The Threat to the Soul of Interventional Radiology Escalated by COVID-19

Graphical abstract

The coronavirus disease 2019 (COVID-19) pandemic has been a historic health event worldwide. The suffering, fear, uncertainty, and loss of more than 6 million lives globally, one-fifth of these being Americans, affected every person on the planet. Despite rising rates of immunity and declines in death rates, the effects will ripple for decades as the mid- and long-term effects of this pandemic crystallize.

The effects of the pandemic on the healthcare workforce have been particularly acute. The overwhelming loss of life alone has been a heavy burden for all caregivers to bear. This injury has been intensified for healthcare workers by the personal risk of COVID-19 infection that each healthcare professional accepted to provide care (sometimes without adequate personal protective equipment), isolation from family and friends, and moral distress related to the politicization of good faith medical care.

Thus, it is no surprise that burnout among U.S. physicians, which was a major problem even before the pandemic, has escalated to the highest level on record in recent longitudinal studies (1,2). Burnout is defined as a cluster of symptoms that occur because of professional stressors, resulting in emotional exhaustion and depersonalization (3). Studies (2,4, 5, 6) of interventional radiologists and other minimally invasive specialists (eg, neurointerventionists, vascular surgeons, and cardiologists) have demonstrated the prevalence of burnout as ranging from 41% to 72% despite a trend of greater resilience among physicians in procedural specialties (7). Evidence suggests that practice alterations owing to the COVID-19 pandemic have severely increased feelings of anxiety and distress among interventional radiologists (8).

Despite the deep expertise of interventional radiologists, during the prevaccine phase of the pandemic, interventional radiologists were required to apply their expertise in performing a higher volume of more basic procedures, such as venous access and drainages, to treat critically ill patients with COVID-19 at the expense of more technically challenging and better reimbursed vascular disease and interventional oncology procedures. In addition, especially important for interventional radiologists, was the disruption of the supply chain resulting in a shortage of medical devices, which included more than 100 devices on the most recent Food and Drug Administration (FDA) list of short supplies (7) and, at one point, included contrast medium, the basic lifeblood of image-guided interventions (9).

Beyond the personal consequences, physician burnout has important implications on the quality of care and the patient experience, as well as access to care, affected by attrition, turnover, and the compromise of clinical productivity (10). A recent study (11) examining the number of healthcare providers filing direct patient care–related insurance claims in 2021 in the United States reported that 334,000 healthcare workers left the workforce, including over 100,000 physicians. The total number of professionally active physicians in the United States is approximately 1 million. This exodus partially reflects a broader change in the U.S. labor market, where nearly 47 million workers resigned from their jobs in 2021, termed “the Great Resignation” (12). However, this phenomenon predates 2021, with reports citing that nearly 20% of healthcare workers left their jobs since February 2020 (13). This trend is likely to continue and possibly worsen according to the finding from an Elsevier Health survey (14) that 47% of U.S. healthcare workers plan to leave their positions in the next 2–3 years. Healthcare workers are leaving conventional employment in hospitals and clinics to work in freelance traveling positions and other unconventional business models or to leave patient-facing environments altogether (15). Many physicians who exhibit burnout but stay in healthcare reduce their working hours (16). The reasons reported for this exodus include stressors from the COVID-19 pandemic, burnout, and compensation not commensurate with demands (Fig 1 ) (13). This decrease in the physician and healthcare workforce creates additional burden on the healthcare workers who remain, creating a vicious downward spiral (17). Before the pandemic, the Association of American Medical Colleges projected a shortage of physicians of between 37,800 and 124,000 by the year 2034 (17).

Figure 1.

Drivers of engagement or burnout related to professional work for physicians. Reproduced with permission from (24).

The stress on healthcare has increased not only because of a shortage of healthcare professionals (supply) but also because of an increase in the need for healthcare services (demand). As the world emerges from the most severe stages of the pandemic, many patients with conditions that are managed by interventional radiologists will present with more advanced stages of illness because of missed routine screenings and the ignored early symptoms and signs of their underlying conditions (18,19). The Centers for Disease Control has recognized the effect of delayed use of healthcare services on worsening of chronic conditions (20), including diseases managed by interventional radiologists, such as peripheral artery disease, acute and chronic venous diseases, and cancers. These patients will likely require procedures whose beneficial outcomes are not as assured in late-stage disease, placing additional stress on interventionists.

The detrimental effects of burnout and distress are also evident in the nonclinical aspects of the field of interventional radiology. One measure of academic productivity, the number of submissions to Journal of Vascular and Interventional Radiology, reached a record peak during the lockdown of 2020 but has since decreased by 30% and is back to the prepandemic levels recorded in 2019. Submissions from the United States are down to 2018 levels. In addition, even as Society of Interventional Radiology membership increased by 31% for medical students in the past 2 years, it decreased by 3% for full members, by 15% for associate members, and by 9% for members-in-training. Perhaps reflecting COVID-induced career pivots, Emeritus membership increased by 9%. The continued extraordinary increases in medical student membership clearly highlight the attractiveness of the field and signal that the future of interventional radiology in the United States is bright.

Another stressor has been the financial pressures placed upon healthcare systems passed down as cost management strategies that adversely affect physicians. Reimbursement challenges during the height of the pandemic combined with inflation and public market investment losses have resulted in 2022 projections that more than half the hospitals will have negative margins and poor financial performance. This directly affects physicians who have sought employed practice models in recent years (21). As hospitals and healthcare institutions attempt to climb out of this financial turmoil, many have reduced compensation for physicians, limited cost of living increases, and even delayed funding of retirement plans of employed physicians. An important additional financial burden for healthcare systems to consider is that the estimated cost of recruitment for job positions lost to burnout is between 7.4 million and 22 million USD per year for an organization with approximately 2,000 physicians (22). Thus, organizations developing strategies to mitigate burnout need to account for costs of burnout, including costs related to turnover, lost revenue, reduced productivity, and poor healthcare quality caused by burnout, which decreases patient satisfaction and increases risk to patient safety (23).

The devaluation of the work product of interventional radiologists extends to the federal government. Based on the 2023 changes to the Centers for Medicare and Medicaid Services annual updates to the conversion factor and relative value unit (RVU) structures, the impact at the code level for interventional radiology professional services averaged a decrease of 6% for nonfacility (office-based) settings and a decrease of 4% for in-facility (hospital-based and ambulatory surgical center) settings. The conversion factor for 2023 is $33.0607, a decrease of 4.5% from 2022. Changes to RVUs for physician work, practice expense, and malpractice costs and risks will also negatively impact reimbursement. Physician reimbursement may be subjected to an additional 4% decrease for Pay As You Go and another 2% decrease for Sequestration. These cuts will spare the technical fees paid to facilities and shift compensation to nonprocedural specialties dependent on evaluation and management reimbursement, and away from all surgical and procedural specialties, including interventional radiology. Unfortunately, because RVU payments for a given service decrease, the financial health of healthcare systems typically try to offset the organizational impact by raising productivity expectations and work burden for employed physicians.

As the pandemic evolves to become an endemic condition, the public remains concerned about returning to “normalcy,” regaining economic stability, addressing children’s social and educational regression from the missed years of peer interaction and in-person education, and dining at restaurants. However, the public has little insight into the disruption of the foundational core of healthcare in the United States. The soul of U.S. healthcare is composed of the healthcare professionals who have, for generations, provided care to all patients without judgment and with absolute commitment to serve the best interest of patients while causing no harm. Continuous access to healthcare is assumed and considered by many to be a human right without an understanding of the shrinking and threatened pool of professionals qualified to provide such care. Banging pots and pans on the balcony each evening stopped long ago, and physicians and public health officials now endure death threats when they issue recommendations that are considered inconvenient.

In contrast to the tapering of the number and severity of COVID-19 cases, the burnout epidemic among interventional radiologists will not resolve by natural or acquired immunity (Fig 2 ). Active interventions must be pursued to identify the characteristics of the current healthcare system that are driving the problem, to disseminate evidence proving that interventional radiologists are integral to the future of healthcare, to create a more suitable and sustainable practice environment, and to reorient social and financial goals to ensure that interventional radiologists are appropriately valued (21, 22, 23, 24). Actions to reverse this disenfranchisement of interventional radiologists should include the following:

• 1.A public awareness campaign to inform the public of the importance of an engaged and valued interventional radiology workforce.
• 2.Advocacy by all professional medical societies affiliated with interventional radiology aligned with political action groups to advance the reimbursement and employment policies for interventional radiologists.
• 3.Organization-based interventions that provide interventional radiologists greater voice and input into decisions, improve efficiency and optimize the practice environment, and eliminate unnecessary administrative burden.
• 4.Creating payment policies for hospitals and healthcare systems that reward interventional radiologists for engagement and quality outcomes in patient care.
• 5.Provision of adequate staffing by attending to the unique needs of different disciplines across the healthcare workforce (which will require constructive collaboration with labor unions representing healthcare and other essential workers).
• 6.Modifications in medical school and graduate medical education training environments so that they foster professional development, financial and employment management, health policy and advocacy, and strategies to maintain wellness.
• 7.Encouraging interventional radiologists to seek leadership positions in hospitals, healthcare systems, and physician practices.

Figure 2.

Examples of negative drivers affecting interventional radiologists related to or exacerbated by the coronavirus disease 2019 (COVID-19) pandemic.

Interventional radiologists have historically thrived by working in unheralded capacities out of the spotlight, providing care under conditions requiring sacrifice, improvisation, and coping. Despite the emergence of interventional radiology as a primary specialty in 2012, the recent pandemic has highlighted that this culture of anonymity and acquiescence is no longer sustainable. With throngs of enthusiastic, energetic, overachieving students vying to enter the field, the soul of the field must be resurrected to provide them with a fertile environment for long, productive, engaged careers.