Playing with Fire: Burnout Among Radiologists a Growing Concern
By Reeves K
Earlier this year, Medscape’s Physician Burnout and Depression Report1 revealed what radiologists already know: they are among the most burned-out specialists in medicine. Some 54% report experiencing “long-term, unresolved, job-related stress leading to exhaustion, cynicism, detachment from job responsibilities, and lacking a sense of personal accomplishment.”
Implications of burnout and poor work-life balance across the specialty include the risk of depression, perpetuation of a negative professional culture, and performance difficulties.
“Burnout is an extraordinarily important topic across medicine … and in radiology, there has been a significant increase in reported burnout compared to the rest of medicine and, of course, the general population,” says Clifford Weiss, MD, professor of radiologic science and biomedical engineering at Johns Hopkins University in Baltimore.
“Studies report increasing disengagement across many, if not all medical specialties,” observes Dr Weiss, also director of the Johns Hopkins Hereditary Hemorrhagic Telangiectasia Center of Excellence.
In addition to disengagement, burnout sufferers can experience irritability, anger, emotional instability, distractedness, and a general lack of interest or excitement in performing work.
“Mentally checking out” often prevents physicians from doing their share, which can impact entire departments, says Christopher Bailey, MD, assistant professor of vascular and interventional radiology in the Russell H. Morgan department of radiology and radiological science at Johns Hopkins.
“Physicians have a team mentality and radiology is certainly a team sport both on the diagnostic and interventional side. Burnout affects overall team morale and the day to day. You have a group of people who aren’t excited to come to work and get the work done together,” Dr Bailey says.
Academic, diagnostic, interventional—burnout is prevalent across radiology, both pre- and post-pandemic. One survey of breast radiologists2 found that 78.4% of respondents were highly burned out in at least one dimension of burnout. In a survey of academic radiologists,3 29% of respondents met all three criteria for high burnout, including high emotional exhaustion, high depersonalization, and low personal accomplishment, while 79% had at least one symptom. Of neuroradiologists, at least one burnout measure was reported by 85.2% of respondents.4
“[The prevalence] of signs and symptoms of burnout in our surveys is growing,” reports Frank Lexa, MD, MBA, professor and vice chair of radiology at the University of Pittsburgh. “This wasn’t true 20 years ago … it’s getting worse. People are being asked to work much harder while work structures are changing, so they are feeling burned out.”
While early signs may present as behavioral changes like aggression, rudeness, hiding from work responsibilities, or working excessively, prolonged or severe burnout can lead to relationship problems, self-medicating, neglect of personal hygiene, or self-harm.
“On a psychological level, burnout is on the depression spectrum and can contribute to physician suicide,” says Dr Weiss, co-author of an article on burnout, “Understanding and appreciating burnout in radiologists.”5 “In our article,we try not to dichotomize depression and burnout. There is evidence that burnout is at least partially a depressive syndrome.”
As more radiologists experience chronic job-related stress, it’s important to identify specialty-specific causes of burnout and consider mitigation strategies for achieving healthy work-life balance.
Growing Workload, Shrinking Staff Add Fuel to the Fire
It’s no revelation that physicians are trained to push their limits to care for patients under stress, a physically and mentally draining responsibility. While it was initially thought that working long hours was the primary catalyst for burnout, the experience of radiologists today reveals varied and complex contributing factors.
Regardless of environment or subspecialty, radiologists experience unique work conditions. Scans are often read in isolation, which became more prevalent during the pandemic. For radiologists energized by social interaction, the shift to remote work-stations along with the proliferation of IT systems that reduce personal communication with others is a contributing factor to burnout, Dr Lexa says. Further, an aging population demands more studies and follow-ups, with a growing complexity in interpretation, he adds.
“A head CT has changed radically in my own lifetime, from 37 images to 10 times as many per study,” says Dr Lexa, who is also the chief medical officer of the Radiology Leadership Institute of the American College of Radiology. “So we’re getting half as many dollars to read ten times as many images. That’s one big issue.”
Requirements of various classification systems and detailed reporting criteria are also growing, further weighing down radiologists.
The surging volume and accompanying expectation of referring physicians simply do not honor the value of the interpretation by board-certified diagnostic radiologists, Dr Bailey says. “The radiologist is being treated almost like a blood test: ‘I ordered this CT and I just need it read.’ There’s so much imaging availability, which contributes significantly to burnout,” he says.
An aging, sicker population, fear of litigation, and a trend toward preventive medicine all contribute to imaging overutilization, explains Rama Ayyala, MD, associate professor of radiology at Cincinnati Children’s Hospital Medical Center and division director of thoracoabdominal imaging. “We have to support radiologists and also ensure clinicians are aware of the repercussions of ordering these exams, hopefully decreasing waste,” Dr Ayyala argues.
Dr Bailey notes that interventional radiologists have become overwhelmed with procedures like central line placements and paracenteses, which were previously performed by other physicians. He says many hospitals have transitioned to centralizing procedures to one service, leading to a much larger workload for interventionalists. “It ends up creating a huge backlog,” he says.
Across settings, radiologists are finding it nearly impossible to get their work done during shifts, crowding out other professional interests and causing laborious workarounds.
“They do a couple hours of work at home in the morning, drive to work, work hard, come home late, maybe eat dinner with their spouse, then do more at night. That’s the only way to get it done,” Dr Lexa says. “That burns people out. That’s cognitive dissonance.”
Mounting radiologist workloads result in large part from physician and staff shortages, says Dr Weiss, calling attention to the “gap” between the number of new radiologists entering the field and the growing workload.
“The national shortage of radiologists will be extremely hard to address,” agrees Dr Lexa, adding that insufficient radiologic technologist and nurse staffing contribute to the strain on radiologists. While locum tenens can help, he says, they cannot replace the experience and expertise of tenured technologists.
Amid such conditions, radiologists are often forced to perform tasks that are far below their level of training, such as managing insurance issues or transporting patients, further compounding frustration and burnout.
Tangled up in Red Tape
Backlogged tasks and insurance company headaches can also be a significant source of stress, says Dr Weiss, citing growing bureaucracy, documentation, regulations, and focus on financial performance.
Dr Lexa notes that the corporatization of medicine means more radiologists are working for large, third-party groups—and losing autonomy over daily workflow decisions and technology implementation.
“People who work for themselves are less likely to feel burned out, because they’re passionate about practicing and feel in control,” Dr Lexa says, noting the inverse is true. “When you’re just working for someone else and they don’t appreciate you or care about your opinion, you may feel that it’s ‘just a job,’ and possibly not a very good one,” he says.
“In 2023, there’s a lot of administrative oversight by individuals who may not be medical professionals and don’t have the same perspective. If there’s something that causes burnout and destroys demeanor, it’s that loss of autonomy,” agrees Dr Bailey. “It can get taken away or muzzled. It’s so important to protect.”
Mitigating Burnout is a Team Effort
While the experience of burnout varies with individuals, it isn’t typically confined to one person in a given group or department. Solutions must be implemented institution-, practice-, hospital-, or even system-wide, says Dr Lexa.
“If I were in charge … I’d stop reducing how much we get paid per study because it’s insulting. It means that every year we have to work harder to get paid less,” he says. “Using work RVU reimbursement as the metric of how we pay radiologists needs to be reframed because we bring value that’s above and beyond this metric that keeps getting discounted.”
Dr Weiss suggests that implementing artificial intelligence and new protocols to reduce workloads is one way to make things easier on radiologists.
“Take away what’s [not essential] to provide patient care. Remove obstacles between me and my patients,” he says, arguing that reigniting a commitment to and passion for patient care is key to combatting radiologist burnout.
“I’d love to see physicians wide eyed and excited again, like they were when they entered medical school. Ask yourself, ‘how can I find that again?’ As an institution, how can you help move people toward this?” he says.
Dr Lexa, who mentors other radiologists, takes such an approach when he works with those who are experiencing burnout.
“I begin with helping them frame their attitude toward the job—how it fits with the career they wanted and the career they’d like to have in five or 10 years,” he says, noting that this often requires identifying a passion project like research and asking for the resources to carry it out. “People will be happier and work harder if they get time to work on things close to their heart.”
It also requires setting boundaries around oneself with respect to what is and isn’t acceptable to maintain well-being. “Being active in one’s self-care and being conscious of stress is vital. You have to set limits,” says Dr Weiss. He suggests that
radiologists constrain extraneous work activities by, for example, limiting the length and number of meetings or after-hours paperwork. “It’s really about taking care of yourself, building your resilience, taking back some of your autonomy, and deciding what’s important in life,” Dr Weiss says.
“It’s easy to get lost in medicine as it becomes part of your identity because you’ve dedicated so much thought and energy to it,” agrees Dr Bailey. “But it’s just one part. You have to remember to focus on other priorities.”
If measures like these don’t seem to help, it’s time to take advantage of wellness and other programs that include therapy or peer-to-peer support. Something as simple as a sympathetic ear can help bring relief.
“If you look hard in your institution and understand that perhaps up to half [of your colleagues] may be at risk of burnout, you can see the symptoms occurring—whether it be someone checking out, acting out, or no longer taking care of themselves,” Dr Lexa says. “Talk to your fellow radiologist. If you see someone getting into trouble, take care of each other.”
Fighting the Fire: This Radiologist is Using Her Experience To Help Others
At one of her first jobs in radiology, Rama Ayyala, MD, experienced a strange contradiction: while she loved her job and her colleagues, she dreaded going to work.
“I started withdrawing from friends and family and spent most of my time working and very little time doing anything for myself,” recalls Dr Ayyala. “I was slowly becoming depressed.”
“It came down to being asked to do more than what I could do—more than I should have been expected to do,” she says. “I was losing my joy of why I went into pediatric radiology because I felt like I was just doing work too quickly without being able to enjoy it.”
After hearing others’ experiences, Dr Ayyala realized she was burnt out. She took steps to assess both her job and herself by talking to trusted colleagues and a mental health therapist about her struggles. She has switched jobs—a few times—to find the right professional fit. Today, she prioritizes her family, friends, staying healthy, and taking care of herself.
Dr Ayyala has also published a number of wellness-related studies to advocate for and support radiologists who are feeling burnt out.
“Radiologists are at higher risk for burnout than other subspecialities … there’s a lot that’s asked of us,” Dr Ayyala says, citing challenges related to imaging overutilization and the high cognitive load required by interpretations.
Dr Ayyala also notes that, with their responsibilities at work and home, women are more prone to burnout than are men. “There’s also this idea in healthcare that we need to do more to prove ourselves compared to men,” she adds, noting that burnout is a systemic issue that cannot necessarily be cured at the individual level.
However, she is grateful to have found relief through guidance, mentorship, and meaningful change. “Addressing my burnout was a combination of getting support at work and being able to have the time to invest in myself,” she says.
References
- Kane L. “I cry but no one cares”: Physician burnout and depression report 2023. Medcape, https://www.medscape.com/slideshow/2023-lifestyle-burnout- 6016058?faf-1#1. Accessed Oct. 25 2023.
- Parikh JR, Sun J, Mainiero MB. Prevalence of burnout in breast imaging radiologists. JBI. 2020; 2(2): 112–118. doi: https://doi.org/10.1093/jbi/wbz091
- Ganeshan D, Rosenkrantz AB, Bassett RL Jr, Williams L, Lenchik L, Yang W. Burnout in academic radiologists in the United States. Acad Radiol. 2020 Sep;27(9):1274-81. doi: 10.1016/j.acra.2019.12.029. Epub 2020 Feb 7. PMID: 32037261.
- Chen JY, Vedantham S, Lexa FJ. Burnout and work-work imbalance in radiology-wicked problems on a global scale. A baseline pre-COVID-19 survey of US neuroradiologists compared to international radiologists and adjacent staff. Eur J Radiol. 2022 Oct;155:110153. doi: 10.1016/j.ejrad.2022.110153. Epub 2022 Jan 7. PMID: 35058099
- Bailey C, Bailey A, McKenney AS, Weiss C. Understanding and appreciating burnout in radiologists. Radiographics online; Jul 15 2022. doi: https://doi. org/10.1148/rg.220037