The prevalence of impostor phenomenon and its association with burnout amongst urologists.

OBJECTIVES: To characterise the prevalence of impostor phenomenon (IP; tendency for high-achieving individuals to perceive themselves as fraudulent in their successes) amongst attending staff in urology, to identify variables that predict more severe impostorism, and to study the association of IP with burnout. SUBJECTS AND METHODS: A survey composed of the Clance Impostor Phenomenon Scale (CIPS), demographic information, practice details, and burnout levels was e-mailed to urologists via urological subspecialty societies. Survey results were analysed to identify associations between IP severity, survey respondent characteristics, and symptoms of professional burnout. This study was conducted in the United States of America. RESULTS: A total of 614 survey responses were received (response rate 11.0%). In all, 40% (n = 213) of responders reported CIPS scores qualifying as either 'frequent' or 'intense' impostorism (i.e., scores of 61-100). On multivariable analysis, female gender, fewer years in practice (i.e., 0-2 years), and lower academic rank were all independently associated with higher CIPS scores (adjusted P < 0.05). Regarding burnout, 46% of responders reported burnout symptoms. On multivariable analysis, increase in CIPS score was independently associated with higher odds of burnout (odds ratio 1.06, 95% confidence interval 1.04-1.07; P < 0.001). CONCLUSION: Impostor phenomenon is prevalent in the urological community and is experienced more severely in younger and female urologists. IP is also independently associated with burnout. Increased female representation may improve IP amongst our female colleagues. More work is needed to determine strategies that are effective in mitigating feelings of IP and professional burnout amongst urologists, particularly those earlier in their careers.

Practice Patterns of Korean Urologists Regarding Positive Surgical Margins after Radical Prostatectomy: a Survey and Narrative Review.

BACKGROUND: There is no clear consensus on the optimal treatment with curative intent for patients with positive surgical margins (PSMs) following radical prostatectomy (RP). The aim of this study was to investigate the perceptions and treatment patterns of Korean urologists regarding the resection margin after RP. METHODS: A preliminary questionnaire was prepared by analyzing various studies on resection margins after RP. Eight experienced urologists finalized the 10-item questionnaire. In July 2019, the final questionnaire was delivered via e-mail to 105 urologists in Korea who specialize in urinary cancers. RESULTS: We received replies from 91 of the 105 urologists (86.7%) in our sample population. Among them, 41 respondents (45.1%) had performed more than 300 RPs and 22 (24.2%) had completed 500 or more RPs. In the question about whether they usually performed an additional biopsy beyond the main specimen, to get information about surgical margin invasion during surgery, the main opinion was that if no residual cancer was suspected, it was not performed (74.7%). For PSMs, the Gleason score of the positive site (49.5%) was judged to be a more important prognostic factor than the margin location (18.7%), multifocality (14.3%), or margin length (17.6%). In cases with PSMs after surgery, the prevailing opinion on follow-up was to measure and monitor prostate-specific antigen (PSA) levels rather than to begin immediate treatment (68.1%). Many respondents said that they considered postoperative radiologic examinations when PSA was elevated (72.2%), rather than regularly (24.4%). When patients had PSMs without extracapsular extension (pT2R1) or a negative surgical margin with extracapsular extension (pT3aR0), the response 'does not make a difference in treatment policy' prevailed at 65.9%. Even in patients at high risk of PSMs on preoperative radiologic screening, 84.6% of the respondents said that they did not perform neoadjuvant androgen deprivation therapy. Most respondents (75.8%) indicated that they avoided nerve-sparing RP in cases with a high risk of PSMs, but 25.7% said that they had tried nerve-sparing surgery. Additional analyses showed that urologists who had performed 300 or more prostatectomies tended to attempt more nerve-sparing procedures in patients with a high risk of PSMs than less experienced surgeons (36.6% vs. 14.0%; P = 0.012). CONCLUSION: The most common response was to monitor PSA levels without recommending any additional treatment when PSMs were found after RP. Through this questionnaire, we found that the perceptions and treatment patterns of Korean urologists differed considerably according to RP resection margin status. Refined research and standard practice guidelines are needed.

Toward a Platform for Structured Data Acquisition in Oncology: A Pilot Study on Prostate Cancer Screening.

INTRODUCTION: Physicians spend an ever-rising amount of time to collect relevant information from highly variable medical reports and integrate them into the patient's health condition. OBJECTIVES: We compared synoptic reporting based on data elements to narrative reporting in order to evaluate its capabilities to collect and integrate clinical information. METHODS: We developed a novel system to align medical reporting to data integration requirements and tested it in prostate cancer screening. We compared expenditure of time, data quality, and user satisfaction for data acquisition, integration, and evaluation. RESULTS: In a total of 26 sessions, 2 urologists, 2 radiologists, and 2 pathologists conducted the diagnostic work-up for prostate cancer screening with both narrative reporting and the novel system. The novel system led to a significantly reduced time for collection and integration of patient information (91%, p < 0.001), reporting in radiology (44%, p < 0.001) and pathology (33%, p = 0.154). The system usage showed a high positive effect on evaluated data quality parameters completeness, format, understandability, as well as user satisfaction. CONCLUSION: This study provides evidence that synoptic reporting based on data elements is effectively reducing time for collection and integration of patient information. Further research is needed to assess the system's impact for different patient journeys.

Listening to Music during Outpatient Cystoscopy Reduces Pain and Anxiety and Increases Satisfaction: Results from a Prospective Randomized Study.

BACKGROUND: This study investigates the effect of classical music, music of patients' own choice, or no music on pain reduction during elective cystoscopy. OBJECTIVES: The aim of the study was to describe the effect of listening to classical music, music of patients' own choice, or no music on patient's pain and satisfaction rates when carrying out an elective cystoscopy and the effect on the assessment capability of the performing urologist. DESIGN, SETTING, AND PARTICIPANTS: This randomized trial included 127 patients undergoing elective cystoscopy at the Urological Department of the University Clinic of Munich between June 2019 and March 2020. Outcome Measurements and Statistical Analysis: Patients were assigned randomly to 3 groups: group I: listening to standardized classical music (n = 35), group II: listening to music according to the patients' choice (n = 34), and control group III: no music (n = 44). Prior to cystoscopy, anxiety levels were assessed by the Beck Anxiety Inventory (BAI). The Visual Analog Scale (VAS, range 1-100) was used for a self-assessment of pain, discomfort, and satisfaction. Statistical analysis was done with Spearman's rank correlation and t-tests. RESULTS AND LIMITATIONS: The median age was 63 (range 27-91) years. The duration of cystoscopy was 5.7 (1-30) min. Patients had undergone a median of 2.3 cystoscopies in the past. Between giving informed consent and cystoscopy, patients had to wait for a median of 64 (0-260) min. The median VAS pain score was significantly lower in group I at 1.7 and group II at 2.3 versus 5.2 in the control group III (p < 0.001). The control group III had significantly worse pain and patient satisfaction rates compared with groups I and II. Group I had a significant lower VAS pain score than groups II and III (p < 0.001). Classical music also increased the assessment capability of the preforming urologist. CONCLUSIONS: Listening to music during elective cystoscopy significantly reduces pain and distress and leads to higher patient and surgeon satisfaction. We recommend listening to classical music or music chosen by the patients during outpatient flexible/rigid cystoscopy in daily clinical routine. Patient Summary: In this study, we found that patients who listened to classical music or music of their own choice while undergoing a cystoscopy showed significant reduction of pain and distress.

The increasing use of renal tumor biopsy amongst Canadian urologists: When is biopsy most utilized?

INTRODUCTION: The role of renal tumor biopsy (RTB) in the management of small renal masses (SRMs) is progressively being recognized as a tool to decrease overtreatment. While an increasing number of studies assessing its role in diagnostics are becoming available, RTB remains variably used amongst urologists. Many patient-, tumor-, and institution-related factors may influence urologists on whether to perform a RTB to help guide management. OBJECTIVE: We aimed at identifying factors associated with the use of RTB for localized SRMs within a number of centers contributing data to the Canadian Kidney Cancer information system. MATERIAL AND METHODS: We identified 3,838 patients diagnosed with a localized SRM (≤4 cm) between January 2011 and December 2018. Patients were stratified based on whether a RTB was performed prior to the primary therapeutic intervention. Factors associated with use of RTB were assessed using univariable and multivariable logistic regression models. RESULTS: A total of 993 patients (25.9%) underwent an RTB. There was an overall increase in RTB use over time (P < 0.001), with patients diagnosed between 2015 and 2018 undergoing more RTB than patients diagnosed between 2011 and 2014 (29.8% vs. 22.2%, respectively; P < 0.001). Patients managed in centers with the highest patient-volume had RTB more frequently than patients managed in low-volume centers. On multivariable analysis, increasing year of diagnosis was significantly associated with more RTB use. Patients treated with surgery underwent RTB statistically less often than patients undergoing thermal ablation (P < 0.001) or managed with active surveillance (P < 0.001). Larger SRMs were associated with more RTB use in patients on active surveillance (P = 0.009), but with less RTB in patients undergoing surgery (P = 0.045). CONCLUSION: This large multicenter cohort study reveals an increasing adoption and overall use of RTB amongst Canadian urologists. Patients managed in high-volume centers and those undergoing non-surgical management were associated with greater use of RTB. Tumor size was also associated with RTB use. This study highlights the influence that physician perceptions and clinical factors may have in the decision to use RTB prior to initiating a therapeutic approach.

An Updated Review on Physician Burnout in Urology.

Physician burnout is an issue having an impact on all of medicine but having a significant impact on the field of urology. Burnout begins in medical school and worsens in residency. Increased workload leads to increased burnout both in residency and in practice. Issues with work-life balance, electronic medical record usage, decreasing reimbursements, and increased Centers for Medicare & Medicaid Services burden all have an impact on physician satisfaction with their practices. Burnout should be acknowledged, and measures for prevention should be taken by hospitals and residency programs to decrease and prevent physician burnout.

Assessment of sexual life in spina bifida patients: A survey among pediatric urologists.

OBJECTIVE: To assess the status of the sexual education approach with spina bifida (SB) patients. MATERIALS AND METHODS: An online survey was sent to 223 pediatric urologists from Latin countries, all contacted using email or mobile messaging software. There were 12 questions about participants' demographic characteristics and SB-specific care topics. Data was collected from January 2019 to January 2020. Checklist for reporting results of internet e-survey (CHERRIES) guidelines were followed to ensure the quality of this study. RESULTS: We received 101 valid answers from participants practicing in seven different countries. Among these, 98.4% confirmed that sexuality in the SB population is considered relevant, nevertheless it is only evaluated by 62.5%. Transitional urologists discuss sexuality more often than those whose practice consists solely of pediatric patients (70% vs. 50%). Basic surgeon training (urologist vs. pediatric surgeon), age, part or full-time pediatric urology practice and country of participants were of no statistically different influence inrates of approach to sexuality. CONCLUSION: Our study demonstrates that pediatric urologists are insufficiently addressing sexuality in SB patients. Those who practise transitional urology show higher rates of approach to sexuality with SB patients, which suggests this is an important model of care.

Large reduction in opioid prescribing by a multipronged behavioral intervention after major urologic surgery.

BACKGROUND: Surgeons play a pivotal role in combating the opioid crisis that currently grips the United States. Changing surgeon behavior is difficult, and the degree to which behavioral science can steer surgeons toward decreased opioid prescribing is unclear. METHODS: This was a single-institution, single-arm, pre- and postintervention study examining the prescribing of opioids by urologists for adult patients undergoing prostatectomy or nephrectomy. The primary outcome was the quantity of opioids prescribed in oral morphine equivalents (OMEs) after hospital discharge. The primary exposure was a multipronged behavioral intervention designed to decrease opioid prescribing. The intervention had 3 components: 1) formal education, 2) individual audit feedback, and 3) peer comparison performance feedback. There were 3 phases to the study: a pre-intervention phase, an intervention phase, and a washout phase. RESULTS: Three hundred eighty-two patients underwent prostatectomy, and 306 patients underwent nephrectomy. The median OMEs decreased from 195 to 19 in the prostatectomy patients and from 200 to 0 in the nephrectomy patients (P < .05 for both). The median OMEs prescribed did not increase during the washout phase. Prostatectomy patients discharged with opioids had higher levels of anxiety than patients discharged without opioids (P < .05). Otherwise, prostatectomy and nephrectomy patients discharged with and without opioids did not differ in their perception of postoperative pain management, activity levels, psychiatric symptoms, or somatic symptoms (P > .05 for all). CONCLUSIONS: Implementing a multipronged behavioral intervention significantly reduced opioid prescribing for patients undergoing prostatectomy or nephrectomy without compromising patient-reported outcomes.

Gender-based Differences in Career Plans, Salary Expectations, and Business Preparedness Among Urology Residents.

OBJECTIVE: To characterize gender-related differences between the values and salary expectations of US urology residents. METHODS: We analyzed 2016-2018 American Urological Association Census data regarding residents' demographics, motivations, and concerns. To explore gendered differences, we queried Census items related to demographics, values, and preparedness for the business of practice. Descriptive statistics and test of hypotheses were used for analysis. RESULTS: A total of 705 residents responded of whom 196 (28%) were female. More than half of residents (54%) reported educational debt >$150,000. Factors influencing choice of practice setting included lifestyle (87%), compensation (82%), and location (78%) and was not significantly different between males and females. There were also no differences regarding planned practice setting. However, women had significantly lower first year salary expectations; 53% expected to make <$300,000, compared with only 32% of men (P <.001). Finally, significantly more women reported feeling unprepared to handle the business of urology practice, including salary negotiation, (74% vs 53%, P <.001). CONCLUSION: Among a nationally representative sample of urology residents, women had significantly lower salary expectations and expressed significantly more discomfort with the business aspects of medicine, including contract negotiation, than their male counterparts. These observational findings may contribute to and potentially perpetuate the urology wage gap.

Impact of COVID-19 on clinical practice, income, health and lifestyle behavior of Brazilian urologists

ABSTRACT Objectives To evaluate the impact of COVID-19 on clinical practice, income, health and lifestyle behavior of Brazilian urologists during the month of April 2020. Materials and Methods A 39-question, web-based survey was sent to all urologist members of the Brazilian Society of Urology. We assessed socio-demographic, professional, health and behavior parameters. The primary goal was to evaluate changes in urologists' clinical practice and income after two months of COVID-19. We also looked at geographical differences based on the incidence rates of COVID-19 in different states. Results Among 766 urologists who completed the survey, a reduction ≥ 50% of patient visits, elective and emergency surgeries was reported by 83.2%, 89.6% and 54.8%, respectively. An income reduction of ≥ 50% was reported by 54.3%. Measures to reduce costs were implemented by most. Video consultations were performed by 38.7%. Modifications in health and lifestyle included weight gain (32.9%), reduced physical activity (60.0%), increased alcoholic intake (39.9%) and reduced sexual activity (34.9%). Finally, 13.5% of Brazilian urologists were infected with SARS-CoV-2 and about one third required hospitalization. Urologists from the highest COVID-19 incidence states were at a higher risk to have a reduction of patient visits and non-essential surgeries (OR=2.95, 95% CI 1.86 - 4.75; p< 0.0001) and of being infected with SARS-CoV-2 (OR=4.36 95%CI 1.74-10.54, p=0.012). Conclusions COVID-19 produced massive disturbances in Brazilian urologists' practice, with major reductions in patient visits and surgical procedures. Distressing consequences were also observed on physicians' income, health and personal lives. These findings are probably applicable to other medical specialties.

To defer or not to defer? A German longitudinal multicentric assessment of clinical practice in urology during the COVID-19 pandemic.

INTRODUCTION: After the outbreak of COVID-19 unprecedented changes in the healthcare systems worldwide were necessary resulting in a reduction of urological capacities with postponements of consultations and surgeries. MATERIAL AND METHODS: An email was sent to 66 urological hospitals with focus on robotic surgery (RS) including a link to a questionnaire (e.g. bed/staff capacity, surgical caseload, protection measures during RS) that covered three time points: a representative baseline week prior to COVID-19, the week of March 16th-22nd and April 20th-26th 2020. The results were evaluated using descriptive analyses. RESULTS: 27 out of 66 questionnaires were analyzed (response rate: 41%). We found a decrease of 11% in hospital beds and 25% in OR capacity with equal reductions for endourological, open and robotic procedures. Primary surgical treatment of urolithiasis and benign prostate syndrome (BPS) but also of testicular and penile cancer dropped by at least 50% while the decrease of surgeries for prostate, renal and urothelial cancer (TUR-B and cystectomies) ranged from 15 to 37%. The use of personal protection equipment (PPE), screening of staff and patients and protection during RS was unevenly distributed in the different centers-however, the number of COVID-19 patients and urologists did not reach double digits. CONCLUSION: The German urological landscape has changed since the outbreak of COVID-19 with a significant shift of high priority surgeries but also continuation of elective surgical treatments. While screening and staff protection is employed heterogeneously, the number of infected German urologists stays low.

Comparison of Urologist Satisfaction for Different Types of Prostate MRI Reports: A Large Sample Investigation.

OBJECTIVE: To evaluate urologist satisfaction on structured prostate MRI reports, including report with tumor-node-metastasis (TNM) staging (report B) and with Prostate Imaging Reporting and Data System (PI-RADS) score with/without TNM staging (report C, report with PI-RADS score only [report C-a] and report with PI-RADS score and TNM staging [C-b]) compared with conventional free-text report (report A). MATERIALS AND METHODS: This was a prospective comparative study. Altogether, 3015 prostate MRI reports including reports A, B, C-a, and C-b were rated by 13 urologists using a 5-point Likert Scale. A questionnaire was used to assess urologist satisfaction based on the following parameters: correctness, practicality, and urologist subjectivity. Kruskal-Wallis H-test followed by Nemenyi test was used to compare urologists' satisfaction parameters for each report type. The rate of urologist-radiologist recalls for each report type was calculated. RESULTS: Reports B and C including its subtypes had higher ratings of satisfaction than report A for overall satisfaction degree, and parameters of correctness, practicality, and subjectivity (p < 0.05). There was a significant difference between report B and C (p < 0.05) in practicality score, but no statistical difference was found in overall satisfaction degree, and correctness and subjectivity scores (p > 0.05). Compared with report C-b (p > 0.05), report B and C-a (p < 0.05) showed a significant difference in overall satisfaction degree and parameters of practicality and subjectivity. In terms of correctness score, neither report C-a nor C-b had a significant difference with report B (p > 0.05). No statistical difference was found between report C-a and C-b in overall satisfaction degree and all three parameters (p > 0.05). The rate of urologist-radiologist recalls for reports A, B, C-a and C-b were 29.1%, 10.8%, 18.1% and 11.2%, respectively. CONCLUSION: Structured reports, either using TNM or PI-RADS are highly preferred over conventional free-text reports and lead to fewer report-related post-hoc inquiries from urologists.

A survey and panel discussion of the effects of the COVID-19 pandemic on paediatric urological productivity, guideline adherence and provider stress.

INTRODUCTION: The COVID-19 pandemic has led to an unprecedented need to re-organise and re-align priorities for all surgical specialties. Despite the current declining numbers globally, the direct effects of the pandemic on institutional practices and on personal stress and coping mechanisms remains unknown. The aims of this study were to assess the effect of the pandemic on daily scheduling and work balances, its effects on stress, and to determine compliance with guidelines and to assess whether quarantining has led to other areas of increased productivity. METHODS: A trans-Atlantic convenience sample of paediatric urologists was created in which panellists (Zoom) discussed the direct effects of the COVID-19 pandemic on individual units, as well as creating a questionnaire using a mini-Delphi method to provide current semi-quantitative data regarding practice, and adherence levels to recently published risk stratification guidelines. They also filled out a Perceived Stress Scale (PSS) questionnaire to assess contemporary pandemic stress levels. RESULTS: There was an 86% response rate from paediatric urologists. The majority of respondents reported near complete disruption to planned operations (70%), and trainee education (70%). They were also worried about the effects of altered home-lives on productivity (≤90%), as well as a lack of personal protective equipment (57%). The baseline stress rate was measured at a very high level (PSS) during the pandemic. Adherence to recent operative guidelines for urgent cases was 100%. CONCLUSION: This study represents a panel discussion of a number of practical implications for paediatric urologists, and is one of the few papers to assess more pragmatic effects and combines opinions from both sides of the Atlantic. The impact of the pandemic has been very significant for paediatric urologists and includes a decrease in the number of patients seen and operated on, decreased salary, increased self-reported stress levels, substantially increased telemedicine usage, increased free time for various activities, and good compliance with guidelines and hospital management decisions.

Emergency Surgery in Urology during the COVID-19 Pandemic.

Proposal: To highlight the indications for emergency surgery during the 2019 Coronavirus pandemic (COVID-19) that support recommendations published in mid-March 2020 by the American Confederation of Urology on its website. MATERIALS AND METHODS: A bibliographic search was conducted in PubMed and Cochrane Library to perform a non-systematic review, using key words: Urology, Emergency and COVID-19, to determine recommendations for patients that should receive emergency care due to urological pathology. RESULTS: The main recommendations and protocols in the management of different urological emergencies during the COVID-19 pandemic are reviewed and discussed. CONCLUSIONS: We are living a new condition with the COVID-19 pandemic, which obliges urologists to conform to the guidelines that appear on a daily basis formulated by multidisciplinary surgical groups to manage urological emergencies. Consequently, in this time of health crisis, we must adapt to the resources available, implementing all biosecurity measures to protect patients and all health personnel who are in charge of patient management.

COVID-19: Measures to prevent hospital contagion. what do urologists need to know?

ABSTRACT A new outbreak of respiratory infection caused by the novel coronavirus in late December 2019 in China caused standards of medical care to change not only for related areas but for the entire healthcare system, and when the WHO declared COVID-19 a pandemic new strategies of patient care had to be defined initially to optimize resources to confront the pandemic and then to protect healthcare personnel. As urologists, we must be involved in these new standards, since without an effective vaccine the risk of contagion is high; thus, the purpose of this review is to have orientation on the measures urologists should take in their everyday clinical practice.