Team Approach to Improving Radiologist Wellness: a case-based methodology

Abstract

Radiologist wellness is important on an individual and group/institutional level and helps to promote a strong and healthy working environment, which can improve radiologist retention and engagement. This paper will discuss case examples of radiologist wellness improvements in a single academic institution over a three-year period using the DMAIC (Define, Measure, Analyze, Improve, and Control) model. Leveraging this framework led to the implementation of reading room assistants, reduction in work-related injuries by improvements in ergonomics, and the formation of a faculty mentorship program.

Introduction

Physician burnout is a significant national problem, and is worsening (1). Burnout increased and satisfaction with work-life integration decreased among US physicians between 2011 and 2014, although burnout decreased in 2017 back to 2011 levels (2, 3). Physicians in general are at increased risk for burnout and suicide relative to other occupations (2–4). Radiologists had the 4^th highest percentage reporting burnout compared with other specialties, with 61% reporting symptoms of burnout (3). Maslach’s three dimensions of burnout include emotional exhaustion, depersonalization, and ineffectiveness (5).

Healthcare leaders have acknowledged that burnout is a systemic problem (6). There are multiple models describing work issues that can lead to physician burnout. One such model by Maslach includes excessive workload, lack of control, insufficient rewards or recognition, lack of community, lack of fairness, and conflict in values (7).

To help improve physician wellness on a group level, radiology leadership should ask themselves, “Is burnout a problem in my group?” and “What are the problems contributing to burnout in my practice?”

Radiologists can answer these questions in a multitude of ways, including informally talking to their colleagues, formal interviews, discussing issues which contribute to burnout in a group or section meeting, holding a specific focus group to discuss such issues, analyzing institutional engagement data, or through a survey.

Surveying colleagues can provide a lot of data as to whether or not burnout is a problem in your practice, and identify which issues contribute to burnout. The “Mini-Z” single question assessment of burnout (8) is a popular and easy way to assess self-reported burnout:

“Overall, based on your definition of burnout, how would you rate your level of burnout?

1. I enjoy my work. I have no symptoms of burnout.

2. Occasionally, I am under stress, and don’t always have as much energy as I did, but I don’t feel burned out.

3. I am definitely burning out and have one or more symptoms of burnout, e.g., emotional exhaustion.

4. The symptoms of burnout that I am experiencing won’t go away. I think about work frustrations a lot.

5. I feel completely burned out. I am at the point where I may need to seek help.”

Other questions can be asked of the radiologists at the surveyor’s discretion to discover what the “hot button” issues are that are driving the burnout.

Although there are individual and national factors that may contribute to physician burnout, implementing changes at a group or practice level may ameliorate burnout and improve physician wellness with greater impact and chance for success (9). Once radiologists have determined the main “driver” of burnout in their practice, they can begin to explore what types of practice changes might make the biggest improvements for their group (Table 1). Examples and strategies for group projects which can improve radiologist wellness are outlined in several radiology publications (10–12).

Table 1.

Examples of projects to improve radiologist wellness organized by the cause of physician burnout in a practice.

Driver of Burnout	Example projects to improve radiologist wellness
Work overload	Improve efficiency with workflow software in radiology Reading room assistants Ergonomic improvements Hire radiologists/locum tenens/moonlighting
Lack of control	Give radiologists more leadership roles More control over scheduling Better able to make requests
Lack of community	Happy hours Celebrations Lunches together
Lack of fairness	Make sure workload is divided "evenly“ Re-evaluate: Rotations Worklists Traveling to different locations Call schedule
Conflicting values	For academics, make sure radiologist knows what leadership wants -Most RVUs? publications? Give lectures? Grants? For private practice -Faster TAT? More accuracy? Add value in institution?
Rewards and recognition	Review salary and bonus/incentive compensation structure, partnership tracts Recognition for administrative work/other responsibilities Awards, scholarly work Mentorship or coaching programs

The team driving the improvements for a radiology practice can be organized in several ways, but ideally should have a leader, an executive sponsor, team members, and process owners. The leader of this team might be a radiologist who is a wellness “champion” or wellness officer for the group, either self-identified or appointed by radiology group leadership. The executive sponsor might be the radiology department chair, or a chief officer within the group’s hospital or institution, who can help assess proposed wellness solutions and provide the support to implement changes. Team members could be radiologists or other physicians who are part of a group or department wellness committee or task force, who can help provide support, suggestions, and execute tasks during process improvement to help the wellness officer. Process owners can be non-physician managers or support staff who make sure that once a process has been changed to improve radiologist wellness, the changes continue to be maintained and sustained over time. The wellness champion can decide how the team works together, whether the committee or task force meets at regular intervals or on an as-needed bases. The executive sponsor might additionally drive when meetings are held to discuss proposed changes. Having a timeline of steps to complete a proposed wellness improvement project is also very helpful in keeping the wellness champion and committee on track to ensure progress is made.

The DMAIC model is one change management process improvement strategy that can be used to make a practice change to improve and sustain wellness(13). DMAIC stands for Define, Measure, Analyze, Improve, and Control; examples of how to implement an improvement project using DMAIC are shown in Table 2. Leveraging the DMAIC methodology allows one to ensure they are solving the root causes of burnout within a practice.

Table 2.

How to use the DMAIC practice improvement model in order to improve radiologist group wellness.

DMAIC	How to use DMAIC to improve radiologist group wellness
Define	Define the problem(s) leading to radiologist burnout
Measure	Collect data regarding drivers of burnout in the group using surveys, focus groups, and/or interviews; compare with outside group practices
Analyze	Analyze the data to determine what practice elements to improve, possible solutions, and how to implement change
Improve	Get buy in from stakeholders and put the practice improvements into place
Control	Figure out a way to sustain improvements so that they are not “rolled back”

After defining the radiology group’s work issues perceived to be leading to burnout, and analyzing collected data from radiologists within the group, possible solutions to the group’s drivers of burnout can be explored. The goal for a given wellness improvement project should be clearly defined. Many times, the problems are similar among different physician groups, and so radiologists can look to their colleagues practicing elsewhere for possible solutions. Social media outlets such as Facebook, Twitter, and radiologist listserves can be very helpful in “crowd sourcing” possible solutions. Demonstrating that the proposed initiative has already worked in other practices or institutions may reassure practice leaders; alternately, highlighting the innovation of the proposed solution may serve as a selling point for their practice.

The radiologist and wellness team leading these potential improvements to the practice also needs to think about the interests of the stakeholders and relevant outcomes. Can the intervention to improve radiologist wellness improve finances of the practice? Can the intervention help with radiologist recruitment, delay radiologist retirement, create a competitive advantage, or improve engagement scores? If the proposed projects to improve physician wellness relate to one of these outcomes, there may be increased buy-in from stakeholders such as the practice leaders. Those leading the changes should ensure they address any concerns the practice leaders or administrators have regarding the proposed changes. It is crucial not to over-promise and under-deliver, or to make promises that one cannot keep when working with the stakeholders. Engaging practice leaders and stakeholders at the beginning, and throughout the entire project, is central to gaining buy-in and support for recommended improvements. Their continued engagement will improve access to institutional resources (e.g., information services, employee health), financial resources as needed, and dedicated time.

When speaking to practice leaders to practice good change management, a radiologist leading the wellness improvements should adopt a “team” mindset of working together so that everyone involved with making the improvements receives credit for doing their share of the project. Finger pointing or blame for past problems should be avoided to try to move forward making practice improvements. DMAIC focuses on solving processes that are “broken” versus blaming people or teams.

When working with practice leaders, data, photos, and quotes can be persuasive. If PowerPoint is used to show a proposed solution to a driver of burnout, use the fewest number of slides possible. It is best to have a clear outline of what steps are needed to implement your improvement, and make sure to end a presentation with whatever “next steps” are needed and how they will be done. Positive messages rather than negative ones will be better received and may be more effective in leading to improvements.

This paper will discuss the application of DMAIC methodology to team approach to radiologist wellness. Case examples from a single academic radiology department will be presented to illustrate methodology and result driven strategies. Radiologists in this department were surveyed regarding wellness and burnout to better understand the extent of physician burnout and target which drivers of burnout should be addressed to improve wellness. This survey showed that the main driver of burnout was work overload, followed by lack of control, and insufficient rewards and recognition (Figure 1), and so interventions to improve physician wellness were aimed at these drivers.

Figure 1.

Survey results from a single academic radiology department show the drivers of burnout in this physician group (n=59). Given that the main drivers of burnout were work overload, followed by lack of control, and insufficient rewards and recognition, interventions to improve physician wellness were aimed at these drivers.

Case example I: Reading room assistants

Define

Over the course of two decades an academic institution saw growth in the number of reading rooms, the number of radiology faculty and trainees, and the volume of imaging performed and interpreted. This growth unsurprisingly led to an increase in the number of phone calls to the radiology reading rooms. Interruptions from phone calls regarding protocols, results, and other patient matters resulted in radiologists losing their place in their search pattern, slowing down image interpretation, and led to anger and frustration. Interruptions also increase the chance for errors in reporting and interpretation and are a patient safety issue (14, 15). Having a reading room assistant was hypothesized to improve physician wellness by addressing work overload, decreasing the number of non-interpretive tasks expected of the radiologists.

Measure

Surveys were sent to faculty and trainee radiologists to assess the need for and interest in hiring reading room assistants to handle non-interpretive tasks such as answering and triaging the phones as well as contacting health care providers, technologists, and information technology staff.

Analyze

Radiologists were overwhelmingly in favor of hiring reading room assistants, with 45/46 (98%) of radiologist respondents in favor of having a reading room assistant for non-interpretive tasks. The importance of reading room assistance was clear when 44/46 (96%) of radiologist respondents thought that having workflow disruptions and interruptions negatively impacted imaging report accuracy and interpretation, a potential patient safety issue. Radiologists also perceived that a reading room assistant would improve their mood and happiness (41/45, 91%), allow interpretation of a greater number of exams (43/45, 96%), and improve turnaround time (40/45, 89%) (Table 3).

Table 3.

Radiologists support having a reading room assistant, as shown in the affirmative responses to the question below. (N= 45 radiologist).

Would having a reading room assistant:
Improve your mood and happiness level with your job	41/45	91%
Minimize interruptions, thereby improving imaging report accuracy and patient safety	45/45	100%
Allow you to interpret a greater number of imaging exams	43/45	96%
Improve your turnaround time	40/45	89%
Allow you to spend more time on tasks which “add value”, such as consultations with referring physicians	41/45	91%

Practice leaders and administrators were convinced by the survey data that 1) not having the assistants was a patient safety and liability issue, 2) report turnaround times may decrease with fewer phone interruptions, 3) greater volumes of imaging might be able to be interpreted in a shorter amount of time, and 4) radiologist satisfaction/engagement might increase.

Improve

Reading room assistants were phased in over a few years to multiple sections within the radiology department, and were trained by a radiologist in conjunction with administrative staff. Because the number of reading rooms was greater than the number of assistants hired, one assistant was stationed in each building where radiologists were working, with reading room phone lines forwarded to the assistant to be able to triage calls.

Feedback from radiologists regarding the reading room assistants after their installation over time was positive, with 89.5% (17/19) of one group of radiologists reporting that the addition of an assistant in the emergency department reading room improved their mood. Other comments one year after installation of a reading room assistant in the body CT room included, “Helps tremendously with the workflow,” “Would probably drown under phone calls without her,” and “Always respectful and helpful on the telephone… a great addition.”

Control

The radiologist who initiated this project helped to oversee the reading room assistants, and a department administrator was their supervisor. The radiologist helped with onboarding, training, and hiring of the reading room assistants, as well as adjustments in the job description, as needed. For example, during the first wave of the COVID pandemic, the reading room assistants were instrumental in triaging phone calls to radiologists who were working remotely, and replenishing supplies like hand sanitizer and disinfecting wipes. The radiologist liaison also helped with communication between other radiology faculty, trainees, and staff and the reading room assistant. Recent literature also supports that reading room assistants contribute to radiologist well-being (11, 12).

Ergonomics and Work-Related Injuries

Define

Radiology faculty and trainees were noted to be suffering from repetitive stress injuries (RSIs) particularly involving their hands, thumbs, and wrist, but also back and neck, hypothesized to be due to inferior mice and extensive scrolling through exams with thousands of images (especially CT angiograms and MRI exams) over long shifts of many hours. Radiologists' repetitive stress injuries had been responsive to ergonomic interventions previous literature (16). It was thought that improving ergonomics in the radiology department might improve wellness by decreasing workload, through being able to work through cases more quickly, and also by increasing control, so that radiologists could have choice and comfort in their workspace.

Measure

Radiology faculty and trainees in a single academic institution were surveyed regarding physician wellness, workstations, RSIs, and ergonomics knowledge. Occupational health was engaged to evaluate the radiology workstations.

Analyze

As reported in [blinded for review; now published], when surveyed, 40/59 radiologists (68%) reported a current or prior RSI. Of those respondents, 17/40 (42%) reported that their RSIs caused symptoms of burn out; 15/40 (37%) reported that their injury made them think about leaving their job. Wrist, finger, neck, and back were the most common sites of injury. Radiologists identified the tables, chairs, and mouse as the biggest factors contributing to their injury (17). Occupational health made several recommendations, including ergonomic/programmable mice, sit/stand desks, ergonomic chairs, headsets or mountable system for Dictaphone, under desk space decluttering and organizing cords, and breaks at least every 45 minutes for stretching and position changes (Figure 2).

Figure 2.

Selection from the Occupational Health and Employee Safety Ergonomic Assessment Form recommendations for radiology PACS workstations to minimize risk of injuries.

Improve

A radiology department ergonomics committee was formed, which included radiology faculty and trainees, IT staff, and a radiology manager. Education was provided to the radiologists on “Ergonomics best practices” by the occupational health representative at a faculty meeting and resident/fellow conference, including a lecture and a handout. Ergonomic wrist pads and wireless mice were installed. Broken chairs were replaced. Many of the workstation tables which were old or broken were also replaced with sit-to-stand desks. Cords were organized below the workstations to reduce risk of injury due to tripping.

Control

Radiologists were surveyed the year following the ergonomics improvements described above. As previously reported, of those radiologists with active RSI during the year of the interventions, 9/25 (36%) reported their RSI resolved and 13/25 (52%) RSI improved (17). Only 3/25 (12%) of respondents reported that their RSIs did not improve. RSI improvements were attributed to ergonomic interventions in 19/25 (76%) of respondents. Among the full sample surveyed, 45/65 (69%) radiologists thought the ergonomic improvements would help to decrease the risk of developing future RSIs. Improving the ergonomic design of their workstation was reported to contribute to the overall wellbeing of the radiologist for 53/64 (83%) of the respondents (17). The ergonomics committee met approximately once every 6 months for 2 years, and now is under the umbrella of the department Radiology Wellness Council to foster ongoing sustainment. A lasting change from this project is that radiologists feel more empowered and in control of their workspace, and they know who to turn to (the Radiology Wellness Council leader or members) if an additional improvement in the workspace needs to be made, or if they have suggestions for workspace improvements.

Radiology Faculty Mentorship Program

Define

Junior radiology faculty at an academic institution gave feedback that they desired more formal mentorship. Many assistant professors stayed at that rank for more years than was thought to be desirable by the institution. At the request of the department chair, a radiology mentorship committee was formed, composed of senior and junior representatives from each of the sections of the radiology department. A focus group was also run to better define the mentoring needs of the department. The amount and forms of mentorship across the radiology department was inconsistent between sections, some junior and mid-career faculty reported that they were not receiving enough sponsorship to assist with academic career development at a national level, and there was a lack of understanding of what was required for promotion. A mentorship program can help improve physician wellness by addressing drivers of work overload (mentees learn from mentors how to work more efficiently), lack of control (mentees feel more in control of their career development), and improving rewards and recognition (both mentees and mentors get increased recognition of their scholarly work).

Measure

Radiology faculty were surveyed to ascertain whether or not they currently had a mentor, if they would like have a mentor assigned to them, who they might like to have as a mentor, whether or not they were willing to be a mentor, who they were currently mentoring, their current level of mentoring satisfaction, their mentoring needs, what areas they felt comfortable mentoring in, and what topics they would like to learn about in faculty development workshops. Forty-eight radiologists, both mentees and mentors, responded to the initial survey. The top three areas in which the most radiologists reported needing mentoring included research (25/48, 52%), career development (17/48, 35%), and promotions (15/48, 31%). The topics in which faculty most wanted workshops included goal setting (23/48, 48%), learning to lead (20/48, 42%), improving lectures (19/48, 40%), promotion tips (19/48, 40%), time management (18/48, 38%), and networking (18/48, 38%).

Analyze

Following an analysis of radiology faculty survey results, feedback from the radiology mentorship committee, focus group results, mentorship literature, and other mentorship programs, identified goals for a radiology mentorship program included: mentorship for promotions, research, and career and leadership development, in the context of the “mentee’s” goals. The mentorship program structure thought to have the greatest chance for success was to “pair” mentees with mentors in dyads, and to educate the faculty through a series of faculty development workshops.

Improve

Junior faculty within 5–6 years of graduating from training, as well as Assistant Professors who desired more mentorship were paired with a mentor. The mentor-mentee pairing was based on mentees’ preferred mentor pairing, balanced with mentors’ availability and the wishes of the section chiefs and department chair. No mentors were assigned more than three mentees. Mentor- mentee pairs were instructed to “meet” a minimum of three times per year. Mentees were also taught to write a career development plan, including their goals for the coming year, which could be used to guide the mentor-mentee meetings. Faculty development workshops were conducted approximately every 2–3 months based on the topics the faculty requested: Mentor training, How to write a career development plan with SMART goals, Aligning mentor-mentee expectations, Tips for Promotions, How to improve your virtual and in-person teaching, Time management, and Learning to Lead.

Control

Reminders were sent every few months to faculty to encourage mentor-mentee meetings, including inspirational material. Administrative assistants were engaged to help with scheduling mentor-mentee meetings when necessary. The mentorship program was re-evaluated yearly in order to assess mentor-mentee pairs, and allow mentees to “switch” to a different mentor if desired, allow mentors to switch to different mentees, allow faculty to “graduate” from the program, and allow new faculty to join the program if desired. The yearly re-evaluation was by faculty survey to re-evaluate if structural changes were needed in the program.

Results of a faculty survey one year after beginning the program demonstrated that program goals were being met. Responding on a scale from 1 = definitely not to 5 = definitely, mentees (N=25 responses) indicated they perceived the mentorship program helped career development (M = 4.32, SD = 0.80), and helped progress to promotion (M = 4.00, SD = 0.87) (Figure 3). Among mentor respondents, 13/14 (93%) indicated willingness to continue with their assigned mentees; 22/25 (88%) mentees indicated willingness to continue with their assigned mentors. Other comments from mentees included “Having 1 on 1 time with a really good mentor was super helpful,” “Being paired 1:1 with a mentor with regular check-ins which helps you stay on track and accountable with your career goals,” “[the program] has increased the visibility and importance of mentorship,” and “Great program!”

Figure 3.

Results from a survey to faculty mentees one year after starting the faculty mentorship program show that the mean response by faculty mentees (n=25) demonstrate that goals of the mentorship program (stars) are being met. (1= definitely not, 2= probably not, 3= neutral, 4= probably, 5= definitely)

Limitations and Follow Up

While many interventions in a radiology group to improve wellness can be aimed at a specific driver or drivers, there are many confounding variables which make it difficult to show with statistical significance that a physician group’s overall rate of burnout has improved due to interventions, such as personal issues affecting wellness in physicians’ lives, national/international phenomena such as the Covid-19 pandemic, and radiologist turnover in a group over the course of wellness interventions (different radiologists filling out the pre- and post-intervention surveys).

In the single academic radiology department in which these wellness projects were performed, several wellness metrics on the ACGME (Accreditation Council for Graduate Medical Education) faculty survey improved between the 2018–2019 survey (given in early 2019) and the 2020–2021 survey (given in early 2021, when all of the case examples described had been in place for at least 1 year). While radiologists who fill out the ACGME faculty survey represent a subset of the radiologists in the department, all sections are represented, and this ACGME faculty survey data can be used internally by academic radiology departments to help guide wellness interventions.

Some wellness interventions in a radiology group have the advantage of not only helping to prevent physician burnout, but also potentially may improve radiologist productivity and group finances. Various metrics such as work relative value units (wRVUs) and turnaround time can and should be analyzed before and after a wellness intervention, but due to many confounding variables occurring at the same time as the wellness interventions, such as installing new radiology hardware and software, the Covid-19 pandemic causing changes in the amounts of imaging obtained, and turnover of radiologists, it can be difficult to prove with statistical significance that a wellness intervention improves productivity. For example, in the radiology department where the case examples explained here were implemented, wRVUs grew in 2019, decreased in 2020 due to the Covid pandemic, and increased in 2021 more than expected. However, of the variables which changed over time, installation of additional radiology equipment in the last year probably had the most impact on the wRVUs. Careful attention to metrics both before and after an intervention over a short time span aimed at a specific driver of burnout may be able to show productivity results as well as improve physician wellness.

Conclusion

Radiologist wellness is important on an individual and group/institutional level. Improvements to radiologist wellness on a group level can be made using the DMAIC model, which promotes a strong and healthy working environment and in turn helps with radiologist retention and enjoyable employment. This framework supports radiology autonomy and control. When a problem is identified, radiologists are empowered to drive measurable and sustainable change. Many initiatives to improve radiologist wellness do not have to be costly, and some have potential to improve practice finances. A team approach toward making improvements to radiologist wellness increases chances for sustained success, particularly when efforts are led by a wellness “champion” who is supported by leadership and backed up by a committee or task force. Improving wellness is a win-win for individual radiologists and radiology leaders.

Highlights:

• Radiologist wellness helps to promote a strong and healthy working environment.

• Improvement can be made using the DMAIC (Define, Measure, Analyze, Improve, and Control) model.

• The team includes a wellness “champion”, group leadership, and a wellness committee or task force.

• Example projects: Reading room assistants, ergonomic improvements, and mentorship programs.

• Improving wellness is a win-win for radiologists, radiology groups, and academic institutions.