Addressing Burnout in Urology: Strategies for a Sustainable Career and Personal Well-being - Phillip Pierorazio

June 25, 2024

Ruchika Talwar and Phil Pierorazio discuss the challenges of burnout and retention within the urology workforce. Dr. Pierorazio underscores the persistence of high burnout rates despite growing awareness and targeted efforts to mitigate them. He discusses the complex demands on urologists, highlighting the broad scope of care that extends beyond surgery to long-term patient management, which often contributes to stress and burnout. The conversation emphasizes the importance of recognizing early signs of burnout, such as irritability, and adopting both personal and systemic strategies to ensure a sustainable career. They explore practical measures, including mindfulness and maintaining physical health, to enhance professional longevity and personal well-being. This discussion offers critical insights into improving life-work balance and fostering a healthier, more resilient urologic workforce.


Phillip Pierorazio, MD, Urologist, Professor of Surgery, University of Pennsylvania, Penn Presbyterian Medical Center, Philadelphia, PA

Ruchika Talwar, MD, Assistant Professor of Urology, Urologic Oncologist, and Associate Medical Director in Population Health, Vanderbilt University Medical Center, Nashville, TN

Read the Full Video Transcript

Ruchika Talwar: Hi everyone. Welcome back to UroToday's Health Policy Center of Excellence. As always, my name is Ruchika Talwar, and today we'll be discussing a topic that is very important, in my opinion, to retention and ensuring a healthy urologic workforce. I'm joined today by Dr. Phil Pierorazio, who is a professor and chief of urology at Penn Presbyterian Medical Center in Philadelphia. Thank you so much, Dr. Pierorazio, for spending time with us today.

Phillip Pierorazio: Dr. Talwar, it's always amazing to spend time with you.

Ruchika Talwar: So, let's head right into our discussion. We've had a lot of talk recently about this workforce shortage, and in my opinion, we need to ensure that we have enough urologists to take care of our aging population. A big piece of that is making sure our existing workforce is healthy, both from a physical and wellbeing standpoint. So I'm just curious, what are your thoughts on increasing burnout rates that have been really starkly affecting both urology and medicine as a whole?

Phillip Pierorazio: Yeah, I think they're really interesting. And what's fascinating is if you look at the last AUA urology census, the burnout rates aren't decreasing. Despite our awareness, despite supposed efforts to improve this, they are not decreasing.

But it's also kind of this weird dichotomy because if you talk to most of us, most urologists are pretty happy. And I think what we see and what we know is that most urologists most of the time are in a good place. But all of us have really experienced a profound burnout episode in the last year also. And there's lots of reasons for that and possible mechanisms, a lot of it having to do with the breadth of care we deliver. We don't have a primary care specialty. We deliver the longevity of care for our patients. And there's a lot on us in terms of not only surgical management and those issues, but medical management, long-term care, coordination of care, response to patients through electronic medical records. So, it's a real challenge to keep all of that in line and it becomes a challenge both for the individual and institutions in keeping a sustainable long career.

Ruchika Talwar: Yeah, absolutely. So, I think there has been a lot of progress made in awareness, but what are some early signs that urologists should look for and be aware of in your opinion?

Phillip Pierorazio: Yeah, I think that when you're thinking about your own personal journey through all of this, often the most common sign of burnout is irritability. So, if you find yourself all of a sudden snapping off at people that you wouldn't normally snap off at, particularly at home, your spouse, your significant other, your children, your beloved nurse or clinic staff, if you're snapping off at people that are good to you on a regular basis, it's time to look inward and see what's going on and where you can make adjustments. And so, that's often the most common sign. There's a lot of other insidious things that can be going on. Sleep management, diet, nutrition, all of these things play into it, but irritability is often the easiest sign that's overlooked.

Ruchika Talwar: So then, let's say we identify one of those signs, what's next?

Phillip Pierorazio: So, I try and talk to everybody now about individual and institutional approaches to burnout and sustainability. Burnout's one component, but the goal is really a long, sustainable career.

And the way I always put this, or I think a nice analogy comes from sports, professional athletes, particularly if you look at things like the NFL or the NBA, they're brought into these leagues for 3, 5, 8 year careers if they're lucky. And they're given a ton upfront in rookie camps and such about how to prepare for that career and how to keep them involved for that extended period of time. We're expected to have 30-year careers in surgery, if you think about the time we leave medicine or residency and then practice, and we are given very little in training and maintenance of our careers, and that has to do with everything from our physical wellbeing, our mental and emotional wellbeing, our financial wellbeing, all of these things tie into that.

So, as I said, that all can then come back to the individual and the institution. And the first and I think most important part that I always like to stress with everybody is the 20% number, and that's an important figure to remember. And what that refers to is only about, if you think of the average urologist or the average physician, only about 20% of what contributes to burnout or sustainability is really under our personal control. You can control your schedule, you can control the number of patients you see to a certain degree, depending on where you are, but 80% of it is out of your control. So, the first part is just recognize that it's not all under your control. And if you start getting really upset and investing a lot of energy and effort and time in that 80%, you're wasting it because you're really just spinning your wheels.

Flip side, focus on the 20% that you can control and you can see tremendous benefits. And then, I always tell people, "If the 80% is really bothering you, do what you're doing, climb the ladder, get involved in policy and advocacy and administration and leadership because we need those people too, and you can work on that 80%."

And then, the last part of that 20% really to remember is that you only need, the data really says in multiple careers and in multiple professions, you really only need 20% of your time to be doing what you enjoy doing to be, "Happy." So you're setting yourself up for failure if you say every minute of every day at work needs to be happiness. That's a problem. It's not achievable. 20% is a low bar. I tell people to aim more in the range of 30 to 40%. So, one to two days of the week should be doing stuff that you really enjoy doing. But if you can meet that low bar, you will have a much more efficient time, much better time at work, and it'll promote a longer, sustainable career.

Ruchika Talwar: Yeah, absolutely. I mean, expectation setting I think is key and being practical. So, along those lines, awareness, expectation setting, let's move on to mindfulness. It's something I know you've talked about a lot, and there is definitely a misconception that mindfulness means yoga and reaching nirvana and all of these things, but I know that you're a big believer in integrating mindfulness into all aspects of our personal and professional lives. So, just tell me a little bit about what mindfulness means to you and what you think it should mean as urologists aim to integrate it into their lives.

Phillip Pierorazio: Yeah, I think it's a great question, and you're right, it's this huge misconception about what mindfulness is. And listen, you can sit on a mat and cross your legs and meditate every day. I do that, but I actually don't advocate that for everybody. That's not going to work for the vast majority of people.

What mindfulness really is about is controlling your attention and what you're paying attention to and how you can manipulate that. And there's a variety of ways to do that. You could have a formal meditation practice, but exercise can be incredibly mindful, surgery can be incredibly mindful, cooking, gardening, reading, all of these activities can be mindful. And if we think about what our attention does, we can focus on something specific, we can notice what's going on around us, or we can basically work in executive functions. We can plan and evaluate and do all of these other things. That's what our attention can do, and we can practice those things.

So, in the traditional sense, in a mindfulness practice, you focus on your breathing. So, that's pointing your attention and bringing it back every three seconds when it gets distracted. That also, believe it or not, helps you in the operating room. It helps you in the clinic. It helps you in the rest of your life. Then you can do the same thing whether you're running, hiking, cooking, gardening, as I said before. All of ways to practice mindfulness. And one of the points I always like to make is we have incredibly physical jobs as surgeons, we do, but the majority of our career is actually spent using our brains. It's cognitive function.

If you think about the way we train in real life, most of us do some form of physical activity. We exercise our muscles and our cardiovascular systems. But that's not what we spend most of our time doing as surgeons and as physicians. And so, really devoting 10, 20 minutes a day on cognitive activities like mindfulness activities that can help hone your attention and your focus are really beneficial practices for the short and long-term.

Ruchika Talwar: Now, let's get really practical, for someone who hears the world mindfulness and literally does not know where to start, what do you recommend there?

Phillip Pierorazio: Yeah, I'm blanking on his name right now, but he was the executive who brought mindfulness training to Google, and he called it the one breath policy, and it's really easy; commit to one breath a day. We can all do that, right? Sit there and take one deep breath. Really focus on the breath in and the breath out, and what you're feeling in your body, what you're feeling around you, what you may notice during that one breath. Once you're comfortable with one breath, maybe try a minute. A lot of us have smart watches or devices that can tell us when a minute's up, try a minute. And the next thing you know, a minute turns into two, two turns into 10, and the data says 12 minutes a day of mindfulness practice is extremely beneficial.

Once again, that's probably the low bar, right? You can do 20 or 30 minutes, I don't. I do 10 to 12 minutes a day. That's my practice. Because that's what fits into my life. But that's where you start. And once again, mindfulness doesn't necessarily have to be breathing. There's lots of ways to do this. There are things called body scans, where you just pay attention to your body. There are meditation practices, where you can just sit outside and look at nature, focus on one thing at nature. So, there's a variety of ways to do this. And if you're really unsure of where to start or none of these things resonate with you, Google and YouTube, there's really great short meditations, short mindfulness practices that aren't necessarily meditations, Peloton App, Nike app, all of these things now have mindfulness and meditative practices, just to help you get started, and they're designed for beginners.

Ruchika Talwar: Yeah, yeah. Great points. So, let's zoom out as we wrap up here. Outside of mindfulness and breathing, tell me your thoughts on what are just three simple things that you recommend that all urologists do to ensure a long, productive, and importantly, healthy career?

Phillip Pierorazio: That's a great question. And obviously this will be highly individualized, but I think the first thing that we often neglect is our physical health. And so, physical health is the foundation of being able to do any of these higher order thought processes. If you want to have a good clinic, if you want to build good relationships at work, if you want to start climbing a ladder, you need to take care of yourself first. That gives you the best foundation to be able to do that. So, that involves three key components. So, your physical health, and that is working out in a variety of settings. It should be a mix of cardiovascular and strength training. It has to do with a nutritious diet. So, we really need to watch what we eat. And the two keys I always give surgeons, to people in general, first of all, don't drink calories. Avoid liquid sugars. You can get sugars in other parts of your diet that's less bad, but avoid liquid sugars.

And we are going to be under stress. It's part of our job. It's what we do. One of the stress responses is to consume calories, and that's okay, but try to make them healthy calories instead of reaching for the Snickers bar or McDonald's when you're having a bad day or a bad night. Try to get something healthy in there and recognizing that you're going to want to eat more.

And lastly is sleep. And this took me a really long time, and I'm still working on this, but seven to nine hours of sleep opportunity a night will make tremendous impacts in the way your days and your weeks progress. So, physical health.

The second thing I would say is be very intentional with what you're doing on a regular basis. Don't just go through the motions. What is the goal of your operation today? What is the goal of the clinic today? What is the goal of you and I having this meeting? Set out the goals and be thoughtful of what you're doing. It helps clear some of the noise around you and helps you be focused and save some of that cognitive energy for other things.
And then, the last thing I would say is be grateful. We have amazing lives. We have incredible opportunities to shape people around us, our patients, our trainees, the people we interact with, in our offices, our colleagues. So, be grateful. And once a day, give yourself the opportunity to say thank you. You can say it to yourself, it can be done silently, you can say it out loud to somebody who really has earned it, or not earned it.

But those are the three things I would say. So, take care of your physical health, practice with intention, set goals, be clear on what you're doing, and practice gratitude. Let people know how grateful you are for what you're doing.

Ruchika Talwar: Awesome. Well, along those lines, thank you, Dr. Pierorazio. We are very grateful that you spent a few minutes with us today discussing this really important topic. I think it's one thing to start having these kinds of conversations and improve awareness, but I do still think there is a gap that we need to fill with actionable solutions. And I'm really excited that our UroToday community has an opportunity to hear your thoughts on how to make sure we live long, fulfilled, both professional and personal lives. So, we appreciate your time.

Phillip Pierorazio: Thank you, Ruchi. And I'll just, quick plug, people like Ruchi and I are working on the institutional plans, but we also work on individual plans. So, if anybody wants to work on an individual plan or is struggling, just reach out. Always happy to talk to people. You can reach out to me through social media or email. I'm kind of an open book, so happy to chat with you.

Ruchika Talwar: Awesome. And I can say from personal experience that Dr. Pierorazio absolutely is available. I have tapped him for advice many a time, and we really appreciate that offer. To our UroToday audience, thank you again for joining us. I learned a lot from this, and I hope you did too. We'll see you next time.