The once seemingly distant crisis of a strained workforce coupled with a growing demand for imaging services is now upon us. Finding solutions will require a shift in practice and thinking about efficiency and embracing positive disruptors that may reshape radiologists’ role in providing high-quality, unhindered services. The first article in the Bulletin series on the radiology workforce landscape explored current and near-term challenges to existing delivery models and feasible strategies to mitigate negative outcomes. Here, we look at how burnout is compounding an already dire situation — and the importance of addressing the problem before physicians and the patients they serve pay the price.

It is a generally accepted truth that a happy and healthy employee is a productive employee. In healthcare settings across the globe, however, physicians and other medical professionals are feeling the crunch of producing more with less as workforce shortages and rising volumes have hit crisis levels. During a time when safe and efficient patient care depends on everyone giving 110%, no radiology practice or academic department can afford to overlook or ignore the signs of burnout.

Burnout has been defined as a workplace syndrome characterized by physical and emotional exhaustion, a low sense of accomplishment or self-value and cynicism. There is often an economic cost to physician burnout — with turnover and lost revenue from decreased productivity. While the numbers around burnout among physicians have leveled out in the last year, 71% of physicians experiencing burnout report having felt that way for longer than 13 months. Radiologists fall somewhere in the middle of specialties with the highest rates of burnout, with 44% of male radiologists and 65% of female radiologists saying they feel burned out or burned out and depressed. 

“I know a lot of radiology groups sometimes struggle with trying to get their organizations to support efforts around burnout,” says Jay R. Parikh, MD, FACR, professor of diagnostic radiology at MD Anderson Cancer Center and a member of the ACR Commission on Human Resources. “Not only are radiologists suffering,” Parikh says, “but the other side of the equation that can’t be ignored is that there are benefits to health systems when they address physician burnout.”

Burnout is associated with lower productivity and a desire to find happier and healthier settings by physicians, but because of its contagious nature puts team members at risk, Parikh says. “Fewer staff means reduced access to studies for patients and higher costs for health systems. Hiring temporary employees to fill the gaps is not cost-efficient and really a Band-Aid approach,” he says.

Looking at supply in comparison to demand within multiple physician categories, demand is projected to continue to grow faster than supply under the most likely scenarios, according to a report from the Association of American Medical Colleges (AAMC). This is expected to lead to a total shortage of between 13,500 and 86,000 physicians by 2036. Radiology falls within the AAMC’s “other specialties” category, which estimates a combined specialty shortage of 19,500 physicians.

A Perfect Storm

Drivers of the current workforce crisis are many — and are daunting or impossible to slow down. An aging Baby Boomer population, imaging overutilization, an increase in insured patients and the changing makeup of radiology groups are some of the main drivers. Other factors exacerbating the crisis include an overreliance on imaging by non-radiologist providers, the expanded capabilities of diagnostic imaging that make it ubiquitous in healthcare, evolving ideals around job satisfaction and work-life balance, hiring practices and employee retention, fewer training opportunities, stagnant residency slots and resistance to modifying workplace environments and culture.

There is a general lack of support and promotion of wellness programs and resources, Parikh says. “We must keep the conversation going if we want to meet the challenges of the current workforce landscape. The impact on radiologists, the health system and patient care is devastating.”

Not only are radiologists suffering, but the other side of the equation that can't be ignored is that there are benefits to health systems when they address physician burnout.

The consequences of physician and support staff burnout impact the entire healthcare value chain. For staff, relationships at work and at home may suffer, physical health may decline and low morale and job satisfaction lead to turnover. Interactions with patients and referring physicians can suffer, impacting the overall coordination and quality of patient care.

“Burnout is associated with poor patient care, medical errors and more negative outcomes,” Parikh says. “You may also find lower patient satisfaction scores. Radiology leaders who are working to address burnout should recognize the problem as a patient care issue,” he says.

“There can often be a fundamental decline in self-care, substance abuse, depression and even suicide,” Parikh says. “Self-valuation is impacted when self-care is diminished, leading to adverse outcomes, be they clinical, legal or other. Not giving yourself compassion is a problem, and it would be nice if more organizations would home in on this issue.”

Risks and Costs

The well-being of radiologists and the overall efficiency of healthcare delivery go hand in hand. While always putting the health of their physicians first, administrators and radiology leaders should recognize the dangers of compromised patient care and the inflated costs associated with burnout. 

An already strained workforce cannot afford to lose staff and revenue from the detrimental stressors that contribute to burnout. Access to services could be at risk, resulting in fewer patient studies. Burned-out staff may struggle to keep up with the demand for imaging interpretations, resulting in backlogs and longer wait times for patients. Process improvements to streamline workflows are essential, and reducing excessive paperwork, calls and administrative tasks that take away time from complex clinical duties can assuage physician frustration or fatigue.

From a patient safety perspective, fatigue and stress can lead to higher rates of diagnostic medical errors, resulting in costly legal claims and patient care complications. Errors also require additional review, taking much needed time away from other tasks.

Attrition is a costly consequence of burnout, both financially and operationally. Strained radiologists may leave the profession altogether or switch to part-time work. If the specialty gains a reputation for low job satisfaction and burnout, it could deter medical students and residents from pursuing radiology, potentially narrowing the flow of new talent to the field, Parikh says.

Help Wanted: Attentive Leaders

Radiology leaders are often the first line of defense against burnout — with the power to provide support for staff and colleagues. This may range from helping to reduce administrative burdens, enabling technology solutions or creating a positive learning environment. 

“Those in positions of leadership must address practice operations and efficiencies so that physicians can work at the top of their licenses and aren’t dealing with tasks or other issues that ancillary staff could support,” Parikh says. Radiology leaders are going to be increasingly held accountable and expected to describe to their superiors (and to their teams) their reasons for not addressing burnout.

One thing people need is time away from the stress of their daily responsibilities [see 1st callout box]. As a leader, being able to provide administrative leave or PTO can help your situation. “Reducing workloads where possible or employing some remote work so radiologists can get time away from the physical environment and stress in the workplace may be beneficial,” Parikh says.

Increased stress and fatigue can impair a radiologist's ability to maintain diagnostic accuracy, leading to misdiagnoses or delayed diagnoses. There may be opportunities, in breast imaging as an example, to introduce less stressful rotations, Parikh says. “Some physicians would benefit from the opportunity to do screening mammograms, because it's a chance to get away from the hustle and bustle of doing a heavy load of diagnostic work or interventional procedures.”

Leaders need to carefully consider whether new hires are a good match for the expectations of a position. Those in a position to do so should also invest in reliable and user-friendly IT systems to reduce physician and staff frustrations over inefficiencies. Reducing workloads means constant monitoring — of any process changes — to ensure they are effective and manageable in the long-term.

Organized wellness efforts are needed at more practices and institutions. “We published a study in the JACR^® showing that, at that time, just over 20% of leaders reported having effective mechanisms in place to address burnout,” Parikh says. At the very least, efforts to create and maintain a more comfortable work environment to reduce physical strain, while at the same time building a culture of support and sensitivity, must be top of mind, he says.

Leading through Burnout

It is important to remember that leaders themselves are susceptible to burnout, Parikh says. “This is true in private practice and academics. The more burned-out leaders are, the less effective they are.” Radiology leaders must attend to their own physical and mental and emotional health before being of true value and in a good place to help their team.

Burned-out leaders tend to get a lower leadership score from the physicians they supervise, Parikh notes. “I have some sympathy for these leaders because while they may have good intentions, they may also be answering to someone higher up the chain who is not supportive of well-being efforts.”

It comes back to a shared, collaborative responsibility for patient care and reducing costs while helping your physicians stay well to prevent physician and support staff loss, Parikh says. “If there is one thing that the pandemic taught us, it is that the mantra for operations needs to shift from what has historically been ‘no margin, no mission’ towards ‘no people, no mission.’”

Heart of the Problem

“Burnout among radiologists has many direct and indirect effects on the workforce,” says Darcy J. Wolfman, MD, clinical associate at Johns Hopkins School of Medicine. “The direct effects include radiologists working part-time or leaving the workforce, adding to the physician shortage. Indirect effects — not talked about as often, but potentially more damaging to the profession as a whole — include decreased morale and the feeling that you aren’t making a positive difference,” she says.

Burnout can spread among a group as more work is shouldered by fewer individuals. “The technologists, nurses, physician extenders and others who work in tandem with radiologists may also feel increasing levels of stress that elevate to burnout,” Wolfman says. These members of a radiology team can be just as difficult and costly to replace as when a radiologist unexpectedly leaves.

“The biggest difference between radiology and most other specialties when it comes to burnout is that we do not see our impact on patient care on a regular basis, while almost every other specialty does,” Wolfman says. “In radiology, this takes more active work on our part and time that is already in short supply. Time is valuable, but one reason I enjoy attending and participating in multi-disciplinary conferences is because I get to see how much our input impacts patient care. Seeing your direct impact on patient care can be powerful and fulfilling as a physician,” Wolfman says. “You are more than just a report generator.”

Burnout is a systemic issue, not a personal issue. “Pre-pandemic, imaging volumes were increasing and physicians in leadership roles were decreasing and widespread burnout was starting to get some attention,” Wolfman says. COVID-19 accelerated the problem, making rising burnout rates seem to come out of nowhere, she says. “But it had been there for years already — it was simply ignored by the largely non-physician leadership in medicine.”

Wolfman says that most radiologists she has spoken to have zero interest in formal well-being programs that are centered around personal care (exercise, yoga, eating right, therapy, etc.). “I am in their camp, because many of these programs are established to treat the symptoms of burnout on a personal level, not the cause, which is systemic,” she points out. “Well-being programs that are designed to mitigate pain points in the workday, on the other hand, are very well-received.”

To decrease burnout, leadership must talk to people — find out what could make their day better and not assume they already know what changes need to be made, Wolfman says. “At the end of the day, radiologists want to feel heard, and that stress, fatigue and burnout are taken seriously. No one expects a panacea, but acknowledgement of a growing problem and a willingness to attempt to solve it shows respect and a commitment to alleviating staff frustrations and ensuring their well-being.”

For example, one group may identify that the schedule is a pain point. “Taking staff requests into account when making a schedule can go a long way to improving morale within a radiology group, but it also takes more time for the scheduler to accommodate,” Wolfman says. “This means leadership must value the efforts of the scheduler, who is spending more time and paying close attention when creating a schedule that makes employees’ lives easier.”

Another example would be a group identifying that a policy they have that all studies time-stamped at 5 p.m. or earlier must be read before a radiologist can leave was a source of stress and was eroding morale within the group.  “By agreeing to change the policy to a 4:30 cutoff, a small, cost free change with minimal effect on workflow, morale improved as radiologists were able to leave on time. Wolfman says.

Stigma and Coming Forward

“There is a longstanding stigma around physicians’ mental health,” Parikh points out. “So, when a physician actually comes forward, it is important for leadership to embrace this and leverage resources as much as possible to give the physician some time to potentially recalibrate and recharge,” he says.

The stigma around mental health and burnout can lead to a poor home life, substance abuse, eroded relationships with colleagues and sometimes, tragically, suicide, Parikh says. What can be done to reduce or eliminate this stigma? “There has been a lot of talk around burnout, but it is almost as if many radiology groups or institutions are saying, ‘Yes, it’s a problem, and we’ll get around to addressing it just as soon as we get our volume and staffing issues fixed.’”

“I think the medical community has been more willing to talk about burnout than they have been in the past,” Wolfman notes. “Hopefully, physicians are embracing these discussions now and are becoming more cognizant of the warning signs and symptoms for staff. They should be able to recognize these signs in themselves as well to effectively address staff issues,” she says.

“As for the stigma of mental health, I feel like the medical community has come a very long way since I was a resident,” Wolfman says. “Physicians now are more willing to speak out about burnout and mental health in general than they once were.”

Securing Team Support

It is critical to normalize talking about mental health. Your colleagues may understand what you are going through and can be a valuable source of support. Start conversations about stress, fatigue, burnout and mental health issues in general with your peers.

Find out what resources your employer offers — which may include traditional mental health and substance use disorder benefits through your health insurance, an employee assistance program (EAP), a peer support group, or other resources. Check the confidentiality rules around disclosure for EAPs and traditional therapy so you will feel more comfortable when talking to colleagues or administrators about them. Asking for help is a sign of strength, not weakness.

It is okay to ask a trusted friend or colleague with an objective perspective to help you root out more information that could improve your health and your situation. Consider who in your work environment is likely to be supportive of addressing the factors that cause stress, anxiety and low work satisfaction. Show your support by sharing your own experiences, always using respectful language and not making the issue about you. The National Alliance on Mental Illness provides healthcare peer support resources and offers guidance on how healthcare workers can form connections with colleagues through these types of conversations.  The ACR Radiology Well-Being Program also features resources for all members, including residents, fellows and medical students.

Well-Being Advocacy

The ACR is also here to help. The College, through its advocacy efforts to protect and empower the specialty, has been on the forefront of recognizing and supporting physician well-being. The College recently joined other organizations in voicing their support to the Senate Health, Education, Labor and Pensions (HELP) Committee for the reauthorization of the Dr. Lorna Breen Health Care Provider Protection Act. The bill reauthorizes ACR-supported legislation to provide grants to help healthcare organizations offer behavioral health services for front-line medical workers.

Signed into law in early 2022, the Act allocated funds for grants to address physician burnout, suicide prevention, mental health conditions and substance use disorders. To date, the law has provided $100 million in funding to support physicians and other health care professionals across the country. The law will expire on Sep. 30, 2024, absent congressional action. The Senate HELP Committee in May voted to advance reauthorization of the Act, and companion legislation has also advanced out of the House Energy and Commerce Committee.

“Unmanageable workloads can lead to burnout,” says Ashley Walton, ACR Government Affairs director. “And burnout definitely contributes to individuals leaving the profession early.” Increasing after-hour work, chaotic work environments and bureaucratic tasks contribute to staff frustration and resignation — and ultimately put further strain on the rest of the workforce.

Considering the workforce constraints, it is especially important to educate clinicians about the appropriate use of imaging, Walton says. The ACR for years has encouraged the use of Appropriateness Criteria^® (AC) and clinical decision support tools to minimize or stop unnecessary imaging, which contributes to higher volumes with minimal or no benefits to patients. 

Breaking the Cycle

“The bottom line is: We need to stop trying to redesign physicians and start trying to redesign processes that are fundamental to creating a culture of wellness,” Parikh says. “Multiple studies have shown that physicians who spend just 20% of their time doing something they find professionally fulfilling are less likely to burn out and be in a better position to support the radiology group or practice.”

Those in positions of leadership must address practice operations and efficiencies so that physicians can work at the top of their licenses and are not dealing with tasks or other issues that ancillary staff could support, Parikh says. “When you are looking at those redesigns of improving physician efficiency and reducing burnout, one way to approach it is to look at the metrics — what physicians are telling you both before and after an intervention about what may work and what will not. You can then see if what you are implementing is making a difference.”

“This is a major issue as many radiology groups and institutions are failing to realize that volume and staffing issues are some of the most important factors driving burnout and the mental health issues that arise from it,” Wolfman says. “It becomes a vicious cycle that I have seen firsthand. Administration refuses to cut volumes because of understaffing, leading to increased workloads for radiologists.” This in turn leads to burnout, which leads some radiologists to exit their situation, which increases volume even more for the radiologists and supporting staff who remain, says Wolfman.

In uncertain times, one thing is for sure: Not addressing burnout will directly contribute to a worsening situation in terms of managing volume, offering high-quality patient services and retaining talented staff who may be the ones with innovative solutions for managing the increasingly unmanageable.

“We know the cause of burnout is multi-factorial and therefore the solutions are also multi-factorial and largely dependent on specific practices,” Wolfman says. “This is what makes fighting burnout so challenging.” Successfully combating burnout requires discussions with the radiologists and leadership about what would make their work-life balance better. “This is not one size fits all,” she says. “What works well for one practice and its patients could be a disaster for another.”

Burnout: Did You Know?

• Women are more burned out than men. Factors may include the compensation gap between men and women, fewer mentoring or sponsorship opportunities, fewer career advancement opportunities and more caregiver responsibilities at home.
• Vacation is important. 7 of 10 radiologists say that taking time off is “very important” to their well-being. 
• Many physicians say their depression or burnout causes them to feel exasperated with patients.
• Therapy is underutilized among physicians. Time demands, high demand for psychotherapy services and a systemic stigma around therapy are barriers.
• More than half of radiologists would take a cut in pay in exchange for a better work-life balance. 
• Burnout is so severe among some radiologists that they are considering leaving — with 14% of men and 16% of women reporting they may stop full-time practice or leave their position.
• Nearly half of physicians do not think their employer recognizes the signs of burnout or the potential problems of employees who are struggling.
• Adding support staff, increasing compensation and making work schedules more flexible are the top three ways physicians believe would help with burnout.

2024 ACR Virtual Career Fair: Connecting Job Seekers with Employers / August 14, 5-8 p.m. ET

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