Department of Urology

Faculty of Medicine, Universitas Indonesia

Departement of Urology, Cipto Mangunkusumo Hospital

Jakarta, Indonesia

RESEARCH PROTOCOL

Burnout among Urologist and Resident of Urologist: A

Multicenter Cross-Sectional Study

Correspondence:

Departemen of Urology

Cipto Mangunkusumo Hospital

Jl. Diponegoro No. 71 Jakarta 10430 Indonesia

 RESEARCH SUMMARY
Burnout among Urologist and Resident of Urologist: A Multicenter Cross-
Title
Sectional Study

Aim Evaluate the prevalence of urologist burnout, verify risk factors, and solutions for
colleagues at risk or suffering from burnout.

Questionnaire data were taken from all urologists and

urology residents from 5 different urology centers

Data is collected and divided according to

Study
concept
certain subgroups

Data from MBI questionarre were analyzed and

presented

Study This is a multicenter cross sectional study which data will be collected from
Procedure Maslach Burnout inventory questionarre

Sample size All urologists and urology residents from 5 different urology centers in Indonesia
and study will be used as target population. This study will be conducted in December 2019
period
– March 2020

Statistical Univariate analysis of both groups characteristic will be conducted based on

analysis questionare and bivariate analysis will be conducted to compare between sample
characteristic and Maslach Burnout Inventory score mean. If the numerical data is
normal, statistical analysis to compare means between group will be conducted
using independent t-test, if not, mann-whitney will be used; while for factors that
is more than 2 variables, statistical analysis will be conducted using one-way
ANOVA for normal data distribution and kruskall-wallis if not. For categorical
data, chi-square analysis will be used for statistical analysis. Multivariate analysis
will be conducted using linear regression, based on bivariate analysis results.
INTRODUCTION

Burnout was found to have an effect on personality. Maslach and Jackson in 1981
defined this syndrome, by using three non-mutually exclusive dimensions: emotional
exhaustion (EE), depersonalization (DP), and a low sense of personal achievement (PA). In
addition to fatigue, an overwhelming stress response, which is related to the development of
burnout, can be detrimental towards performance and technical skills, as well as vigilance,
memory, and other cognitive processes. This can contribute towards inadequate treatment of
patients by physicians.1
Recent multispecialty studies suggest that urologists have higher rates (up to 63.6%)
of burnout compared to physicians in other specialties. Several reports demonstrate that
burnout permeates our medical culture as early as residency training and continues to be a
major factor in job dissatisfaction, interpersonal conflicts, and substance abuse, even for
urologists who are well into their senior years of practice. Although several international
reports confirm the existence of burnout, only a few probe its etiology and even fewer
propose solutions.2
Over the past 15 years, there has been an increased attentions of the effects of burnout
and methods by which to mitigate its predictable sequelae. Many studies evaluating burnout
have turned to using the Maslach Burnout Inventory (MBI), which is a validated
questionnaire that assesses three classical components of burnout: 1) emotional exhaustion:
feeling of being emotionally overextended and exhausted by one’s work; 2)
depersonalization: an unfeeling and impersonal response toward recipients of one’s service;
and 3) decreased sense of personal accomplishment: feelings of competence and successful
achievement in one’s work.

STUDY AIM
This research aim to review the prevalence of urologist burnout, identify risk factors, and
solutions for colleagues at risk or suffering from burnout.

STUDY METHODOLOGY
Study Design
Cross-sectional study will be used as this research study design. This study will divide
sample into two major groups, urologist and urology residents.

Statistical Analysis
We decided to collect data from MBI questionnaire in Indonesia language (MBI-Ina).
Process of translation and adaption of instruments, consist of these following steps: forward
translations (at least two independent translators), a consensus meeting with the coordinator
of the translation, a check by a bilingual expert in the application field of the scale to evaluate
the scientific correctness of the wording, a backward translation, a consensus meeting among
the translators with the coordinator, and finally a pretest with a few persons the test is
designed for.
The reliability of the MBI-Ina were tested in two method, by testing internal
consistency and test-retest on the sample. Test of internal consistency obtained by calculating
Cronbach alpha coefficient of the MBI-Ina. Limitation Cronbach alpha coefficient range
from 0 (very unreliable) to 1 (very reliable), generally score above 0,8 indicates an acceptable
level of realiblity. Test-retest will analyze the subject MBI score at the initial sample with
the same subject score results at one week after the initial examination. Reliability of test-
retest test dne by assessing the intra-class correlation coefficient (ICC), which also has a
limited value of 0 (very unreliable) to 1 (very reliable).
Each sample characteristics and Maslach Burnout Inventory (MBI-Ina) will be
compared within each group. Univariate analysis of both groups characteristic will be
conducted based on questionare and bivariate analysis will be conducted to compare between
sample characteristic and Maslach Burnout Inventory score mean. If the numerical data is
normal, statistical analysis to compare means between group will be conducted using
independent t-test, if not, mann-whitney will be used; while for factors that is more than 2
variables, statistical analysis will be conducted using one-way ANOVA for normal data
distribution and kruskall-wallis if not. For categorical data, chi-square analysis will be used
for statistical analysis. Multivariate analysis will be conducted using linear regression, based
on bivariate analysis results.

POPULATION AND SAMPLE

Population
All urologists and urology residents from 5 different urology centers in Indonesia will
be used as target population. Randomization will be conducted within each group to ensure
there is no selection bias.

Sample Size
This study sample size will be formulated using sample size formula for proportion
difference between independent groups.

2
{𝑍𝛼√2 𝑃̅ (1 − 𝑃̅ ) + 𝑧𝛽 √𝑃1 (1 − 𝑃1 ) + 𝑃2 (1 − 𝑃2 ) }
𝑛=
(𝑃1 − 𝑃2 )2

Minimal sample calculation will be calculated using 1.96 as Zα value and 0.84 as Zβ.
P1 value will be 38.8%, this was extracted from previous study and for P2 value will be 9.5%,
therefore the minimal sample size are 30 for each group.

Questionnaire Tools
The questionnaire consists two parts. The principal part use the MBI to objectively
assess for workplace burnout. Maslach Burnout Inventory (MBI) will be used in this study
to measured burnout among urologists and urology residents. There are three major parts in
MBI, including emotional exhaustion (EE), depersonalization (DP), and low personal
accomplishment (PA). The 22-question assessment evaluates and scores the three
dimensions of burnout: EE, DP, and PA. Scores are then termed as low (EE = 0–16, DP = 0–
6, PA ≥39), moderate (EE = 17–26, DP = 7–12, PA = 32–38) or high (EE ≥27, DP ≥13, PA
= 0–31)
 Our second part of this questionnaire includes a specific characteristic about our
participants. Characteristic quesionnaire in this study will be consist of demographic points
such as age, gender, race, marriage status and ethnicity; education or training level
spesifically for urology residents; practice characteristic spesifically for urologist (primary
or other sub-speciality areas, practice setting, employment status); workload for both groups
(hours worked in patient care and other duties per week, and number of vacation days in
previous year).

Study Procedures

Design Proposal

Ethical clearance

Validating the
Questionnaire

Inclusion/exclusion criteria

Collecting data

Analyzing data

Study Result

Research Site
This research will be held in five urology centers in Indonesia during December 2019 –
March 2020.

Research Schedule
Timeline
No. Activity
11.19 12.19 1.20 2.20 3.20 4.20 5.20
1 Ethical Clearance

2 Validating questionnaire
and collecting data
3 Analyzing and processing
data
4 Presenting data
5 Final Result

REFERENCES LIST

1. Kelly FO, Manecksha RP, Quinlan DM, Reid A, Joyce A, et.al. Rates of self-reported
“burnout” and causative factor amongst urologist in Ireland and the UK: a
comparative cross-sectional study. BJU International. 2016; 117: 363–372.
2. Guimond JF, McNeil B, Schlossberg SM, North AC, Sener A. Urologist burnout:
frequency, causes, and potential solutions to an unspoken entity. Can Urol Assoc J.
2018 Apr; 12(4): 137–142.
3. Maslach C, Leiter M. Maslach Burnout Inventory Manual. 3rd ed. Palo Alto, CA:
Consulting Psychologists Press; 1996.
4. Heinemann LA, Saad F, Zimmermann T, Novak A, Myon E, Badia X, et al. AMS
Scale: Update and compilation of international versions. Health and Quality of Life
Outcomes 2003, 1:15