In Medscape's recently released 2020 National Physician Burnout and Suicide Report, urology once again found itself at the top of the charts. With 54% of urologists endorsing burnout the specialty is now 12% above the average seen in the overall cohort of over 15,000 physicians. If this is an error, then that error seemed to also have occurred in 2019 when urology, still at the top, was shown to have a 54% prevalence of burnout. The same goes for 2017 when urologists' level of burnout appeared to be the highest in severity of any specialty. In fact, we have to go back to 2013 to find urology not toward the top of the list in specialty burnout, and even then it fell in the top third.

During the past few years I have found myself in the position of a de facto liaison for the field of urology while presenting at national and international conferences on physician burnout. In these meetings, even when giving talks that do not mention urology, the same question seems to always arise from the audience: “Why are burnout rates so high in your field?” The truth is that I don't know. Yet I have offered up myriad excuses to try and explain this phenomenon. Here are some explanations that I have previously offered, and why they don't actually hold up.

“The Doximity survey isn't a validated survey. We aren't sure how reliable it is.” While this may be true, it still signals that, on this survey measuring distress, urologists continue to top the medical field. At the same time, urologists appear to have among the highest rates of burnout in a variety of other national studies. Data from 6,880 physicians collected in 2014 showed urology as having the second highest level of burnout at 63.6%. ¹ That same study revealed that urologists had the worst work–life integration of all surveyed specialties with only 29.3% endorsing satisfaction with work–life balance. Repeated in 2017, this AMA-sponsored national survey of 5,197 physicians showed an overall decrease in burnout symptoms. At 48.4%, urologists remained in the bottom quartile for burnout while still maintaining a place as the specialty with the lowest satisfaction with work–life balance. ² A similar phenomenon was observed in a national study of 4,732 residents, which showed urology trainees as having the highest level of burnout at 63.8%. ³ Yes, these studies are imperfect in their own ways. But the findings in them, as they pertain to urology, are consistent.

“All these studies have a small number of urologists.” While this statement is true at face value, it ignores the consistent relative representation of urologists in the cohort. For example, in the national study conducted in 2011, 2014 and 2017, roughly 1.7% of the overall responses came from urologists (see table). With urologists making up 1.5% of the overall physician workforce, our specialty appears slightly overrepresented. ⁴ At the same time, cohort analysis demonstrates a nondifference between the sample group and the overall complement of U.S. physicians. ¹ Finally, specialty representation tended to mirror the overall proportions of physicians within that specialty (eg radiation oncology 0.8%, neurosurgery 1.1%, pathology 2.5%, radiology 3% etc). If the issue with the data were a sampling error, that issue would be expected to be reflected across the board in all specialties.

“But I've never met an unhappy urologist.” In many ways this is the argument I have heard and uttered the most and is the reason why we remain at the bottom of the burnout barrel. As a field we remain committed to the communal folklore of our exceptionalism. It is the reason why our field remains among the least studied on the drivers and associations of burnout. It is also why we continue to fall behind other specialties in terms of action. We do not have enough taskforces dedicated to urology well-being, and we do not have enough leadership investment in solutions.

So when it comes to answering why urology remains the field with the highest burnout, the simple answer is this: we are too focused on excuses rather than solutions.