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Burnout in Academic Radiologists in the United States
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Burnout in Academic Radiologists in the United States Dhakshinamoorthy Ganeshan, MD, Andrew B Rosenkrantz, MD, Roland L Bassett Jr, MS, Lori Williams, MSN, PHD, RN, Leon Lenchik, MD, Wei Yang, MD
Rationale and Objectives: To assess the prevalence and associated factors of burnout among U.S. academic radiologists. Materials and Methods: An online survey was sent to the radiologists who were full members of the Association of University Radiologists in December 2018. Burnout was measured using the abbreviated Maslach Burnout Inventory Human Services Survey. Survey respondents were also requested to complete questions on demographics, potential professional stressors, sense of calling, and career satisfaction. Associations between survey participants’ characteristics and burnout were tested using logistic regression model. Results: The survey response rate was 27% (228/831). Twenty-nine percent met all three criteria for high burnout, including high emotional exhaustion, high depersonalization, and low personal accomplishment. Seventy-nine percent had one or more symptoms of burnout. Numerous factors including work overload, inability to balance personal and professional life, lack of autonomy, lack of appreciation from patients and other medical staff were significantly associated (p < 0.05) with high burnout. Older age (OR, 0.95; 95%CI 0.920.98; p < 0.05), higher number of years of experience practicing as radiologists (OR, 0.95; 95%CI 0.920.98; p < 0.05), and holding academic rank of professor (OR, 0.25; 95%CI 0.110.56; p < 0.05) were factors associated with lower odds of experiencing burnout. Radiologists with high burnout were more likely to be dissatisfied with their career (OR, 2.28; 95%CI 1.703.07; p < 0.0001) and less likely to identify medicine as a calling. Conclusion: Multiple factors contribute to high burnout in academic radiologists. Familiarity with these factors may help academic radiology departments to develop strategies to promote health and wellness of their faculty Key Words: Burnout; Radiology; Emotional exhaustion. © 2020 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.
INTRODUCTION
P
hysician burnout has reached alarming proportions worldwide. In the United States, over 50% of physicians report experiencing one or more symptoms of burnout (1,2). Physician burnout is associated with many deleterious effects, impacting physicians, patients, institutions, and society as a whole. The individual physician afflicted with burnout may experience decline in physical, emotional, and mental wellbeing, which could result in depression, selfharm, or sometimes, tragically even suicide (3). Physician burnout may also negatively impact patient care, compromising patient safety (4). From an organization’s standpoint, disruptive behavior of affected physicians can lead to serious loss of morale among other members of the health care team,
Acad Radiol 2020; &:1–8 From the Department of Abdominal Imaging, Unit 1473, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 770304009 (D.G.); NYU Langone Health, New York, New York (A.B.R.); MD Anderson Cancer Center, Department of Biostatistics, Houston, Texas (R.L.B.); MD Anderson Cancer Center, Symptom Research CAO, Houston, Texas (L.W.); Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina (L.L.); Department of Breast Imaging, The University of Texas MD Anderson Cancer Center, Houston, Texas (W.Y.). Received December 6, 2019; revised December 24, 2019; accepted December 27, 2019. Disclosures: All authors confirm that there are no relevant disclosures. IRB statement: This study was approved by the MD Anderson Cancer Center institutional review board. Address correspondence to: D.G. e-mail: [email protected] © 2020 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.acra.2019.12.029
resulting in a poor work place environment and loss of productivity (5,6). A high physician burnout rate may result in excessive staff turnover, hurting faculty retention and recruitment (7). Finally, physician burnout also takes its toll on society. Burnout may result in physicians decreasing their work hours or quitting medicine altogether (6). This may eventually result in a physician shortage, ultimately negatively impacting population health. Physician burnout also has immense financial repercussion. Reports on the estimated cost of physician burnout in the United States reveal staggering numbers. The National Taskforce for Humanity in Healthcare recently reported that the costs for burnout-associated physician turnover approach $1.7 billion annually among hospital-employed physicians (8). Similarly, a study utilizing cost-consequence analysis reported that the annual costs related to physician turnover and reduced clinical hours secondary to burnout in the United States are approximately $4.6 billion (9). The first step in designing interventions to decrease physician burnout is to measure its prevalence. Various survey instruments have been used to measure burnout (10). Maslach Burnout Inventory Human Services Survey for Medical Personnel (MBI-HSS) is a well-established validated tool for measuring burnout (11). The MBI-HSS provides subscale scores for the 3 domains of burnout: emotional exhaustion, depersonalization, and personal accomplishment (10). High burnout has been defined as coexistence of high emotional exhaustion score (score of 27 on the emotional exhaustion
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subscale), high depersonalization score (score of 10 on the depersonalization subscale), and low personal accomplishment score (score of 33 on the personal accomplishment subscale) (1115). However, it is known that physicians may experience burnout, despite having a sense of high personal accomplishment; several studies have reported burnout in physicians manifesting as high emotional exhaustion and/or high depersonalization (1620). Various factors may contribute to professional stress in physicians, resulting in burnout (21). However, it remains unclear which factors are dominant in physician burnout. Further, it would be helpful to identify factors that can help prevent or reduce burnout in physicians. Medicine as a sense of calling has been defined as “committing one’s life to work that is personally meaningful and has a prosocial purpose” (2224). Studies have reported that physicians who identify medicine as a sense of calling are more likely to experience a greater sense of career satisfaction and less likely to suffer from burnout (25,26). Radiologists play a major role in the modern health care environment and are exposed to various work-related stresses, just like other health care professionals. However, there are only limited studies in the radiology literature that have specifically evaluated the prevalence of burnout among practicing U.S. radiologists. It has been reported that around 72% of interventional radiologists, 66% of pediatric radiologists, and 80% of musculoskeletal radiologists may be experiencing burnout symptoms (16,27,28). While these data are helpful, they are limited to specific subspecialties, which may not provide a holistic view of the entire specialty. Further, the work pattern and responsibilities of radiologists in an academic institution may be different compared to those working in community or private hospital settings. In addition, prior studies have not fully evaluated potentially important aspects of radiologist burnout, including levels of career satisfaction, and sense of calling. The aim of our study was to estimate the prevalence of burnout in radiologists working in academic radiology departments in the United States and identify factors associated with high burnout in academic radiologists. We also aimed to identify professional stressors associated with burnout in radiologists and evaluate the association between the degree of burnout, career satisfaction, and radiologists’ sense of calling MATERIALS AND METHODS A cross-sectional online survey was administered to academic radiologists who were full members of the Association of University Radiologists (AUR) in December 2018. The survey incorporated questions validated and employed in prior studies relating to burnout, career satisfaction, and sense of calling in physicians from various medical and surgical specialties (1,1115,17,18,2023, 25,26). The survey was divided into five components. The first addressed respondent demographics, including age, gender, race, duration of time on faculty, radiological subspecialty, and 2
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estimated number of hours worked per week. The second comprised the abbreviated MBI-HSS for measuring burnout (11). The third included questions on professional stressors. Respondents were asked to indicate the level to which each potential stressor may have affected their professional life using a Likert scale (Not at all/Slight amount/Moderate amount/Large amount/Extreme amount). The fourth addressed career satisfaction. Radiologists were asked to indicate their degree of career satisfaction using a five point Likert scale ranging from “very satisfied” to “very dissatisfied”. The fifth measured sense of calling, using a previously reported validated tool (2226). In total, the survey comprised 44 optional questions. However, given the study’s primary aim to assess prevalence of burnout, respondents who skipped any of the 12 questions comprising the abbreviated MBI-HSS were excluded. The survey was confidential, voluntary, and administered online. Participants’ responses were collected and managed using Research Electronic Data Capture (REDCap, version 6.15.11, Vanderbilt) tools. An email with a link to the online survey was sent to AUR members. This was followed by two reminder emails, sent at 2 weeks and 4 weeks following the first email. This study was approved by our institutional review board. STATISTICAL ANALYSIS Demographics and workplace characteristics of the survey participants were summarized in terms of frequencies, percentages, mean, median, standard deviation, and range. Logistic regression was used to assess the association between burnout and factors captured. Statistical analyses were performed using R version 3.6.0, and statistical tests used a significance level of 5%. RESULTS Of the 831 AUR members recruited, 244 participated in the survey. 16 survey respondents did not complete all 12 questions on MBI-HSS and were excluded. Thus, a total of 228 academic radiologists completed all the 12 questions on abbreviated MBI-HSS and were included in the study, resulting in a response rate of 27%. Participants’ mean § standard deviation (SD) age was 48 § 11 years (range 3275 years). Participants’ mean § SD years of experience in academic radiology was 15 § 10 years (range 145 years). The average § SD number of work hours per week was 56 § 11 hours (range 30100 hours). Table 1 summarizes the survey respondent characteristics (categorical variables). Professional stressors most often scored by respondents as causing large or extreme amounts of stress were work overload (50%), lack of balance between personal and professional life (45%), lack of autonomy (28%), lack of appreciation by other health care staff (28%), and dispute with hospital leadership (25%) (Table 2). 179 respondents (79%) had one or more symptoms of burnout, demonstrating high emotional exhaustion and/or
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TABLE 1. Summary (Categorical)
of
Radiologist
Characteristics
Variable*
Levels
Gender
Female Male Asian Black or African American Native Hawaiian or other Pacific Islander White Other Assistant professor Associate professor Instructor Professor Other Abdominal radiology Breast radiology Cardiothoracic radiology Emergency/trauma radiology General radiology Interventional radiology Multiple subspecialties Musculoskeletal radiology Neuroradiology Nuclear medicine Other Pediatric radiology Full time Part time
Race
Rank
Subspecialty
Work schedule
BURNOUT IN ACADEMIC RADIOLOGISTS IN THE US
n
%
100 125 28 1 1
44.4 55.6 12.5 0.4 0.4
182 12 68 82 4 71 3 45 27 32 7 2 24 7 33 24 2 3 19 197 28
81.2 5.4 29.8 36.0 1.8 31.1 1.3 20.0 12.0 14.2 3.1 0.9 10.7 3.1 14.7 10.7 0.9 1.3 8.4 87.6 12.4
* Total number of respondents to survey items in Table 1 varies, given optional nature of demographic questions. 228 survey respondents completed all the 12 questions of MBI-HSS and were included in the study. Optional questions on gender, race, rank, subspecialty and work schedule pattern were completed by 225, 224, 228, 225 and 225 survey respondents respectively.
high depersonalization (Table 3). Sixty-six respondents (29%) met all three criteria for high burnout, characterized by the presence of high emotional exhaustion, high depersonalization, and low personal accomplishment scores. Various professional stressors including work overload, inability to balance personal and professional life, concern about not being promoted to higher academic rank, lack of autonomy, lack of appreciation from other medical staff, lack of appreciation from patients, concern about malpractice litigation, job insecurity, and dispute(s) with departmental/hospital leadership were significantly associated with high burnout (p < 0.05) (Table 4). Older age (OR, 0.95; 95%CI 0.920.98; p < 0.05), higher number of years of experience practicing as radiologists (OR, 0.95; 95%CI 0.920.98; p < 0.05), and holding academic rank of professor (OR, 0.25; 95%CI 0.110.56; p < 0.05) were factors associated with lower odds of experiencing burnout. With regards to career satisfaction, 26 (11%) respondents reported that they were either very dissatisfied or somewhat
TABLE 2. Professional Radiologists Variable* Work overload
Balance personal and professional life
Concern about promotion
Lack of autonomy
Lack of appreciation (staff)
Lack of appreciation (patients)
Concern about malpractice
Job insecurity 2 3 4 5 Dispute(s) w/ hospital leadership
Stressors
Causing
Stress
in
Likert score y
n
%
1 2 3 4 5 1
13 27 74 72 42 9
5.7 11.8 32.5 31.6 18.4 4.0
2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1
60 56 73 30 104 53 39 22 10 50 62 53 46 17 46 76 41 40 25 108
26.3 24.6 32.0 13.2 45.6 23.2 17.1 9.6 4.4 21.9 27.2 23.2 20.2 7.5 20.2 33.3 18.0 17.5 11.0 47.4
2 3 4 5 1
73 27 14 6 93
32.0 11.8 6.1 2.6 40.8
2 3 4 5 1
1
88 32 8 7 134 73 13 4 4 55
38.6 14.0 3.5 3.1 58.8 32.0 5.7 1.8 1.8 24.1
2 3 4 5
71 44 31 27
31.1 19.3 13.6 11.8
* All the 228 survey respondents completed the questions on professional stressors. y Professional stressors were rated using Likert scale from 15 (Not at all = 1; Slight amount = 2; Moderate amount = 3; Large amount = 4; Extreme amount = 5).
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GANESHAN ET AL
TABLE 3. Burnout in Academic Radiologists Burnout Score* High emotional exhaustion (EE) score High depersonalization (DP) score Low personal accomplishment score High burnout One or more symptoms of burnout (high EE score and/ or high DP score)
n
%
Absent
97
42.5
Present Absent
131 62
57.5 27.2
Present Absent
166 130
72.8 57.0
Present Absent Present Absent
98 162 66 49
43.0 71.0 28.9 21.5
Present
179
78.5
* High burnout defined as coexistence of high emotional exhaustion score (score of 27 on the emotional exhaustion subscale) plus high depersonalization score (score of 10 on the depersonalization subscale) plus low personal accomplishment score (score of 33 on the personal accomplishment subscale). All the 228 survey respondents included in the study completed all the questions on abbreviated MBI-HSS used for measuring burnout.
dissatisfied, with their career in radiology. Radiologists who were dissatisfied with their career had higher odds of experiencing burnout (OR, 2.28; 95%CI 1.703.07; p < 0.0001) (Table 4). Radiologists who had high burnout were less likely to identify medicine as a sense of calling and had lower odds of finding their work rewarding (OR, 0.16; 95%CI 0.060.40; p < 0.001), seeing their work as the most important thing in life (OR, 0.29; 95%CI 0.150.58; p < 0.001) or enjoying talking about their work with others (OR, 0.31; 95%CI 0.160.59; p < 0.001) (Table 4). Radiologists with burnout also had lower odds of choosing their current work life again, if they had the opportunity (OR, 0.38; 95%CI 0.200.72; p = 0.003) or continuing with their current line of work if they were financially secure (OR, 0.42; 95%CI 0.220.79; p = 0.008). Sixty percent of the participants reported that their institution had a burnout prevention support group for faculties. DISCUSSION Burnout affecting physicians is rapidly rising in prevalence in the United States. No medical specialty seems to be spared, with reported rates of burnout ranging from 38% to 70% (29). In our study, 79% of academic radiologists experienced one or more symptoms of burnout. Excessive work load and work-life imbalance were the top two factors causing the highest amount of stress in radiologists. Demanding too much work to be completed within too little time leads to physical, mental, and emotional exhaustion (30). When 4
radiologists are working with a singular aim of meeting high relative value unit targets, they may feel rushed to complete the studies to achieve a faster turnaround time. Radiologists may also become less inclined to spend time discussing patients with referring physicians. All of these may lead to radiologists developing a callous attitude towards patients (depersonalization). No single solution is available for a problem of this magnitude. Multiple physician-specific and organization-specific interventions may be required (31). This should begin with an honest appraisal by leadership to understand what can be reasonably expected from radiologists in a given time period, accounting for the complexity of the cases and procedures performed. Ensuring adequate staffing to meet job demands and providing appropriate resources to enhance efficiency can also help alleviate work overload related stress (29,3234). Besides excess clinical workload, other factors may also be contributing to the excessive workload in radiologists; academic radiologists have numerous other professional commitments including education, research, administration, and quality improvement. Pursuing these activities often requires committing time outside of normal work hours, which may contribute to the perception of being overworked and negatively impact work-life balance (35). Interventions that may be helpful in addressing burnout have been described previously (31). Radiologists should devote appropriate amount of time for activities related to self-care and personal wellness, including adequate amount of sleep, proper nutrition, exercise, yoga, sports, meditation, and mindfulness. Spending quality time with family and friends may also be helpful to overcome burnout. Working remotely when possible, working part time, or reducing work hours are some of the options that may be explored to address the work-life imbalance, although it may not be applicable to all radiologists. When an institution’s leadership encourages and champions work-life balance, the physicians are likely to become highly engaged in their work, which can ultimately result in a happy work environment (35,36). In our study, lack of autonomy and disputes with institutional leadership were associated with high burnout in 28% of the survey respondents. Our study did not elucidate what factors led to disputes with institutional leadership and what issues contributed to lack of autonomy; however, it is reasonable to hypothesize that radiologists may perceive the inability to choose their work pattern as lack of autonomy. Similarly, the perception that their voices go unheard and that their views are not taken into account when decisions are made that directly concern their work life may also contribute to the sense of lack of autonomy. Addressing these issues may require intervention at both individual and organizational levels. Health care organizations must appreciate that burnout affects radiologists at all levels in their professional career, including radiology residents and department chairs (37,38). Hospital administration should strive to address any systemic issues that may be contributing to this epidemic. Having an open-minded approach, actively seeking input
Level
Gender
Female Male Asian Black or African American Native Hawaiian or other Pacific Islander Other White Assistant professor Associate professor Instructor Other Professor Full time Part time Continuous Continuous
Racey
Ranky
Work schedule
Career satisfaction I would choose my current work life again if I had the opportunity My work is one of the most important things in my life Enjoy talking about my work to others
N with Burnout
Odds Ratio
Lower CI
Upper CI
p value
100 125 28 1 1
24 40 11 1 1
— 1.49 — 4.565 4.565
— 0.823 — 0.046 0.046
— 2.697 — 449.344 449.344
— 0.1875 — 0.5167 0.5167
12 182 68 82 4 3 71 197 28 228 228
4 47 29 23 0 3 11 59 7 66 66
0.806 0.533 — 0.529 0.149 9.373 0.255 — 0.78 2.088 1.845
0.197 0.233 — 0.268 0.005 0.296 0.115 — 0.314 1.514 1.378
3.299 1.219 — 1.043 4.041 296.796 0.564 — 1.933 2.878 2.471
0.7638 0.1362 — 0.0661 0.2580 0.2043 0.0008 — 0.5911 <0.0001 <0.0001
Continuous Continuous Continuous Continuous
228 228 228 228
66 66 66 66
1.491 1.681 1.717 1.956
1.175 1.311 1.354 1.463
1.893 2.156 2.179 2.615
0.0010 <0.0001 < 0.0001 <0.0001
Continuous Continuous Continuous No
228 228 228 91
66 66 66 30
1.563 1.475 1.341 —
1.17 1.056 1.077 —
2.087 2.06 1.669 —
0.0025 0.0228 0.0087 —
Yes Continuous No
135 227 59
35 65 26
0.712 2.289 —
0.398 1.705 —
1.274 3.073 —
0.2523 <0.0001 —
Yes No
167 45
39 23
0.387 —
0.207 —
0.724 —
0.0030 —
Yes No
182 56
43 27
0.296 —
0.15 —
0.582 —
0.0004 —
Yes
171
39
0.317
0.168
0.598
0.0004 (continued on next page)
BURNOUT IN ACADEMIC RADIOLOGISTS IN THE US
Work overload Balance between personal & professional life Concern about promotion Lack of autonomy Lack of appreciation from staff Lack of appreciation from patients Concern about malpractice Job insecurity Dispute(s) w/ hospital leadership Institution has burnout support group
Total
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Parameter*
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TABLE 4. Logistic Regression Models for Burnout
Parameter*
Level
Find my work rewarding If financially secure, I would continue with my current line of work even if I were no longer paid Primary reason for working is financial-to support my family and lifestyle
Odds Ratio
Lower CI
Upper CI
p value
No Yes No
24 203 137
16 50 49
— 0.163 —
— 0.066 —
— 0.405 —
— <0.0001 —
Yes No
89 92
17 21
0.424 —
0.225 —
0.799 —
0.0080 —
Yes No
132 114
44 28
1.69 —
0.922 —
3.101 —
0.0898 —
Yes Continuous Continuous Continuous Continuous Continuous
111 219 228 222 227 227
38 62 66 64 66 65
1.599 0.953 0.954 1.003 1.001 1.007
0.896 0.923 0.924 0.997 0.975 0.994
2.854 0.984 0.985 1.009 1.028 1.021
0.1123 0.0029 0.0044 0.2705 0.9189 0.2965
Continuous
227
65
0.989
0.972
1.007
0.2181
Continuous
227
66
1.005
0.979
1.033
0.6989
Continuous
219
64
1.021
0.982
1.061
0.3014
Continuous Continuous Continuous
228 228 228
66 66 66
1.112 1.232 0.758
1.077 1.157 0.701
1.147 1.311 0.818
<0.0001 <0.0001 <0.0001
* Total number of respondents to survey items in Table 4 varies, given optional nature of some of the questions. 228 survey respondents completed all the 12 questions of MBI-HSS and were included in the study. All the 228 survey respondents completed all questions on professional stressors. Optional questions on gender, age, race, rank, work schedule pattern, number of years practicing, total faculty in department, hours worked per week, percentage of time spent in patient care, administration, teaching and research availability of institutional burnout support group and career satisfaction were completed by 225, 219, 224, 228, 225, 228, 222, 227, 227, 227, 227, 219, 226, and 227 survey respondents respectively. Optional questions on sense of calling including “I would choose my current work life again if I had the opportunity,” “My work is one of the most important things in my life,” “I enjoy talking about my work to others,” “I find my work rewarding,” “If I was financially secure, I would continue with my current line of work even if I were no longer paid,” “My primary reason for working is financial-to support my family and lifestyle” and “I view my job as just a necessity of life, much like breathing or sleeping” were completed by 226, 227, 227, 227, 226, 224, and 225 survey respondents respectively. y Indicates that model fit with Firth penalized likelihood method due to lack of events in one or more categories.
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Age Number of years practicing Total faculty in dept. Hours worked per week % of work hours spent in patient care % of work hours spent in administration % of work hours spent in teaching % of work hours spent in research Emotional exhaustion score Depersonalization score Personal accomplishment score
N with Burnout
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View job as just a necessity of life, much like breathing or sleeping
Total
GANESHAN ET AL
TABLE 4. (Continued)
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from radiologists on matters that directly concerns them, and taking steps to promote work-life integration may be mutually beneficial. Radiologists should figure out what component of autonomy they value the most and hold open discussions with leadership. However, radiologists should also be cognizant of the fact that any desire for increased autonomy does not impede patient care. Lack of appreciation (both from other medical staff and from patients) are associated with high burnout. Diagnostic radiologists frequently work in isolation as they seek to decrease distractions, improve their efficiency, productivity, and accuracy in image interpretation. The unintended consequence may be erosion of the physician-patient encounter which diminishes the value of radiologists’ in direct patient care. Lack of meaningful interactions with patients can dehumanize physicians leading to depersonalization. Creating more opportunities for radiologists to interact with patients can strengthen the patient-physician relationship and may potentially help re-energize the original calling to medicine (39). Equally, the opportunity to collaborate with referring physicians through ad hoc interactions such as communication of imaging findings, multidisciplinary conferences, and dedicated radiology consultation clinics can enhance direct communication with referring physicians and patients (4042). Interestingly, although concern about malpractice litigation and job insecurity were associated with burnout, these were rated relatively low as professional stressors compared to the factors described previously. Only 6.6% and 3.6% reported experiencing large or extreme amount of stress from malpractice litigation and job insecurity respectively. Working in academia comes with many benefits. It is possible that working in an academic radiology department as part of the university system may confer a greater sense of job security and reduced malpractice concerns among academic radiologists. However, we acknowledge that these stressors also need addressing. Being more aware of what may and may not be potential malpractice lawsuits could help dispel some myths and alleviate the fear. Furthermore, peer learning, can be a powerful educational tool which may help reduce diagnostic errors in radiology (4345). Continuous self-learning in a supportive environment amongst peers may mitigate against the fears of job insecurity. Sense of calling refers to “committing one’s life to a work that is personally meaningful and serving with a deep sense of purpose for the greater good of society” (22,24). A few studies have shown that physicians with a sense of calling are more likely to have greater career satisfaction and less likely to burnout. In a study involving 896 primary care physicians and 312 psychiatrists, physicians who viewed medicine as a calling experienced higher levels of career satisfaction and greater resilience from burnout (26). Similarly, Jager et al reported that physicians with eroded sense of calling are more likely to experience burnout (25). In another study involving 1156 physicians working in end-of-life specialties, burned-out physicians working in profitcentered clinical environments experienced more emotional exhaustion when providing care for the dying while those
BURNOUT IN ACADEMIC RADIOLOGISTS IN THE US
physicians who identified medicine as a calling were more likely to feel emotionally energized when caring for the patients (46). In our study as well, radiologists who reported medicine as a calling were less likely to experience burnout. We believe this is an important finding. Re-igniting the physicians’ sense of calling may be an antidote for combating emotional exhaustion and depersonalization. Teaching trainees the importance of patient centered care may act as a helpful tool to reduce burnout and enhance their wellbeing throughout their professional careers (38,47). Leaders of health care systems may consider restructuring organizational design to incorporate more than one parameter of measuring physician value. Empowering physicians to make decisions on how to provide patient-centered care together with other academic priorities may increase engagement, thereby promoting physician wellness (48,49). Our study has limitations. The response rate was 27%, thereby creating biases inherent in any survey with a low response rate. Another limitation of the survey is that there may have been a difference in the response rate to the survey between academic radiologists with and without burnout that could have skewed the results of the survey. Further, it is possible that other professional stressors not reflected in the survey may also be contributing to burnout in radiologists. A longitudinal study with larger study population would be helpful. In summary, our study showed that a significant percentage of academic radiologists are experiencing one or more symptoms of burnout. Considering the known considerable adverse effects of physician burnout, urgent measures are needed to address this malady and promote health and wellness among radiologists. Institutional leadership should pursue meaningful steps to provide an emotionally thriving environment for the physicians to perform at their best. FUNDING This study was supported by MD Anderson Cancer Center Support Grant No. NIH/NCI P30 CA016672 from the National Cancer Institute, National Institutes of Health. ACKNOWLEDGMENT The authors thank the AUR for their support, and their assistance in the distribution of the survey. We also thank the academic radiologists for their participation in the survey. REFERENCES 1.
Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clin Proc. 2015; 90(12):1600–1613. 2. Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with worklife balance among US physicians relative to the general US population. Arch Intern Med 2012; 172(18):1377–1385. 3. Shanafelt TD, Dyrbye LN, West CP. Addressing physician burnout: the way forward. JAMA 2017; 317(9):901–902.
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4. Panagioti M, Geraghty K, Johnson J, et al. Association between physician burnout and patient safety, professionalism, and patient satisfaction: a systematic review and meta-analysis. JAMA Intern Med 2018; 178 (10):1317–1330. 5. Willis MH, Friedman EM, Donnelly LF. Optimizing performance by preventing disruptive behavior in radiology. Radiographics 2018; 38(6):1639–1650. 6. Shanafelt T, Goh J, Sinsky C. The business case for investing in physician well-being. JAMA Intern Med 2017; 177(12):1826–1832. 7. Hamidi MS, Bohman B, Sandborg C, et al. Estimating institutional physician turnover attributable to self-reported burnout and associated financial burden: a case study. BMC Health Serv Res 2018; 18(1):851. 8. Healthcare NTfHi. The business case for humanity in healthcare. Available at: http://healthcareexcellence.org/wp-content/uploads/2018/04/ NTH-Business-Case_2018.pdf. Accessed October 28, 2019. 9. Han S, Shanafelt TD, Sinsky CA, et al. Estimating the attributable cost of physician burnout in the United States. Ann Intern Med 2019; 170 (11):784–790. 10. Medicine NAo. Valid and reliable survey instruments to measure burnout, well-being, and other work-related dimensions. Available at: https://nam. edu/valid-reliable-survey-instruments-measure-burnout-well-work-relateddimensions/. Accessed December 24, 2019. 11. Maslach CLM. 3rd ed. Maslach burnout inventory manual, 317. Palo Alto, CA: Consulting Psychologists Press, Inc., 1996:36–37. 12. Cruz OA, Pole CJ, Thomas SM. Burnout in chairs of academic departments of ophthalmology. Ophthalmology 2007; 114(12):2350–2355. 13. De Oliveira Jr. GS, Ahmad S, Stock MC, et al. High incidence of burnout in academic chairpersons of anesthesiology: should we be taking better care of our leaders? Anesthesiology. 2011; 114(1):181–193. 14. Gabbe SG, Melville J, Mandel L, et al. Burnout in chairs of obstetrics and gynecology: diagnosis, treatment, and prevention. Am J Obstet Gynecol 2002; 186(4):601–612. 15. Johns 3rd MM, Ossoff RH. Burnout in academic chairs of otolaryngology: head and neck surgery. Laryngoscope 2005; 115(11):2056–2061. 16. Bundy JJ, Hage AN, Srinivasa RN, et al. Burnout among interventional radiologists. J Vasc Interv Radiol 2019; pii: S1051-0443(19)30546-9. 17. Busis NA, Shanafelt TD, Keran CM, et al. Burnout, career satisfaction, and well-being among US neurologists in 2016. Neurology. 2017; 88 (8):797–808. 18. Shanafelt TD, Gradishar WJ, Kosty M, et al. Burnout and career satisfaction among US oncologists. J Clin Oncol 2014; 32(7):678–686. 19. Streu R, Hansen J, Abrahamse P, et al. Professional burnout among US plastic surgeons: results of a national survey. Ann Plast Surg 2014; 72 (3):346–350. 20. Schaufeli WB, Bakker AB, Hoogduin K, et al. On the clinical validity of the maslach burnout inventory and the burnout measure. Psychol Health 2001; 16(5):565–582. 21. West CP, Dyrbye LN, Shanafelt TD. Physician burnout: contributors, consequences and solutions. J Intern Med 2018; 283(6):516–529. 22. Rasinski KA, Lawrence RE, Yoon JD, et al. A sense of calling and primary care physicians’ satisfaction in treating smoking, alcoholism, and obesity. Arch Intern Med 2012; 172(18):1423–1424. 23. Curlin FA, Dugdale LS, Lantos JD, et al. Do religious physicians disproportionately care for the underserved? Ann Fam Med. 2007; 5(4):353–360. 24. Wrzesniewski AMC, Rozin P, Schwartz B. Jobs, careers, and callings: people’s relations to their work. J Res Personal 1997; 31(1):21–33. 25. Jager AJ, Tutty MA, Kao AC. Association between physician burnout and identification with medicine as a calling. Mayo Clin Proc 2017; 92(3):415–422.
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26. Yoon JD, Daley BM, Curlin FA. The association between a sense of calling and physician well-being: a national study of primary care physicians and psychiatrists. Acad Psychiatry 2017; 41(2):167–173. 27. Ayyala RS, Ahmed FS, Ruzal-Shapiro C, et al. Prevalence of burnout among pediatric radiologists. J Am Coll Radiol 2019; 16(4 Pt A):518–522. 28. Chew FS, Mulcahy MJ, Porrino JA, et al. Prevalence of burnout among musculoskeletal radiologists. Skeletal Radiol 2017; 46(4):497–506. 29. Doshi AM, Moore WH, Kim DC, et al. Informatics solutions for driving an effective and efficient radiology practice. Radiographics 2018; 38 (6):1810–1822. 30. Cohan RH, Davenport MS. Productivity, meet burnout. Acad Radiol. 2018; 25(12):1513–1514. 31. Chetlen AL, Chan TL, Ballard DH, et al. Addressing burnout in radiologists. Acad Radiol 2019; 26(4):526–533. 32. Lewis C, Restauri N, Clark T. Strategies for increasing radiologist efficiency. Curr Probl Diagn Radiol 2019; 48(2):103–104. 33. Bluth EI, Bender CE, Parikh JR. Burnout: redesign the work process rather than the person. J Am Coll Radiol 2017; 14(10):1375–1376. 34. Tibor LC, Schultz SR, Menaker R, et al. Improving efficiency using time-driven activity-based costing methodology. J Am Coll Radiol 2017; 14(3):353–358. 35. Raja S, Stein SL. Work-life balance: history, costs, and budgeting for balance. Clin Colon Rectal Surg 2014; 27(2):71–74. 36. Witzig TE, Smith SM. Work-Life Balance Solutions for Physicians-It’s All About You, Your Work, and Others. Mayo Clin Proc 2019; 94(4):573–576. 37. Ganeshan D, Wei W, Yang W. Burnout in chairs of academic radiology departments in the United States. Acad Radiol 2019; 26(10):1378–1384. 38. Guenette JP, Smith SE. Burnout: job resources and job demands associated with low personal accomplishment in United States radiology residents. Acad Radiol 2018; 25(6):739–743. 39. Herr KD, Hanna TN, Restauri N. Cultivating physician character in diagnostic radiology through virtuous caring and collaborative professionalism. Acad Radiol 2018; 25(11):1497–1502. 40. Kallianos KG, Muhoozi BN, Gottschalk A, et al. Dedicated diagnostic radiology/radiation oncology rounds: added value beyond traditional tumor boards. Curr Probl Diagn Radiol 2019; pii: S0363-0188(19)30027-1. 41. Patel TY, Gupta S. More than an order: the radiologist-Patient Consultation Clinic Conundrum. J Am Coll Radiol 2019; 16(7):1003–1005. 42. Salama GR, Sullivan C, Holzwanger D, et al. Improving care and education through a radiology resident-driven clinical consultation service. Acad Radiol 2017; 24(9):1175–1181. 43. Burns J, Miller T, Weiss JM. Just culture: practical implementation for radiologist peer review. J Am Coll Radiol 2019; 16(3):384–388. 44. Trinh TW, Boland GW, Khorasani R. Improving radiology peer learning: comparing a novel electronic peer learning tool and a traditional scorebased peer review system. AJR Am J Roentgenol 2019; 212(1):135–141. 45. Larson DB, Donnelly LF, Podberesky DJ, et al. Peer feedback, learning, and improvement: Answering the call of the institute of medicine report on diagnostic error. Radiology 2017; 283(1):231–241. 46. Yoon JD, Hunt NB, Ravella KC, et al. Physician burnout and the calling to care for the dying: a national survey. Am J Hosp Palliat Care 2017; 34 (10):931–937. 47. Wild D, Nawaz H, Ullah S, et al. Teaching residents to put patients first: creation and evaluation of a comprehensive curriculum in patient-centered communication. BMC Med Educ 2018; 18(1):266. 48. Restauri N, Nyberg E, Clark T. Cultivating meaningful work in healthcare: A paradigm and practice. Curr Probl Diagn Radiol 2019; 48(3):193–195. 49. West P, Gee PM. Building a resilient workforce: promoting joy in clinical care. Front Health Serv Manage 2018; 35(2):14–23.
Burnout in Academic Radiologists in the United States Dhakshinamoorthy Ganeshan, MD, Andrew B Rosenkrantz, MD, Roland L Bassett Jr, MS, Lori Williams, MSN, PHD, RN, Leon Lenchik, MD, Wei Yang, MD
Rationale and Objectives: To assess the prevalence and associated factors of burnout among U.S. academic radiologists. Materials and Methods: An online survey was sent to the radiologists who were full members of the Association of University Radiologists in December 2018. Burnout was measured using the abbreviated Maslach Burnout Inventory Human Services Survey. Survey respondents were also requested to complete questions on demographics, potential professional stressors, sense of calling, and career satisfaction. Associations between survey participants’ characteristics and burnout were tested using logistic regression model. Results: The survey response rate was 27% (228/831). Twenty-nine percent met all three criteria for high burnout, including high emotional exhaustion, high depersonalization, and low personal accomplishment. Seventy-nine percent had one or more symptoms of burnout. Numerous factors including work overload, inability to balance personal and professional life, lack of autonomy, lack of appreciation from patients and other medical staff were significantly associated (p < 0.05) with high burnout. Older age (OR, 0.95; 95%CI 0.920.98; p < 0.05), higher number of years of experience practicing as radiologists (OR, 0.95; 95%CI 0.920.98; p < 0.05), and holding academic rank of professor (OR, 0.25; 95%CI 0.110.56; p < 0.05) were factors associated with lower odds of experiencing burnout. Radiologists with high burnout were more likely to be dissatisfied with their career (OR, 2.28; 95%CI 1.703.07; p < 0.0001) and less likely to identify medicine as a calling. Conclusion: Multiple factors contribute to high burnout in academic radiologists. Familiarity with these factors may help academic radiology departments to develop strategies to promote health and wellness of their faculty Key Words: Burnout; Radiology; Emotional exhaustion. © 2020 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.
INTRODUCTION
P
hysician burnout has reached alarming proportions worldwide. In the United States, over 50% of physicians report experiencing one or more symptoms of burnout (1,2). Physician burnout is associated with many deleterious effects, impacting physicians, patients, institutions, and society as a whole. The individual physician afflicted with burnout may experience decline in physical, emotional, and mental wellbeing, which could result in depression, selfharm, or sometimes, tragically even suicide (3). Physician burnout may also negatively impact patient care, compromising patient safety (4). From an organization’s standpoint, disruptive behavior of affected physicians can lead to serious loss of morale among other members of the health care team,
Acad Radiol 2020; &:1–8 From the Department of Abdominal Imaging, Unit 1473, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 770304009 (D.G.); NYU Langone Health, New York, New York (A.B.R.); MD Anderson Cancer Center, Department of Biostatistics, Houston, Texas (R.L.B.); MD Anderson Cancer Center, Symptom Research CAO, Houston, Texas (L.W.); Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina (L.L.); Department of Breast Imaging, The University of Texas MD Anderson Cancer Center, Houston, Texas (W.Y.). Received December 6, 2019; revised December 24, 2019; accepted December 27, 2019. Disclosures: All authors confirm that there are no relevant disclosures. IRB statement: This study was approved by the MD Anderson Cancer Center institutional review board. Address correspondence to: D.G. e-mail: [email protected] © 2020 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.acra.2019.12.029
resulting in a poor work place environment and loss of productivity (5,6). A high physician burnout rate may result in excessive staff turnover, hurting faculty retention and recruitment (7). Finally, physician burnout also takes its toll on society. Burnout may result in physicians decreasing their work hours or quitting medicine altogether (6). This may eventually result in a physician shortage, ultimately negatively impacting population health. Physician burnout also has immense financial repercussion. Reports on the estimated cost of physician burnout in the United States reveal staggering numbers. The National Taskforce for Humanity in Healthcare recently reported that the costs for burnout-associated physician turnover approach $1.7 billion annually among hospital-employed physicians (8). Similarly, a study utilizing cost-consequence analysis reported that the annual costs related to physician turnover and reduced clinical hours secondary to burnout in the United States are approximately $4.6 billion (9). The first step in designing interventions to decrease physician burnout is to measure its prevalence. Various survey instruments have been used to measure burnout (10). Maslach Burnout Inventory Human Services Survey for Medical Personnel (MBI-HSS) is a well-established validated tool for measuring burnout (11). The MBI-HSS provides subscale scores for the 3 domains of burnout: emotional exhaustion, depersonalization, and personal accomplishment (10). High burnout has been defined as coexistence of high emotional exhaustion score (score of 27 on the emotional exhaustion
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subscale), high depersonalization score (score of 10 on the depersonalization subscale), and low personal accomplishment score (score of 33 on the personal accomplishment subscale) (1115). However, it is known that physicians may experience burnout, despite having a sense of high personal accomplishment; several studies have reported burnout in physicians manifesting as high emotional exhaustion and/or high depersonalization (1620). Various factors may contribute to professional stress in physicians, resulting in burnout (21). However, it remains unclear which factors are dominant in physician burnout. Further, it would be helpful to identify factors that can help prevent or reduce burnout in physicians. Medicine as a sense of calling has been defined as “committing one’s life to work that is personally meaningful and has a prosocial purpose” (2224). Studies have reported that physicians who identify medicine as a sense of calling are more likely to experience a greater sense of career satisfaction and less likely to suffer from burnout (25,26). Radiologists play a major role in the modern health care environment and are exposed to various work-related stresses, just like other health care professionals. However, there are only limited studies in the radiology literature that have specifically evaluated the prevalence of burnout among practicing U.S. radiologists. It has been reported that around 72% of interventional radiologists, 66% of pediatric radiologists, and 80% of musculoskeletal radiologists may be experiencing burnout symptoms (16,27,28). While these data are helpful, they are limited to specific subspecialties, which may not provide a holistic view of the entire specialty. Further, the work pattern and responsibilities of radiologists in an academic institution may be different compared to those working in community or private hospital settings. In addition, prior studies have not fully evaluated potentially important aspects of radiologist burnout, including levels of career satisfaction, and sense of calling. The aim of our study was to estimate the prevalence of burnout in radiologists working in academic radiology departments in the United States and identify factors associated with high burnout in academic radiologists. We also aimed to identify professional stressors associated with burnout in radiologists and evaluate the association between the degree of burnout, career satisfaction, and radiologists’ sense of calling MATERIALS AND METHODS A cross-sectional online survey was administered to academic radiologists who were full members of the Association of University Radiologists (AUR) in December 2018. The survey incorporated questions validated and employed in prior studies relating to burnout, career satisfaction, and sense of calling in physicians from various medical and surgical specialties (1,1115,17,18,2023, 25,26). The survey was divided into five components. The first addressed respondent demographics, including age, gender, race, duration of time on faculty, radiological subspecialty, and 2
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estimated number of hours worked per week. The second comprised the abbreviated MBI-HSS for measuring burnout (11). The third included questions on professional stressors. Respondents were asked to indicate the level to which each potential stressor may have affected their professional life using a Likert scale (Not at all/Slight amount/Moderate amount/Large amount/Extreme amount). The fourth addressed career satisfaction. Radiologists were asked to indicate their degree of career satisfaction using a five point Likert scale ranging from “very satisfied” to “very dissatisfied”. The fifth measured sense of calling, using a previously reported validated tool (2226). In total, the survey comprised 44 optional questions. However, given the study’s primary aim to assess prevalence of burnout, respondents who skipped any of the 12 questions comprising the abbreviated MBI-HSS were excluded. The survey was confidential, voluntary, and administered online. Participants’ responses were collected and managed using Research Electronic Data Capture (REDCap, version 6.15.11, Vanderbilt) tools. An email with a link to the online survey was sent to AUR members. This was followed by two reminder emails, sent at 2 weeks and 4 weeks following the first email. This study was approved by our institutional review board. STATISTICAL ANALYSIS Demographics and workplace characteristics of the survey participants were summarized in terms of frequencies, percentages, mean, median, standard deviation, and range. Logistic regression was used to assess the association between burnout and factors captured. Statistical analyses were performed using R version 3.6.0, and statistical tests used a significance level of 5%. RESULTS Of the 831 AUR members recruited, 244 participated in the survey. 16 survey respondents did not complete all 12 questions on MBI-HSS and were excluded. Thus, a total of 228 academic radiologists completed all the 12 questions on abbreviated MBI-HSS and were included in the study, resulting in a response rate of 27%. Participants’ mean § standard deviation (SD) age was 48 § 11 years (range 3275 years). Participants’ mean § SD years of experience in academic radiology was 15 § 10 years (range 145 years). The average § SD number of work hours per week was 56 § 11 hours (range 30100 hours). Table 1 summarizes the survey respondent characteristics (categorical variables). Professional stressors most often scored by respondents as causing large or extreme amounts of stress were work overload (50%), lack of balance between personal and professional life (45%), lack of autonomy (28%), lack of appreciation by other health care staff (28%), and dispute with hospital leadership (25%) (Table 2). 179 respondents (79%) had one or more symptoms of burnout, demonstrating high emotional exhaustion and/or
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TABLE 1. Summary (Categorical)
of
Radiologist
Characteristics
Variable*
Levels
Gender
Female Male Asian Black or African American Native Hawaiian or other Pacific Islander White Other Assistant professor Associate professor Instructor Professor Other Abdominal radiology Breast radiology Cardiothoracic radiology Emergency/trauma radiology General radiology Interventional radiology Multiple subspecialties Musculoskeletal radiology Neuroradiology Nuclear medicine Other Pediatric radiology Full time Part time
Race
Rank
Subspecialty
Work schedule
BURNOUT IN ACADEMIC RADIOLOGISTS IN THE US
n
%
100 125 28 1 1
44.4 55.6 12.5 0.4 0.4
182 12 68 82 4 71 3 45 27 32 7 2 24 7 33 24 2 3 19 197 28
81.2 5.4 29.8 36.0 1.8 31.1 1.3 20.0 12.0 14.2 3.1 0.9 10.7 3.1 14.7 10.7 0.9 1.3 8.4 87.6 12.4
* Total number of respondents to survey items in Table 1 varies, given optional nature of demographic questions. 228 survey respondents completed all the 12 questions of MBI-HSS and were included in the study. Optional questions on gender, race, rank, subspecialty and work schedule pattern were completed by 225, 224, 228, 225 and 225 survey respondents respectively.
high depersonalization (Table 3). Sixty-six respondents (29%) met all three criteria for high burnout, characterized by the presence of high emotional exhaustion, high depersonalization, and low personal accomplishment scores. Various professional stressors including work overload, inability to balance personal and professional life, concern about not being promoted to higher academic rank, lack of autonomy, lack of appreciation from other medical staff, lack of appreciation from patients, concern about malpractice litigation, job insecurity, and dispute(s) with departmental/hospital leadership were significantly associated with high burnout (p < 0.05) (Table 4). Older age (OR, 0.95; 95%CI 0.920.98; p < 0.05), higher number of years of experience practicing as radiologists (OR, 0.95; 95%CI 0.920.98; p < 0.05), and holding academic rank of professor (OR, 0.25; 95%CI 0.110.56; p < 0.05) were factors associated with lower odds of experiencing burnout. With regards to career satisfaction, 26 (11%) respondents reported that they were either very dissatisfied or somewhat
TABLE 2. Professional Radiologists Variable* Work overload
Balance personal and professional life
Concern about promotion
Lack of autonomy
Lack of appreciation (staff)
Lack of appreciation (patients)
Concern about malpractice
Job insecurity 2 3 4 5 Dispute(s) w/ hospital leadership
Stressors
Causing
Stress
in
Likert score y
n
%
1 2 3 4 5 1
13 27 74 72 42 9
5.7 11.8 32.5 31.6 18.4 4.0
2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1
60 56 73 30 104 53 39 22 10 50 62 53 46 17 46 76 41 40 25 108
26.3 24.6 32.0 13.2 45.6 23.2 17.1 9.6 4.4 21.9 27.2 23.2 20.2 7.5 20.2 33.3 18.0 17.5 11.0 47.4
2 3 4 5 1
73 27 14 6 93
32.0 11.8 6.1 2.6 40.8
2 3 4 5 1
1
88 32 8 7 134 73 13 4 4 55
38.6 14.0 3.5 3.1 58.8 32.0 5.7 1.8 1.8 24.1
2 3 4 5
71 44 31 27
31.1 19.3 13.6 11.8
* All the 228 survey respondents completed the questions on professional stressors. y Professional stressors were rated using Likert scale from 15 (Not at all = 1; Slight amount = 2; Moderate amount = 3; Large amount = 4; Extreme amount = 5).
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GANESHAN ET AL
TABLE 3. Burnout in Academic Radiologists Burnout Score* High emotional exhaustion (EE) score High depersonalization (DP) score Low personal accomplishment score High burnout One or more symptoms of burnout (high EE score and/ or high DP score)
n
%
Absent
97
42.5
Present Absent
131 62
57.5 27.2
Present Absent
166 130
72.8 57.0
Present Absent Present Absent
98 162 66 49
43.0 71.0 28.9 21.5
Present
179
78.5
* High burnout defined as coexistence of high emotional exhaustion score (score of 27 on the emotional exhaustion subscale) plus high depersonalization score (score of 10 on the depersonalization subscale) plus low personal accomplishment score (score of 33 on the personal accomplishment subscale). All the 228 survey respondents included in the study completed all the questions on abbreviated MBI-HSS used for measuring burnout.
dissatisfied, with their career in radiology. Radiologists who were dissatisfied with their career had higher odds of experiencing burnout (OR, 2.28; 95%CI 1.703.07; p < 0.0001) (Table 4). Radiologists who had high burnout were less likely to identify medicine as a sense of calling and had lower odds of finding their work rewarding (OR, 0.16; 95%CI 0.060.40; p < 0.001), seeing their work as the most important thing in life (OR, 0.29; 95%CI 0.150.58; p < 0.001) or enjoying talking about their work with others (OR, 0.31; 95%CI 0.160.59; p < 0.001) (Table 4). Radiologists with burnout also had lower odds of choosing their current work life again, if they had the opportunity (OR, 0.38; 95%CI 0.200.72; p = 0.003) or continuing with their current line of work if they were financially secure (OR, 0.42; 95%CI 0.220.79; p = 0.008). Sixty percent of the participants reported that their institution had a burnout prevention support group for faculties. DISCUSSION Burnout affecting physicians is rapidly rising in prevalence in the United States. No medical specialty seems to be spared, with reported rates of burnout ranging from 38% to 70% (29). In our study, 79% of academic radiologists experienced one or more symptoms of burnout. Excessive work load and work-life imbalance were the top two factors causing the highest amount of stress in radiologists. Demanding too much work to be completed within too little time leads to physical, mental, and emotional exhaustion (30). When 4
radiologists are working with a singular aim of meeting high relative value unit targets, they may feel rushed to complete the studies to achieve a faster turnaround time. Radiologists may also become less inclined to spend time discussing patients with referring physicians. All of these may lead to radiologists developing a callous attitude towards patients (depersonalization). No single solution is available for a problem of this magnitude. Multiple physician-specific and organization-specific interventions may be required (31). This should begin with an honest appraisal by leadership to understand what can be reasonably expected from radiologists in a given time period, accounting for the complexity of the cases and procedures performed. Ensuring adequate staffing to meet job demands and providing appropriate resources to enhance efficiency can also help alleviate work overload related stress (29,3234). Besides excess clinical workload, other factors may also be contributing to the excessive workload in radiologists; academic radiologists have numerous other professional commitments including education, research, administration, and quality improvement. Pursuing these activities often requires committing time outside of normal work hours, which may contribute to the perception of being overworked and negatively impact work-life balance (35). Interventions that may be helpful in addressing burnout have been described previously (31). Radiologists should devote appropriate amount of time for activities related to self-care and personal wellness, including adequate amount of sleep, proper nutrition, exercise, yoga, sports, meditation, and mindfulness. Spending quality time with family and friends may also be helpful to overcome burnout. Working remotely when possible, working part time, or reducing work hours are some of the options that may be explored to address the work-life imbalance, although it may not be applicable to all radiologists. When an institution’s leadership encourages and champions work-life balance, the physicians are likely to become highly engaged in their work, which can ultimately result in a happy work environment (35,36). In our study, lack of autonomy and disputes with institutional leadership were associated with high burnout in 28% of the survey respondents. Our study did not elucidate what factors led to disputes with institutional leadership and what issues contributed to lack of autonomy; however, it is reasonable to hypothesize that radiologists may perceive the inability to choose their work pattern as lack of autonomy. Similarly, the perception that their voices go unheard and that their views are not taken into account when decisions are made that directly concern their work life may also contribute to the sense of lack of autonomy. Addressing these issues may require intervention at both individual and organizational levels. Health care organizations must appreciate that burnout affects radiologists at all levels in their professional career, including radiology residents and department chairs (37,38). Hospital administration should strive to address any systemic issues that may be contributing to this epidemic. Having an open-minded approach, actively seeking input
Level
Gender
Female Male Asian Black or African American Native Hawaiian or other Pacific Islander Other White Assistant professor Associate professor Instructor Other Professor Full time Part time Continuous Continuous
Racey
Ranky
Work schedule
Career satisfaction I would choose my current work life again if I had the opportunity My work is one of the most important things in my life Enjoy talking about my work to others
N with Burnout
Odds Ratio
Lower CI
Upper CI
p value
100 125 28 1 1
24 40 11 1 1
— 1.49 — 4.565 4.565
— 0.823 — 0.046 0.046
— 2.697 — 449.344 449.344
— 0.1875 — 0.5167 0.5167
12 182 68 82 4 3 71 197 28 228 228
4 47 29 23 0 3 11 59 7 66 66
0.806 0.533 — 0.529 0.149 9.373 0.255 — 0.78 2.088 1.845
0.197 0.233 — 0.268 0.005 0.296 0.115 — 0.314 1.514 1.378
3.299 1.219 — 1.043 4.041 296.796 0.564 — 1.933 2.878 2.471
0.7638 0.1362 — 0.0661 0.2580 0.2043 0.0008 — 0.5911 <0.0001 <0.0001
Continuous Continuous Continuous Continuous
228 228 228 228
66 66 66 66
1.491 1.681 1.717 1.956
1.175 1.311 1.354 1.463
1.893 2.156 2.179 2.615
0.0010 <0.0001 < 0.0001 <0.0001
Continuous Continuous Continuous No
228 228 228 91
66 66 66 30
1.563 1.475 1.341 —
1.17 1.056 1.077 —
2.087 2.06 1.669 —
0.0025 0.0228 0.0087 —
Yes Continuous No
135 227 59
35 65 26
0.712 2.289 —
0.398 1.705 —
1.274 3.073 —
0.2523 <0.0001 —
Yes No
167 45
39 23
0.387 —
0.207 —
0.724 —
0.0030 —
Yes No
182 56
43 27
0.296 —
0.15 —
0.582 —
0.0004 —
Yes
171
39
0.317
0.168
0.598
0.0004 (continued on next page)
BURNOUT IN ACADEMIC RADIOLOGISTS IN THE US
Work overload Balance between personal & professional life Concern about promotion Lack of autonomy Lack of appreciation from staff Lack of appreciation from patients Concern about malpractice Job insecurity Dispute(s) w/ hospital leadership Institution has burnout support group
Total
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Parameter*
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TABLE 4. Logistic Regression Models for Burnout
Parameter*
Level
Find my work rewarding If financially secure, I would continue with my current line of work even if I were no longer paid Primary reason for working is financial-to support my family and lifestyle
Odds Ratio
Lower CI
Upper CI
p value
No Yes No
24 203 137
16 50 49
— 0.163 —
— 0.066 —
— 0.405 —
— <0.0001 —
Yes No
89 92
17 21
0.424 —
0.225 —
0.799 —
0.0080 —
Yes No
132 114
44 28
1.69 —
0.922 —
3.101 —
0.0898 —
Yes Continuous Continuous Continuous Continuous Continuous
111 219 228 222 227 227
38 62 66 64 66 65
1.599 0.953 0.954 1.003 1.001 1.007
0.896 0.923 0.924 0.997 0.975 0.994
2.854 0.984 0.985 1.009 1.028 1.021
0.1123 0.0029 0.0044 0.2705 0.9189 0.2965
Continuous
227
65
0.989
0.972
1.007
0.2181
Continuous
227
66
1.005
0.979
1.033
0.6989
Continuous
219
64
1.021
0.982
1.061
0.3014
Continuous Continuous Continuous
228 228 228
66 66 66
1.112 1.232 0.758
1.077 1.157 0.701
1.147 1.311 0.818
<0.0001 <0.0001 <0.0001
* Total number of respondents to survey items in Table 4 varies, given optional nature of some of the questions. 228 survey respondents completed all the 12 questions of MBI-HSS and were included in the study. All the 228 survey respondents completed all questions on professional stressors. Optional questions on gender, age, race, rank, work schedule pattern, number of years practicing, total faculty in department, hours worked per week, percentage of time spent in patient care, administration, teaching and research availability of institutional burnout support group and career satisfaction were completed by 225, 219, 224, 228, 225, 228, 222, 227, 227, 227, 227, 219, 226, and 227 survey respondents respectively. Optional questions on sense of calling including “I would choose my current work life again if I had the opportunity,” “My work is one of the most important things in my life,” “I enjoy talking about my work to others,” “I find my work rewarding,” “If I was financially secure, I would continue with my current line of work even if I were no longer paid,” “My primary reason for working is financial-to support my family and lifestyle” and “I view my job as just a necessity of life, much like breathing or sleeping” were completed by 226, 227, 227, 227, 226, 224, and 225 survey respondents respectively. y Indicates that model fit with Firth penalized likelihood method due to lack of events in one or more categories.
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Age Number of years practicing Total faculty in dept. Hours worked per week % of work hours spent in patient care % of work hours spent in administration % of work hours spent in teaching % of work hours spent in research Emotional exhaustion score Depersonalization score Personal accomplishment score
N with Burnout
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View job as just a necessity of life, much like breathing or sleeping
Total
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TABLE 4. (Continued)
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from radiologists on matters that directly concerns them, and taking steps to promote work-life integration may be mutually beneficial. Radiologists should figure out what component of autonomy they value the most and hold open discussions with leadership. However, radiologists should also be cognizant of the fact that any desire for increased autonomy does not impede patient care. Lack of appreciation (both from other medical staff and from patients) are associated with high burnout. Diagnostic radiologists frequently work in isolation as they seek to decrease distractions, improve their efficiency, productivity, and accuracy in image interpretation. The unintended consequence may be erosion of the physician-patient encounter which diminishes the value of radiologists’ in direct patient care. Lack of meaningful interactions with patients can dehumanize physicians leading to depersonalization. Creating more opportunities for radiologists to interact with patients can strengthen the patient-physician relationship and may potentially help re-energize the original calling to medicine (39). Equally, the opportunity to collaborate with referring physicians through ad hoc interactions such as communication of imaging findings, multidisciplinary conferences, and dedicated radiology consultation clinics can enhance direct communication with referring physicians and patients (4042). Interestingly, although concern about malpractice litigation and job insecurity were associated with burnout, these were rated relatively low as professional stressors compared to the factors described previously. Only 6.6% and 3.6% reported experiencing large or extreme amount of stress from malpractice litigation and job insecurity respectively. Working in academia comes with many benefits. It is possible that working in an academic radiology department as part of the university system may confer a greater sense of job security and reduced malpractice concerns among academic radiologists. However, we acknowledge that these stressors also need addressing. Being more aware of what may and may not be potential malpractice lawsuits could help dispel some myths and alleviate the fear. Furthermore, peer learning, can be a powerful educational tool which may help reduce diagnostic errors in radiology (4345). Continuous self-learning in a supportive environment amongst peers may mitigate against the fears of job insecurity. Sense of calling refers to “committing one’s life to a work that is personally meaningful and serving with a deep sense of purpose for the greater good of society” (22,24). A few studies have shown that physicians with a sense of calling are more likely to have greater career satisfaction and less likely to burnout. In a study involving 896 primary care physicians and 312 psychiatrists, physicians who viewed medicine as a calling experienced higher levels of career satisfaction and greater resilience from burnout (26). Similarly, Jager et al reported that physicians with eroded sense of calling are more likely to experience burnout (25). In another study involving 1156 physicians working in end-of-life specialties, burned-out physicians working in profitcentered clinical environments experienced more emotional exhaustion when providing care for the dying while those
BURNOUT IN ACADEMIC RADIOLOGISTS IN THE US
physicians who identified medicine as a calling were more likely to feel emotionally energized when caring for the patients (46). In our study as well, radiologists who reported medicine as a calling were less likely to experience burnout. We believe this is an important finding. Re-igniting the physicians’ sense of calling may be an antidote for combating emotional exhaustion and depersonalization. Teaching trainees the importance of patient centered care may act as a helpful tool to reduce burnout and enhance their wellbeing throughout their professional careers (38,47). Leaders of health care systems may consider restructuring organizational design to incorporate more than one parameter of measuring physician value. Empowering physicians to make decisions on how to provide patient-centered care together with other academic priorities may increase engagement, thereby promoting physician wellness (48,49). Our study has limitations. The response rate was 27%, thereby creating biases inherent in any survey with a low response rate. Another limitation of the survey is that there may have been a difference in the response rate to the survey between academic radiologists with and without burnout that could have skewed the results of the survey. Further, it is possible that other professional stressors not reflected in the survey may also be contributing to burnout in radiologists. A longitudinal study with larger study population would be helpful. In summary, our study showed that a significant percentage of academic radiologists are experiencing one or more symptoms of burnout. Considering the known considerable adverse effects of physician burnout, urgent measures are needed to address this malady and promote health and wellness among radiologists. Institutional leadership should pursue meaningful steps to provide an emotionally thriving environment for the physicians to perform at their best. FUNDING This study was supported by MD Anderson Cancer Center Support Grant No. NIH/NCI P30 CA016672 from the National Cancer Institute, National Institutes of Health. ACKNOWLEDGMENT The authors thank the AUR for their support, and their assistance in the distribution of the survey. We also thank the academic radiologists for their participation in the survey. REFERENCES 1.
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