Prevalence and Predictors of Burnout in Urology Professionals in Pakistan

Abstract

Background/Objectives: This study aims to assess the prevalence and predictors of burnout among urology professionals in Pakistan using a validated tool and to explore underlying causes through qualitative input. Methods: A cross-sectional survey was conducted among urology trainees, fellows, and consultants across Pakistan. Burnout was measured using the Maslach Burnout Inventory–Human Services Survey (MBI-HSS). Burnout was defined using a criterion of high emotional exhaustion or high depersonalization. Descriptive statistics and chi-square tests were used to assess associations. Thematic analysis was applied to open-ended responses. Results: A total of 183 responses were received. When using the high emotional exhaustion (EE) or depersonalization (DP) criterion, 62% was classified as experiencing burnout. Significant predictors included excessive working hours (more than 80 h per week), frequent night calls, avoidance-based coping, workplace favouritism, and discrimination. No association was found with gender, age, or designation. Thematic responses highlighted five common causes of burnout. Conclusions: Burnout is prevalent among urology professionals in Pakistan and is largely driven by modifiable factors. Interventions must target institutional support, work–life balance, and healthier coping mechanisms.

1. Introduction

Burnout, defined as a state of emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment, is a well-established consequence of chronic occupational stress among healthcare professionals [1]. Its implications are relevant to physician well-being, clinical decision making, patient safety, and the core sustainability of healthcare systems [2,3]. Physician trainees, particularly those in high-intensity specialities, are at elevated risk due to long working hours, frequent night shifts, emotional demands, and limited recovery time [1,4].

In Pakistan, healthcare providers commonly report excessive workloads, often exceeding 70–90 h per week, with frequent on-call duties, minimal rest days, and limited access to institutional support systems [4,5]. These conditions contribute significantly to professional stress and make physicians vulnerable to burnout.

Several cross-sectional studies have investigated burnout among resident physicians in Pakistan. One multicenter study reported that approximately 32% of postgraduate residents exhibited high burnout levels, with excessive workload (odds ratio [OR] 1.92) and poor supervisory support identified as key contributing factors [6]. Another study from a tertiary care hospital in Peshawar found that over 95% of physicians demonstrated either high depersonalization or low personal accomplishment, with emotional exhaustion prevalent in 34% [7]. Similar findings have been reported among emergency physicians and military doctors, with burnout rates ranging from 27% to over 60%, often associated with working more than 40 h per week [8,9].

As is true for most other specialities, there is a lack of published data on burnout among urology trainees in Pakistan. Urology as a speciality presents unique challenges, including surgical workload, night on-call hours, career progression and ever-changing new technologies. These factors may compound the risk of burnout, yet this subgroup remains understudied.

This study aimed to assess the prevalence of burnout among urology trainees and consultant urologists in Pakistan, identify factors associated with burnout, and explore participant perspectives on its underlying causes and potential solutions. These findings may inform targeted interventions to improve trainee well-being and promote sustainability within the urology workforce.

2. Materials and Methods

This was a prospective, cross-sectional study conducted in May 2025. An anonymous online questionnaire was disseminated via WhatsApp groups and email lists targeting urology professionals in Pakistan, including residents, fellows/registrars (completed urology training, pending exam outcomes), and consultants. Urologists not currently in clinical practice or residing outside Pakistan were excluded. The study aimed to include all eligible respondents during the study period to provide an overview of burnout prevalence and associated factors; a formal sample size was not calculated.

Approximately 500 professionals were invited through a convenience sampling approach using urology networks. However, an exact denominator could not be determined due to the open distribution method. A total of 187 responses were received, and 183 of them consented to participate. All included questionnaires were complete, and no data variables were missing. The survey consisted of three sections. The first section collected demographic and work-related data, including age, gender, marital status, designation (trainee vs. consultant), province, training pathway (Fellow of the College of Physicians and Surgeons/Master of Surgery in Urology), institution type (public/private), working hours per week, and night on-call frequency. The second section assessed Burnout using the Maslach Burnout Inventory – Human Services Survey (MBI-HSS), a validated tool for healthcare professionals. The questionnaire was developed by Mind Garden, Inc. (Menlo Park, CA, USA) and includes three domains: Emotional Exhaustion (EE), Depersonalization (DP), and Personal Accomplishment (PA). [1]. The third section focused on available mental health support and coping mechanisms. This also included open-ended questions asking for perceived causes of burnout and recommended solutions by participants.

Data were collected via Microsoft Forms and stored anonymously. Informed consent was obtained electronically from all participants before survey access. This study involved anonymous, voluntary survey responses from healthcare professionals. No patient data, clinical interventions, or identifiable personal information were collected. Therefore, no formal ethical review was required.

Survey data were exported from Microsoft Forms and cleaned in Microsoft Excel. Subsequent statistical analysis was performed using R statistical software (version 4.3.1; R Foundation for Statistical Computing, Vienna, Austria). Participants with a high EE score (score ≥ 27) or a high DP score (score ≥ 13) were classified as having burnout. Categorical variables were compared using Chi-square or Fisher’s exact tests, with significance set at p < 0.05. Qualitative data were analysed using an inductive thematic approach. Themes were identified based on repeated appearance across responses and their conceptual relevance to burnout and workplace experience, rather than a predefined numerical threshold. Only themes that emerged consistently across multiple responses and were deemed conceptually meaningful were included in the final analysis.

3. Results

A total of 183 urology professionals consented to participate in the survey. The demographic characteristics are given in Table 1.

Table 1. Demographic characteristics.

Age (mean)		33.4 years (SD 5.4)
Gender	Male	151 (82.5%)
	Female	28 (15.3%)
	Prefer not to say	04 (2.2%)
Marital status	Married	136 (74.3%)
	Unmarried	47 (25.6%)
Trainee status	Trainee	109 (59.6%)
	Consultant	74 (40.4%)
Hospital status	Public sector	137 (74.9%)
	Private sector	46 (25.1%)
Province	Sindh	94 (51.4%)
	Punjab	47 (25.7%)
	Khyperpakhtunkhuwah	13 (7.1%)
	Balochistan	17 (9.3%)
	Others (GB *, FATA **)	12 (6.6%)

* Gilgit-Baltistan; ** federally administered tribal areas. SD: standard deviation.

The overall burnout levels and individual domain scores are shown in Table 2. Burnout levels were not significantly associated with gender (p = 0.06), age group (p = 0.91), marital status (p = 0.62), designation (trainee vs. consultant) (p = 0.97), training pathway (Fellow of the College of Physicians and Surgeons [FCPS] vs. Master of Surgery [MS]; p = 0.56), type of institution (public vs. private; p = 1.0) and whether the respondent worked in native city (p = 0.56).

Table 2. Burnout classification according to MBI criteria.

Burnout	High EE or High DP	62% (114)
Emotional exhaustion	High ≥ 27	60% (106)
	Moderate 17–26	25% (46)
	Low ≤ 16	17% (31)
Depersonalisation	High ≥ 13	31% (55)
	Moderate 7–12	28% (52)
	Low ≤ 6	41% (76)
Personal accomplishment	Low ≤ 31	52% (96)
	Moderate 32–38	31% (57)
	High ≥ 39	16% (30)

MBI: Maslach Burnout Inventory; EE: emotional exhaustion; DP: depersonalization.

Though not statistically significant, there was a trend toward higher burnout in female respondents compared to males (21% vs. 13%, p = 0.06). A statistically significant association was observed between province and burnout status (p = 0.026), with higher burnout reported among participants from Sindh.

Regarding workload, 72 participants (39.3%) reported working more than 80 h per week, and 38 (20.8%) had eight or more night calls per month. A substantial proportion, 102 (56.8%), reported feeling only “sometimes” or “rarely” supported in their current role. Table 3 describes work-related factors and their association with burnout. The results from thematic analysis of open-ended questions are shown in Table 4.

Table 3. Workplace-related factors and burnout.

Factors	Reported Frequency (n)	High Burnout (n = 27)	Moderate/Low Burnout (n = 156)	p Value
Excessive workload	131	26 (19.8%)	105 (80.1%)	0.004
Favouritism	110	21 (19.0%)	89 (81.0%)	0.011
Lack of support	98	21 (21.4%)	77 (78.5%)	0.011
Lack of recognition	88	21 (23.8%)	67 (76.1%)	0.001
Discrimination	68	16 (23.5%)	52 (76.4%)	0.018
Avoidance/Denial as a coping mechanism	52	14 (26.9%)	38 (73.0%)	0.007
Work hours/week > 80	69	17 (24.6%)	52 (75.3%)	0.017

Table 4. Thematic analysis of qualitative questions.

In your opinion, what are the main causes of burnout in urology professionals?
Themes	Common response words
Long working hours and excessive workload	Never-ending duty hours
	Too many patients
	No time to rest
Lack of support	Isolated
	Left to struggle
	Unsupported by seniors
Toxic work environment	Hostile culture
	Biased seniors
	Harassment
Administrative inefficiencies	Poor scheduling
	Unclear promotions
	Bureaucratic pressure
Emotional drain	Mentally drained
	Emotionally burnt
	On the edge every day
What changes would you recommend to reduce burnout in urology professionals?
Themes	Common response words
Limiting duty hours and enforcing a strict shift schedule	Structured work week
	Reduction in night duties
	Enforcement of labour hours caps
Fair treatment and a merit-based system	Eliminating favouritism
	Ensuring transparency in promotion
	Equal opportunities in training
Formal residency and leadership training programmes	Structured rotations
	Protracted teaching times
	Periodic review of workload
Improved work–life balance	Adequate leave
	Mental health days
	Institutional flexibility
	Active support for juniors

4. Discussion

This study highlights a substantial burden of burnout among urology professionals in Pakistan, which stands at 62% using the commonly reported criteria of high EE or high DP domains. Key contributors to burnout include excessive workload, long working hours (>80/week), maladaptive coping mechanisms such as avoidance, and workplace issues including favouritism and discrimination.

Notably, more than two-thirds of participants fell within the partial or moderate burnout category, defined by elevation in one or two Maslach Burnout Inventory (MBI) domains. Burnout is recognised as a continuum, and even intermediate levels have been associated with adverse psychological outcomes, reduced job satisfaction, and impaired professional functioning [10]. If unaddressed, such patterns may progress to more severe burnout states, underscoring the importance of early identification and preventive interventions targeting this group.

In the international context, the issue among urologists consistently exceeds that of many specialities. The 2016 American Urological Association (AUA) census reported that approximately 39% of practising urologists met burnout criteria based on the high EE and DP criteria [11]. Broader multispecialty surveys have found burnout rates in urologists as high as 54–63% [12]. In Canada, the 2018 Canadian Urological Association (CUA) census showed that nearly 40% of urologists scored high on EE or DP domains [13]. Data from a UK and Ireland study in 2016 found that 38% of the urologists were struggling with burnout [14].

Although comparable urology-specific data from Europe are limited, studies from high-income countries in general surgery and other procedural specialities consistently report burnout rates between 30% and 50% [15]. It is worth mentioning that in our cohort, using the two-domain criterion, the burnout prevalence jumps to 62%, which aligns closely with these international trends, though at the higher spectrum. In reality, burnout seems to be a common issue gripping the developed and developing healthcare systems beyond borders.

The open-ended responses reveal the emotional and structural strain faced by professionals. Participants commonly cited unsupportive leadership, lack of mentorship, and unclear career progression pathways as core issues. These qualitative findings reinforce the need for systemic reform.

Participants using avoidance or denial as coping strategies were significantly more likely to be burnt out (p = 0.007). This supports global evidence linking maladaptive coping to depersonalisation and low personal accomplishment [10], and highlights the need for resilience training with a focus on healthy coping techniques.

The role of institutional culture is underscored by the fact that support perception was a major predictor of burnout (p = 0.038). Evidence-based interventions at the institutional level, such as optimising staffing, formal mentorship programmes, wellness committees, and policy changes to limit duty hours, can change the landscape of well-being in urology professionals [3,16,17]. Leadership engagement is critical—programmes that promote transparent communication, recognise physician effort, and integrate clinician feedback into policy have been associated with improved morale and reduced burnout [18].

On an individual level, mindfulness, peer support, and resilience training have demonstrated modest benefits [19,20]. However, such strategies are not a substitute for structural change and should complement broader institutional initiatives.

This study has several limitations. The cross-sectional design precludes causal inference, and the use of convenience-based, self-reported data may have introduced selection and reporting bias. The sample size, while comparable to similar studies, may not have been sufficient to detect more subtle subgroup differences. Most respondents were from public-sector institutions and based in Sindh, which may limit generalisability to other regions or private-sector settings. Although marital status was recorded, detailed information regarding family structure or dependents was not assessed, which may influence stress perception and coping. The qualitative analysis was conducted by a single researcher; while a systematic inductive approach was used, the absence of independent coding may limit interpretative depth. Large language model-based tools were used only to assist with the organisation of themes and not for primary analysis. Finally, the relatively small proportion of female participants may have limited the ability to detect gender-based differences, and future studies with greater female representation are warranted.

5. Conclusions

Burnout among urology professionals in Pakistan is high and is driven by long work hours, poor institutional support, workplace toxicity, and maladaptive coping patterns. Efforts to address burnout must extend beyond individual-level resilience. Institutional and national training programmes should enhance visibility and accessibility of mental health support, train senior staff in mentorship, enforce safe working hours and equitable task distribution and equip urologists with adaptive coping strategies. Addressing these issues head-on is critical to maintaining a healthy, sustainable urology workforce in resource-limited settings.