A new study suggests physician burnout is increasing among doctors in many specialties, and the statistics for urology are troubling.
National Report-A new study suggests physician burnout is increasing among doctors in many specialties, and the statistics for urology are troubling. Solutions need to go beyond what individual physicians do for themselves to prevent and address burnout. This is a systemwide issue that needs to be addressed, according to the study’s authors, from Mayo Clinic in Rochester, MN and the American Medical Association.
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Researchers published an update (Mayo Clin Proc 2015; 90:1600-13) from a 3-year study looking at burnout and work-life balance among U.S. physicians. The study compares data from 2011 to that collected in 2014. The latest survey is based on 6,880 physician responders; just under 2% were urologists.
Dr. ShanafeltWhile the sample of urologists is relatively small, findings about the specialty are notable, according to Tait Shanafelt, MD, a Mayo Clinic hematologist and the study’s first author.
“At the time of our 2011 study, urologists had a below-average rate of burnout among physician specialty disciplines. Between 2011 and 2014, urologists had one of the largest increases in burnout of all specialties [increasing from 41% to 64%],” Dr. Shanafelt said. “In 2014, urology ranked second highest of 24 specialties evaluated [vs. 15th out of 24 in 2011]. Urologists also had a decline in satisfaction with work-life balance, moving from the 15th most favorable score out of 24 specialties to the 23rd most favorable score.”
Overall, 54.4% of the physicians surveyed had at least one professional burnout symptom, compared to 45.5% in 2011. Satisfaction with work-life balance declined, too, going from 48.5% in 2011 to 40.9% in 2014, according to the study.
Dr. MofficPsychiatrist H. Steven Moffic, MD, said burnout has many definitions, including the simple: “Burnout is emotional exhaustion from undue stress.”
The current study authors describe burnout as a syndrome of emotional exhaustion, loss of meaning in work, feelings of ineffectiveness, and a tendency to view people as objects instead of human beings.
Based on the definition, researchers categorized burnout drivers into five dimensions: excessive workload; inefficiency, encompassing clerical burden; loss of autonomy or control over work; problems with work-life integration; and a loss of meaning in work, according to Dr. Shanafelt.
“Although some dimensions of practice are common to all physicians, others, including hours worked per week, productivity expectations, call schedule, control over work, and other variables can vary by specialty and practice setting,” Dr. Shanafelt said.
Dr. MillerIn general, physicians are prime candidates for burnout. The very traits that led them to pursue medical school might work against them later, according to psychiatrist Merry Noel Miller, MD, author of the book, “Finding Your Emotional Balance: A Guide for Women” (Johns Hopkins University Press).
“Often doctors are competitive and perfectionistic, and they may be very unforgiving with themselves when errors inevitably occur. Their self-doubt can get in the way of developing supportive relationships. The expectations for their time can be limitless, and doctors often adopt attitudes that they must always say yes when asked to do anything. Over time, they can become resentful of this unhealthy lifestyle, and start to acquire an ‘I don’t care’ attitude, instead,” Dr. Miller said.
Dr. HannoIt doesn’t surprise Philip M. Hanno, MD, MPH, that urologists are feeling burned out. Dr. Hanno said big stressors include the drive for relative value units (RVUs), resulting in physicians’ being pushed to see significantly more patients in significantly less time.
“And [academic physicians] have less time for doing clinical research, basic research, and the kinds of things that they probably went into academic medicine for,” said Dr. Hanno, professor of urology at the University of Pennsylvania, Philadelphia.
Steven Wahle, MD, a general urologist at the Physicians Clinic of Iowa, a large multispecialty group in Cedar Rapids, said after-hours call is one of the biggest sources of stress among the physicians in his group.
“The after-hours call is very busy. That can really lead to issues with fatigue and lack of sleep. The larger the group, the less the call. But when you’re on call, you’re covering for the whole group, so you have more late-night clinical work,” Dr. Wahle said. “One of the stresses that I hear from all of my partners is that when they are on call, it’s not that the work that is stressful, but the hours are stressful.”
The other big source of stress is the added clerical burden associated with electronic medical records, according to Dr. Wahle.
“It adds about 50 to 90 minutes a day of nonclinical time to finish your clinic notes, and at the hospital we are asked to do more and more clerical tasks.” he said.
Dr. Wahle“At the hospital, we’re also dealing with increased stressors. Hospital administrators are under the gun right now with reduced reimbursement issues, so they tend to homogenize the OR staff. We’ve lost some of our clinically subspecialized support staff in the OR, so you’re dealing with new people who are unfamiliar with the equipment. The ward staff and nurses are becoming younger and younger, with less experience, and they’re less subspecialized in urology, which makes rounding and clinical calls more labor intensive.”
There’s more, he said. Competitive hospital systems are pressuring independent urologists for more and more market share.
“Trying to accommodate referral patterns with the right hospital can be less inefficient for our busy schedules, adding to travel time and longer days.” Dr. Wahle said.
Doctors who are burning out often begin to lose enthusiasm for work and no longer feel that what they do is meaningful or effective, according to Dr. Shanafelt.
Physicians and others can recognize burnout by the presence of fatigue, cynicism, and a loss of compassion, Dr. Miller pointed out.
Dr. Moffic, who wrote “The Ethical Way: Challenges and Solutions for Managed Behavioral Healthcare” (Jossey-Bass), said symptoms can be psychological and/or physical, including boredom, irritability, tiredness, and poor sleep.
Recognizing these feelings is part of the challenge.
“In national studies conducted in collaboration with the American College of Surgeons, we have also found that many physicians [do not accurately] calibrate their level of distress or well-being,” said Dr. Shanafelt, citing an article in Annals of Surgery (2014; 259:82-8). “This often leads to physicians neglecting to seek help or make a change to promote wellness until they hit rock bottom or experience adverse professional effects.”
Even doctors who recognize the symptoms might rationalize the problem is temporary-the result of bad days. Others might not come forward because they feel weakness and a stigma are associated with admitting to be burned out, according to Dr. Moffic.
Physicians or others who suspect burnout can take a test. According to Dr. Miller, the Maslach Burnout Inventory, which is available online (www.mindgarden.com/117-maslach-burnout-inventory), helps people assess themselves for burnout.
Burnout has been shown in one study to substantially impact quality of care. It also has been associated with increased medical error risk (Ann Surg 2010; 251:995-1000).
“Burnout is also associated with… physician turnover and reductions in clinical work hours, which can have profound implications for the adequacy of the physician work force,” Dr. Shanafelt said.
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The departure of urologists from the profession due to burnout is a big concern. And that’s precisely what’s happening, according to Dr. Hanno.
“You have all these people who are very well trained, doing very special work, and they give it up,” Dr. Hanno said.
Dr. Hanno said he knows a middle-aged urologist who left the specialty because of the increased workload, decreased compensation, and the feeling that he was under a microscope.
“Ultimately, he said this just isn’t worth it,” Dr. Hanno said.
Dr. Wahle is witnessing the attrition, too.
“I have a 50-year-old colleague-one of the best urologists I’ve ever worked with-who is retiring. He just can’t do this anymore. I have my three younger partners in their 40s, and one says he’s out as soon as he reaches a certain economic stability. It stuns me to see how common that is even in the younger age ranges,” Dr. Wahle said.
Studies have found associations between physician burnout and broken relationships, problematic alcohol use (Arch Surg 2012; 147:168-74), and suicidal ideation (Arch Surg 2011; 146:54-62), according to Dr. Shanafelt.
While burnout is a problem, it isn’t universal. There are many in urology who admit there have been unwanted changes in the profession in recent years, but they don’t feel burned out.
Dr. BurnettArthur L. Burnett, II, MD, MBA, professor of urology at Johns Hopkins University School of Medicine in Baltimore, said there are more regulations and documentation demands and less freedom to practice now than in the past. But despite these challenges, he doesn’t feel burned out.
“I feel privileged to be a physician and to have responsibility for patients. By and large, I’m having an important impact on people’s lives. Being in an academic environment, I have the good fortune of a balanced practice that crosses the practice of urology, teaching residents, involvement in projects of discovery, and that sort. I play a role in our society and that allows me to travel and meet other urologists. For me, I don’t feel burned out. I feel I’m thriving,” Dr. Burnett said.
In general, Dr. Hanno said, urologists are adaptable, have a great attitude, and enjoy what they’re doing.
“There’s so much variation in what we do every day, from going to the operating room, to seeing patients, to academic pursuits, to clinical research-even if you’re not in academic urology,” Dr. Hanno said.
“But there’s no question that we’re under a lot more stress than we were many years ago,” he added.
The problem is bigger than what individuals can do on their own to prevent and overcome professional burnout, according to Dr. Shanafelt.
“Physician burnout is largely a system-based problem and addressing physician burnout is the shared responsibility of physicians and health care organizations,” according to Dr. Shanafelt.
He said health care organizations should focus on improving practice environment efficiency, reducing clerical tasks by transferring them to support staff, and nurturing a practice environment that cultivates flexibility and control.
“Organizational approaches to help physicians optimize meaning in their work and build connections with their colleagues have also been shown to reduce physician burnout in randomized trials,” Dr. Shanafelt said. “In the present study, over 40% of physicians worked more than 60 hours per week as compared to [about] 7% of general U.S. workers.”
Urologists in independent groups and other practice settings need to help identify those colleagues they think might be burning out and reach out, Dr. Wahle said.
“You really have to get to know your colleagues,” he said. “So, is there a family issue going on? Is there a financial issue going on? Is there a bad clinical outcome that has put them in a vulnerable place? Identify those providers that are in that vulnerable time and come together and rally around them to take some of their call or give them a couple of extra days off to settle a family issue.”
This is no small issue, according to Dr. Moffic.
“I would say that burnout is the number one problem affecting physicians and medicine today,” he said.
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