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The role of the pandemic and what radiology can do to mitigate its burnout effect.
Maintaining personal wellness and preventing professional burnout have an established role in the modern medical theater. The World Health Organization differentiates personal wellness from health as it involves fulfilment and realization of that person both as an individual “physically, psychologically, socially, spiritually and economically” and their perceived role in their social circles.
This heady definition attempts to simplify esoteric components of an extremely personal idea of mental health and satisfaction that really can only be identified by that individual. Burnout on the other hand is a more specific syndrome: emotional exhaustion from stress on the job, de-personalization and detachment from patients, and a demarcated shift in projections of professional self-worth and competence1. Physicians are particularly vulnerable to experiencing burnout and sacrificing their personal wellness for their job, with radiologists facing challenges unique from their colleagues.
These vulnerabilities have only been stressed by recent accommodations necessitated by the COVID-19 pandemic’s strain on the healthcare system. Recent surges in radiologist burnout have raised alarms concerning compromised patient care and deteriorating provider wellness2. Despite these challenges, there are simple practices that the individual can take to help combat the decline of their personal wellness and stave off burnout even with the added stress of the current health emergency.
Factors Behind Burnout
There are many factors contributing to the rise in work fatigue and declined wellness in radiology. Institutionally, the paradigm of patient-centered physician values and the growing push for productivity and cost/revenue control by the hospital and insurance industries can produce cognitive dissonance3. Specific to radiologists, an increasing emphasis on reading speed and studies per day has resulted in an accumulation of more burnout than ever with rates of burnout symptoms hovering around 50 percent by some measures4.
Additionally, as patient care and quality control measures get more complex, the burden of work for physicians before care can be performed has become somewhat daunting. Some may feel that more of their time is spent maneuvering bureaucratic tape than performing radiology and medicine3. As more is expected out of radiologists during the workday, the corners that are cut can frequently be those that preserve wellness, such as lunch breaks and diverse time for academics or research. Radiology inherently lends itself poorly to much meaningful personal interaction on the day-to-day with either patients or other faculty. For some, this can be a source of fatigue and should be addressed. With these challenges in the forefront, a radiologist’s risk of facing deteriorating personal motivation and wellness in the modern age of medicine is substantial.
Radiology residents face different challenges from their full-fledged attending physician counterparts and suffer from substantially increased rates of burnout ranging from 40 percent to 80 percent – a level greater than either medical students or physicians5. They still have to deal with all the same issues that practicing radiologists do, but with the added stressors of being in the middle of a chain of educators -- being both student and teacher and being expected to internalize great amounts of information and balance that learning and teaching with their patient responsibilities.
Radiology residents have some of the worst rates of burnout of all fields. Nearly 85 percent of trainees experience some decline in emotional wellness, feelings of personal accomplishment, and other affects consistent with burnout6. This article by Mendoza and Bertino cites tedious training modules, long hours, and low levels of social interaction responsible for producing this number. Residents are also more vulnerable to feelings of inadequacy due to imagined and actual perceptions of being inexperienced.
Resident radiologists are set up to burn out during their training and carry that vulnerability into their working careers. Reinforcing the wellness of their trainees should be a high priority for programs not simply to encourage enrollment or placate concerns of overworking, but to facilitate learning and promote good practices for burnout resilience during and after residency.
The Impact of COVID-19
While burnout and wellness statistics among radiologists, both attendings and trainees, have been morbid in recent years, the onset of practices to combat COVID-19 has disrupted even those with otherwise stable personal wellness. With long work hours and limited personal interaction already being the cause of much of the burnout radiologists currently experience, the social isolation and increased need for personnel that the pandemic brought on has surely only made this worse.
Studies looking at previous endemics and pandemics have revealed that not only is the populace at large exposed to increased mental stress, but physicians have increased rates of mental distress and even post-traumatic stress disorder following participation in managing these outbreaks2. Between the looming threat of infection and the increased scrutiny by the public and public health officials, stress levels are at an all-time high. Even though much of the public sentiment is positive regarding “healthcare heroes,” those that feel that the title is unwarranted or unfulfilled may have their self-worth damaged by the additional expectations.
Additionally, harassment by social media conspiracy activists claiming mask exemption, pandemic hoaxes, and other similar falsities may exacerbate feelings of not being able to effectively control the outbreak while individuals refuse to follow guidelines. While the focus is appropriately on patient care and increased demands during the ongoing outbreak, attention should still be directed towards maintaining wellness.
Addressing burnout and maintaining wellness can be targeted either at the institutional level or by the individual. Institutions have a vested interest in keeping their workforce healthy and fully functional. Constant interruptions and long hours lead to burned-out physicians and overlooked mistakes4.
Daily Practices to Alleviate Burnout
As for residents, while many programs may try to implement mandatory wellness lectures or provide meditation services and other such at-will avenues to increase burnout resilience, only work-hour limits have been strongly associated with improvement in emotional exhaustion and burnout5.
On the individual level, many small practices can be integrated into daily life to preserve wellness and prevent oneself from being burned out. Drs. Fessell and Cherniss suggest a small list of “micropractices” to help strengthen resilience to burnout and keep wellness balanced7. These are things like diaphragmatic breathing and taking a “moment for mindfulness:” this means taking a moment to reflect inwards when doing something like hand washing, centering oneself, and analyzing their current state. This allows a chance to address feelings from the last case or make sure that personal needs are met.
Another such micropractice involves naming complex emotions as they are experienced to aid self-awareness and facilitate a return to calm. Lastly, sharing cases and frustrations with peers is a great way to acknowledge that others are facing similar problems and get practical tips to internalize7. These are things that must be consciously done regularly to keep wellness a priority during a complex and hectic workday.
Maintaining wellness can be a challenge even under ideal circumstances, let alone during a world-wide health emergency. Maneuvering the modern medical landscape of high demands, impersonal patient interactions, and complicated infectious precautions has produced a large burden of burned-out physicians. The challenges that radiologists face are different from their colleagues and require specific and deliberate attention.
Every radiologist should try to be more aware of the state of their personal wellness and take steps to remedy shortcomings and reinforce resilience to burnout. Sacrificing mental health and wellness in the name of patient care, dedication, or monetary gains in reality is harmful to both the physician and the patient. Burnout is not a burden that has to be borne, but it takes deliberate effort and acknowledgement by institutions and individuals.
1. Maslach, C., Jackson, S. E., & Leiter, M. P. (2018). Maslach burnout inventory: Manual. Menlo Park, CA, CA: Mind Garden.
2. Shah K, Kamrai D, Mekala H, Mann B, Desai K, Patel RS. Focus on Mental Health During the Coronavirus (COVID-19) Pandemic: Applying Learnings from the Past Outbreaks. Cureus. 2020;12(3):e7405. Published 2020 Mar 25. doi:10.7759/cureus.7405
3. Berg, S. (2020, May 28). The 12 factors that drive up physician burnout. Retrieved June 07, 2020, from https://www.ama-assn.org/practice-management/physician-health/12-factors-drive-physician-burnout
4. Cohan RH, Davenport MS. Productivity, Meet Burnout. Acad Radiol. 2018;25(12):1513‐1514. doi:10.1016/j.acra.2018.08.001
5. Busireddy KR, Miller JA, Ellison K, Ren V, Qayyum R, Panda M. Efficacy of Interventions to Reduce Resident Physician Burnout: A Systematic Review. J Grad Med Educ. 2017;9(3):294‐301. doi:10.4300/JGME-D-16-00372.1
6. Mendoza, D., & Bertino, F. J. (2019). Why Radiology Residents Experience Burnout and How to Fix It. Academic Radiology, 26(4), 555-558. doi:10.1016/j.acra.2018.08.009
7. Fessell D, Cherniss C. Coronavirus Disease 2019 (COVID-19) and Beyond: Micropractices for Burnout Prevention and Emotional Wellness. J Am Coll Radiol. 2020;17(6):746‐748. doi:10.1016/j.jacr.2020.03.013