Abstract
According to the International Classification of Diseases version 11 (ICD-11), burnout is now a well-established syndrome in the occupational context and is characterized by three key aspects: (1) mental fatigue (feelings of energy depletion or exhaustion), (2) depersonalization (work-related cynicism), and (3) impaired job performance. 1
Physician burnout is on the rise and is a well-documented reason for adverse emotional and physical effects in health care providers with potentially harmful consequences for patient safety and good performance of health care systems. 2
First and foremost, medicine is considered a unique profession in countless aspects. Physicians need to have complex scientific knowledge combined with a humanistic view. However, profitable “health care” systems have adopted analysis metrics that can sometimes be counterproductive. The influence of mixing private practice and public health care with a daily overload of tasks in electronic databases has reduced the flexibility of the doctor–patient relationship and taken up doctors' time, eventually generating stress. 3 The status quo, in which productivity revenue model pays more for an intervention than for an empathetic and compassionate consultation and follow-up, has brought conflicting feelings to professionals. Consequently, medical consults have become shorter and vital human connections have been depleted, thus acting as a silent productivity killer leading to a reduction in doctors' working capacities.
Except for Europe and the Western Pacific, new confirmed cases of SARS-Cov-2 (COVID-19) continue to grow, leading to terrible consequences and close to 300,000 confirmed deaths. 3
Amidst the COVID-19 pandemic, physicians' psychosocial well-being and physical resilience are jeopardized, especially for those in “the line of duty.” Reports already indicate health care workers are experiencing unprecedented levels of excessive anxiety, fears of pathogen exposure, and lack of personal protective equipment, fatigue, long working hours, insufficient sleep, and day/night/rotating shift work. During these unprecedented times, doctors are even at higher risk for “classic” burnout. 4
In urology, the reallocation of resources and the prioritization of care for COVID patients brings uncertainties regarding delayed diagnosis and surgery postponements. 5 When endourology is concerned, preventable cases of obstructive pyelonephritis and urosepsis as well as risks of renal function deterioration may occur. As for cancer care, underdiagnosis and inadequate treatment of malignant conditions may lead to worse outcomes. 6 These clinical worries psychologically affect the urologist in charge of the case and all other health care providers.
Added to this more-than-expected effect, doctors now face unusual and unprecedented situations. It is part of the doctor's day-to-day job to clarify health doubts. However, at present, conflicting messages are coming from all kinds of sources. Intoxicating fake news on social media, media disinformation, and nonpeer-reviewed articles are released at record speed to the lay public. Misleading simulations, personal opinions, and unrestricted defense of nonevidence-based treatments by nonhealth authorities and governments are used as political gambling to provide a false sense of hope and cause additional detrimental effects on health care providers.
Orders of stay-at-home by public health experts and policy makers have apparently flattened the curve and allowed health care capacity not to be exhausted. Social distancing and quarantine led to a “new normal” era and are themselves risk factors for mental distress. 7
Some doctors, who had their main activities canceled, are working remotely. This type of health care is not working for many. Fears are likely intensified when changes in personal and professional lives suddenly occur. Although some colleagues have a higher adaptative capacity, our assumption is that others are working at home for the first time and are struggling.
Social distancing guidelines prohibit gatherings, and medical societies have canceled conferences and rethought and modified their continuous education strategy. Many international initiatives are considering intensifying and expanding their medical education strategies through virtual meetings, webinars, and podcasts. The health care industry is amplifying these efforts. Coronavirus might have played a critical role in everyday life and has accelerated the implementation of digital interactions through social media, lives, webinars, podcasts, and virtual meetings. This huge amount of virtual commitment is the new reality, and this virtual overload we suggest should be termed “digital burnout.”
At first glance, working from home may look great. Not having to endure morning traffic or the tube at rush hour plus the unrealistic idea of working and wearing pajamas or shorts is initially appealing. However, life at home is actually different from this initial idea. We were used to our mobile devices that kept providing endless work messages, but now indisputably, everything is online. For a new homeworker, the new routine makes it difficult to clearly divide workplace and home. Physicians are having a hard time controlling their virtual agenda and are struggling to participate in the extensive offer of online classes, courses, and board and committee meetings. Indeed, it is not surprising that several physicians feel that they are not being productive enough.
Suddenly, and without proper training, caregivers have to learn how to be polite while in virtual meetings and deal with fears related to their privacy, to abuses by “zoom-bombing” trolls, and ways to incorporate security tips. People's homes were not prepared to embrace this kind of technology. A myriad of variables results in distractions and anxiety. Some concerns are the difficulty of focusing on virtual meetings, worrying about lighting, ways to look ok on camera, proper eye height, how to dress, battling with bad Wi-Fi zones, and isolating oneself in confined inadequate spaces.
Also, remote care through telemedicine has become a new reality. In many countries it was regulated and temporarily authorized in an expedited manner. Before COVID-19, telemedicine was not practiced by the vast majority of physicians and it was restricted to specific projects. In a short period of time, urologists had to get trained and started experiencing video consultations. 8 Video consultations reimbursement is an uncertainty and may also have an effect on burnout. Because telemedicine has only recently been introduced, billing regulations are not well established yet.
The logistics of a video visit or telephone encounter can be significantly different from an in-person appointment, which subsequently affects the duration of patient encounters and the total number of patients that can be treated in a day. Given the drastic reduction in overall clinical volume and the different levels of reimbursement for these virtual visits, a significant income cutback was noted. 9 In addition, the pressure from hospital administration to maintain a certain level of productivity can also contribute to physician burnout.
In response to the pandemics, academic centers had to be digitally transformed. Entire university communities all over the world are rapidly transitioning to remote learning and some of them are doing it for the first time. Adapting from face-to-face to distance learning is more than replicating the same tools and methods that educators were comfortable within presential classes. Considering physicians involved in medical training and their welfare, faculty members face genuine challenging circumstances trying to integrate synchronous and asynchronous instructional opportunities. The well-being of a considerable portion of teachers and students can be compromised by the lack of technology infrastructure of their institutions and by the resistance to use unfamiliar and complex virtual teaching tools.
The normal clear line between job and home is now blurred. In the recent past, being more present in childcare was a recommended intervention for relieving psychologic and physical problems. However, nowadays, working in the home environment brings work–family conflicts, and parent physicians are facing new challenges on integrating childcare, leisure time, schoolwork, and their professional lives. COVID-19 has made concurrent multitasking a necessity for many. Parental control of screen time has been rethought in these times of school closures. The overload of a virtual work-related agenda causes stress and risks of burnout and also has negative impacts on childcare and family relationships.
We believe that special attention must be taken toward recognition and management of anxiety and the sensation of underachievement caused by the extensive number of digital meetings and scientific events that are currently offered and penetrate the personal lives of health care workers, thus leading to new mental health issues.
Mitigation burnout campaigns provide a road map of solutions to create a healthy workplace. Designed to be delivered as part of an integrated health and wellness strategy that deals with prevention, early diagnosis, and interdisciplinary connections that focus on supporting physicians and health care workers for improving their quality of life, these interventions to protect mental health must now consider this new digital perspective in future research.
In their core, current best practices of controlled interventions to reduce burnout are based in low to moderate levels of evidence. 10 First, awareness of early signs and symptoms of burnout and behavioral changes is important. Efforts that could promote desirable outcomes and boost doctor morale, such as rest breaks, set starting and finishing times, and intensifying social support and respect for health care workers and their families, should be adopted.
Second, to get different tasks done, trying to focus on a to-do list, limiting distractions that waste time, prioritizing what is important in the beginning of the day, and having realistic expectations about productivity should be attempted. In addition, acceptance can help minds cope with the disturbing times in which we live and strategies to create an environment for an ideal work-from-home place interlinking opportunities for exercise and recreation, eating healthier meals, reviving positive social interaction with video chats, pursuing hobbies to de-stress, and creating occasions may bring happiness and a much-needed feeling of reward until calmer times.