Hot Topic! Has PACS Ignited an Epidemic of Burnout?

Nearly half of U.S. physicians responding to a survey about burnout reported at least one symptom of burnout, researchers reported in a study published online August 20, 2012, in Archives of Internal Medicine. The researchers reported that radiologists face a slightly higher than average rate of burnout, a finding that doesn’t surprise many radiologists.

Peter S. Moskowitz, MD, founder and executive director of the Center for Personal & Professional Renewal and clinical professor of radiology, emeritus at Stanford University School of Medicine in Stanford, Calif., led workshops focused on burnout and avoidance at RSNA in 2011 and 2012. He played to a sold-out house of radiologists from around the world, illustrating the international scope of the problem and a stark contrast to the mid-1990s, when Moskowitz first started researching physician burnout. At that time, research on burnout was nearly nonexistent.

Today, more radiologists are succumbing to the physicians’ plague with potentially dire effects on patients and practice. Error and malpractice rates are suspected to be higher for burned out physicians, says Richard B. Gunderman, MD, PhD, vice chairman of radiology at Indiana University School of Medicine in Indianapolis. The current epidemic of medical errors in the U.S. is connected to the epidemic of physician burnout, adds Moskowitz. Turnover is likely higher among burned out physicians, and a toxic doctor can infect an entire practice. On the plus side, researchers are diving into the problem and leaders are acknowledging its existence, which mitigates some of the stigma associated with burnout.

The cure for burnout may be as complex as its causes and consists of an array of fixes from reading room design to technology to mentoring and therapy.

Diagnosis: Burnout

Burnout, explains Moskowitz, is a syndrome characterized by somatic, psychological and interpersonal symptoms. Radiologists in the early stages of burnout may report exhaustion, insomnia, fatigue, headaches, gastrointestinal disturbances and shortness of breath. If not addressed, the symptoms can progress to anxiety, depression, irritability, negative thinking, cynicism, and social withdrawal. “All of this often leads to pervasive anger and irritability that keeps others off balance,” says Moskowitz.

The radiology reading rooms at Rhode Island Hospital in Providence, R.I., have been redesigned as open spaces to facilitate interaction and communication among radiologists, which reduces the sense of isolation that can spark burnout.

Compounding the problem is physicians’ reluctance to admit vulnerability and ask for help. Thus, physicians often present in advanced stages of burnout and on the verge of emotional and physical bankruptcy, says Moskowitz.

Burnout can be an individual problem or departmental disease. At Rhode Island Hospital in Providence, R.I., John Cronan, MD, chief of the department of diagnostic imaging, like many of his colleagues across the world, observed a change in the departmental disposition after PACS implementation.

The reading room, which had been a hub of activity and social interaction, had become dull and gloomy. Radiologists dreaded the isolation and lack of connection. 

In fact, the Brown reading room of yesteryear could have been the reading room at just about any radiology department in the world. While many departments have invested in ergonomic chairs and other tools to minimize stress on the body, few have focused on de-stressing the mind, observes Allison Tillack, MA, a student in the MD/PhD program at the University of California-San Francisco. Cubicles and sound barriers are the norm and effectively increase isolation.

The PACS problem

Cronan characterizes the advent of PACS as a double-edged sword. PACS enabled radiologists to become hyper-efficient reading machines. But they paid a price. At Brown, Cronan estimates radiologists’ reading room interactions with physicians dropped from 500 to 600 per day in the early 1980s to a mere trickle by the mid-‘90s.

“It takes a toll on physicians if they don’t see the people who depend on them, whose lives they impact—referring physicians, patients. You can begin to wonder if your work is having the kind of impact you hoped it would,” explains Gunderman. That also can negatively impact referrals.

Radiologists are not immune to the drivers that increase all physicians’ risk for burnout. These include changing reimbursement models, which likely mean continued downward pressure on reimbursement for the next five to 10 years. The work environment continues to deteriorate for physicians, adds Moskowitz. “They used to be the captains of the healthcare ship, but physicians have lost much of their autonomy.” 

Most physicians face ongoing, nagging worry about the threat of malpractice cases (and similarly paying for rising malpractice insurance rates), and the rising cost of medical education poses a hefty financial burden on young physicians, with the average graduate incurring $180,000 in educational debt before earning an MD.

In addition to PACS, radiologists also face other stressors. Volume has been anointed king, and radiologists are pressured to read faster and faster. The use of relative value units (RVUs) as a performance evaluation measure for salary and bonuses fans the flames of burnout, continues Moskowitz.

Individual remedies, group fixes 

Burnout should be addressed at the individual, departmental and specialty levels.

Physicians diagnosed with excessive stress and early-to-moderate burnout require a combination of approaches, including one-on-one coaching or mentoring, skill building in stress management and coping skills, workplace modifications and implementing values-based time and money management strategies that emphasize work-life balance, says Moskowitz.

More severe cases of burnout may require temporary leaves of absence, psychological assessment for major depression and comorbid diagnoses and evaluation for antidepressant medication. “There isn’t a magic bullet. Addressing burnout really requires a paradigm shift on the part of the professional involved and a dedicated strategy to manage stress in an effective way,” explains Moskowitz.

Experts emphasize that radiology and hospital leadership have to identify solutions to build community among professional staff, increase job satisfaction and teach stress management skills.

At Brown, Cronan and colleagues decided to reconfigure the reading room to recreate a social network for radiologists. They created larger reading rooms for different areas with three attending physicians and three medical students as well as several other physicians assigned to each area. “It’s helped a lot. The social interactions make work so much more pleasant.”

In fact, the fix so pleased radiologists that most are reluctant to take on the requisite solo duty in Brown’s six outpatient sites because of the lack of social stimulation at these sites.

Cronan couldn’t excuse radiologists from solitary confinement, but he turned to IT for a fix and equipped the PACS workstations with instant messaging software. Radiologists, particularly those under 40 years of age, love it, because it reduces the isolation factor and facilitates professional and social connections during the work day.

Similarly, Gunderman emphasizes the value of face-to-face interactions. “Make a commitment as a department to get every radiologist involved in a weekly or monthly conference.” When a chest radiologist conferences with medical oncologists and chest surgeons, he or she becomes part of a team and can see his or her role in patient care.

The Brown radiology department made a commitment to increase conference participation among radiologists. Although many were lukewarm initially, Cronan and department leaders held their ground. They made a case for participation by linking the initiative to the American College of Radiology’s Imaging 3.0 campaign, which strives to increase patient engagement, and curbing radiologists’ gnawing sense of isolation. 

The reluctant radiologists quickly changed their tune about multidisciplinary conferences, says Cronan, and now want to chime in on every case. Plus, referring physicians have welcomed their participation and invited radiologists to additional conferences.

Another avenue for interaction and networking is grand rounds, which provides a way for radiologists to present their work, engage in clinical practice and communicate with other health professionals.

Gunderman also suggests radiology departments commit to regular patient interviews, which can provide an opportunity to improve patient care and motivate radiology staff when a patient describes how imaging impacted his or her treatment. “These can be powerful conversations and help radiologists appreciate the human implications of their work,” says Gunderman.

Like PACS, increased patient communication is a double-edge sword. It can temper radiologists’ sense of isolation, reduce the risk of burnout and tie in with organizational campaigns to increase radiologists’ visibility. 

However, efficiency takes a hit. Cronan acknowledges his department is somewhat less efficient than it was prior to the reading room redesign and networking initiatives. But as healthcare edges away from fee-for-service reimbursement and toward value-based purchasing, these conversations provide substantial additional value. “Imaging is a critical part of the diagnostic workup and represents 8 to 10 percent of costs,” explains Cronan. Bundled payments and capitation require radiologists to guide physicians to the right studies, which, in turn, hinges, on communication and networking.

“As we move forward, radiologists will not just be rewarded for generating a report, they’ll be rewarded for participating in patient care,” sums Cronan.   

The rewards extend beyond the financial, as stronger connections with referring physicians and patients can help to inoculate radiologists against burnout. But these strategies are not a panacea; some radiologists will require additional remedies including counseling and training to address burnout. Keep your eyes open and offer solutions—to everyone’s benefit.