- Email: [email protected]
Prevalence of Burnout Among Canadian Radiologists and Radiology Trainees
Canadian Association of Radiologists Journal xx (2018) 1e6 www.carjonline.org
Health Policy and Practice/Sante: politique et pratique medicale
Prevalence of Burnout Among Canadian Radiologists and Radiology Trainees Nanxi Zha, MDa, Michael N. Patlas, MD, FRCPCa,*, Nick Neuheimer, MSb, Richard Duszak Jr., MDc a
Division of Emergency/Trauma Radiology, Department of Radiology, McMaster University, Hamilton, Ontario, Canada b Canadian Association of Radiologists, Ottawa, Ontario, Canada c Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, United States
Abstract Purpose: Physician burnout is on the rise compared to the average population, and radiology burnout rates are ranked high compared to other specialties. We aim to assess radiologist and radiology trainee burnout in Canada. Methods: A survey using the abbreviated 7-item Maslach Burnout Inventory that characterizes burnout symptoms into personal accomplishment, emotional exhaustion, and depersonalization was sent to all eligible members of the Canadian Association of Radiologists in January 2018. The anonymous survey was hosted on SurveyMonkey for 1 month. A reminder e-mail was sent halfway through the survey period. Results: Overall, 262 of 1401 invited radiology trainees and radiologists completed the survey (response rate 18.7%). With regards to personal accomplishment, we observed that (1) burnout in this domain improved with increased years worked and (2) milder symptoms were observed in community radiologists compared with their academic counterparts. In comparison with other studies of radiologist burnout, we found mild burnout symptoms in personal accomplishment, but severe symptoms in the burnout domains of both emotional exhaustion and depersonalization. Conclusions: Canadian radiologists and radiology trainees reported above average burnout symptoms with regard to both emotional exhaustion and depersonalization. Future research directions include exploring etiologies of burnout and implementation of treatment strategies based on these identified problem areas. Resume Objet : L’epuisement professionnel est en hausse chez les medecins par rapport a la population moyenne. Chez les radiologistes, le taux d’epuisement est eleve comparativement aux autres specialites. Notre etude vise a evaluer le taux d’epuisement professionnel chez les radiologistes et les etudiants en radiologie. Methodes : Un sondage utilisant une version abregee en sept points de l’inventaire d’epuisement professionnel de Maslach, qui caracterise les sympt^omes de l’epuisement professionnel selon trois volets, soit la perte d’efficacite personnelle, l’epuisement emotionnel et la depersonnalisation, a ete envoye a tous les membres admissibles de l’Association canadienne des radiologistes en janvier 2018. Ce sondage anonyme est reste sur le site SurveyMonkey pendant un mois. Un rappel a ete envoye par courriel deux semaines avant la fin de cette periode. Resultats : Au total, 262 des 1 401 etudiants et radiologistes invites ont repondu au sondage (soit un taux de reponse de 18.7%). En ce qui concerne la perte d’efficacite personnelle, nous avons constate premierement que les risques d’epuisement professionnel diminuent a mesure que le nombre d’annees d’exercice augmente et deuxiemement, que les radiologistes travaillant dans la collectivite presentent des sympt^ omes moins marques que leurs collegues travaillant dans des etablissements d’enseignement. Par rapport aux autres etudes realisees sur l’epuisement professionnel chez les radiologistes, nous avons observe des sympt^ omes benins pour le volet de la perte d’efficacite personnelle, mais des sympt^omes graves pour l’epuisement emotionnel et la depersonnalisation.
* Address for correspondence: Michael N. Patlas, MD, FRCPC, Division of Emergency/Trauma Radiology, Department of Radiology Hamilton General Hospital, Hamilton, Ontario L8L 2X2, Canada.
E-mail address: [email protected] (M. N. Patlas).
0846-5371/$ - see front matter Ó 2018 Canadian Association of Radiologists. All rights reserved. https://doi.org/10.1016/j.carj.2018.05.005
2
N. Zha et al. / Canadian Association of Radiologists Journal xx (2018) 1e6
Conclusions : Les radiologistes et les etudiants en radiologie au Canada disent presenter des sympt^ omes d’epuisement emotionnel et de depersonnalisation plus eleves que la moyenne. Les prochaines recherches devront mettre l’accent sur l’etiologie de l’epuisement professionnel et la mise en œuvre de strategies de traitement axees sur les problemes observes ci-dessus. Ó 2018 Canadian Association of Radiologists. All rights reserved. Key Words: Burnout; Canada; Radiologists; Radiology residents
Nearly half of all physicians experience some symptoms of burnout [1]. Between 2011 and 2014, a significant increase in burnout rates was observed in physicians compared to the general working population internationally [2,3]. Additionally, reports of increased burnout symptoms in recent years have been reported across various medical disciplines [2,4,5]. Aside from leading to poorer patient care [6] and physician mental health [7], burnout is estimated to cost the Canadian health care system of approximately $213.1 million annually [8]. According to the Maslach Burnout Inventory (MBI), burnout can be characterized as emotional exhaustion, depersonalization, and perceived lack of personal accomplishments [9]. A 22-item survey was previously created and validated to quantify these characteristics [10]. This survey can be further distilled into 7 items for ease-ofuse consisting of 5 questions on personal accomplishments, one on emotional exhaustion, and one on depersonalization [11,12]. While technology has revolutionized the field of radiology and its role in health care, it has also exacerbated burnout rates in terms of increased volume, work isolation, and workflow inefficiencies [13]. In fact, radiology burnout rates rank high amongst specialists in the United States [1,14]. Adverse events related to radiology burnout include substandard patient care and the lack of opportunity for nonclinical professional work for professional growth [15]. The health care delivery system in the United States is different, however, from that in Canada. To our knowledge, burnout in Canadian radiologists and radiology trainees has not previously been studied. Therefore, we aim to assess radiology burnout amongst Canadian radiologists and radiology trainees as an initial step towards improving working conditions and, therefore, potentially patient care. Methods Data Collection Our study protocol was approved by both a local research ethics board and the Canadian Association of Radiologists (CAR). The CAR assisted our project by contacting all 1401 eligible members (residents, fellows, and staff radiologists practicing in Canada who previously agreed to receive promotional emails) in January of 2018. Willing members were asked to complete an electronic survey via a link within the e-mail. The survey was hosted by SurveyMonkey and remained open for 1 month. A reminder e-mail was sent at
approximately the 2-week mark to individuals who had yet to click on the survey link. In order to optimize survey integrity, the online survey platform was structured to permit only 1 response per computer IP address. Physician subject consent was collected electronically prior to each participant’s commencement of the survey. Other than basic demographic information, no individually identifying participant data was collected (Table 1). Due to the sensitive and self-reflective nature of this survey, a link to online physician mental health resources (https://www.cma.ca/En/Pages/provincialphysician-health-programs.aspx) was additionally included as part of the survey should any participant wish to seek help for their burnout symptoms. Maslach Burnout Inventory The MBI consists of 22 items on emotional exhaustion, depersonalization, and perceived lack of personal accomplishments. In our study, an abbreviated version of the MBI was used to encourage participation. Previous work has validated the abbreviation of emotional exhaustion and depersonalization symptoms to one question each [11,12,16]. The questions were scored on a 7-point ordinal scale of symptoms experienced ‘‘never’’ to ‘‘everyday,’’ which were then categorized into low, medium, and high degrees of burnout [10]. A low score on personal accomplishment questions while high scores on the emotional exhaustion and depersonalization questions were regarded as symptoms of severe burnout. Scoring for the abbreviated MBI consists of 1.6-fold emphasis on sum of scores for the personal accomplishments, 9-fold emphasis on the single-question emotional exhaustion score, and 5-fold emphasis on the Table 1 Demographics Demographics Gender Male Female Undisclosed Years in practice Radiology resident/fellow Less than 20 years More than 20 years Practice location Academic site Community site Other
Responders 176 (67.2) 83 (31.7) 3 (1.2) 46 (17.6) 111 (42.4) 105 (40.1) 140 (53.4) 119 (45.4) 3 (1.2)
Data are number of respondents with percentages in parentheses.
Burnout among Canadian Radiologists / Canadian Association of Radiologists Journal xx (2018) 1e6
3
single-question depersonalization score [11]. In the personal accomplishments domain, scores of less than 32 were considered low, scores between 32-38 moderate, and scores above 38 high. For the emotional exhaustion domain, scores of less than 17 were considered low, between 17-26 moderate, and greater than 27 high. Finally, scores less than 7 in the depersonalization domain were considered low, scores between 7-12 moderate, and scores greater than 12 high [10]. Low levels in personal accomplishments and high levels in emotional exhaustion and depersonalization were categorized as burnout. In addition to questions pertaining to the abbreviated MBI, 3 questions related to demographics were added (gender, years in practice, and type of workplace) to permit subgroup analysis. The survey in its entirety is found in Appendix 1. Analysis Statistical analysis was performed using Graphpad Prism 7, version 7.03 (Graphpad Software, Inc, San Diego, CA). For normative data, unpaired t tests and ordinary 1-way analysis of variance tests were used to calculate significant difference. For non-normative data, Mann-Whitney and Kruskal-Wallis tests were used for significance calculations. Significant results were defined as a < 0.05, with Bonferroni correction used to account for multiplicity. To compare our study against existing radiology burnout studies, we performed a literature search on PubMed using key words ‘‘radiology burnout Maslach.’’ Six relevant studies were initially identified [14,17e21]; however, 2 of these studies did not disclose overall mean scores in the three MBI domains and, thus, were excluded from the comparison [17,18]. Results From the 1401 Canadian radiology residents, fellows, and staff physicians contacted, we obtained responses from
Figure 1. Overall Maslach Burnout Inventory symptoms breakdown. Percentage of respondents experiencing each burnout symptom categorized by low (black), moderate (grey), and high (white) burnout scores.
Figure 2. Burnout symptoms breakdown by demographics. (A) Burnout symptoms by gender. Mean burnout scores attained by male (black) and female (white) respondents for each burnout symptom. (B) Burnout symptoms by training level. Mean burnout scores attained by trainees (black), <20 years worked (grey), and >20 years worked (white) for each burnout symptom. (C) Burnout symptoms by work site. Mean burnout scores attained by academic (black) and community (white) respondents for each burnout symptom. Significant results are indicated by asterisk.
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N. Zha et al. / Canadian Association of Radiologists Journal xx (2018) 1e6
191 and 71 participants after the first and second solicitations respectively, for a total of 262 responses (response rate 18.7%). As outlined in Table 1, 176 of 262 (67.2%) respondents were male, 83 of 262 (31.7%) respondents were female, and 3 of 262 (1.2%) respondents chose to not disclose their gender. In terms of work experience, 46 of 262 (17.6%) respondents were trainees (radiology residents or fellows), 111 of 262 (42.4%) respondents were less than 20 years into practice as a staff radiologist, and 105 of 262 (40.1%) respondents were more than 20 years into practice. Lastly, 140 of 262 (53.4%) respondents indicated an academic site of practice, while 119 of 262 (45.4%) indicated a community site, and 3 of 262 (1.2%) indicated other types of practice sites. In the personal accomplishments domain, 46 of 262 (17.6%) respondents scored low, 97 of 262 (37.0%) scored moderate, and 119 of 262 (45.4%) scored high. In the emotional exhaustion domain, 40 of 262 (15.3%) respondents scored low, 34 of 262 (13.0%) scored moderate, and 188 of 262 (71.8%) scored high. In the depersonalization domain, 95 of 262 (36.3%) respondents scored low, 41 of 262 (15.7%) scored moderate, and 126 of 262 (48.1%) respondents scored high. These results are represented graphically in Figure 1. Figure 2 illustrates burnout scores based on gender, training level, and work site. After accounting for multiplicity, significant differences in burnout symptoms were observed in personal accomplishments across training levelsdas the radiologist progressed in number of years worked, an improvement in his or her level of burnout in this domain was observed (P < .0001). In addition, there was significantly less burnout related to personal accomplishment in community radiologists relative to their academic counterparts (P < .005). Table 2 highlights results of our study compared to other radiology burnout studies that have utilized the MBI, as well as the Maslach burnout study on health care professionals. In our survey, we observed a lower level of burnout symptoms in the personal accomplishments domain but higher levels of burnout symptoms in the emotional exhaustion and depersonalization domains. Given the methodological differences in these surveys, we are unable to comment on the significance of these comparisons.
Discussion Experiences of burnout amongst radiologists are well documented internationally [14,17,18]. To our knowledge, ours is the first study of burnout symptoms of Canadian radiologists and radiology trainees. Utilizing the MBI, we characterized radiologist burnout in 3 well accepted and interrelated domains: personal accomplishments, emotional exhaustion, and depersonalization. For individuals experiencing burnout, emotional exhaustion is often the first sign of workplace challenges, which is thought to be the lack of energy to face challenges and stress [23]. Depersonalization is a interpersonal detachment response due to an overload of emotional exhaustion [23]. Personal accomplishment is a self-protective response against burnout [10]. Hence, high scores in emotional exhaustion and depersonalization, together with low scores in personal accomplishment, implies severe burnout symptoms [10]. We observed that burnout patterns amongst Canadian were similar to those of radiologists in other countries. Specifically, the elevation in emotional exhaustion and depersonalization we noted have been observed elsewhere [14,22]. In addition, our findings also comport with those from a recent study that investigated gender trendsdhigher personal accomplishment scores in men compared to women, implying perhaps men had more burnout-protective factors than women [20]. Similar to another study, we also found that women scored higher on emotional exhaustion and depersonalization [19]. In terms of training level, we observed a significant increase in personal accomplishment scores as the physicians attain years in work experience. This finding is a novel one, not explored in previous studies of radiologists. Lastly, we noted significantly higher mean MBI score in the community sites compared to academic work site, which again comports with prior work outside of Canada [20]. In terms of overall trends, we found on average higher scores in personal accomplishment, emotional exhaustion, and depersonalization compared to previous studies (Table 2), suggesting the Canadian radiologists, despite experiencing more burnout in the emotional exhaustion and depersonalization domains, had good burnout-protective factors as observed by their high personal accomplishment scores. Previous studies have alluded to burnout etiologies ranging from financial challenges during
Table 2 Comparison of burnout rates against other studies Mean MBI Score Study
Country
Personal accomplishments
Emotional exhaustion
Depersonalization
Porrino et al [19] Guenette et al [14] Chew et al [20] Singh et al [22] Maslach et al [21] This study
United States United States United States New Zealand United States Canada
28.4 33.0 32.6 32.9 36.5 37.5
25.1 24.3 28.7 44.9 22.2 31.8
11.1 10.6 9.3 20.6 7.1 12.7
Data in parentheses are standard deviation when available. MBI ¼ Maslach Burnout Inventory.
(7.8) (10.3) (4.9) (7.3) (7.2)
(12.4) (14.4) (7.1) (9.5) (15.3)
(6.9) (9.3) (5.6) (5.2) (9.1)
Burnout among Canadian Radiologists / Canadian Association of Radiologists Journal xx (2018) 1e6
training [12] to organizational discomforts [24] to rapid changes in the health care models [19]. The influence of these various factors on radiology burnout is an opportunity for future study. Given the relatively few radiologists in all of Canada, one limitation of our study was its relatively small sample size. Anticipating low response rates as a potential issue, we opted to utilize the abbreviated 7-questions MBI survey (instead of the comprehensive 22-question survey) to enhance our response rate, and, additionally, utilized a reminder e-mail halfway through the survey period. A strength of this study was our partnership with the CAR, which graciously approved our study and helped encourage member participation. In addition, we used an online, anonymized platform for our survey, as this has been shown previously to be helpful in reaching potentially hidden populations (eg, individuals who otherwise would not feel comfortable disclosing high burnout) [25]. Finally, we quantified burnout symptoms with the well-accepted and validated MBI, which enabled meaningful comparisons between our study and previous studies. Conclusion In conclusion, burnout in radiology is a significant issue worldwide, and in this regard, Canadian radiologists are not immune. Given its impact on both physician labor and patient care, more work is necessary. Burnout prevention strategies includes programs to better communications [26], improve constructive trainee feedback [27], decrease workplace isolation [13], and strengthen resiliency [28]. Acknowledgements The authors would like to thank Dr Jason Ko for proofreading the manuscript. References [1] Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med 2012;172:1377e85. [2] 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: 1600e13. [3] Cohen D, Rhydderch M. Measuring a doctor’s performance: personality, health and well-being. Occup Med 2006;56:438e40. [4] Panagioti M, Geraghty K, Johnson J. How to prevent burnout in cardiologists? A review of the current evidence, gaps, and future directions. Trends Cardiovasc Med 2018;28:1e7. [5] Ames SE, Cowan JB, Kenter K, Emery S, Halsey D. Burnout in orthopaedic surgeons: a challenge for leaders, learners, and colleagues: AOA critical issues. J Bone Joint Surg Am 2017;99:e78. [6] Klein J, Grosse Frie K, Blum K, von dem Knesebeck O. Burnout and perceived quality of care among German clinicians in surgery. Int J Qual Health Care J Int Soc Qual Health Care 2010;22:525e30. [7] Asai M, Morita T, Akechi T, et al. Burnout and psychiatric morbidity among physicians engaged in end-of-life care for cancer patients:
[8]
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[12]
[13]
[14]
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[16]
[17]
[18]
[19]
[20]
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[26]
[27]
[28]
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a cross-sectional nationwide survey in Japan. Psychooncology 2007;16: 421e8. Dewa CS, Jacobs P, Thanh NX, Loong D. An estimate of the cost of burnout on early retirement and reduction in clinical hours of practicing physicians in Canada. BMC Health Serv Res 2014;14:254. Maslach C, Schaufeli WB, Leiter MP. Job burnout. Ann Rev Psychol 2001;52:397e422. Maslach C, Jackson S, Leiter M. Maslach Burnout Inventory manual. 3rd ed. Menlo Park, CA: Mind Garden; 1996. West CP, Dyrbye LN, Satele DV, Sloan JA, Shanafelt TD. Concurrent validity of single-item measures of emotional exhaustion and depersonalization in burnout assessment. J Gen Intern Med 2012; 27:1445e52. McNeeley MF, Perez FA, Chew FS. The emotional wellness of radiology trainees: prevalence and predictors of burnout. Acad Radiol 2013;20:647e55. Restauri N, Flug JA, Mcarthur TA. A picture of burnout: case studies and solutions toward improving radiologists’ well-being. Curr Probl Diagn Radiol 2017;46:365e8. Guenette JP, Smith SE. Burnout: prevalence and associated factors among radiology residents in New England with comparison against United States resident physicians in other specialties. AJR Am J Roentgenol 2017;209:136e41. Chen JY, Lexa FJ. Baseline survey of the neuroradiology work environment in the United States with reported trends in clinical work, nonclinical work, perceptions of trainees, and burnout metrics. AJNR Am J Neuroradiol 2017;38:1284e91. West CP, Dyrbye LN, Sloan JA, Shanafelt TD. Single item measures of emotional exhaustion and depersonalization are useful for assessing burnout in medical professionals. J Gen Intern Med 2009;24:1318e21. Graham J, Ramirez AJ, Field S, Richards MA. Job stress and satisfaction among clinical radiologists. Clin Radiol 2000;55:182e5. discussion 186. Lim RCH, Pinto C. Work stress, satisfaction and burnout in New Zealand radiologists: comparison of public hospital and private practice in New Zealand. J Med Imaging Radiat Oncol 2009;53:194e9. Porrino J, Mulcahy MJ, Mulcahy H, Relyea-Chew A, Chew FS. Emotional wellness of current musculoskeletal radiology fellows. Acad Radiol 2017;24:682e93. Chew FS, Mulcahy MJ, Porrino JA, Mulcahy H, Relyea-Chew A. Prevalence of burnout among musculoskeletal radiologists. Skeletal Radiol 2017;46:497e506. Maslach C, Jackson S, Leiter M. Maslach Burnout Inventory: manual and non-reproducible instrument and scoring guides. Mountain View, CA: CPP, Inc; 2010. Singh N, Knight K, Wright C, et al. Occupational burnout among radiographers, sonographers and radiologists in Australia and New Zealand: findings from a national survey. J Med Imaging Radiat Oncol 2017;61:304e10. Maslach C, Leiter MP. New insights into burnout and health care: Strategies for improving civility and alleviating burnout. Med Teach 2017;39:160e3. Magnavita N, Fileni A, Magnavita G, et al. Work stress in radiologists. A pilot study. Radiol Med (Torino) 2008;113:329e46. Rhodes SD, Bowie DA, Hergenrather KC. Collecting behavioural data using the world wide web: considerations for researchers. J Epidemiol Community Health 2003;57:68e73. Rosenkrantz AB, Kang SK, Rybak L, Alexa D, Recht MP. The reading room coordinator: reducing radiologist burnout in the digital age. J Am Coll Radiol JACR 2018;15:65e8. Guenette JP, Smith SE. Burnout: job resources and job demands associated with low personal accomplishment in United States radiology residents. Acad Radiol 2018;25:739e43. Sood A, Sharma V, Schroeder DR, Gorman B. Stress Management and Resiliency Training (SMART) program among department of radiology faculty: a pilot randomized clinical trial. EXPLORE J Sci Heal 2014; 10:358e63.
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Appendix 1. Burnout in Radiology Questionnaire Demographics 1. Gender a. Male b. Female
c. Prefer not to disclose
2. Years in practice as a staff radiologist. a. Resident/fellow b. <20 years c. >20 years 3. Practice location where I spend the most time. a. Academic site b. Community site c. Other Personal accomplishment 4. I can effectively solve the problems that arise in my work. 0. 1. 2. 3. 4. 5. 6. Never Everyday 5. I feel I am making an effective contribution to my radiology department. 0. 1. 2. 3. 4. 5. 6. Never Everyday 6. In my opinion, I am good at my job. 0. 1. 2. 3. 4. 5. 6. Never Everyday
7. I have accomplished many worthwhile things to the radiology field. 0. 1. 2. 3. 4. 5. 6. Never Everyday 8. I feel I am making an effective contribution to patient care. 0. 1. 2. 3. 4. 5. 6. Never Everyday Emotional exhaustion 9. I feel burned out from my work. 0. 1. 2. 3. 4. 5. 6. Never Everyday Depersonalization 10. I have become more callous toward people since I took this job. 0. 1. 2. 3. 4. 5. 6. Never Everyday
Health Policy and Practice/Sante: politique et pratique medicale
Prevalence of Burnout Among Canadian Radiologists and Radiology Trainees Nanxi Zha, MDa, Michael N. Patlas, MD, FRCPCa,*, Nick Neuheimer, MSb, Richard Duszak Jr., MDc a
Division of Emergency/Trauma Radiology, Department of Radiology, McMaster University, Hamilton, Ontario, Canada b Canadian Association of Radiologists, Ottawa, Ontario, Canada c Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, United States
Abstract Purpose: Physician burnout is on the rise compared to the average population, and radiology burnout rates are ranked high compared to other specialties. We aim to assess radiologist and radiology trainee burnout in Canada. Methods: A survey using the abbreviated 7-item Maslach Burnout Inventory that characterizes burnout symptoms into personal accomplishment, emotional exhaustion, and depersonalization was sent to all eligible members of the Canadian Association of Radiologists in January 2018. The anonymous survey was hosted on SurveyMonkey for 1 month. A reminder e-mail was sent halfway through the survey period. Results: Overall, 262 of 1401 invited radiology trainees and radiologists completed the survey (response rate 18.7%). With regards to personal accomplishment, we observed that (1) burnout in this domain improved with increased years worked and (2) milder symptoms were observed in community radiologists compared with their academic counterparts. In comparison with other studies of radiologist burnout, we found mild burnout symptoms in personal accomplishment, but severe symptoms in the burnout domains of both emotional exhaustion and depersonalization. Conclusions: Canadian radiologists and radiology trainees reported above average burnout symptoms with regard to both emotional exhaustion and depersonalization. Future research directions include exploring etiologies of burnout and implementation of treatment strategies based on these identified problem areas. Resume Objet : L’epuisement professionnel est en hausse chez les medecins par rapport a la population moyenne. Chez les radiologistes, le taux d’epuisement est eleve comparativement aux autres specialites. Notre etude vise a evaluer le taux d’epuisement professionnel chez les radiologistes et les etudiants en radiologie. Methodes : Un sondage utilisant une version abregee en sept points de l’inventaire d’epuisement professionnel de Maslach, qui caracterise les sympt^omes de l’epuisement professionnel selon trois volets, soit la perte d’efficacite personnelle, l’epuisement emotionnel et la depersonnalisation, a ete envoye a tous les membres admissibles de l’Association canadienne des radiologistes en janvier 2018. Ce sondage anonyme est reste sur le site SurveyMonkey pendant un mois. Un rappel a ete envoye par courriel deux semaines avant la fin de cette periode. Resultats : Au total, 262 des 1 401 etudiants et radiologistes invites ont repondu au sondage (soit un taux de reponse de 18.7%). En ce qui concerne la perte d’efficacite personnelle, nous avons constate premierement que les risques d’epuisement professionnel diminuent a mesure que le nombre d’annees d’exercice augmente et deuxiemement, que les radiologistes travaillant dans la collectivite presentent des sympt^ omes moins marques que leurs collegues travaillant dans des etablissements d’enseignement. Par rapport aux autres etudes realisees sur l’epuisement professionnel chez les radiologistes, nous avons observe des sympt^ omes benins pour le volet de la perte d’efficacite personnelle, mais des sympt^omes graves pour l’epuisement emotionnel et la depersonnalisation.
* Address for correspondence: Michael N. Patlas, MD, FRCPC, Division of Emergency/Trauma Radiology, Department of Radiology Hamilton General Hospital, Hamilton, Ontario L8L 2X2, Canada.
E-mail address: [email protected] (M. N. Patlas).
0846-5371/$ - see front matter Ó 2018 Canadian Association of Radiologists. All rights reserved. https://doi.org/10.1016/j.carj.2018.05.005
2
N. Zha et al. / Canadian Association of Radiologists Journal xx (2018) 1e6
Conclusions : Les radiologistes et les etudiants en radiologie au Canada disent presenter des sympt^ omes d’epuisement emotionnel et de depersonnalisation plus eleves que la moyenne. Les prochaines recherches devront mettre l’accent sur l’etiologie de l’epuisement professionnel et la mise en œuvre de strategies de traitement axees sur les problemes observes ci-dessus. Ó 2018 Canadian Association of Radiologists. All rights reserved. Key Words: Burnout; Canada; Radiologists; Radiology residents
Nearly half of all physicians experience some symptoms of burnout [1]. Between 2011 and 2014, a significant increase in burnout rates was observed in physicians compared to the general working population internationally [2,3]. Additionally, reports of increased burnout symptoms in recent years have been reported across various medical disciplines [2,4,5]. Aside from leading to poorer patient care [6] and physician mental health [7], burnout is estimated to cost the Canadian health care system of approximately $213.1 million annually [8]. According to the Maslach Burnout Inventory (MBI), burnout can be characterized as emotional exhaustion, depersonalization, and perceived lack of personal accomplishments [9]. A 22-item survey was previously created and validated to quantify these characteristics [10]. This survey can be further distilled into 7 items for ease-ofuse consisting of 5 questions on personal accomplishments, one on emotional exhaustion, and one on depersonalization [11,12]. While technology has revolutionized the field of radiology and its role in health care, it has also exacerbated burnout rates in terms of increased volume, work isolation, and workflow inefficiencies [13]. In fact, radiology burnout rates rank high amongst specialists in the United States [1,14]. Adverse events related to radiology burnout include substandard patient care and the lack of opportunity for nonclinical professional work for professional growth [15]. The health care delivery system in the United States is different, however, from that in Canada. To our knowledge, burnout in Canadian radiologists and radiology trainees has not previously been studied. Therefore, we aim to assess radiology burnout amongst Canadian radiologists and radiology trainees as an initial step towards improving working conditions and, therefore, potentially patient care. Methods Data Collection Our study protocol was approved by both a local research ethics board and the Canadian Association of Radiologists (CAR). The CAR assisted our project by contacting all 1401 eligible members (residents, fellows, and staff radiologists practicing in Canada who previously agreed to receive promotional emails) in January of 2018. Willing members were asked to complete an electronic survey via a link within the e-mail. The survey was hosted by SurveyMonkey and remained open for 1 month. A reminder e-mail was sent at
approximately the 2-week mark to individuals who had yet to click on the survey link. In order to optimize survey integrity, the online survey platform was structured to permit only 1 response per computer IP address. Physician subject consent was collected electronically prior to each participant’s commencement of the survey. Other than basic demographic information, no individually identifying participant data was collected (Table 1). Due to the sensitive and self-reflective nature of this survey, a link to online physician mental health resources (https://www.cma.ca/En/Pages/provincialphysician-health-programs.aspx) was additionally included as part of the survey should any participant wish to seek help for their burnout symptoms. Maslach Burnout Inventory The MBI consists of 22 items on emotional exhaustion, depersonalization, and perceived lack of personal accomplishments. In our study, an abbreviated version of the MBI was used to encourage participation. Previous work has validated the abbreviation of emotional exhaustion and depersonalization symptoms to one question each [11,12,16]. The questions were scored on a 7-point ordinal scale of symptoms experienced ‘‘never’’ to ‘‘everyday,’’ which were then categorized into low, medium, and high degrees of burnout [10]. A low score on personal accomplishment questions while high scores on the emotional exhaustion and depersonalization questions were regarded as symptoms of severe burnout. Scoring for the abbreviated MBI consists of 1.6-fold emphasis on sum of scores for the personal accomplishments, 9-fold emphasis on the single-question emotional exhaustion score, and 5-fold emphasis on the Table 1 Demographics Demographics Gender Male Female Undisclosed Years in practice Radiology resident/fellow Less than 20 years More than 20 years Practice location Academic site Community site Other
Responders 176 (67.2) 83 (31.7) 3 (1.2) 46 (17.6) 111 (42.4) 105 (40.1) 140 (53.4) 119 (45.4) 3 (1.2)
Data are number of respondents with percentages in parentheses.
Burnout among Canadian Radiologists / Canadian Association of Radiologists Journal xx (2018) 1e6
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single-question depersonalization score [11]. In the personal accomplishments domain, scores of less than 32 were considered low, scores between 32-38 moderate, and scores above 38 high. For the emotional exhaustion domain, scores of less than 17 were considered low, between 17-26 moderate, and greater than 27 high. Finally, scores less than 7 in the depersonalization domain were considered low, scores between 7-12 moderate, and scores greater than 12 high [10]. Low levels in personal accomplishments and high levels in emotional exhaustion and depersonalization were categorized as burnout. In addition to questions pertaining to the abbreviated MBI, 3 questions related to demographics were added (gender, years in practice, and type of workplace) to permit subgroup analysis. The survey in its entirety is found in Appendix 1. Analysis Statistical analysis was performed using Graphpad Prism 7, version 7.03 (Graphpad Software, Inc, San Diego, CA). For normative data, unpaired t tests and ordinary 1-way analysis of variance tests were used to calculate significant difference. For non-normative data, Mann-Whitney and Kruskal-Wallis tests were used for significance calculations. Significant results were defined as a < 0.05, with Bonferroni correction used to account for multiplicity. To compare our study against existing radiology burnout studies, we performed a literature search on PubMed using key words ‘‘radiology burnout Maslach.’’ Six relevant studies were initially identified [14,17e21]; however, 2 of these studies did not disclose overall mean scores in the three MBI domains and, thus, were excluded from the comparison [17,18]. Results From the 1401 Canadian radiology residents, fellows, and staff physicians contacted, we obtained responses from
Figure 1. Overall Maslach Burnout Inventory symptoms breakdown. Percentage of respondents experiencing each burnout symptom categorized by low (black), moderate (grey), and high (white) burnout scores.
Figure 2. Burnout symptoms breakdown by demographics. (A) Burnout symptoms by gender. Mean burnout scores attained by male (black) and female (white) respondents for each burnout symptom. (B) Burnout symptoms by training level. Mean burnout scores attained by trainees (black), <20 years worked (grey), and >20 years worked (white) for each burnout symptom. (C) Burnout symptoms by work site. Mean burnout scores attained by academic (black) and community (white) respondents for each burnout symptom. Significant results are indicated by asterisk.
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191 and 71 participants after the first and second solicitations respectively, for a total of 262 responses (response rate 18.7%). As outlined in Table 1, 176 of 262 (67.2%) respondents were male, 83 of 262 (31.7%) respondents were female, and 3 of 262 (1.2%) respondents chose to not disclose their gender. In terms of work experience, 46 of 262 (17.6%) respondents were trainees (radiology residents or fellows), 111 of 262 (42.4%) respondents were less than 20 years into practice as a staff radiologist, and 105 of 262 (40.1%) respondents were more than 20 years into practice. Lastly, 140 of 262 (53.4%) respondents indicated an academic site of practice, while 119 of 262 (45.4%) indicated a community site, and 3 of 262 (1.2%) indicated other types of practice sites. In the personal accomplishments domain, 46 of 262 (17.6%) respondents scored low, 97 of 262 (37.0%) scored moderate, and 119 of 262 (45.4%) scored high. In the emotional exhaustion domain, 40 of 262 (15.3%) respondents scored low, 34 of 262 (13.0%) scored moderate, and 188 of 262 (71.8%) scored high. In the depersonalization domain, 95 of 262 (36.3%) respondents scored low, 41 of 262 (15.7%) scored moderate, and 126 of 262 (48.1%) respondents scored high. These results are represented graphically in Figure 1. Figure 2 illustrates burnout scores based on gender, training level, and work site. After accounting for multiplicity, significant differences in burnout symptoms were observed in personal accomplishments across training levelsdas the radiologist progressed in number of years worked, an improvement in his or her level of burnout in this domain was observed (P < .0001). In addition, there was significantly less burnout related to personal accomplishment in community radiologists relative to their academic counterparts (P < .005). Table 2 highlights results of our study compared to other radiology burnout studies that have utilized the MBI, as well as the Maslach burnout study on health care professionals. In our survey, we observed a lower level of burnout symptoms in the personal accomplishments domain but higher levels of burnout symptoms in the emotional exhaustion and depersonalization domains. Given the methodological differences in these surveys, we are unable to comment on the significance of these comparisons.
Discussion Experiences of burnout amongst radiologists are well documented internationally [14,17,18]. To our knowledge, ours is the first study of burnout symptoms of Canadian radiologists and radiology trainees. Utilizing the MBI, we characterized radiologist burnout in 3 well accepted and interrelated domains: personal accomplishments, emotional exhaustion, and depersonalization. For individuals experiencing burnout, emotional exhaustion is often the first sign of workplace challenges, which is thought to be the lack of energy to face challenges and stress [23]. Depersonalization is a interpersonal detachment response due to an overload of emotional exhaustion [23]. Personal accomplishment is a self-protective response against burnout [10]. Hence, high scores in emotional exhaustion and depersonalization, together with low scores in personal accomplishment, implies severe burnout symptoms [10]. We observed that burnout patterns amongst Canadian were similar to those of radiologists in other countries. Specifically, the elevation in emotional exhaustion and depersonalization we noted have been observed elsewhere [14,22]. In addition, our findings also comport with those from a recent study that investigated gender trendsdhigher personal accomplishment scores in men compared to women, implying perhaps men had more burnout-protective factors than women [20]. Similar to another study, we also found that women scored higher on emotional exhaustion and depersonalization [19]. In terms of training level, we observed a significant increase in personal accomplishment scores as the physicians attain years in work experience. This finding is a novel one, not explored in previous studies of radiologists. Lastly, we noted significantly higher mean MBI score in the community sites compared to academic work site, which again comports with prior work outside of Canada [20]. In terms of overall trends, we found on average higher scores in personal accomplishment, emotional exhaustion, and depersonalization compared to previous studies (Table 2), suggesting the Canadian radiologists, despite experiencing more burnout in the emotional exhaustion and depersonalization domains, had good burnout-protective factors as observed by their high personal accomplishment scores. Previous studies have alluded to burnout etiologies ranging from financial challenges during
Table 2 Comparison of burnout rates against other studies Mean MBI Score Study
Country
Personal accomplishments
Emotional exhaustion
Depersonalization
Porrino et al [19] Guenette et al [14] Chew et al [20] Singh et al [22] Maslach et al [21] This study
United States United States United States New Zealand United States Canada
28.4 33.0 32.6 32.9 36.5 37.5
25.1 24.3 28.7 44.9 22.2 31.8
11.1 10.6 9.3 20.6 7.1 12.7
Data in parentheses are standard deviation when available. MBI ¼ Maslach Burnout Inventory.
(7.8) (10.3) (4.9) (7.3) (7.2)
(12.4) (14.4) (7.1) (9.5) (15.3)
(6.9) (9.3) (5.6) (5.2) (9.1)
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training [12] to organizational discomforts [24] to rapid changes in the health care models [19]. The influence of these various factors on radiology burnout is an opportunity for future study. Given the relatively few radiologists in all of Canada, one limitation of our study was its relatively small sample size. Anticipating low response rates as a potential issue, we opted to utilize the abbreviated 7-questions MBI survey (instead of the comprehensive 22-question survey) to enhance our response rate, and, additionally, utilized a reminder e-mail halfway through the survey period. A strength of this study was our partnership with the CAR, which graciously approved our study and helped encourage member participation. In addition, we used an online, anonymized platform for our survey, as this has been shown previously to be helpful in reaching potentially hidden populations (eg, individuals who otherwise would not feel comfortable disclosing high burnout) [25]. Finally, we quantified burnout symptoms with the well-accepted and validated MBI, which enabled meaningful comparisons between our study and previous studies. Conclusion In conclusion, burnout in radiology is a significant issue worldwide, and in this regard, Canadian radiologists are not immune. Given its impact on both physician labor and patient care, more work is necessary. Burnout prevention strategies includes programs to better communications [26], improve constructive trainee feedback [27], decrease workplace isolation [13], and strengthen resiliency [28]. Acknowledgements The authors would like to thank Dr Jason Ko for proofreading the manuscript. References [1] Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med 2012;172:1377e85. [2] 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: 1600e13. [3] Cohen D, Rhydderch M. Measuring a doctor’s performance: personality, health and well-being. Occup Med 2006;56:438e40. [4] Panagioti M, Geraghty K, Johnson J. How to prevent burnout in cardiologists? A review of the current evidence, gaps, and future directions. Trends Cardiovasc Med 2018;28:1e7. [5] Ames SE, Cowan JB, Kenter K, Emery S, Halsey D. Burnout in orthopaedic surgeons: a challenge for leaders, learners, and colleagues: AOA critical issues. J Bone Joint Surg Am 2017;99:e78. [6] Klein J, Grosse Frie K, Blum K, von dem Knesebeck O. Burnout and perceived quality of care among German clinicians in surgery. Int J Qual Health Care J Int Soc Qual Health Care 2010;22:525e30. [7] Asai M, Morita T, Akechi T, et al. Burnout and psychiatric morbidity among physicians engaged in end-of-life care for cancer patients:
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Appendix 1. Burnout in Radiology Questionnaire Demographics 1. Gender a. Male b. Female
c. Prefer not to disclose
2. Years in practice as a staff radiologist. a. Resident/fellow b. <20 years c. >20 years 3. Practice location where I spend the most time. a. Academic site b. Community site c. Other Personal accomplishment 4. I can effectively solve the problems that arise in my work. 0. 1. 2. 3. 4. 5. 6. Never Everyday 5. I feel I am making an effective contribution to my radiology department. 0. 1. 2. 3. 4. 5. 6. Never Everyday 6. In my opinion, I am good at my job. 0. 1. 2. 3. 4. 5. 6. Never Everyday
7. I have accomplished many worthwhile things to the radiology field. 0. 1. 2. 3. 4. 5. 6. Never Everyday 8. I feel I am making an effective contribution to patient care. 0. 1. 2. 3. 4. 5. 6. Never Everyday Emotional exhaustion 9. I feel burned out from my work. 0. 1. 2. 3. 4. 5. 6. Never Everyday Depersonalization 10. I have become more callous toward people since I took this job. 0. 1. 2. 3. 4. 5. 6. Never Everyday