Tag Archive for: residency

Posts

Article of the month: Resident burnout in USA and European urology residents: an international concern

Every month, the Editor-in-Chief selects an Article of the Month from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an editorial  and a visual abstract written by members of the urological community, and a video prepared by the authors. These are intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation. 

If you only have time to read one article this month, it should be this one.

Resident burnout in USA and European urology residents: an international concern

Daniel Marchalik*, Charlotte C. Goldman, Filipe F. L. Carvalho*, Michele Talso§, John H. Lynch*, Francesco Esperto, Benjamin Pradere**, Jeroen Van Besien†† and Ross E. Krasnow‡‡

 

*Department of Urology, MedStar Georgetown University Hospital, Washington, DC, MedStar Health, Office of Physician Well-being, Columbia, MD,Georgetown University School of Medicine, Washington DC, USA, §Urology DepartmentMonza Brianza, Azienda Socio-Sanitaria Territoriale (ASST) Vimercate Hospital, Vimercate, Department of Urology, Humanitas Gavazzeni, Bergamo, Italy, **Academic Department of Urology, CHRU Tours, François Rabelais University, Tours, France,††Department of Urology, Ghent University Hospital, Ghent, Belgium, and ‡‡Department ofUrology, MedStar Washington Hospital Center, Washington DC, USA

 

Abstract

Objective

To describe the prevalence and predictors of burnout in USA and European urology residents, as although the rate of burnout in urologists is high and associated with severe negative sequelae, the extent and predictors of burnout in urology trainees remains poorly understood.

Subjects and methods

An anonymous 32‐question survey of urology trainees across the USA and four European countries, analysing personal, programme, and institutional factors, was conducted. Burnout was assessed using the validated abridged Maslach Burnout Inventory. Univariate analysis and multivariable logistic regression models assessed drivers of burnout in the two cohorts.

Fig.1. The predicted probability of burnout in residents stratified by non‐medical reading.

Results

Overall, 40% of participants met the criteria for burnout as follows: Portugal (68%), Italy (49%), USA (38%), Belgium (36%), and France (26%). Response rates were: USA, 20.9%; Italy, 45.2%; Portugal, 30.5%; France, 12.5%; and Belgium, 9.4%. Burnout was not associated with gender or level of training. In both cohorts, work–life balance (WLB) dissatisfaction was associated with increased burnout (odds ratio [OR] 4.5, P < 0.001), whilst non‐medical reading (OR 0.6, P = 0.001) and structured mentorship (OR 0.4, P = 0.002) were associated with decreased burnout risk. Lack of access to mental health services was associated with burnout in the USA only (OR 3.5, P = 0.006), whilst more weekends on‐call was associated with burnout in Europe only (OR 8.3, P = 0.033). In both cohorts, burned out residents were more likely to not choose a career in urology again (USA 54% vs 19%, P < 0.001; Europe 43% vs 25%, P = 0.047).

Conclusion

In this study of USA and European urology residents, we found high rates of burnout on both continents. Despite regional differences in the predictors of burnout, awareness of the unique institutional drivers may help inform directions of future interventions.

Editorial: The pursuit of purpose: reframing strategies to prevent physician burnout

If there is one virtue that drives surgery residents to toil away in sterile, brightly lit operating rooms for extended hours for the best years of their life, it is the pursuit of purpose. However, these extended hours can also lead to what the WHO has now officially recognized as a medical condition: burnout. In a study in this issue of BJUI, Marchalik et al. [1] use qualitative analysis to elaborate on the prevalence and predictors of burnout among urology residents in the USA and in four European countries. Using an anonymous survey, the authors report a high prevalence of burnout in urology residents in both cohorts, with the European residents (44%) experiencing a higher burden than their US counterparts (38%). Given the recent focus, in the academic as well as general media, on the importance and severe implications of physician burnout, and the recognition of burnout as a disease by WHO, the timing of this publication for concrete organizational action seems propitious, especially since this analysis combines data from two continents with different institutional and educational frameworks, providing more granular data for a particularly immersive surgical specialty with a high rate of burnout.

Most recently, a costconsequence analysis reported that physician burnout costs approximately $4.6 bn each year to the US healthcare system, with a cost of $7600 per‐physician‐per‐year at the institutional level resulting from reduced clinical productivity and turnover [2]. While addressing these economic losses from burnout is important from an organizational and health system point of view, focusing on these alone would be missing the larger picture. It is only when we consider the depersonalization, emotional drainage, and loss of professional and personal accomplishment associated with burnout that we begin to realize the scope of this epidemic. Deservedly, burnout is being recognized as a ‘moral injury’ [3]. And indeed, it is a moral injury: when physicians working under systems that betray their purpose as a healer, the damage is not only professional and systematic, but deeply personal as well.

The constant act of balancing competing demands – the financial interests of the healthcare institutions, looming litigations and ever‐changing documentation requirements – has undermined effective human interactions with patients and diminished the zeal that drives physicians to spend a major part of their youth in training. Journalist Diane Silver defines moral injury as ‘a deep soul wound that pierces a person’s identity, sense of morality, and relationship to society’ [3]. Except in the context of healthcare delivery, this injury extends to deterioration of relationships with patients and fellow physicians. Indeed, burnout among physicians has been demonstrated to be associated with suboptimal patient care [4], and the consequent inability to deliver high‐quality care because of health system deficiencies leads to decline in physician well‐being and professional dissatisfaction [5].

While the urgency of addressing physician burnout is obvious, this study by Marchalik et al. is also valuable as it highlights some of the practices that are protective, revealing lessons that can be implemented. The authors report that burnout was significantly lower among residents who sought mental health services and those who had access to structured mentorship. Unsurprisingly, those who had a caring environment experienced less depersonalization and emotional drainage. This is an instructive lesson for the residency programme directors: if they want their most important human resource to flourish, they need to start building supportive work environments. This could start with pairing interns and residents with dedicated and experienced faculty mentors; these initiatives would facilitate career coaching and provide space where residents feel comfortable seeking information on mental healthcare.

Interestingly, the authors also found a significant doseresponse relationship between the number of non‐medical books residents read per month and decreased rates of burnout. This finding may surprise some healthcare administrators, who have routinely attempted to integrate ‘wellness’ and ‘mindfulness’ into clinical programmes to stimulate physician motivation, without much benefit. However, the positive relationship between non‐medical literature and medicine is an ancient one. Fortunately, in the last few decades, this relationship has witnessed a comeback and an increasing number of trainees are finding solace in their engagement with medical humanities and narrative medicine. These engagements have led to physicians developing emotional intelligence, empathy for patients and colleagues, and an opportunity to examine their role as healers [6]. This insight from the study should be another lesson for medical educators, who can encourage inclusion of reflections on life as a physician.

The epidemic of burnout among surgery residents requires immediate attention. Taking proactive action towards this is not only a matter of preventing economic loss or improving physician productivity, but an urgent ethical issue. All stakeholders – hospital administrators, healthcare policy‐makers, and regional physician leaders – must work together in developing inventive solutions to address the burnout epidemic. This will be essential to realizing the maximal potential of residency and reinstating purpose of clinical work.

References

  1. Marchalik, DGoldman, CCCarvalho, FFL et al. Resident burnout in USA and European urology residents: an international concern. BJU Int 2019124349‐ 56
  2. Han, SShanafelt, TDSinsky, CA et al. Estimating the attributable cost of physician burnout in the United States cost of physician burnout. Ann Intern Med 2019170784‐ 90
  3. Dean, WTalbot, SPhysicians aren’t ‘burning out.’ They’re suffering from moral injury. STAT News 2018. Available at: https://www.statnews.com/2018/07/26/physicians-not-burning-out-they-are-suffering-moral-injury/. Accessed May 29, 2019.
  4. Shanafelt, TDBradley, KAWipf, JEBack, ALBurnout and self‐reported patient care in an internal medicine residency program. Ann Intern Med 2002136358– 67
  5. Friedberg, MWChen, PGBusum, KR et al. Factors affecting physician professional satisfaction and their implications for patient care, health systems, and health policy. Rand Health Q 201431
  6. Bonebakker, VLiterature & medicine: humanities at the heart of health care: a hospital‐based reading and discussion program developed by the Maine humanities council. Acad Med 200378:963– 7

 

Video: Resident burnout in USA and European urology residents

Resident burnout in USA and European urology residents: an international concern

Abstract

Objective

To describe the prevalence and predictors of burnout in USA and European urology residents, as although the rate of burnout in urologists is high and associated with severe negative sequelae, the extent and predictors of burnout in urology trainees remains poorly understood.

Subjects and methods

An anonymous 32‐question survey of urology trainees across the USA and four European countries, analysing personal, programme, and institutional factors, was conducted. Burnout was assessed using the validated abridged Maslach Burnout Inventory. Univariate analysis and multivariable logistic regression models assessed drivers of burnout in the two cohorts.

Results

Overall, 40% of participants met the criteria for burnout as follows: Portugal (68%), Italy (49%), USA (38%), Belgium (36%), and France (26%). Response rates were: USA, 20.9%; Italy, 45.2%; Portugal, 30.5%; France, 12.5%; and Belgium, 9.4%. Burnout was not associated with gender or level of training. In both cohorts, work–life balance (WLB) dissatisfaction was associated with increased burnout (odds ratio [OR] 4.5, P < 0.001), whilst non‐medical reading (OR 0.6, P = 0.001) and structured mentorship (OR 0.4, P = 0.002) were associated with decreased burnout risk. Lack of access to mental health services was associated with burnout in the USA only (OR 3.5, P = 0.006), whilst more weekends on‐call was associated with burnout in Europe only (OR 8.3, P = 0.033). In both cohorts, burned out residents were more likely to not choose a career in urology again (USA 54% vs 19%, P < 0.001; Europe 43% vs 25%, P = 0.047).

Conclusion

In this study of USA and European urology residents, we found high rates of burnout on both continents. Despite regional differences in the predictors of burnout, awareness of the unique institutional drivers may help inform directions of future interventions.

 

Residents’ podcast: Resident burnout

Maria Uloko is a Urology Resident at the University of Minnesota Hospital. In this podcast she discusses the following BJUI Article of the month:

Resident burnout in USA and European urology residents: an international concern

Abstract

Objective

To describe the prevalence and predictors of burnout in USA and European urology residents, as although the rate of burnout in urologists is high and associated with severe negative sequelae, the extent and predictors of burnout in urology trainees remains poorly understood.

Subjects and methods

An anonymous 32‐question survey of urology trainees across the USA and four European countries, analysing personal, programme, and institutional factors, was conducted. Burnout was assessed using the validated abridged Maslach Burnout Inventory. Univariate analysis and multivariable logistic regression models assessed drivers of burnout in the two cohorts.

Results

Overall, 40% of participants met the criteria for burnout as follows: Portugal (68%), Italy (49%), USA (38%), Belgium (36%), and France (26%). Response rates were: USA, 20.9%; Italy, 45.2%; Portugal, 30.5%; France, 12.5%; and Belgium, 9.4%. Burnout was not associated with gender or level of training. In both cohorts, work–life balance (WLB) dissatisfaction was associated with increased burnout (odds ratio [OR] 4.5, P < 0.001), whilst non‐medical reading (OR 0.6, P = 0.001) and structured mentorship (OR 0.4, P = 0.002) were associated with decreased burnout risk. Lack of access to mental health services was associated with burnout in the USA only (OR 3.5, P = 0.006), whilst more weekends on‐call was associated with burnout in Europe only (OR 8.3, P = 0.033). In both cohorts, burned out residents were more likely to not choose a career in urology again (USA 54% vs 19%, P < 0.001; Europe 43% vs 25%, P = 0.047).

Conclusion

In this study of USA and European urology residents, we found high rates of burnout on both continents. Despite regional differences in the predictors of burnout, awareness of the unique institutional drivers may help inform directions of future interventions.

BJUI Podcasts now available on iTunes, subscribe here https://itunes.apple.com/gb/podcast/bju-international/id1309570262

Article of the week: Behind the curve: residents’ access to RAL is poor in Europe

Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by prominent members of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video of Dr. Furriel discussing his paper.

If you only have time to read one article this week, it should be this one.

Training of European urology residents in laparoscopy: results of a pan-European survey

Frederico T.G. Furriel, Maria P. Laguna*, Arnaldo J.C. Figueiredo, Pedro T.C. Nunes and Jens J. Rassweiler

Department of Urology and Renal Transplantation, University Hospital of Coimbra, Coimbra, Portugal, *Department of Urology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands, and Department of Urology, Klinikum Heilbronn, University of Heidelberg, Heilbronn, Germany

OBJECTIVE

• To assess the participation of European urology residents in urological laparoscopy, their training patterns and facilities available in European Urology Departments.

MATERIALS AND METHODS

• A survey, consisting of 23 questions concerning laparoscopic training, was published online as well as distributed on paper, during the Annual European Association of Urology Congress in 2012.

• Exposure to laparoscopic procedures, acquired laparoscopic experience, training patterns, training facilities and motivation were evaluated.

• Data was analysed with descriptive statistics.

RESULTS

• In all, 219 European urology residents answered the survey.

• Conventional laparoscopy was available in 74% of the respondents’ departments, while robotic surgery was available in 17% of the departments.

• Of the respondents, 27% were first surgeons and 43% were assistants in conventional laparoscopic procedures. Only 23% of the residents rated their laparoscopic experience as at least ‘satisfactory’; 32% of the residents did not attend any course or fellowship on laparoscopy.

• Dry laboratory was the most frequent setting for training (33%), although 42% of the respondents did not have access to any type of laparoscopic laboratory.

• The motivation to perform laparoscopy was rated as ‘high’ or ‘very high’ by 77% of the respondents, and 81% considered a post-residency fellowship in laparoscopy.

CONCLUSIONS

• Urological laparoscopy is available in most European training institutions, with residents playing an active role in the procedure. However, most of them consider their laparoscopic experience to be poor.

• Moreover, the availability of training facilities and participation in laparoscopy courses and fellowships are low and should be encouraged.

 

Read Previous Articles of the Week

 

Editorial: Minimally invasive surgical training: do we need new standards?

The pan-European survey conducted by Furriel et al. [1] in this issue of BJUI is a timely address of a hot topic in urology.

More than 20 years have passed since the first laparoscopic nephrectomy was performed by Clayman et al. [2] in 1991, and now all urological major interventions have been performed with one or more different minimally invasive techniques (standard, single-site or robot-assisted laparoscopy); some of them have passed the judgment of time becoming ‘gold standard’ treatments, while others are still under evaluation. Specifically, the European Association of Urology (EAU) guidelines recommend laparoscopic radical nephrectomy as the ‘standard of care’ over open surgery, report favorable outcomes for robot-assisted laparoscopic radical prostatectomy, and propose as optional treatments laparoscopic or robot-assisted partial nephrectomy and radical cystectomy [3].

Obviously, this surgical revolution brings two major new issues: (i) Starting from academic and training centres, hundreds of Urology Departments throughout Europe need to update their surgical knowledge and expertise, making senior urologists perform up-to-date procedures; (ii) Residents and young urologists require adequate and possibly standardised training in minimally invasive surgery, learning at least the basic laparoscopic skills. The study by Furriel et al. [1] correctly highlights both problems.

First, according to the survey, penetration of laparoscopy in the most important urological training centres is unexpectedly low. In fact, more than one out of four centers (26%) do not perform minimally invasive surgery, even for the ‘standards of care’, such as laparoscopic radical nephrectomy. Moreover, as the survey was conducted specifically on the topic of minimally invasive surgery, it is probable that unexposed residents were less interested in responding, making the data of penetration probably even worse than reported. This fact reflects a serious problem present in most training centres. While previously surgery slowly evolved, laparoscopy and technology brought sudden innovations, putting several senior urologists ‘out of the game’. Hence, today, training is needed not only for residents, but also for consultants. In the meantime, it is important that residents are trained in centres were minimally invasive surgery is already widely available. In this perspective, European educational authorities should endeavour to certificate the residents’ training centres, for example on the basis of adherence to EAU guidelines. Academic or non-academic training centres not adherent to guidelines (and thus not performing minimally invasive surgery) should therefore be deprived of residents.

Secondly, training residents in minimally invasive surgery can be approached in different ways, from low-cost self-made dry laboratories to expensive virtual reality or robotic three-dimensional simulators. According to the survey, >40% of centres have no training facilities available. It has been shown that self-built, cheap, dry laboratories are as efficient in training as the industrial ones [4], so that it is not a matter of costs but a matter of interest. We strongly believe that watching surgical videos, observing live surgeries and using (low-cost or not) dry laboratories are fundamental steps in acquiring the basic skills in laparoscopy, while the modular training proposed by Stolzenburg et al. [5] for laparoscopic radical prostatectomy is the best live training model and can be exported to other kinds of surgery, such as radical or partial nephrectomy. In the centres where robot-assisted surgery is available, working as a table-side assistant is another good way to acquire laparoscopic skills.

A great debate is currently ongoing about credentialing in minimally invasive surgery training [6]. Pragmatically, when the European training centres are certificated for adherence to the EAU guidelines, there will be no need for a specific credentialing in laparoscopic skills, because it will be included in the standard training path, together with endoscopic and open surgery.

In conclusion, the survey by Furriel et al. [1] shows that times are changed: the old axiom ‘big cut, big surgeon’ is not valid anymore. The emerging urological generations know it, and ask to be adequately trained. Training centres must evolve, because in 2013 minimally invasive surgery has formally to be considered as part of the standard urological armoury.

Antonio Galfano and Aldo Massimo Bocciardi
Department of Urology, Ospedale Niguarda Ca’ Granda, Milan, Italy

References

  1. Furriel F, Laguna MP, Figueiredo A, Nunes P, Rassweiler JJ. Training of European urology residents in laparoscopy: results of a pan-European surveyBJU Int 2013; 112: 1223–1228
  2. Clayman RV, Kavoussi LR, Soper NJ et al. Laparoscopic nephrectomyN Engl J Med 1991; 324: 1370–1371
  3. EAU Guidelines, edition presented at the 28th EAU Annual Congress, Milan 2013. ISBN 978-90-79754-71-7. EAU Guidelines Office, Arnhem, The Netherlands. Available at: https://www.uroweb.org/guidelines/online-guidelines/. Accessed September 2013
  4. Beatty JD. How to build an inexpensive laparoscopic webcam-based trainerBJU Int 2005; 96: 679–682
  5. Stolzenburg JU, Schwaibold H, Bhanot SM et al. Modular surgical training for endoscopic extraperitoneal radical prostatectomy. BJU Int 2005; 96: 1022–1027
  6. Lee JY, Mucksavage P, Sundaram CP, McDougall EM. Best practices for robotic surgery training and credentialingJ Urol 2011;185: 1191–1197

Video: How do urology residents rate their laparoscopic experience?

Training of European urology residents in laparoscopy: results of a pan-European survey

Frederico T.G. Furriel, Maria P. Laguna*, Arnaldo J.C. Figueiredo, Pedro T.C. Nunes and Jens J. Rassweiler

Department of Urology and Renal Transplantation, University Hospital of Coimbra, Coimbra, Portugal, *Department of Urology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands, and Department of Urology, Klinikum Heilbronn, University of Heidelberg, Heilbronn, Germany

OBJECTIVE

• To assess the participation of European urology residents in urological laparoscopy, their training patterns and facilities available in European Urology Departments.

MATERIALS AND METHODS

• A survey, consisting of 23 questions concerning laparoscopic training, was published online as well as distributed on paper, during the Annual European Association of Urology Congress in 2012.

• Exposure to laparoscopic procedures, acquired laparoscopic experience, training patterns, training facilities and motivation were evaluated.

• Data was analysed with descriptive statistics.

RESULTS

• In all, 219 European urology residents answered the survey.

• Conventional laparoscopy was available in 74% of the respondents’ departments, while robotic surgery was available in 17% of the departments.

• Of the respondents, 27% were first surgeons and 43% were assistants in conventional laparoscopic procedures. Only 23% of the residents rated their laparoscopic experience as at least ‘satisfactory’; 32% of the residents did not attend any course or fellowship on laparoscopy.

• Dry laboratory was the most frequent setting for training (33%), although 42% of the respondents did not have access to any type of laparoscopic laboratory.

• The motivation to perform laparoscopy was rated as ‘high’ or ‘very high’ by 77% of the respondents, and 81% considered a post-residency fellowship in laparoscopy.

CONCLUSIONS

• Urological laparoscopy is available in most European training institutions, with residents playing an active role in the procedure. However, most of them consider their laparoscopic experience to be poor.

• Moreover, the availability of training facilities and participation in laparoscopy courses and fellowships are low and should be encouraged.

© 2020 BJU International. All Rights Reserved.