generation EHRs were typically deployed on local servers that require upgrades and maintenance and were often plagued by performance issues, design flaws, and bugs. Modern systems are deployed in the cloud, are more reliable, and have a better (faster) user experience. If you are still on an early system, consider changing to address your burnout. (Warning: Changing EHRs is stressful, too!)

Second, almost all small and medium practices underinvest in initial training and completely ignore ongoing training. The inevitable result is an undertrained physician user who forges a path of least resistance and hardens inefficient or redundant workflows. This is completely preventable and a correctable contribution to burnout; users do not know what they don’t know. The contemporary EHR is typically upgraded and enhanced several times a year, resulting in new features, many of them time-saving. Retraining requires a small investment of time; it will return huge dividends. This may be the single most treatable contribution to physician burnout.

Third and related: Many physicians do not use order sets, macros, favorites, or other time-saving features of almost all EHRs; they may not believe there is a better or faster way, especially if they have been using the system for years. Open your mind to the possibility that there may be a faster way of doing computer tasks, and that you may need training to even understand the possibilities. Finally, if you truly blame the computer or your EHR for your burnout, take another look at a scribe. The evidence is strong that scribes reduce physician burnout

Bottom line: Burnout is a real and serious phenomenon with multiple contributing causes and significant consequences. Some burned-out physicians may surrender to the idea that there is nothing they can do, leading to depression or more serious outcomes—including “reduced professional efficacy.” I challenge you to instead believe it can be better and to take some simple steps under your control. Targeted review of your documentation habits, your schedule, your EHR, and your benchmarked expenses may provide an opportunity to improve your professional satisfaction, extend your career, and optimize your “professional efficacy.”

1. World health Organization. Burn-out an “occupational phenomenon.” 

International Classification of Diseases, Eleventh Revision

. Accessed October 19, 2021. https://www.who.int/news/item/28-05-2019-burn-out-an-occupational-phenomenon-international-classification-of-diseases

2. Dowling R. How does urology’s 2019 MIPS performance stack up? 

®. August 26, 2021. Accessed October 14, 2021. https://www.urologytimes.com/view/how-does-urology-s-2019-mips-performance-stack-up-

3. Corby S, Ash JS, Mohan V, et al. A qualitative study of provider burnout: do medical scribes hinder or help? 

2021;4(3):ooab047. doi:10.1093/jamiaopen/ooab047

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Keeping up to date on EHR updates is 1 step you can take.

Practical ways to address burnout in your urology practice

Whether you embrace, resent, or harbor mixed emotions about the adoption of information technology in your practice, physicians and patients now have a number of tools at their disposal for data collection, education, documentation, and even improving health. Technology in general has become highly portable and mobile, and spawned the widespread adoption of mobile applications. According to a May 2013 press release from Apple, “Customers are downloading more than 800 apps per second at a rate of over 2 billion apps per month” from the Apple App Store alone.

	With such an overwhelming number of choices, it can be daunting to find apps that have practical use for urologists or their patients, and also work well. In this article, I will provide some direction and references to help you find the right app for your purpose.

	If you already use mobile technology, a good place to start is your platform’s app store. Searching the Apple App Store, for example, with the keyword “urology” returns about 60 apps, most of which are free. Clicking on any app will allow you to quickly view a description, read reviews and ratings, and link out directly to similar apps. It took me about 15 minutes to separate the wheat from the chaff.

	The website UrologyMatch posts reviews of urology apps for mobile devices (

). When I accessed this in October 2013, I found about 20 apps reviewed, with the most recent posting from December 2012.

	There are other websites I would recommend when you are shopping for urology apps. One of the most comprehensive compilations of apps for the practicing physician is by Epocrates (now owned by athenahealth, 

). Applications available free of charge or by subscription include drug databases, dermatology atlases, CME apps, National Comprehensive Cancer Network guidelines for prostate cancer, medical Spanish apps, and more. The apps are available for iOS or Android platforms. Drugs.com also has some inexpensive apps related to medications and drug references (

). The AUA also maintains a virtual app store where you can find links to apps for publications, AUA guidelines, member directories, and more (

	Finally, two resources offer helpful information on apps designed for patients. 

 recently published an article about the top 10 apps that physicians recommend to their patients; while this piece is oriented to the primary care physician, watch for specialty-related articles on the subject (

“Patient Apps for Improved Healthcare” from the IMS Institute for Healthcare Informatics is an in-depth report about the role of consumer apps in disease prevention and treatment that includes lists of top-rated apps (downloadable at 

Some apps benefit physicians and patients

	There are a few apps that deserve special attention because they solve everyday problems for urologists and their patients, and may even save time and money. Maintaining an accurate medication list is a common challenge, especially when patients receive a prescription from another physician but are unable to remember the drug’s name. An app that has been getting some attention to solve this problem is ID My Pill (

). The app leverages the use of the built-in phone camera to take a picture of the pill and instantly identify it; designed primarily for patients, I see an important use for this in the office as well. There are other apps without the camera feature that can help identify a pill (eg, 

	Another very popular app is drawMD Urology (

). This app allows physicians to draw on an image for patient education, then save, e-mail, or even export the image (see related article). There are over 30 mobile “charge capture” apps in the Apple App Store, many of which are free but have no reviews. If your EHR or practice management software vendor does not have an affordable solution, you may wish to try out an app and do away with those index cards to avoid missed hospital charges.

	Bottom line: We simply don’t have time to keep on top of the rush of information technology and all the applications of its use. Most of us carry a smartphone or tablet because we have grown dependent on its functions and easy user interface. Adding a few simple apps to those devices can return time, money, and even satisfaction on our busy days. Use some of the tools provided here to do your own shopping, and check out the app for 

 to get monthly news from the leading news source for urologists.
	 

With such an overwhelming number of choices, it can be daunting to find apps that have practical use for urologists or their patients, and also work well. In this article, I provide some direction and references to help you find the right app for your purpose.

Mobile apps offer many benefits to busy urologists

	The evaluation and management of patients with urinary tract infections occupies a significant amount of time, energy, and resources in the typical general urology practice. One large clinical data set demonstrates that urinary tract infection (ICD-9-CM code 599.0) is the seventh most common diagnosis code employed by urologists (almost 6% of all office visits).

	In this article, I will examine and question the phenomenon of “the urine drop-off”-having the patient with suspected UTI collect a urine sample at home and drop it off at the practice-in the context of best clinical practice, common sense, and basic office efficiency.

	While no precise data are available, most would agree that a significant number of phone calls in and out of the urology office deal with symptoms of a UTI. Among this population are women with uncomplicated lower urinary tract infections, children and older adults with complicated UTIs, postoperative patients, patients with indwelling or intermittent catheters, and others. As the urinalysis has become a “vital sign” in the urology practice-obtained on almost every patient as part of their clinical intake-many practices have developed workflows for obtaining or even requiring a urine specimen on a patient who calls with symptoms of a UTI.

	What is the available clinical guidance on whether a urinalysis or urine culture is necessary in the evaluation and treatment of patients with symptoms of a UTI? A good summary of three available clinical guidelines for the management of lower urinary tract infections can be found at the 

	While one of the guidelines is silent on the subject of diagnostic testing, there is consensus between the other two that women with symptoms of recurrent uncomplicated UTIs can be treated without lab tests if they have been previously evaluated and are aware of their symptoms. Many such patients exist in a urology practice, and for that subpopulation there is clinical guidance that dropping off urine is not indicated.

	Would dropping off urine actually change the evaluation or management of a patient? There are many scenarios where it might: One example is deferring the treatment of a patient who is not acutely ill, perhaps with a history of drug-resistant infections, until the results of a urine culture are returned. There are other scenarios where a urine test-especially a urinalysis-might not change the treatment decisions at all: a patient who has undergone transurethral resection of the prostate and is on broad-spectrum antibiotics who calls with a fever, for example. No two patients are alike, but before asking a patient to drop off a urine specimen for testing, it is reasonable to consider whether the results would change your clinical decision making.

	Are the results of a urine drop-off accurate and reliable? The predictive value of a dipstick and microscopic urinalysis compared to a urine culture on a properly obtained urine specimen is well studied; it is not a highly accurate test to confirm or rule out a UTI under the most controlled circumstances (

http://www.aafp.org/afp/2005/0315/p1153.html

). Collection of a specimen outside the office introduces additional influences on accuracy of both urinalysis and culture: The method of collection cannot be observed or controlled; the jar may not be clean or sterile; and the storage time and temperature can significantly affect the results. These sources of contamination should be carefully considered when asking a patient to drop off a urine sample and predicting the value of the information so obtained.

	Is the result of the urine drop-off alone sufficient information needed to make the next decision, and can it substitute for an office visit? Patients who cannot adequately describe their symptoms might best be assessed with professional history-taking skills during a face-to-face encounter. A patient with a new physical finding-a swollen testicle, for example-may require a physical exam by a qualified provider.

	Other patients may have a constellation of symptoms and findings that cannot possibly be determined on the phone and require more than a urine specimen for decision making. Unless the urine specimen is the only piece of critical and missing information, an alternative to the urine drop-off should be considered.

	Other questions you may wish to consider: Is the urine drop-off a reimbursable or even profitable service line? Does your staff perform insurance eligibility checks on services for these patients? Does dropping off a urine sample create the potential for workplace safety issues (urine on the floor), specimen handling issues (front office staff), patient safety issues (labeling), and/or liability issues (scope of practice of office employees)?

	Also: Is it more appropriate or convenient for a patient to drop off the urine sample at a qualified lab facility rather than the busy urologist’s office? Is it really more or less efficient (than an office visit) to return a phone call, request a urine specimen, process the specimen, send the results to a busy provider for review, phone the patient back, and initiate therapy remotely in your practice?

	Bottom line: The urine drop-off has probably evolved because it is perceived as a convenient alternative to the office visit, and it is an appropriate approach to the management of select patients. However, this workflow has the potential to be inappropriately generalized in a busy practice. Urologists should create or review policies that can guide their staff to know when it is, and when it isn’t, necessary and appropriate to ask a patient to “drop off a urine.”

In this article, I examine and question the phenomenon of “the urine drop-off”-having the patient with suspected UTI collect a urine sample at home and drop it off at the practice-in the context of best clinical practice, common sense, and basic office efficiency.

Robert A. Dowling, MD

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Do ‘urine drop-offs’ make sense in your practice?