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Productivity, Meet Burnout

Published:October 24, 2018DOI:https://doi.org/10.1016/j.acra.2018.08.001
      Declining per-case reimbursement has brought an expectation that radiologists must work harder to keep department and hospital revenues from declining. Although technological advances such as Picture Archiving and Communications Systems and electronic medical records have improved radiologist efficiency and accuracy, there is a point at which no effective additional improvements in work flow can be made without sacrificing the well-being of practicing radiologists.
      We may now be approaching that point. Radiologists are still being told to work faster as the screws continue to tighten: more images, greater case volume, increasing complexity, and less time to do the work. In search of bandwidth, radiologists will also look to the edges of the work day, resulting in longer hours, shorter lunches, and preoccupied evenings. As clinical work dominates, other priorities like education and research fall by the wayside. Resident and fellow training are threatened and radiologist well-being is in jeopardy. At the center of this, nexus lives burnout.
      Burnout has been defined as a workplace condition that includes emotional exhaustion, depersonalization, and declining workplace accomplishment (
      • Maslach C
      • Jackson SE
      • Leiter MP
      Maslach burnout inventory.
      ). Burnout can result in apathy toward patients and peers and feelings of inadequacy (
      • Nicola R
      • McNeeley MF
      • Bhargava P
      Burnout in radiology.
      ). Medical errors are more likely in radiologists experiencing burnout, and there are increased risks of depression, substance abuse, and suicide (
      • Nicola R
      • McNeeley MF
      • Bhargava P
      Burnout in radiology.
      ).
      A number of recent surveys have confirmed that alterations in the perceptions of practicing radiologists that can lead to burnout are increasing. In one survey of practicing neuroradiologists (
      • Chen JY
      • Lexa FJ
      Baseline survey of the neuroradiology work environment in the United States with reported trends in clinical work, nonclinical work, perceptions of trainees, and burnout metrics.
      ), metrics placing radiologists at risk for burnout were found to be increasing. Seventy-two percent of respondents stated they were reading more cases per hour than previously, with many respondents noting they were reading faster than their comfort level. Most respondents also noted cutting back on their nonclinical professional activities. These workplace changes led to many respondents noting increasing fatigue, difficulty relaxing after hours, and reduced enthusiasm and effectiveness while at work. Unfortunately, according to the surveyed neuroradiologists, few administrative changes and workday modifications were being made in response to these concerning perceptions. The increasing clinical demands and economic pressures were considered inevitable and not correctable. Another recent survey of musculoskeletal radiologists found similar results (
      • Chew FS
      • Mulcahy MJ
      • Porrino JA
      • et al.
      Prevalence of burnout among musculoskeletal radiologists.
      ). The authors of that study (
      • Chew FS
      • Mulcahy MJ
      • Porrino JA
      • et al.
      Prevalence of burnout among musculoskeletal radiologists.
      ) found the reported prevalence of emotional exhaustion (62%), depersonalization (53%), and lack of personal accomplishment (40%) were much higher than has been previously reported. Also of note, burnout symptoms were significantly more common in women, in radiologists in private practice, and in those who had been practicing for longer periods of time (up to a 21+ year inflection point). These results are ominous.
      To better study radiologist workplace demands, additional objective assessments of the nature and effects of radiologist obligations during clinical workdays are warranted. It is in this light that two investigations in this issue were performed (
      • Al Yassin A
      • Sadaghiana MS
      • Mohan S
      • et al.
      It's about time: academic neuroradiologist time distribution for interpreting brain MRIs.
      ,
      • Wynn R
      • Howe JL
      • Kelahan LC
      • et al.
      Impact of interruptions on chest radiograph interpretation: effects on reading time and accuracy.
      ). In the first study (
      • Al Yassin A
      • Sadaghiana MS
      • Mohan S
      • et al.
      It's about time: academic neuroradiologist time distribution for interpreting brain MRIs.
      ), the mean times required for attending radiologists (12.55 minutes), fellows (18.36 minutes), and residents (16.31 minutes) to interpret brain magnetic resonance imaging examinations in an academic environment were measured. The authors carefully determined the various activities required for magnetic resonance imaging interpretation and the time needed to perform each of these activities. Less than 50% of the time spent on a case actually involved image interpretation, with the remaining examination time spent reviewing medical records, interacting with the voice recognition reporting system, teaching trainees, and dealing with interruptions.
      In the second publication (
      • Wynn R
      • Howe JL
      • Kelahan LC
      • et al.
      Impact of interruptions on chest radiograph interpretation: effects on reading time and accuracy.
      ), the authors evaluated the effect of unpredictable 30-second workflow interruptions on image interpretation time and accuracy for attending physicians and residents evaluating chest radiographs for pneumothorax. They found that interpretation time was prolonged when there were interruptions, even after subtracting the time of the interruption itself. Additionally, subtle pneumothoraces were significantly more likely to be missed when interruptions occurred. This distraction effect has been well studied in the psychology literature and it is not surprising to see it manifest in doctors conducting clinical care activities (
      • Sanders GS
      • Baron RS
      The motivating effects of distraction on task performance.
      ,
      • Gillie T
      • Broadbent D
      What makes interruptions disruptive? A study of length, similarity, and complexity.
      ). Distractions are insidious and common. They occur from email alerts, phone messages, casual conversations, overheard partner dictations, clinical visitations, phone calls, contrast reactions, trainee questions, technologist questions, emergent protocols, etc. Eliminating all of these activities, some of which are required for clinical care, may not be feasible without other potentially adverse consequences. However, we must find ways to limit the adverse effects they have on workplace efficiency.
      Both studies in this issue (
      • Al Yassin A
      • Sadaghiana MS
      • Mohan S
      • et al.
      It's about time: academic neuroradiologist time distribution for interpreting brain MRIs.
      ,
      • Wynn R
      • Howe JL
      • Kelahan LC
      • et al.
      Impact of interruptions on chest radiograph interpretation: effects on reading time and accuracy.
      ) highlight the increasing risk of radiologist burnout. In our opinion, these studies, and others like it, are ringing alarm bells. We are approaching a tipping point in which the rewards of being a radiologist and the conduct of other valuable work (e.g., research and educating trainees) are being overwhelmed by the pressures of an increasingly demanding clinical workday. Misplaced efforts to reduce distractions (
      • Wynn R
      • Howe JL
      • Kelahan LC
      • et al.
      Impact of interruptions on chest radiograph interpretation: effects on reading time and accuracy.
      ) and maximize efficiency could unintentionally produce an insular and isolated environment in which only case throughput is valued. Minimization of human interactions and distancing the radiologist from referring providers to an even greater extent may only add to the likelihood of burnout.
      The psychological burden intrinsic to speed and fundamental to burnout is that greater speed carries a moral hazard: radiologists unconsciously (and consciously) believe speed and longer working hours are contributing to medical error, and the perceived sacrifice of patient safety for clinical throughput confers guilt and professional dissatisfaction. Surprisingly, little objective data is available on the effect of image interpretation speed and duration on image interpretation accuracy. Additional studies are warranted to determine the relationship among these factors. If data were to show that faster or longer reading up to a certain threshold is safe and effective (i.e., different from but unexpectedly noninferior to previous behaviors), that data might mitigate the emotional burden on affected radiologists, at least to some extent.
      In our opinion, the quality of radiology practice is being threatened by an increasingly burdensome workload. In the face of this threat, we must be careful not to compromise the many positive aspects of our profession merely to maximize reimbursement. Departmental leadership and hospital administrations must accept the threat and consequences of burnout. They must respond proactively to the risks of disenfranchising the human beings working in their health care systems, most of whom have a strong desire to deliver the best possible health care to their patients. Steps must be taken to ward against a commoditized and more error-prone paradigm. It is not all about the money.

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