Battling Burnout
By Claudia Stahl
Radiology Today
Vol. 24 No. 5 P. 10 

Mitigating burnout is a continuous process with multiple pathways.

As mask wearing and other cautionary COVID protocols fade into the past, burnout—heightened by the extreme circumstances of the pandemic—continues to affect the staff, patients, and economics of medical practices. 

According to Jeffrey F. Chick, MD, MPH, an interventional radiologist at the University of Washington in Seattle and an expert on physician burnout, the abrupt lifestyle changes, masking, and social distancing of the last two years, coupled with direct occupational exposures, have only increased burnout, anxiety, and PTSD among physicians. “These negative outcomes have remained since the pandemic,” says Chick, who spoke on the subject at the Society of Interventional Radiology (SIR) 2023 meeting this past March in Phoenix.

His session, which reported on the results of a 2019 survey of SIR’s members on burnout, was part of a multipart workshop addressing burnout in IR, with an emphasis on how it uniquely affects women in the field. Paula Novelli, MD, an interventional radiologist at University of Pittsburgh Medical Center, who moderated the program, says she became interested in burnout when it kept emerging as a theme in conversations with colleagues at work, in SIR’s Women in Radiology (WIR) special interest section, and at professional meetings.

“People were seemingly just exhausted, both physically and emotionally, a depersonalized shell of who they were when they were starting their careers,” Novelli says. The pattern upset her because “interventional radiologists are some of the most passionate physicians out there but, for many, that feeling of ‘I can’t believe I get paid to do this’ has been replaced by ‘I just don’t want to go to work today.’”

Burnout Symptoms, Sources, and Stats
Physician burnout leads to reduced productivity and increased physician turnover, and, by some estimates, costs the United States $4.6 billion annually from physician turnover and reduced work hours. The ICD-11 and other sources characterize burnout in terms of energy depletion or exhaustion, job-related depersonalization or cynicism, reduced professional efficacy, apathy, and hopelessness. It’s also a threat to patient safety, as physicians with burnout are twice as likely to provide unsafe care and engage in unprofessional behaviors that lower patient satisfaction.

Radiology consistently ranks in the top 10 medical specialties with the highest rates of burnout, with more cases in IR than diagnostic radiology. The 2020 Medscape National Physician Burnout and Suicide Report revealed that 46% of radiologists are burned out, as compared with 42% of all physicians, and among the 339 interventional radiologists who participated in the SIR survey, 72% have experienced at least one form of burnout.

Novelli says, “late days, middle-of-the-night cases, as well as the urgency of the work at times,” contribute to the field’s high rate of burnout, along with administrative tasks, productivity pressures, and practice-related frustrations like case delays and poor ancillary support. As someone who routinely spends 60 to 70 hours a week on clinical, research, and academic responsibilities, she feels physically and emotionally tired when the workday ends, but “I enjoy my work at a high level on most days and can’t describe more than a few situations that would meet the full criteria for burnout.”

Her schedule, while far from light, falls under the burnout threshold reported in research, which shows that interventional radiologists who work more than 80 hours per week are seven times more likely to report burnout than those who work fewer hours. Other well documented sources of burnout in IR include diagnostic responsibilities, contentious relationships with diagnostic radiologists, lack of recognition and respect from other medical and surgical subspecialties, and inappropriate consultations from other medical professionals that add to the workday.

Medical literature reports that burnout in female physicians may be up to 60% greater than that of male physicians, with women experiencing higher rates of emotional exhaustion and men experiencing higher rates of depersonalization. The SIR study found that female interventional radiologists are more than twice as likely to experience burnout than their male counterparts. In addition to the occupational triggers that affect all physicians, women in medicine are disproportionately affected by family responsibilities, childbearing, and fertility concerns. In their careers, women in IR receive less professional recognition, lower pay, and fewer leadership and mentorship opportunities.

Despite having lower negative patient outcomes, “female doctors are more likely to be reported to HR and to administration, have fewer advancement opportunities, and are less likely to become full professors or academic leaders,” Novelli says, “and workplace flexibility is often nonexistent for mothers wanting to participate in their children’s school or after school activities. Blocking midday portions of our schedule can be very problematic, as urgent add-on procedures can’t be predicted.”

Moral Distress
Unlike administrative tasks and workplace relationships, moral distress, a lesser-known cause of burnout, “stems from the feeling that I’m doing something ethically wrong,” explains Bettina Siewert, MD, in an interview with Andrew Rosenkrantz, MD, the editor of the American Journal of Roentgenology. An article by Siewert and her colleagues on the topic was published online in March 2023 in the American Journal of Roentgenology.

It’s a serious component of burnout, affecting 98% of the radiologists (105) who participated in a 2022 study led by Siewert, a diagnostic radiologist and vice chair of quality and safety at Beth Israel Deaconess Medical Center in Boston. The survey, emailed to the National Radiology Society’s quality-and-safety listserv, presented respondents with multiple scenarios associated with moral distress, such as performing procedures considered unsafe, workloads that exceed capacity, morally concerning communication issues between members of the clinical team, lack of informed consent from the patient, and limited support from administrators for clinical work. In addition to experiencing at least one of the given scenarios, 18% of the respondents said they’d left a clinical position— and 28% said they’ve considered leaving positions—due to moral distress; nearly one-half of the participants attributed the circumstances of the COVID-19 pandemic to heightened moral distress.

Mitigation Strategies
In an effort to mitigate burnout, many organizations implement programs to help physicians build resilience and manage stress, such as mindfulness training, small group discussions, and exercise.

Resilience, an essential factor in physician well-being and patient safety, correlates with leadership skills, and “physicians who lack leadership training are more likely to burn out,” wrote Hemasree Yeluru in “Physician Burnout Through the Female Lens: A Silent Crisis,” published May 2022 in Frontiers in Public Health. Effective communication, team building, role modeling, and emotional intelligence— classic leadership skills—“could be the tipping point between burning out and remaining resilient,” and that makes leadership training an important resource for mitigating burnout.

In addition, “workplaces can also consider offering mental health resources, providing regular check-ins with employees, creating a culture of support and teamwork, and implementing policies that promote work-life balance,” says Maria del Pilar Bayona Molano, MD, who presented on prioritizing physical and mental health for the SIR burnout workshop.

She points to Mayo Clinic’s Program on Physician Well-Being, “which offers resources such as coaching, workshops, and retreats,” and Stanford Medicine’s Physician Wellness Committee, “which provides a forum for physicians to discuss their challenges and experiences while also offering educational resources and support,” as examples.

Hospital leaders may refer to successful burnout mitigation programs when building their own, but they should tailor them to the unique population and culture of their workplace, taking generational differences and personality traits into account. Bayona Molano says these programs “should prioritize listening to those affected [by burnout] without judgment … [and] prioritize the wellbeing of the team,” inviting communication and conflict resolution free of stereotypes and microaggressions. She adds that “all staff should receive education on these topics.”

Choosing Wisely
In addition to wellness programs, Chick says, organizations looking to preserve the health of their IR workforce should consider decreasing work hours and other contributors to overall workload while redirecting the organizational focus from finances to patient-focused care.

The Choosing Wisely framework, developed more than a decade ago by the American Board of Internal Medicine Foundation, could serve as a roadmap for eliminating or reducing many of the factors associated with burnout, such as inappropriate referrals and rote administrative tasks. The recommendations provide guidelines to help health systems with eliminating services and practices that place unnecessary burdens on the clinician workforce, lack sufficient evidence to improve clinical quality and organizational outcomes, are unimportant to patients, and are useless or redundant.

In “Enhancing the Value of Clinical Work — Choosing Wisely to Preserve the Clinician Workforce,” published in JAMA Health Forum, Eva Kerr, MD, MPH, and her coauthors recommend that organizations focus their efforts on three areas: asking clinicians to identify low-value management practices, asking leaders to abandon low-value practices that aren’t tied to external regulations, and partnering with regulators and stakeholders to change or eliminate burdensome requirements.

The authors wrote that implementing the Choosing Wisely agenda in concert with other necessary organizational changes “can result in substantial positive changes to clinicians’ everyday lives, changes that are essential to addressing continued operational disruptions due to workforce departures that threaten gains in quality, safety, equity, and trust in the US health care system.”

Elevating Women in IR
Addressing burnout in women radiologists begins with recognizing the unique challenges they face and implementing strategies to support their well-being. Flexible work schedules, mentoring and coaching programs, and support for childcare and eldercare are a good start, but they do not adequately address the professional disparities that women in the field experience.

Novelli says, “practices that have dedicated social and educational activities in place for women radiologists, as we do in my institution and the WIR section within SIR, are working hard … to eliminate gender- based biases and harassment—major contributors to burnout.”

The WIR programs include workshops, webinars, and book clubs intended to help interventional radiologists recognize gender- based and genderless burnout, “and support our male colleagues ... in learning ways to successfully support women in their medical careers,” Novelli says. Men who participate in WIR “become upstanders rather than bystanders” in mitigating burnout in their female colleagues.

The Power of Individual Actions
Hospital-based wellness programs and organizational changes can go a long way toward helping clinicians prevent burnout, but physicians often forget that they hold the keys to life and career fulfillment. In a 2019 article in Seminars in Interventional Radiology, Michael Knox, MD, of Advanced Radiology Services, offers the following strategies to fellow radiologists:

1. Connect to purpose. Reflect on why you chose IR and the benefit of your work.
2. Foster collegiality. Create and embrace the opportunities to interact with colleagues.
3. Share learnings at conferences and through case discussions and relationships.
4. Mentor and be mentored. Share wisdom with younger partners and remain open to learning from them.
5. Consider contributing to IR through committee work, administrative roles, and leadership positions.
6. Take quality time away from clinical care. Recharge through activities that bring personal fulfillment.

Knox’s recommendations stem from more than three decades of work in the field, service on the hospital’s physician wellness committee and in other leadership positions, and time spent on the patient side of health care. In the four years since the article was published, COVID has created some additional complexities by removing the daily interpersonal interactions among physicians and staff that helped build relationships. More than ever, he says, it’s imperative for systems to look for ways to break down barriers and create opportunities for personal connection—from social activities outside of work hours to recognition of colleagues for a job well done, “so that we can create a sense of common purpose and goals.”

The effort will have a systemwide effect. Like other medical specialties that rely on interactions with multiple teams, IR suffers when burnout affects other units or staff within the hospital ecosystem. As Novelli notes, “Stressors specific to one group can affect the entire nurse, technologist, advanced practice provider, physician unit, so we need to make sure that all people … work effectively and happily together.”

— Claudia Stahl is a freelance writer based in Ambler, Pennsylvania. She specializes in writing about the health of people and the planet.