Deborah Abrams Kaplan

Radiology is rising in the burnout ranks, compared to other specialties. Radiology is now the seventh highest specialty for burnout in the 2018 Medscape National Physician Burnout and Depression Report, compared to being 20th highest in 2017 and 10th highest in 2016. Of the 15,543 physicians surveyed for the 2018 report, 42 percent of all physicians reported burnout, with 45 percent of radiologists reporting the same.


Burnout can be defined as emotional exhaustion, feelings of decreased accomplishment and depersonalization. It has high costs not only for the physician’s mental and physical health, but can impact patient health, causing adverse care events and errors as well. Healthcare organizations lose productivity and money if a physician leaves or isn’t working at their best. “Leadership has to recognize that there’s an economic effect to burnout,” says Peter Moskowitz, MD, clinical professor emeritus at Stanford University Radiology and executive director of the Center for Professional and Personal Renewal in Palo Alto, a physician career and life coaching practice.


Though Moskowitz hasn’t seen many organizations or institutions combatting burnout in a meaningful way in the past few years, he says it’s starting to be taken more seriously. “I am encouraged to see the number of articles addressing radiology burnout over the last 12 to 18 months. The subject is getting discussed more than it used to be,” he says. “That’s positive.”


In another sign that at least one well known institution is tackling the issue, Stanford Medicine hired Tait Shanafelt, MD, last fall as chief wellness officer. Stanford is the first U.S. academic medical center to create a position like this, and they specifically acknowledged that physician burnout is reaching an all-time high. Previously, Shanafelt held a similar position at the Mayo Clinic, running a successful program to combat physician burnout, improve wellness and increase doctors’ sense of fulfilment. Shanafelt’s Mayo Clinic initiative targeted leadership, organizational culture, the practice environment and systems, bringing burnout rates down 7 percent over two years, while at the same time nationally, the physician burnout rate rose 11 percent using the same metrics. A subsequent survey showed that the burnout rate decreased around 66 percent compared to national rates.

What individuals can do to combat burnout


It’s important for individual physicians to take charge in handling their feelings of burnout, whether that’s though exercise, spending time with friends and family, mindfulness and staying in the present. Here are some other ways physicians can take control.

 “All doctors went into the field because they found it meaningful,” says Jay Harolds, MD, professor at Michigan State University College of Human Medicine, and a radiologist with Advanced Radiology Services in Grand Rapids. “Sometimes as a result of years of being in the field, people feel trapped with the work and stress, and lose track of the fact that the field really is important. The images we read are not just shadows on a PACS station, but they represent human beings and their families. Everything we do impacts how they fare health wise.”

 It is possible to change the way you think, which can affect a person’s outlook and success. An example is learned optimism, says Harolds. Optimists tend to be more successful, confident and believe that positive events are permanent, not just blips on the radar. Defeats are not reflective of life as a whole, but transient. Optimism can be learned. “Many physicians are hyper critical people, perfectionistic,” he says. They may focus on what is bad or inadequate about themselves, including mistakes. “Instead, it’s better to focus on what’s good, and long and short-term accomplishments.”

What organizations can do to combat burnout


The workplace can positively impact burnout in a number of ways and should be done in tandem with individual physician efforts. “Burnout will not go away simply by spending more time exercising and sleeping,” says Moskowitz. “We need to change the whole culture of the radiology work environment and that is largely dependent on organizational leadership and practices.”

 “We need to move away from RVU productivity as the sole defining assessment for physician effectiveness,” says Moskowitz, as he says it’s killing people. He believes this is a growing issue in radiology as he recently started getting frequent calls about this. “I’m in a unique position to hear about it, because radiologists feel comfortable talking to me confidentially, whereas they might not talk about it to their hospital directors, practice partners or friends.” Radiologists want compensation structured not just on production numbers, but participation in hospital committees, respect from referring clinicians and teaching activities as well. “I know of multiple instances in which radiologist’s status within their practices are being threatened by their inability to reach an RVU production level that is arbitrarily established by non-physician managers.”

 High on the list of factors increasing radiologist burnout from the 2018 Medscape report are bureaucratic tasks and feeling like a cog in the wheel. Both Moskowitz and Harolds recommend that organizations hire reading room coordinators to triage phone calls and track down records or doctors needed for consultation, allowing radiologists to focus on reading.
Reading room set up and ergonomics: Creating healthier work environments includes ergonomic work stations and reading rooms. That means appropriate lighting, stations and frequent work breaks (five minutes every 45-60 minutes). “You’d be surprised how many radiologists say they’re so busy they don’t have time to take a break or eat lunch, because they’re too busy,” says Moskowitz. Individual reading rooms create isolation, which promotes burnout. By designing open reading rooms for multiple radiologists, they can interact with their peers personally and professionally.

 Changing the reading room set up can help strengthen team relationships. With organizations increasing in size, it’s harder for radiologists to interact with their colleagues and referring physicians. Building relationships can be done by scheduling fun activities outside the workplace, or just sharing meals and taking breaks together at work.

 Radiologists tend to work in large groups now, which can easily accommodate doctors with different professional interests. If it’s possible to give radiologists the types of images they prefer to read, they’ll be more engaged with the work.

 Leaders shouldn’t just be people who have been around the longest, but those who communicate well and encourage others to find new ways to solve problems. “If a person is a good leader, the followers have less burnout and more resilience,” Harolds says. A good leader will make work less complex and consult others before implementing changes. Leadership is important in combatting burnout because many radiologists don’t want to talk about the subject. Some haven’t experienced it or dealt with it in their own careers, and are uncomfortable trying to make changes on their own.

 Another reason for burnout cited in the report is a lack of control or autonomy. “Now with larger and larger groups, they have less independence and more measures of productivity,” Harolds says. Organizations can find areas that the individual physicians can have control over. Even minor changes can increase morale.

 Radiologist burnout should be incorporated into national physician meetings, with sections devoted to wellness and burnout. This is a way to share best practices and research, and to show the importance on a national level. These groups can help develop curricula to teach wellness principles residents and fellows.


If not addressed, burnout has the potential to get worse. “As time goes on, I would think the pressures are going to be greater, not less, on physicians because of the costs (of medical care). There will be more pressure in the future,” Harolds says.

Articles

Radiologist burnout is getting worse and action needs to be taken.

Stop Burnout in Radiology Before It Starts

 (AI) is booming in all areas of business and medicine. But it’s taken a special hold in radiology. 

 had its first machine learning showcase, highlighting the companies and technologies already changing how radiology is practiced. About 30 

AI brings a mix of feelings to those who practice radiology, including fear, hope, and hype, said Woojin Kim, MD, a Chief Medical Information Officer for Nuance’s healthcare division, and an MSK radiologist.

Media have bombarded the radiology field with talk of AI.

“Even in mainstream artificial intelligence articles, for some reason, radiology is often used as an example of where machines will replace humans,” he said. What’s inspiring that fear, hope and hype, and is it justified?




“When I see some of the experts in AI talking about radiology, it is evident that they have a very simplified view of what we do as radiologists,” Kim said.

But even some radiologists and those considering the field are fearful. Andrew Ng, a Stanford adjunct professor, and well-known machine learning expert who co-founded Google Brain and recently led Baidu AI Lab, posted an email from a radiology resident on 

. The third-year resident asked whether to quit and do something else, questioning how close radiologists were to being replaced. “It’s clearly affecting the mindset of those who want to go into radiology or who are currently in training,” Kim said. 

Fear of technology is nothing new. With desktop publishing, many typographers may have lost their jobs, but the number of graphic designers increased, he said. Another example is the “Luddite fallacy,” in which English textile workers destroyed textile-making machines out of fear that the technology would put them out of work. Instead, the machines caused the price of textiles to drop, and more people bought them. The textile industry grew.

Just as with these examples, Kim said that technology will not replace radiologists, but will create new opportunities and new ways to provide value.




AI algorithms are getting easier to create. “You can get a set of images for an imaging finding you’re interested in, and with several lines of code or by using a deep learning development environment, you can train deep neural networks,” so much so that it’s almost a cookie-cutter operation for some. Because of that, many algorithms are popping up. If they’re created by someone without deep clinical radiology knowledge, though, the algorithms won’t work well. A granuloma is not the same as a pulmonary nodule, for example. “Coming up with a good medical imaging AI algorithm is a difficult task and still takes a lot of effort,” he said.

From what Kim is seeing, not all AI developers fully leverage radiologists’ knowledge. “That’s what makes our job complex. We need to know about things that can mimic disease, so I don’t call an artifact or benign finding a disease.” That subtle knowledge makes a huge difference in interpretation.

A study published in September 2017 in the

 used IBM’s Watson to determine if a patient should get contrast for a musculoskeletal MRI, based on the study’s free-text clinical indications. The machine performed well in this situation, with 83.2% clinical accuracy for the test set, compared to the original protocol. When compared to the test set and the second radiologist reader concordance, Watson was in agreement 90%.

That’s great news and shows promise. However, if those running the artificial intelligence system don’t understand how the decisions are made in the deep learning algorithms, that can be a problem in medicine, said Kim. This “black box” problem happens when a bad decision is made, but no one understands how the deep learning program arrived at the decision.

In the study, Watson committed 25 classification errors in the 280-case test set. One, however, was potentially fatal: assigning contrast dye to a patient with end-stage renal disease. Watson had a high confidence level for that decision, showing that radiologists can’t rely on AI just because of high confidence levels. If a person makes a mistake, they usually know why, said Kim. Until the black box problem is solved, radiologists must be heavily involved.




The goal should not be replacing radiologists with deep learning algorithms, but making radiologists better. With artificial intelligence working in the background, diagnostic accuracy can increase.

Radiologists and others have tunnel vision for how artificial intelligence can be used in the field. It’s not just about making a finding and auto-generating a report, Kim said. AI can be used in every step of the medical imaging process, including patient scheduling, imaging protocols, workflow, creating actionable reports, communication, quality assessment, and patient safety and follow-ups.

“If I have to make measurements on a bunch of lymph nodes and compare them to two prior studies, that’s a repetitive task that AI is nicely suited for,” said Kim. “I know the really cool thing right now is having the machines make the findings on images, but there are many ways AI can benefit radiology.” The technology can be adopted more quickly when using it for lower hanging fruit than diagnostic use, partly because of the FDA 

One way it can help is by pulling up applicable clinical history and records. “We know we can do a better job as radiologists if we have good clinical information about the patient,” said Kim. A lot of times, that’s missing, and it’s cumbersome to get the needed data. “I don’t need the entire medical history of the patient for every exam I interpret, but it is extremely valuable to have pertinent information from the patient’s medical record that can help me make a better diagnosis.” To do that now, he has to go through dozens of screens and mouse clicks to see if there’s useful information. “This is where artificial intelligence can help out.” It can go through patient’s medical records, looking for lab values, pathology results, and past family, medical and surgical history that might be helpful, and provide a single summary.

AI can help with repetitive work, anything the radiologist has to do more than once a day is a good use for AI. Many academic centers ask doctors to protocol exams in advance, to increase efficiency, so when a patient arrives, the protocol is ready. “Artificial intelligence can help, depending on prior protocols and clinical indication,” Kim said. The AI protocols can be presented to the radiologist, who can agree or disagree, making necessary changes and allowing the neural network to learn to make better future decisions.

patients, like vRad and MetaMind are doing to detect intracranial hemorrhages as part of the workflow.

While AI can provoke a healthy dose of fear factor, it’s a useful technology for radiologists. “We should embrace it, and not put our heads in the sand and ignore it. As a field we have to engage and embrace it, so we can guide the direction of where artificial intelligence should go.” Otherwise, other AI experts will direct it. By staying involved, radiologists can mitigate any negative impact it can have on the field.

How to do that? A hospital administrator may not appreciate the true value of a radiologist, preferring the AI algorithm that works 24/7 at a lower cost. In the future, an algorithm may be able to provide nicely structured and formatted reports with a high degree of accuracy. Radiologists should play an integral role at the hospital, from information technology to hospital management. “If we don’t have close relationships with the hospitals, they’re not going to see our value. We need to be constantly engaged, showing how we provide value and that we’re part of the care management team,” Kim said.

While trained radiologists and those in training may be nervous about AI, they should learn more about it. “That would help alleviate some of the fears,” he said. They can see how AI can play an integral role in their future practice. He recommends that radiology training programs incorporate informatics.

Those wanting to learn more can find information through medical societies like the ACR, RSNA, and SIIM. Kim recommends attending the 

SIIM Conference on Machine Intelligence in Medical Imaging (C-MIMI)

. For hands-on experience with deep learning, the 

 platform allows users to easily design and train neural networks.

Whether radiology tasks will be streamlined as a result of AI remains to be seen. The number of medical images is increasing, as is demand for medical imaging. Medicine relies more heavily on technology for diagnoses. “It’s not a simple formula,” said Kim. “We have to wait and see.”
 

Radiologists have mixed feelings about AI.

Fear, Hope, and Hype For Artificial Intelligence

It’s a struggle for radiology services to balance the complexities of running an efficient and high-quality imaging service, while ensuring that patients get the best experience.

Sometimes they are at odds. Some machines are slow. Appointment times book up far in advance. Staff members’ to-do lists never end. The flip side is that patients who are comfortable are more likely to remain calm and still during studies, improving the image quality, and not needing to redo the study. And patients who are happy with their experience are more likely to return when they need additional care, and tell their friends.

Philips recently published a 

about the patient experience, surveying more than 600 American and German patients about their journey through the imaging process. While the results weren’t shocking, they’re still good reminders about what’s important to patients, how they perceive their treatment by medical staff, and their process in radiology’s care.

Jalal B. Andre, MD, said the study results were similar to what he sees in his practice. “They want faster turnaround time, and to have their time respected,” said Andre, director of neurological MRI at Harborview Medical Center in Seattle, and a University of Washington associate professor of radiology.




The patients’ opinion matters. Medical centers and providers have become more savvy from a business perspective in improving patient care and recognizing that patients are customers, and can choose to go elsewhere.

Historically, doctors placed less emphasis on the patient’s time versus their own, not on purpose, but due to the medical training and busyness of the job. Andre calls it the “conveyor belt approach,” partly driven by insurance demands. The model favors the doctor’s time over the patient’s. However, that’s shifting, as the internet allows patients to share information, giving them more power and choices than they had before. Sharing an experience on social media can sway other people. This is radically shifting how medical staff approach patients now.

“In order to thrive, we really do want to make sure patients want to come to us for their care. If we’re not showing them that compassion, and we’re not open to that patient experience, somebody else will, and they’ll fill that niche,” said Paula Gonyea, director of radiology at UVM Medical Center.

The Philips study showed that radiology offices need to keep their eyes on patient and family-centered care, said Gonyea, something her medical center already does. They have patient and family-centered care teams in all departments. In radiology, that team includes radiologists, managers, and technologists, and each modality has its own quality team. At each quality team meeting, they come up with one or two new things to welcome patients and families. “Welcoming is a big thing in our hospital right now, across the board,” she said.




UVM includes patient advisors on their committees. These are patients who volunteer their time to share personal insights. During a recent hospital renovation project, they redid their waiting rooms and dressing rooms. Two patient advisors on the committee shared what they thought about when waiting for a test, like how to involve their families and make them more comfortable. They also wanted additional dressing rooms, with some redesigned to better accommodate wheelchairs. A lot of what they brought up was the softer side of medical care, Gonyea said.

She agreed with Philips’ study results, that patients want technologists and nurses giving extra care and presenting confidently that the patients are there for the right test for the right diagnosis. At UVM, that might mean the technologist addresses the patient by name, confirming that they are present for a CT scan for a specific diagnosis. Of course, the technologist will also ask about any additional concerns, and share the process for conducting the exam and sharing the results. They scan in the patient’s wrist band bar code to make sure the imaging study goes to the right medical records location.

While not all patients see radiologists as part of their visit, Gonyea said UVM is reviewing their workflow, to see if they can find ways for radiologists to interact with some patients to answer questions. They might try identifying patients who seem anxious when checking in, as good candidates to chat with a radiologist. Currently, a patient not scheduled to see a radiologist has to ask the technologist to see one. “We’re looking to be proactive to offer that,” she said.




Timing is everything when getting patient feedback. Catch someone right after they came out of the scanner when they’ve had a negative experience, and you may get a different answer than when you wait an hour to ask. Wait a week or two, and the response may be completely different.

UVM has comment cards at the reception desks. When the patient checks in, the receptionist encourages them to take a card and hold on to it, dropping it off at the desk on the way out. The comment cards give instant feedback so UVM staff can more quickly track issues needing attention. From comments made on these cards, UVM increased the variety of magazines, learned that patients liked the new mammography waiting room music and the adult coloring pages and pencils offered. “When we make changes, we seem to get more comments,” Gonyea said.

While Gonyea doesn’t have statistics for how many patients fill them out, she said that at one point, they received hundreds of cards per month.

UVM also participates in Press Ganey surveys, mailed a week or two after the appointment. While helpful, those comments tend to be more vague, like the patients said they waited longer than expected, or that things were great.

There are other 


The Philips survey asked patients for the one thing they would change about their imaging experience. The most common answers were that patients wanted their results faster, and didn’t want such a long gap between scheduling and the actual appointment. Fortunately, UVM hasn’t received many complaints about report turnaround time, but the latter issue is common.

“What every hospital struggles with is waiting time to get in for tests with limited equipment, and juggling those appointments,” she said. Most patients understand that there are a lot of people waiting for the same test. “There is only so much you can do,” she said. They work with patients who have coordinating appointments, to get their imaging done in time, and patients appreciate being added to a cancellation list for a possible earlier appointment.

The amount of time that imaging exams take was an issue for some in the Philips study. Radiology groups understand that too. Due to economic pressures, there’s a push for  greater patient through-put in the machines. However, scanners can only go so fast, said Andre. While CT scans may take a few minutes, MRI scans can take 90 minutes.

“Most developers think a 15-minute sequence is reasonable, whereas most clinicians think it has to be under five minutes,” he said. It’s critical for patients to hold still, as motion is a problem. Patient frustration with the long wait time is understandable and can’t always be resolved.

Patients in the survey also asked for more comfortable experiences, which can be difficult when the patient is in pain. Andre said he has been in the scanner many times as a volunteer, having pleasant experiences and often falling asleep. However, he had a wake-up call when in pain, he needed an emergent 45-minute MRI exam two years ago. “Every time the machine pulsed, I felt it go through my body in a way I hadn’t felt before. It hurt lying on the hard surface. The whole thing was a very different experience,” he said. He realized there was probably more they could do to make the patient comfortable, and that they historically haven’t done a good job putting themselves in their patients’ shoes.

Vendors are trying to improve the patient 

, through lighting, distraction, and entertainment options.




With long waits and uncomfortable scans, it’s more important than ever to communicate with the patient and share the status and what to expect. Hospital culture affects how staff members treat the patient experience.

“Patient experience plays a larger role in the discussion. People try to be active listeners in a place like Seattle, and that was new to me, versus what I’d experienced in the past,” said Andre. The good news is that the culture has changed since Andre’s training in New York Where there was less focus on the patient experience.

Image quality and report turnaround time aren’t the only indicators of a successful radiology group.

Listen To Your Patients

Radiology burnout is a topic of frequent discussion among radiologists, and studies continue to look at causes and ways to alleviate it. While three of the radiologists interviewed for this article proactively mentioned burnout as a key issue in radiology today, none of them cited it as a reason that they changed careers.One did warn, however, that burnout and long hours aren’t restricted to doctors. Those looking for a way out may think the grass is greener elsewhere. “Not true,” said Nicholas Argy, MD. “Lawyers work their tails off. Architects work their tails off. Engineers work their tails off.” These featured physicians may be working their tails off in other areas of health care, but some of them say it doesn’t feel like work, as they’re enjoying it so much. “Physicians have passions beyond radiology,” said Argy. They key is to find that passion.

Slideshows

Radiologists who found careers outside of the reading room.

Deborah Abrams Kaplan

Articles

Stop Burnout in Radiology Before It Starts

Fear, Hope, and Hype For Artificial Intelligence

Listen To Your Patients

Radiologists Following a Different Path