Leadership: Causing and Curing Burnout in Radiology

Abstract

Burnout in US radiology has reached crisis proportions. Leaders play critical roles in both causing and preventing burnout. This article will review the current state of the crisis and how leaders can work to stop causing burnout as well as developing proactive strategies for preventing and mitigating burnout.

INTRODUCTION

As of late 2022, the US medical workforce is facing a severe crisis. There is an unprecedented rate of physician burnout with significant associated professional as well as personal and societal consequences. As will be discussed in this article, not only are radiologists seriously affected by burnout, but they are more affected than many other types of US-based medical workers [1]. Radiology leaders have in many instances contributed to this epidemic. In this article, we will examine how leaders can rethink plans, decisions, and leadership actions that may be causing or exacerbating burnout. We will review ways that leaders can stop doing those things that hurt radiologists. We will list ways that leaders can begin to make strong affirmative choices to improve radiology workflow and the imaging workplace and hopefully to begin to decrease the risks of burnout and its sequelae. Leadership can be both the cause as well as the solution to the burnout in health care.

THE PROBLEM

In the mid 2010s, a survey reported that over half of American physicians reported at least one symptom of burnout, a rate that is twice as high as nonmedical workers in the United States [2]. This same article reported a significant rise in burnout among physicians from 45.5% reporting at least one symptom in 2011 to 54.4% in 2014. A more recent survey published in 2022 showed that the rate of burnout in US physicians had continued to rise to the highest levels seen since 2011. That survey performed at the end of 2021 into the beginning of 2022 had 63% of physicians reporting at least one burnout measure with associated decreases in work-life balance [3].

Our specialty of diagnostic radiology is certainly not exempt, and in fact, burnout has become rampant among radiologists working in the United States. A survey of diagnostic imaging practice leaders showed that 77% of them thought that burnout was a significant or very significant problem. However, the same article also found that only 19% of those same leaders reported that they had mechanisms that address burnout [4]. That mismatch suggests that the majority of leaders who know that they have a problem in this sector are not doing or are unable to do much of anything to either stop it or fix it.

A survey in the field of mammography reported that 78% of breast imagers stated that they were highly burned out on at least one measure of burnout (emotional exhaustion, depersonalization, or perceived lack of accomplishment) [5]. The first survey of US neuroradiologists regarding workflow and burnout showed that over 50% of US neuroradiologists reported increases in three burnout measures over the prior 5 years, with only 14% reporting that their administrators were making changes to help [6].

There is a popular perception that things are better for leaders than for those they lead. In some situations, this appears to be true. Some studies of job-related stress and health outcomes in nonmedical fields have reported worse outcomes in workers than in their bosses [7]. However, that is not necessarily the case in US radiology. Burnout and stress are not limited to just the rank-and-file radiologists. Burnout also clearly affects leaders including the alpha leaders. A survey of academic chairs published in 2019 showed that 38% had high burnout scores [8]. A recent survey of US private practice showed a 33% rate of burnout of radiology practice leaders. This study also reported a concomitant inverse relationship with professional fulfillment [9].

Individual physicians need to increase their awareness of burnout and develop personal strategies for handling job stresses. However, individual solutions will likely not be enough. In many situations, that will fail to correct larger, departmental or practice-wide factors and problems that are contributing to burnout.

Many researchers [10,11] have in fact recommended that burnout be viewed as an organizational or system problem. In our field, the ACR has also stated that the paradigm should shift to a focus on dysfunctional institutions and the need for organizational solutions [12].

WHAT IS TO BE DONE?

As a starting point, leaders need to take a hard look at how their choices may be contributing to burnout. Although rising caseloads are not the only problem, workflow choices can worsen or ameliorate burnout. In a time of labor shortage and falling reimbursement rates, these will be very difficult decisions. Deciding how to handle increases in the number and complexity of cases, length of workday shifts, overnight and weekend call responsibilities as well as providing for nonclinical time will all factor into how leaders will need to do better with workflow and workplace choices. In many sites, increasing the number of cases or number of hours are no longer a reasonable options. It simply is not sustainable anymore. Leaders will also have to stop the relentless reductions in reimbursement or radiology will become an unattractive specialty.

Beyond the basics, leaders can take on affirmative roles in preventing burnout. If they are serious about addressing the problem, leaders need to first stop denying that burnout is a problem or ignoring it [13]. In many instances, this has become a moral injury—an act of blaming the victim. Leaders need to acknowledge the problem and their contributions to the circumstances that create it. They then need to start moving to proactively prevent burnout by building resiliency and developing other ways of mitigating and preventing burnout [13]. Once they are past those roadblocks, they can do several additional things.

A TO-DO LIST FOR LEADERS

First, for better (or worse) leaders are role models for those they lead [14]. Although some leaders may not be great role models and many others would argue that that is not part of the job, common sense as well as scientific studies argue otherwise. Members of organizations do pay attention to the leader’s behavior and that affects how they view their workplace. A study has shown that physicians experience their organization through their leadership and that this is a key to value alignment [15]. In a similar vein, within training programs resident perceptions of residency leader behaviors affect the burnout and satisfaction of resident trainees [16].

Second, our leaders can promote other factors and also encourage training to help radiologists build resilience and a stronger sense of purpose. In comparison with other stressful jobs, for example in the military, work hours and stressful decisions per se are not the only factors that lead to burnout. How work is performed is important, sometimes much more so than just the amount of work. A diminished sense of purpose and frustration with lack of accomplishment are important factors in causing both burnout as well as its consequences in challenging work environments. Professional development and leadership training have been recognized as key factors that employees identify as helping with burnout [10]. Beyond that, leaders should also consider including related programs in mentoring and professionalism that can also promote increased resilience and professional satisfaction [17]. Organizations such as the Association of American Medical Colleges and the ACGME have identified the need to develop leadership and management skills for physicians at the undergraduate and postgraduate levels [18]. The ACR has also identified leadership as a key factor in personal and professional success as well as to help provide skills to defend against burnout. The ACR built a leadership institute for its members in 2012 [19].

Third, it is important that leaders take a hard look in the mirror to examine their own behaviors and also take a long, critical look at the impact on the culture of their departments or groups. Psychological safety within an organization and an individual’s being heard within a group are both very important, yet often not appreciated factors [18,20]. Similarly, service chiefs and chairs are in key positions to modulate (for good or ill) another important perceptual issue: perceived appreciation in medical worksites [21]. Leaders, particularly those who are ineffective, downplay or ignore their own potentially negative effects on both individuals and on organizational culture. These can combine to lead to decrements in physician performance. Additional formal training in leading wellness and even term limits should then be considered [13,22].

Fourth, beyond being role models themselves, leaders can and should encourage positive individual choices in both the physical and psychological domains of their teams [23]. There is synergy in combining individual and organizational changes. One without the other is much less likely to work in the long run. Low self-valuation among physicians has been associated with burnout and sleep-related impairment [24].

Fifth and finally, leaders need to work to be better leaders. Leadership style can have a significant impact on burnout [25]. In a study of leaders whose perceived leadership performance metrics were scored by their physician employees, there was a significant association of better performance by leaders with higher employee fulfillment, as well as an association with lower degrees of burnout [26]. Increased stress and burnout occur if people feel helpless and unheard. Leaders should solicit input and constructive solutions from their faculty and colleagues. A later study of physician leaders also showed that leadership quality metrics correlates with professional fulfillment, self-care, and (negatively) with burnout in those leaders [27]. The same article also showed that leader’s sleep related impairment correlated with impairment in those who were led.

CONCLUSION

Although things like yoga, herbal tea, and bicycling may help with job stress and burnout, the time is overdue for deeper thinking and more robust solutions to the current crisis. Leaders in US radiology have the choice of being the solution to burnout instead of being the cause.

TAKE-HOME POINTS.

• Burnout in US radiology has reached crisis proportions.

• Leaders have key roles in reducing and preventing burnout.

• Departmental leaders increasingly will need to work with institutional and other leaders to help make radiology sustainable.