Impact of the COVID-19 Pandemic on Urologist Burnout in the New York Section of the American Urological Association

By: Rashed L. Kosber, BA; Zoë C. Cohen, MD; Ezra J. Margolin, MD; Amanda C. North, MD; Gina M. Badalato, MD | Posted on: 01 Dec 2021

Introduction

The COVID-19 pandemic has placed a massive strain on all aspects of the health care system and has demanded a corresponding shift in resources and priorities. Many urologists, particularly in New York City, were involved in critical care. Working beyond their usual scope of practice, urologists were concerned about the novel virus, inadequate access to personal protective equipment and potential effects on surgical training or career-advancement opportunities.^1,2 While the COVID-19 pandemic continues to place strain on health care professionals, the effects of the pandemic on rates of burnout and depression in urologists should be further characterized. In the Medscape National Physician Burnout, Depression, and Suicide Report 2019, 44% of physicians reported burnout and 66% of urologists reported either burnout or depression.³ We sought to evaluate how the pandemic has affected burnout and depression among urologists in the New York Section (NYS) of the American Urological Association. Additionally, we examined risk factors and protective factors for burnout and depression to promote physician well-being and preserve the quality of urological care in the future.

In July 2020, we administered a survey to attending urologists in the NYS of the AUA. Chi-square tests were used to determine factors associated with rates of burnout or depression. Questions about burnout and depression were largely derived from the 2019 Medscape National Physician Burnout, Depression & Suicide Report.⁴ This report defined burnout as “long-term, unresolvable job stress that leads to exhaustion and feeling overwhelmed, cynical, detached from the job, and lacking a sense of personal accomplishment.” The Medscape report defined colloquial depression as “feeling down, blue, or sad” and clinical depression as “prolonged severe depression that is not caused by a normal grief-associated event.” Our survey incorporated these definitions. Additionally, we adapted many of the factors contributing to burnout and the coping mechanisms from the Medscape report.

Our primary outcome was the rate of self-reported burnout or depression. Univariable logistic regression was used to assess for factors associated with the primary outcome. Logistic regression was repeated for each variable of interest in a multivariable model controlling for age and gender. Secondary outcomes included changes in practice patterns related to the COVID-19 pandemic, factors contributing to burnout/depression, and mechanisms for coping with burnout/depression. Statistical analysis was performed using Stata^® 12.1 (StataCorp, College Station, Texas). This study was approved by the Columbia University Institutional Review Board.

Results

A total of 94 attending urologists completed the survey. The median age category was 50–59 years, and 87% were male. Survey respondents included a combination of academic and nonacademic urologists, as well as general urologists and subspecialists. Table 1 shows additional demographic and professional characteristics. During the COVID-19 pandemic, 80% of urologists reported decreased clinical or surgical volume; however, 39% reported increased workload outside of business hours. Burnout was reported by 32 subjects (34%), and colloquial depression was reported by 7 subjects (7%), for a combined rate of 41%. The most cited contributing factors to burnout were charting/paperwork (56%), emphasis on profits over patients (54%), lack of respect from patients (49%), insufficient salary (46%) and excessive work hours (46%). Decreased job security and decreased salary during the pandemic were reported by 24% and 47%, respectively. After controlling for age and gender, decreased job security (OR 5.96, p <0.01) and decreased salary (OR 2.48, p=0.05) were associated with higher rates of burnout (table 2). Availability of nonphysician providers to assist with clinical tasks was associated with lower rates of burnout (OR 0.34, p=0.02). Of the subjects with burnout or depression, 67% reported an associated impact on patient care.

Table 1. Participant (94) demographics and professional characteristics

	No. (%)
Yrs age
30–39	6 (6)
40–49	19 (20)
50–59	29 (31)
60–69	24 (26)
70 or above	16 (17)
Gender
Male	82 (87)
Female	12 (13)
Professional status
Full-time, academic	51 (54)
Full-time, nonacademic	33 (35)
Part-time	2 (2)
Missing	8 (9)
Yrs in practice
5 or fewer	4 (4)
6–10	13 (14)
11–15	5 (5)
More than 15	72 (77)
Urological subspecialty
General urology	44 (47)
Endourology	5 (5)
Female/voiding dysfunction	10 (11)
Oncology	22 (23)
Pediatrics	6 (6)
Reconstruction	3 (3)
Sexual medicine/infertility	4 (4)+
Primary practice setting
Urban	56 (60)
Suburban	38 (40)
Nonphysician providers assisting with clinical tasks
Yes	52 (55)
No	42 (45)
Work hrs per wk
Fewer than 40	13 (14)
40–50	23 (24)
51–60	23 (24)
61–70	25 (27)
71 or more	10 (11)
No. pts seen over 8 hours
<20	10 (11)
20–25	20 (21)
26–30	31 (33)
31–35	6 (6)
36–40	12 (13)
>40	15 (16)
Clinical volume telemedicine (%)
Less than 10	50 (53)
10–25	22 (23)
26–50	13 (14)
More than 50	9 (10)

Table 2. Factors associated with burnout/depression for 94 participants

	Univariable Logistic Regression			Controlling for Age and Gender
	OR	95% CI	p Value	OR	95% CI	p Value
Yrs age, increasing category	0.89	0.63–1.28	0.54	–	–	–
Male gender	0.99	0.29–3.39	0.99	–	–	–
Academic (vs nonacademic)*	0.53	0.22–1.30	0.17	0.41	0.15–1.10	0.08
Yrs in practice, increasing category	1.18	0.73–1.90	0.50	1.83	0.89–3.79	0.10
Subspecialist (vs general urologist)	0.52	0.22–1.18	0.12	0.45	0.18–1.09	0.08
Urban (vs suburban)	0.67	0.29–1.54	0.34	0.68	0.29–1.59	0.37
Nonphysician providers assisting	0.37	0.16–0.86	0.02	0.34	0.14–0.81	0.02
Work hrs, increasing category	1.26	0.89–1.77	0.19	1.24	0.86–1.80	0.25
No. pts per hr, increasing category	1.18	0.91–1.53	0.21	1.17	0.89–1.56	0.26
Proportion of telemedicine, increasing category	0.76	0.49–1.16	0.21	0.77	0.49–1.21	0.26
Redeployed during pandemic	1.30	0.57–2.96	0.53	1.23	0.52–2.91	0.63
Redeployed to ICU or ED	0.86	0.26–2.87	0.81	0.76	0.22–2.67	0.67
Increased workload outside business hours	1.62	0.70–3.76	0.26	1.57	0.67–3.73	0.31
Decreased job security	5.68	1.97–16.41	< 0.01	5.96	2.03–17.45	< 0.01
Decreased salary	2.10	0.91–4.83	0.08	2.48	1.01–6.07	0.05
Increased sense of purpose	1.67	0.69–4.00	0.25	1.70	0.70–4.10	0.24
*Excluded part-time or missing data.

Overall, 50% of respondents reported involvement in non-urologic care during the pandemic, including 14% who were deployed to the intensive care unit (ICU) and/or emergency department (ED). There was no relationship between redeployment and burnout for redeployed attendings (OR 1.30, p=0.53) or those specifically redeployed to the ED and/or ICU (OR 0.86, p=0.81).

Among respondents who reported burnout or depression, the most common coping mechanisms included exercise (67%), talking with family/friends (46%), alcohol use (31%), and music (31%). Of those with burnout or depression, only 15% sought professional help, and 67% felt that appropriate mental health support was not provided at work. Among those who did not seek professional help, the most common explanation was feeling their symptoms were not severe enough to require help (52%). Additionally, 36% did not think professional help would be beneficial; 36% felt they were too busy to seek help and 9% feared it would be seen as a sign of weakness.

The statistically significant association between decreased job security since the beginning of the pandemic and burnout may stem from an environment of general uncertainty. When this survey was conducted, it was not known when an effective vaccine would become available. Without a clear idea of the future, physicians may have been unable to seize opportunities to network, relocate or otherwise advance their careers. The financial stress on institutions with the cancelation of elective surgeries and the reallocation of resources also may have contributed to the decreased job security reported by nearly a quarter of our study’s respondents.

The decreased revenue associated with scaling back elective surgeries affected many urologists, with nearly half of respondents reporting decreased compensation. These issues have been described during the pandemic among surgeons outside of urology, as well.^4,5

Conclusions

Burnout and depression during the COVID-19 pandemic were highly prevalent among urologists in the NYS of the AUA. The rate of burnout measured in our study, 41%, closely aligns with the rate measured in the largest study on burnout in urology to date, 38.8%.⁶ This high prevalence may be partially related to decreased job security and compensation in the setting of the pandemic. Availability of nonphysician providers to assist with clinical tasks may be protective against burnout.

These data reflect last year’s responses, and further information needs to be collected on the current state of burnout amongst urologists in particular sections and beyond. These findings along with ongoing data acquisition via the AUA Census can continue to help guide programming and outreach regarding this important issue.

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