Radiologists Are Burning Out

Radiologists are among the top 10 most burned out physicians, according to Medscape’s 2015 Physician Lifestyle Report. In seventh place-right behind internal medicine, general surgery, and infectious diseases-the report found that 49% of radiologists felt burned out. The figure is a significant increase from last year’s Physician Lifestyle Report, where radiology ranked low on the list at number 18.

Although it’s difficult to predict who might be at risk, radiologists are not immune to burnout despite radiology’s reputation as a lifestyle specialty. And if the Medscape 2015 Physician Lifestyle Report is any indication, it’s an issue that is bubbling to the surface at a rapid clip.

“Unique aspects of our profession, such as its relatively isolated and sedentary nature, might predispose some radiologists to burnout,” said  Michael F. McNeeley, MD, a fellow in the University of Washington’s department of radiology.

The Medscape report defines burnout as a loss of enthusiasm for work, feelings of cynicism, and a low sense of personal accomplishment.

Isolation-Never an Effective Model
"You can’t chop away in a room just reading images without losing interest in what you are doing,” said  John Cronan, MD, chairman of the department of diagnostic imaging at Brown University’s Alpert Medical School and radiologist-in-chief at Rhode Island Hospital.

Isolation was never an issue for radiologists before PACS. In fact, during the days of film, the radiology department was one of the busiest places in a hospital. Today, however, most radiologists read studies in isolated cubicles. This isolation has been synchronized with decreased reimbursement as well, according to Cronan.

“We are motivated to read more and take advantage of not being interrupted by other doctors,” said Cronan. “Thinking that was good, it has led to total isolation, deprivation and radiologists becoming burned out.”

Cronan calls it the efficiency model.[[{"type":"media","view_mode":"media_crop","fid":"38274","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_7322748515111","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3796","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 256px; width: 250px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"©Lightspring/Shutterstock.com","typeof":"foaf:Image"}}]]

Although PACS has led to many positive gains for radiology and medicine as a whole, at the same time, it has left radiologists with diminished support, fewer professional relationships, and feelings of isolation and loneliness.

At Rhode Island Hospital, Cronan came up with a simple intervention to help try to alleviate the problem.

“We weren’t going to get the referring physicians back but we could cluster the doctors and radiologists together in an open room,” said Cronan.

They started small by breaking down a wall that separated the reading stations of body CT and body ultrasound. Now it’s one big room they call the body room.

“Some interchange and socialization during the day has been huge,” said Cronan.

At the same time, the hospital’s emergency department needed to increase its capacity. Instead of having another radiologist help read ER studies in a different location, Cronan suggested physically putting the attending physicians and residents in the ER together, which has also been successful, especially among radiologists who would rather avoid ER rotations because of the isolation.

Most recently under Cronan’s direction, Rhode Island Hospital has combined diagnostic and screening mammography radiologists in the same room, as well as neurology and spine MR.

“I have come to the conclusion that we have a higher job satisfaction when people work together-and they like working together as a team,” said Cronan.

Contributing Factors
According to the 2014 American Medical Group Association (AMGA) 27^th Annual Medical Group Compensation and Financial Survey, which was also discussed at RSNA 2014, relative value unit (RVU) increased at an even higher rate than compensation for radiologists. RVU rates, which are the primary measure of a physician’s productivity, set reimbursement by the Centers for Medicare and Medicaid Services (CMS).

The study found that RVUs for interventional radiologists increased by 5.8% and by 7.2% for diagnostic radiologists. According to RSNA, the rise represents one of the highest in any specialty, except for psychiatry.

Coupled with this are changes to the Multiple Procedure Payment Reduction (MPPR) as applied to RVUs. In 2012, when CMS expanded MPPR to include a cut to the professional component, RVUs should have been reduced too, since an additional second study only gets credited for 50% of the RVUs as opposed to 100%. Notably higher RVUs-when the MPPR should have made them lower-signifies radiologists are working even harder.

Of all the factors that could be contributing to burnout among radiologists, the increase in work volume may be the overriding factor, according to  Peter Moskowitz, MD, a clinical professor of radiology at Stanford University School of Medicine.

“It seems every year that the number of cases and the daily work volume seems to be getting greater at a time when there is pressure to increase individual work productivity,” said Moskowitz.

He says radiologists’ RVUs are being monitored to the point where some hospital administrators are using RVU output to determine salary and bonuses.

“There is tremendous pressure on radiologists to work more and do it faster and that stress is the major problem,” said Moskowitz.

Without interventions, he said it’s hard to see the situation improving.

Who Might Be Impacted the Most
Moskowitz, who is also founder and executive director of the Center for Professional and Personal Renewal where he coaches physicians on career and life management, said in his 16 years of coaching, radiologists have become his predominant client over the past five years or so.

“It’s becoming more and more of a problem in our field,” he said.

Yet at the same time, he said it’s still the elephant in the room that no one wants to acknowledge. He said the anxiety and depression radiology trainees feel is often not spoken about because many are reluctant to admit they need help in the first place.

Moskowitz cites a particularly high stress rate among radiology trainees, which he has noticed first-hand in many of his radiology residents.

“Burnout is becoming more of a significant issue among trainees in radiology, and if left unaddressed, the natural progression would be that it would start affecting their mood and performance,” said Moskowitz.

McNeeley and his colleagues were the first to look at burnout for radiology trainees. Based on a 2013 study, they found similar levels of burnout among radiologists when compared to internal medicine residents. This correlation signifies something noteworthy because for years radiology has carried a reputation for being a lifestyle specialty.

McNeeley said this could end up misguiding medical students to enter the field for the wrong reasons and perhaps with unreasonable expectations. By the same token, he said it could cause department leaders to underestimate the pressures that their trainees are experiencing and possibly result in a lack of department wellness initiatives that should be in place.

This current situation seems especially worrisome and stressful for radiology trainees. Radiology residents work nights and weekends, take frequent calls, and are not in a position of power, according to Moskowitz.

In addition, they go through a relatively long training period-which includes five years of postgraduate training with fellowships becoming virtually obligatory; they are hit with medical student debt that can easily exceed $150,000 as they begin residency coupled with difficulty finding affordable housing in urban centers when they begin training; and they face an uncertain job market as well as changes in the board certification process.

Moskowitz said those who are single and without the added income from a working spouse are especially susceptible to such financial stress.

“Over time, this financial stress takes a toll,” said Moskowitz.

Both McNeeley and Moskowitz agree that if the topic is not addressed and conditions are not improved, radiology could face a recruitment crisis in the years to come.

Moskowitz said leaders should be concerned if they begin to see residents leaving their training programs before completion.

“It’s a huge issue of tremendous importance-it threatens the very viability of radiology,” he said.