Prevalence of burnout in private practice radiology leaders

Abstract

Rationale and objectives:

To evaluate prevalence and demographic factors associated with both burnout and fulfillment of private practice radiologist leaders within the United States.

Materials and methods:

The study cohort was the largest coalition of wholly radiologist owned, independently practicing radiology groups within the United States. Two designated leaders within each of the 30 radiology private practices within the organization Strategic Radiology were electronically mailed a weblink to a confidential IRB-approved survey in July 2021. Surveys included questions from the Stanford Professional Fulfillment Index, individual and practice demographics, and self-care.

Results:

The overall response rate was 67% (40/60). Fulfillment and burnout scores were calculated from the individual questions, and radiologists were classified as being fulfilled or not and burned out or not based upon score cutoffs previously validated from the Stanford Professional Fulfillment Index (PFI). The overall professional fulfillment rate of staff was 43% and the overall burnout rate was 33%. (Cronbach’s α = 0.90 for fulfillment and 0.91 for burnout). The inverse correlation between professional fulfillment and burnout was highly significant (r = −0.42, p = 0.007). No statistically significant association was seen between either burnout or fulfillment and age, gender, ethnicity, practice geography or practice size.

Conclusion:

Utilizing the validated Stanford PFI for assessment, the prevalence of burnout in private practice radiologist leaders was 33%. The prevalence of professional fulfillment was 43%, with a mild inverse association between professional fulfillment and burnout.

Summary:

In private practice leaders, the prevalence of burnout was 33% and the prevalence of professional fulfillment was 43%.

1. Introduction

As defined by the World Health Organization, burnout is a syndrome conceptualized resulting from chronic workplace stress that has been unsuccessfully managed [1]. Burnout is characterized by three fundamental dimensions of feelings of energy depletion or exhaustion, increased mental distance from one’s job, and a sense of ineffectiveness and lack of accomplishment [2]. Physician burnout has been linked with multiple negative physician outcomes including mental issues, suicidal ideation, alcohol abuse and behavioral issues [3–5]; suboptimal workplace metrics including reduced productivity, job dissatisfaction and higher intention to leave [5–8]; and adverse outcomes related to patient safety [9,10]. Multiple published surveys based on the American Medical Association Physician Masterfile have consistently demonstrated that radiologist burnout is consistently elevated compared to the average prevalence of physician burnout [11,12]. The elevated prevalence of radiologist burnout has now also been consistently established across multiple cohorts of subspecialty radiologists [13–17].

In comparison, minimal research has been conducted regarding burnout of physician practice leaders within radiology. One study investigated the prevalence of burnout of chairs of academic radiology departments [18]. To our knowledge, no studies have specifically investigated burnout of radiology leaders within other practice models. Burnout of physician leadership in radiology may have significant impact on both the practice and the wellness of radiologists. A single-institution study found that each 1-point increase in composite leadership score was associated with a 3.3% decrease in the likelihood of burnout and a 9.0% increase in the likelihood of satisfaction of the supervised physicians [19]. The composite score was the sum of ratings of physicians of the leadership qualities of their immediate supervisor in 12 specific dimensions. These 12 items were designed to assess twelve specific characteristics of leadership that were both measurable and actionable. In a separate single-institution study, burnout, professional fulfillment, and self-care practices of physician leaders were associated with their independently assessed leadership effectiveness [20].

The primary purpose of this study was to survey private practice radiology leaders among the largest cohort of wholly physician owned, independent physician practices within the United States to evaluate the prevalence of physician burnout and physician fulfillment in private practice radiology leaders. Secondary objectives included assessing the association of leadership burnout with demographic factors, self-compassion care and strategies deployed by radiology leadership to address burnout.

2. Materials and methods

This study was deemed exempt from ongoing evaluation by the Institutional Review Board at an academic center.

The studied cohort is the largest coalition of wholly radiologist owned, independent private practice radiologists within the United States. Two designated leaders within of each of the thirty radiology practices that comprised the coalition were electronically mailed a weblink to a confidential IRB-approved survey. The radiology practice leaders list and associated email addresses were confidentially maintained by the coalition cohort; the study authors at the academic institution who received the survey responses and performed the analysis did not have access to the list of radiology practice leaders nor their email addresses.

A confidential survey was prepared and structured at the academic center using Qualtrics (Provo, UT and Seattle, WA). Surveys included questions from the Stanford Professional Fulfillment Index (PFI), individual and practice demographics, and self-care. The Stanford PFI was used to collect data on burnout and professional fulfillment. Fulfillment was defined from Question 16 of the Qualtrics survey. There are 6 sub-questions, each measured on a Likert scale from 0 to 4. Higher scores indicate higher satisfaction. The average of these 6 values was computed, and fulfillment was defined as an average score of greater than 3. Burnout was defined from the 10 items in Questions 17 and 18. Question 17 has 4 sub-questions and measures the dimension of work exhaustion. Question 18 has 6 sub-questions and measures the dimension of interpersonal disengagement. These are also measured on a Likert scale from 0 to 4, with higher scores indicating burnout. The average of the 10 items was computed, and burnout was defined as an average score of greater than 1.33. Demographic questions were based on workforce surveys carried out by the American College of Radiology Commission on Human Resources [21,22]. Proposed strategies in the workplace to address radiologist burnout had previously been raised in a strategy meeting among radiology practice leaders within the coalition cohort on September 21, 2019. Logistic regression was used to assess the association between burnout and demographic and other questions and between fulfillment and the same covariates.

The radiology practice leaders within the coalition received the survey internally by a weekly email on 3 occasions from July 1, 2021 to July 14, 2021. The link in the email only allowed respondents to complete the anonymous survey without recording their email addresses. The survey was closed 30 days after the final reminder. Members of the private practice coalition did not have access to the responses.

Logistic regression was used to assess the association between burnout and covariates of interest. Spearman rank correlation was used to assess the association between burnout and fulfillment scores.

All statistical analyses were performed using R version 3.6.1. All statistical tests used a significance level of 5%. No adjustments for multiple testing were made.

3. Results

The survey was sent to sixty radiology practice leaders from thirty groups within the coalition of wholly radiologist owned, independent private practice radiologists. The survey response rate was 66.7% (40/60). The overall professional fulfillment rate of staff was 43% and the overall burnout rate was 33%. (Cronbach’s α = 0.90 for fulfillment and 0.91 for burnout). The inverse correlation between professional fulfillment and burnout was highly significant (r = −0.42, p = 0.007). Table 1 summarizes characteristics for the 40 respondents with associated univariate logistic regression models for burnout the number of radiologist leaders in each category/level.

Table 1.

Univariate logistic regression models for leadership burnout

Parameter	Level	Odds Ratio	Lower CI	Upper CI	P-Value
Age*	Under 36 years old	–	–	–	0.1376
	36–45 years old	0.0256	0.000106	6.21
	46–55 years old	0.1200	0.001135	12.69
	56–65 years old	0.3846	0.003656	40.46
	Older than 65	0.2000	0.001226	32.62
Race	Asian	–	–	–	0.7719
	White	0.75	0.109	5.17
Length practicing*	5 years or less	–	–	–	0.3745
	6–10 years	0.556	0.00341	90.61
	11–20 years	0.432	0.03105	6.01
	21 years or more	1.508	0.12318	18.46
Region*	Mid-Atlantic	–	–	–	0.8109
	Midwest	1.410	0.10255	19.39
	New England	0.556	0.00341	90.61
	South	0.556	0.03912	7.89
	Southwest	0.333	0.00412	26.95
	West	1.364	0.09339	19.91
Urban/suburban/rural*	Urban	–	–	–	0.9318
	Urban/Suburban	0.548	0.06680	4.49
	Suburban	1.027	0.12387	8.51
	Suburban/Rural	0.778	0.06784	8.92
	Rural	0.467	0.00361	60.40
Radiologists in group	Between 5 and 10	–	–	–	0.6718
	Between 11 and 20	1.143	0.0771	16.95
	Between 21 and 50	1.429	0.0999	20.44
	Between 51 and 75	1.333	0.0668	26.62
	More than 75	0.286	0.0118	6.91
Individual responsibilities*	General and interventional radiology call	–	–	–	0.5889
	General and subspecialty radiology call	0.238	0.02312	2.45
	General radiology call	0.314	0.04023	2.46
	Interventional radiology call	0.143	0.00232	8.81
	No call	1.190	0.06314	22.45
	Subspecialty radiology call	0.429	0.02273	8.08
Take call	Evenings and overnight and weekends	–	–	–	0.4646
	Evenings and weekends	1.11	0.267	4.6
	None	4.80	0.350	65.8
Full/part time	Full-time	–	–	–	0.2187
	Part-Time	4.55	0.372	55.5
Hours worked per week*	0–20	–	–	–	0.8336
	21–40	1.000	0.0335	29.8
	41–60	0.487	0.0273	8.7
	61–80	0.429	0.0129	14.2
Exercise per week*	Zero	–	–	–	0.3459
	Once per week	0.3333	0.02810	3.95
	Two to three times per week	0.8947	0.10124	7.91
	Four to five times per week	0.0909	0.00219	3.78
	More than five times a week	0.4286	0.02356	7.80
Nutritious meals*	Extremely nutritious	–	–	–	0.1271
	Very nutritious	0.882	0.00754	103
	Moderately nutritious	1.457	0.01460	145
	Minimally nutritious	21.000	0.07210	6116
Last annual physical	Within the last year	–	–	–	0.3853
	Between 1 and 3 years	0.343	0.0330	3.56
	Between 3 and 5 years	3.600	0.4537	28.56
	Over 5 years	2.400	0.3553	16.21
	Never	1.200	0.0876	16.44
Evening/weekend call responsibility*	Everybody in the group has to take call	–	–	–	0.8307
	Only partners / shareholders take call	1.800	0.42117	7.69
	Nighthawk Radiologists Employed	0.890	0.08539	9.28
	Outsource call to third party group	0.692	0.00677	70.77
	Other	0.415	0.00892	19.34
Part-time clinical work offered*	No	–	–	–	0.9340
	Yes and no one partakes	1.218	0.16865	8.80
	Yes and many people partake	0.702	0.14731	3.35
	Do not know / Not sure	0.569	0.00567	57.05
Lowest % partners can work and vote	100%	–	–	–	0.9471
	90%	2.0	0.0775	51.60
	80%	0.5	0.0313	7.99
	70%	1.2	0.1303	11.05
	Under 70%	1.0	0.1409	7.10
Weeks allowed for FMLA/maternity leave*	Less than 1 week	–	–	–	0.5057
	1–2 weeks	0.778	0.00521	116.1
	3–5 weeks	1.400	0.05892	33.3
	6–10 weeks	4.200	0.27853	63.3
	More than 10 weeks	1.510	0.13549	16.8
	Do not know / Not sure	0.556	0.04228	7.3
How FMLA compensated during FMLA	They are not compensated	–	–	–	0.7028
	They are partially compensated	2.5	0.341	18.33
	They are compensated at 100%	1.8	0.210	15.41
	Do not know / Not sure	1.0	0.127	7.89
Does practice have lactation facility	Yes	–	–	–	0.3940
	No	0.556	0.06756	4.57
	Do not know / Not sure	0.167	0.00931	2.98
Does practice have wellness committee*	Yes	–	–	–	0.7368
	No	0.749	0.10969	5.11
	Do not know / Not sure	0.280	0.00454	17.27
Financial assistance for burnout*	Yes	–	–	–	0.5786
	No	3	0.0684	132
	Do not know / Not sure	1	0.0052	192
Contract administrative leadership*	Yes	–	–	–	0.7327
	No	0.778	0.16640	3.64
	Do not know / Not sure	0.333	0.00746	14.89
% of time for non-clinical duties*	Zero	–	–	–	0.5024
	1–10%	0.556	0.08327	3.71
	11–20%	1.889	0.25721	13.87
	21–40%	1.889	0.30414	11.73
	Over 40%	0.270	0.00721	10.10
Majority of non-clinical time spent	Education/CME	–	–	–	0.6960
	Finances	0.667	0.02461	18.1
	Governance issues	0.571	0.02756	11.8
	Human resource issues	1.000	0.04074	24.5
	Informatics	1.000	0.01984	50.4
	Other	0.125	0.00391	4.0
	Quality and safety	0.333	0.00931	11.9
Work/life balance overall*	Equal	–	–	–	0.4558
	Life Heavy	1.10	0.010	119.6
	Work Heavy	2.38	0.542	10.5
Preferred work/life balance*	Equal	–	–	–	0.3506
	Life Heavy	1.507	0.32301	7.03
	Work Heavy	0.205	0.00708	5.92
Stresses adversely impacted my health*	Agree strongly	–	–	–	0.7251
	Neither agree nor disagree	1.794	0.43029	7.48
	Disagree	0.974	0.09064	10.47
	Disagree strongly	0.455	0.00958	21.56
I am a role model for others*	Agree strongly	–	–	— 4.42	0.7644
	Neither agree nor disagree	1.119	0.28356	18.28
	Disagree	0.382	0.00798
I manage stress extremely well*	Agree strongly	–	–	–	0.1560
	Neither agree nor disagree	5.36	0.204	141
	Disagree	25.67	0.560	1176
	Disagree strongly	11.00	0.163	742
I manage stress better than others	Agree strongly	–	–	–	0.0090
	Neither agree nor disagree	0.337	0.0649	1.75
	Disagree	9.000	0.8088	100.14

Table 1 summarizes results from univariate logistic regression models for the probability that a radiologist experiences burnout (see above for definition). The table presents the Odds Ratio and corresponding 95% confidence interval (“Lower CI”, “Upper CI”), and p-value for each of the parameters of interest.

The only factor significantly associated with burnout was for the question “I manage stress better than others in my practice”. Radiologists who answered “Neither agree nor disagree” were least likely to experience burnout, while radiologists who answered “Disagree” were most likely.

^aIndicates that model fit with Firth penalized likelihood method due to lack of events in one or more categories.

3.1. Demographics (Questions 1–7)

The table presents the number of radiologist leaders in each category/level. The majority of leaders are between 46 and 65 years old. The vast majority are male, and most are white non-Hispanic. On average, they have been practicing for at least 11 years, and more than half of the respondents were in the Midwest or South. More than half are in urban/suburban or suburban areas.

3.2. Practice characteristics (Questions 8–12)

Most of the respondents are full-time, working 41–60 h per week. The majority of practices have between 11 and 50 radiologists, and they are expected to take calls at least evenings and weekends.

3.3. Self-care (Questions 13–15)

Most leaders report exercising at least once per week, and they indicate that they eat at least moderately nutritious meals. The majority have had a physical within the last 3 years.

3.4. Workplace strategies (Questions 19–29)

To help address wellness in their practices, the majority of the leaders reported that their practice contracted non-physician administrative leadership to help manage their practices, offered participation in voting for partners who work 70% or less in their practice, and offering part-time clinical work. Regarding Family Medical Leave (FML), all respondents (39/39) responded that the clinical shifts are covered by other radiologists, 30 % (12/40) of leaders did not know or were unsure if their practices offered FML, 19/28 responded that their practices offered partial or complete compensation for FML, and 14/28 (50%) allowed more than 10 weeks of leave for FML. A minority of practice leaders reported lactational facilities, formation of a wellness committee, meditation, or financial assistance for burned out radiologists.

3.5. Work–Life balance and stress (Questions 30–34)

The only factor significantly associated with burnout was for the question “I manage stress better than others in my practice”. Radiologists who answered “Neither agree nor disagree” were least likely to experience burnout. Radiologists who answered “Disagree” were most likely to experience burnout.

4. Discussion

In this study, the prevalence of burnout among private practice radiology leaders was 33%. Logistical regression did not demonstrate any statistically significant association of practice leadership burnout with individual demographics, practice demographics, self-care, nor strategies deployed by practice groups to address burnout. The only factor significantly associated with leadership burnout was leader disagreement that they managed stress better than others in their practice. Practice leaders experiencing burnout may therefore benefit from interventions designed to specifically address stress management [23], leveraging positive psychology [24], and coaching [25].

Radiology practice leaders in private practice are constantly at the tip of a spear. In private practice, radiologists have the greatest degree of autonomy to determine their group governance, compensation structures, benefits, and work schedules [26]. However, private practice radiology leaders uniquely must manage a business that demands meticulous administrative duties in addition to routine clinical practice responsibilities. Radiologist compensation is not guaranteed but dependent on adequate contracts, imaging volume, efficiency of practice, clinical productivity, and meticulous business leadership [26]. Private practice radiology leaders carefully navigate their practices through turbulent waters from multiple tectonic forces including practice consolidation, payer consolidation, hospital consolidation, changing payment models, and disruptive technologies [27]. As radiology professional services become increasingly embedded in health care systems, private practice groups are under threat of replacement by hospital-based practices in shared risk models [26]. Private practice leaders face competition for imaging with corporate and academic radiology groups that provide teleradiology and subspecialty services [28,29]. Currently, private practice radiology leaders are contending with recruiting radiologists in a wide-open radiology job market where there are significantly more positions than applicants [21,22] while simultaneously trying to maintain their current radiologist staffing in an environment of active radiologist job separations [30]. All these challenges were further amplified during the COVID pandemic adversely affecting operational volumes and margins, especially in free-standing imaging centers [31,32]. Decisions by leaders can literally either ensure future economic survival or necessitate dissolution of private practice groups [33].

The self-reported prevalence of burnout among private practice radiology leaders in this study is in the same range of burnout (38%) previously reported for academic chairs based on high emotional exhaustion score and/or high depersonalization score [18]. In academic settings, the overarching tripartite mission is related to education, research and clinical care [28]. The additional responsibilities of leading educational and research components of the mission likely contribute to the overall burnout in academic radiology practice leaders [18].

There are multiple common factors that likely contribute to burnout of physician leaders in both private practice and academic radiology. The administrative burden of electronic health records is being increasingly mandated upon radiologists [34]. In addition to the stress imparted upon the practice leadership from challenges related to implementation, training, workflow and reimbursement, the EMR has also been associated with physician burnout in multiple studies [35–37]. Physician leaders are expected to constantly lead by example, serving as role models for building relations with referring clinicians and hospital administrators [38]. This is underscored by a growing expectation of servant-type leadership, where needs of the team are placed ahead of the personal and professional needs of the leader [39–41].

Radiology practice leaders are now expected to address burnout in their practices [42]. A previous national survey conducted by the ACR Commission on Human Resources demonstrated that 77% of radiology practice leaders (including private practice and academic) perceive burnout as a either a very significant or significant problem affecting their practices. Leaders need to be aware of and recognize the three facets of burnout within themselves, their employees and their fellow radiologists. The facet of burnout of emotional exhaustion manifests as feeling personally overextended and having depleted or insufficient physical or emotional abilities for the tasks at hand. The facet of depersonalization translates into having cynical, negative, or detached responses to various aspects of work. The facet of reduced personal accomplishment leads to feelings of incompetence and lack of productivity and achievement at work [2,43]

Unexpectedly, in our study, only one private practice radiology leader out of the forty respondents (2.5%) was female. This is consistent with a low representation of female leaders in a review of 51 major academic radiology faculty rosters in which only 25% of vice chairs and section chiefs and 9% of department chairs were women [44]. In the most recent published ACR Annual Workforce Survey conducted by the Commission on Human Resources, females represented 23.5% of the radiology workforce [22]. The value of diversity is being increasingly recognized across different industries. In 2015, a report by McKinsey & Company found in the business sector that companies in the top quartile for gender diversity were 15% more likely to outperform their competitors [45]. Strategies for private practices groups to increase the pipeline for future female private practice leaders include mitigating unconscious bias in recruitment and hiring [46], mentorship of private practice skills [47], encouragement of formal leadership training [48], and sponsorship [49].

Our study found that private practice radiology leaders are deploying variable strategies within their individual practices to help reduce burnout of themselves and other radiologists in their group. A study of academic faculty showed that those spending less than 20% of their time on the activity that is most important to them experienced higher rates of burnout [50]. Most practices are employing administrative leadership to offset some of the stress from the physician practice leaders, so that they can focus their time on more meaningful activities. Adequate staffing has been recommended s a strategy to help address radiologist burnout by reducing daily workload and improve work-life balance of radiologists [51,52]. To help sustain current radiologists and meet radiologist staffing needs, the majority of practices offered participation in voting for partners who work 70% or more in their practice and offered part-time clinical work.

An important component of wellbeing in today’s generation of physicians is work-life balance and the ability to put family over professional responsibilities addressing the unanticipated family demands, such as a new child or a serious family member health issue, when needed. Our study revealed that, at the specific time of their participation in the survey, 30% of practice leaders were unsure of the specific number of weeks allowed in their practice FML policy, nor were they familiar with the radiologist compensation package specifics for FML for their group. Previous studies of the utilization of the Family and Medical Leave Act (FMLA) in radiology practices in 2016 and 2015 found the three most common reasons, utilized by both male and female radiologist practice members, for FMLA leave were taking care of a newborn or adopted child, personal serious health condition, and caring for an immediate family member [53,54]. Therefore, the authors observe that a potential opportunity for practice leaders to promote their own wellness, as well as the radiologists within their practice, would be to revisit their group’s FML polices with their group members periodically for self-education, to raise awareness in all group members, and to explore possible opportunities to update the benefits provided by the group policies.

Our study demonstrated significant variability between private practices in strategies deployed to address burnout of radiology practice leaders and their radiologists. Multiple factors likely contribute towards this variability, including individual group culture, leadership, support staff available resources, expense, and time. Further research is needed overall to define best practices and to help guide individual radiology practices to promote wellness of radiology practice leaders.

Our study had limitations. The majority of private practices in the coalition are in the Midwest and South, and may not be generalizable to practices in other regions. The majority of respondents were white or Asian males, and results may not be generalizable to all genders, races and ethnicities. Our overall sample size was small, but in the same range as a previously published study of academic radiology leaders [18]. The response rate of the private practice radiology leaders was similar to this study and significantly higher than multiple published voluntary web–based surveys of radiologist burnout [16,17]. Similar to other web-based physician surveys, our responses were prone to voluntary selection type bias - namely, participants with burnout may have been more likely to participate in the survey, elevating the prevalence rate of burnout. Similarly, nonresponse bias may have occurred in the most severely burned out individuals. Because of time constraints and/or higher workload, they may have been less inclined to respond.

In conclusion, our study found that approximately one-third of private practice radiology leaders are burned out, without significant association of individual demographics, practice demographics, self-care, nor strategies deployed by practice groups to address burnout. The only factor significantly associated with leadership burnout was self-perceived stress management. Future research opportunities include investigating the prevalence of burnout in a larger number of private practice radiology leaders in a wider geographic distribution, the association of leadership burnout with burnout of their direct reports, and the association of lactational facility and FML availability with number and diversity of radiologists.