Current Status of Burnout in Canadian Radiology

Abstract

Burnout is a healthcare concern affecting physicians around the world. Physicians experiencing burnout tend to display signs of emotional exhaustion, depersonalization, and low personal accomplishment. Ongoing burnout trends have posed numerous challenges to Canadian physicians, notwithstanding the added complexity of the COVID-19 pandemic’s impact in recent years. In particular, Canadian radiologists frequently reported experiencing high rates of burnout. This review aims to examine prominent factors affecting burnout in Canadian radiologists and summarize the impact of recent trends. In doing so, the overall wellbeing of Canadian radiologists can be assessed, and strategies for improvement can be discussed as the Canadian healthcare system prepares for new challenges of increasing demand and pressures.

Introduction

Burnout is an experience that has been widely reported by physicians. Burnout is often described as some combination of emotional exhaustion, depersonalization, and perceived lack of personal accomplishment. ¹ Nearly half of all US physicians reported experiencing some symptom of burnout in 2012.^2,3 Globally, the prevalence of burnout in some specialties can reach as high as 80.5%. ⁴

Burnout is rising across medical specialties and around the world.^4-6 The experience of physicians in Canada has followed this trend. A national survey conducted in 2017 reported a 30% average burnout rate among Canadian physicians. ⁷ Canadian radiologists were found to report a much higher rate than this average. One study showed that of the 262 radiologists surveyed, 188 (72%) scored high in the emotional exhaustion domain of burnout. ⁸

The added strains on the Canadian healthcare system created by the COVID-19 pandemic have worsened physician burnout and have had a particularly detrimental effect on radiology. ⁹ The pandemic exacerbated existing resource shortages, resulted in delayed or cancelled patient care, and further imperilled work-life balance. ¹⁰ These effects posed a significant challenge to Canadian radiologists, exacerbating pre-pandemic burnout levels at all training levels.^9,11 In light of the ongoing realities of the pandemic, the anticipated demand for radiology services, and the associated need to ensure the resilience of radiology departments and their ability to provide care for patients, it is necessary to review the current status of burnout in Canadian radiology.

Human Resource Shortage

Maintaining an adequate supply of physicians to meet the medical demands of the population contributes to a well-functioning healthcare system. Understaffing in healthcare can contribute to work-related stressors that are associated with burnout. Excessive workload is a common stressor faced by physicians, which manifests in the form of long work hours, higher work intensity, and increased overnight call duties among other things. ¹²

Demand for diagnostic and medical imaging is increasing as the Canadian population ages. ¹³ In fact, both the number of computed tomography (CT) and magnetic resonance imaging (MRI) examinations are expected to more than double in the period from 2017–2040. ¹³ Numerous studies have demonstrated that this trend to increased volumes was already established. From 2006–2013, a study of 3 different Canadian academic centers found that total medical imaging volume during the after-hours time period increased significantly. ¹⁴ Another study observed a 31% increase in CT and a 62% increase in MRI services from 2010–2020, respectively. ¹⁵

Despite the rising demand for imaging services, the supply of radiologists has been projected to fall short of the demands. This predicted workforce shortage originates with stagnating interest in radiology residency programs. In both the US and Canada, the number of applicants ranking diagnostic radiology as their first-choice specialty in 2019 was only half what it was a decade earlier. ¹⁶ Since 2019, snapshots of American and Canadian residency match statistics have shown a steady resurgence in interest in diagnostic radiology, though current interest still falls short of the level reached about a decade ago. Specifically, 4.8% of American applicants selected diagnostic radiology as their first or only choice specialty in 2022 compared to 6.5% in 2010, while in Canada, 3.6% of applicants selected diagnostic radiology as their first-choice specialty in 2022 compared to 4.5% in 2010.^17-20 Decreased interest in radiology could translate to a lower physician to population ratio for this particular field, resulting in an understaffing with subsequent impact on burnout.

Notably, the number of radiology residency spots available to medical students has trended differently between the US and Canada. In the US, the number of diagnostic radiology positions offered to applicants has remained relatively stable, growing by about 2.1% in the 10-years between 2010 and 2020.^19,21 Meanwhile, in Canada, the number of available radiology residency positions decreased significantly in that same 10-year period. ²² A continued trend of decreasing radiology residency spots would translate to a lower number of practicing radiologists. Though population growth in the US and Canada will entail increased demand for imaging services, decreasing radiology residency spots serve as an additional bottleneck in the latter. Consequently, Canadian radiology departments are more likely to be understaffed, causing workload issues for imagers such as increased overtime or unmanageable patient volumes, both of which have been associated with burnout.^12,23

The supply shortage of radiologists is forecasted to be more pronounced in some subspecialty areas than in others. Specifically, mammography, cardiac imaging, and pediatric radiology have been identified as subspecialties where workforce shortages are more likely to occur.^24,25 Residents report decreased desirability in these aforementioned subspecialty areas for a multitude of reasons, namely, lack of interest in mammography and poor remuneration for pediatric radiology. ²⁴ The predicted cardiac imaging shortage is more so attributed to increasing workforce demands that the radiology supply simply cannot keep up with. ²⁴ Meanwhile, radiologists seeking subspecialty training were keener on abdominal and thoracic imaging, which are in fact the only 2 subspecialties where supply was expected to meet the immediate need of the population. ²⁴ The inability to meet the imaging volume demands of certain subspecialty areas places significant strains on the healthcare outcomes associated with those respective areas. For example, a workforce shortage in mammography could potentially threaten the progress made in breast cancer therapy, as decreased access to breast cancer screening would stymy early detection programs that are directly responsible for decreased breast cancer mortality. There may be significant pressure for radiologists to increase their workload to unsustainable levels to compensate for subspecialty shortages against a backdrop of increased demand from an aging population.

Additionally, physician shortages in rural and remote communities exceed those faced by their urban counterparts. ²⁶ This trend is especially acute in radiology. From 2010 to 2020, the number of radiologists practicing in urban areas grew by 24%, while the number of radiologists practicing in rural areas only grew by 5%. ²⁷ In general, the number of Canadian specialist physicians practicing in rural areas grew by 26% in the same period, which means that comparatively, rural growth progress made by radiology falls short of the specialist average. An overburdened rural radiologist workforce is likely to result, increasing the likelihood of burnout. ²³ Other aspects limiting rural growth, which are not necessarily unique to radiology, include high turnover rates, increased workloads, inaccessibility of continuing medical education, and relative unavailability of specialist consultation for professional support. ²⁶

Equipment Shortage

The amount of available equipment to meet the demand for diagnostic imaging can limit the ability of a radiology department to care for patients. Access to and availability of advanced imaging modalities (CT and MRI), is particularly limited in some Canadian jurisdictions. As such, the volume of imaging work that can be done may serve as a bottleneck for Canada’s increasing healthcare needs. More specifically, the number of CT and MRI scanners in the country and their usage rate are both factors that influence whether the demand for imaging can or will be met by radiology departments in the near and more distant future. ¹⁵

From 2003 to 2019, the total annual number of CT scans in Canada has roughly doubled, while the number of MRI scans has roughly tripled. ¹⁰ This increase largely correlates with the average number of scans performed by other Organization for Economic Co-operation and Development (OECD) countries. However, on a per capita basis, Canada has far fewer CT and MRI scanners available, meaning that Canada does more scans per scanner on both these imaging modalities compared to the OECD average. Furthermore, growth in the number of CT and MRI scanners per 1 million population has been slower in Canada than in the rest of the OECD. Given these trends, it is evident that imaging demands on Canadian radiologists have increased to near maximum capacity, and that patient throughput in Canada would be difficult to increase without a corresponding increase in scanner supply. Both high demands at work and lack of resources are significant stressors that contribute to burnout. ²⁸

Radiology departments have been tasked to address growing waitlists because of pressures exacerbated by the COVID-19 pandemic, ultimately contributing to an unsustainable workload. Even before the pandemic, Canadians faced lengthy and growing wait times for diagnostic imaging.^13,15 In 2017, the wait time for a CT scan was expected to be 18 days, and the wait time for an MRI scan was expected to be 64 days. ¹³ Compared to the Canadian CT and MRI benchmarks, the wait time for CT scans falls within the maximum time recommended for semi-urgent examinations, but not emergent or urgent examinations, while the wait time for MRI scans exceeds the maximum time recommended for all priority levels, including non-urgent examinations. ¹³ Increased wait times for diagnostic imaging are particularly concerning because they may result in delays in treatment and subsequent downstream effects of costs to the economy. Complexities in the form of technological advancements and workflow variations across the country both hinder the goal of achieving reasonable wait times as well. Excessive wait times have caught the attention of governmental bodies, resulting in formal guidelines being created for radiologists to follow. ¹³ This acts as an organizational pressure, can intensify burnout in individuals and groups. ²⁸ Overall, Canadian radiologists face a growing demand for diagnostic imaging that may contribute to an increasingly unsustainable workload.

Work-Life Balance

Experiences of burnout can be traced to the increased frequency and intensity of work-related stressors. Globally, physicians suffer from burnout more frequently than the general population, presumably due to the nature of the profession. ²⁸ This is encapsulated by physicians’ exposure to stressful situations from both within and apart from the doctor-patient relationship, such as dealing with feelings of grief experienced by patients and their families, pressure to keep up with advancing medical knowledge and needing to survive in rapidly changing bureaucratic environments. ²⁹

In reference to the Maslach Burnout Inventory (MBI), studies have shown that Canadian radiologists experience higher burnout rates in the emotional exhaustion and depersonalization domains when compared to levels reported by radiologists in the United States.^1,8 However, Canadian radiologists simultaneously scored relatively high in the personal accomplishment domain, which is a protective factor against burnout. ³⁰

There are several underlying factors associated with elevated levels of emotional exhaustion and depersonalization. A study examining Canadian radiology residents demonstrated that approximately half of all residents surveyed experienced either high emotional exhaustion or high depersonalization. These 2 domains of burnout were significantly associated with higher work hours, self-identification of poor work-life balance, feelings of lack of support by staff radiologists, identification of poor education-service balance, and general unhappiness with residency. ³¹

Staff radiologists experience unexpectedly high work volumes at least once a week, ³² and radiology trainees generally report an on-call frequency of 1–2 times per week. ³² The overall finding encapsulated by these 2 statistics is that Canadian radiologists tend to work beyond expected norms. Indeed, this is corroborated by a Canadian Medical Association report, which indicated that 46% of Canadian radiologists feel overworked in their discipline. ³³ As work hours continually increase, the detrimental effects of those hours accrue, including reduced work quality because of the time-constraining nature of unexpected new work, or fatigue due to the increased frequency of on-call duties.

Another factor associated with the physician burnout rate is feelings of isolation. ²⁸ Isolation itself is a multifactorial issue in that feelings could arise from being geographically isolated, professionally isolated, or both. It is perpetuated by the existence of a hidden curriculum of isolation that exists in as much as 80% of major academic radiology centers in Canada, which reinforces the notion that radiologists normally work alone. ³⁴ Common facets of this culture of isolation include residents’ feelings of lack of guidance, overstretched mentorship resources, and minimal protected time for teaching. ³⁴

In addition to the lack of time allocated for teaching, academic radiologists face a number of additional pressures that may contribute to burnout. Canadian radiologists on average spend 4 hours each week on research, well short of the suggested 1 day of protected academic time that another group has suggested.^33,35 Academic isolation in the form of limited protected research time may discourage radiologists from considering new ideas, inducing “research fatigue” and contributing to physicians’ emotional exhaustion.

Pandemic-Related Challenges

At the onset of the COVID-19 pandemic, in the 2-month period from March to April 2020, radiology service output dropped by approximately 50–70%. ³⁶ Imaging backlogs have accumulated to unprecedented levels due to that temporary slump. Due of waitlists that existed even before pandemic, combined with current supply limitations, little to no progress is being made to close the gap between the number of imaging referrals and the total imaging capacity. ³⁶ Looking ahead, the possibility of an overburdened team of radiology professionals is very likely.

Staff shortages are expected to be more pronounced in the future. During peaks and waves of infection, policies were enacted to limit the spread of the disease. Consequently, hospital understaffing became more common as healthcare provider infection rates rose and self-isolation quarantines became more frequent. ³⁷ This inevitably contributed to an additional accumulation and backlog of imaging requests. Currently, radiology departments in Canada are facing a severe lack of health human resources, which includes groups such as technologists, sonographers, and nurses, to help radiologists tackle the immense backlog. ³⁶

The pandemic also exasperated the feelings of isolation that some radiologists face. Work may have been conducted from home, in a hybrid arrangement that limited the amount of rounding, consults, and patient contact radiologists normally experience in a pre-pandemic setting.^38,39 The added feelings of pandemic-related social and professional isolation have undoubtedly contributed to feelings of burnout among radiologists who were already struggling.

Future Uncertainties

Radiology is a specialty that is consistently at the forefront of innovation and technological change in medicine. Changes to the profession can create a dimension of professional uncertainty or worry, which is further heightened by uncertainty related to fee schedules and remunerative models. ⁴⁰

The increase in the application of artificial intelligence (AI) in radiology gives rise to attitudes of unease about this field. ⁴¹ AI, especially in the image processing space, works by taking advantage of deep learning algorithms to facilitate the diagnostic process, sometimes at levels that exceed the performance of human radiologists. ⁴² In Canada, the worry over AI replacing radiologists is more prevalent among junior radiology trainees than senior residents, which is concerning because it could indicate that trainees who have had less exposure in the field are more prone to anticipate AI takeover. ¹⁶ This issue is corroborated by another study, which found that 68% of Canadian medical students feel that AI would work to reduce the need for radiologists in the future job market. ⁴³ Students who would have otherwise ranked radiology first choice did not do so because of their AI anxiety, and this ultimately mirrors the pattern of decreasing first choice specialty selection experienced by radiology residency programs. ⁴³

A major area of concern for Canadian radiologists is the potential for future fee cuts that result from tightening provincial budgets. By and large, the primary remuneration method for Canadian radiologists is fee-for-service, which is covered by provincial health insurance plans. In face of ever-increasing demands, a reduction in remuneration may increase the gap between what radiologists deem fair vs unfair compensation. This is complicated by the fact that technological advancements in diagnostic imaging do not necessarily reduce the workload for radiologists. When increased work is followed by more work and unbalanced rewards, burnout is very likely to occur. ⁴⁴

Solutions

Burnout in Canadian radiology has been a topic of interest in recent years. Because of the high costs to the healthcare system associated with radiologist burnout, solutions are necessary to help radiologists navigate around issues and find balance in a delicate ecosystem.

To directly combat the immediate problem of radiologist supply shortages, especially in face of a growing backlog in a post-pandemic era, investments should be made towards acquiring health human resources. This serves to reduce the workload of existing support staff and technologists, who are already reportedly experiencing significant levels of burnout. ³⁶

For radiologists, more measures could be implemented to enhance job flexibility. This provides more agency to existing staff and works to diminish feelings of powerlessness and isolation, which enhance the progression of burnout. ²⁸ A good opportunity is for groups to offer extra hour pay to members who can voluntarily commit to working longer hours. Consequently, the detrimental effects of unexpected patient volumes could be minimized, and work hours could be allocated more efficiently. Being able to hire for part-time work in addition to full-time practices would enable flexibility and increase workload coverage as well. Moreover, adoption of teleradiology or other forms of remote reporting further improves workload coverage. ⁴⁵ While on-site radiology resources remain critical, especially for services such as the emergency department, the allowance of remote coverage greatly alleviates stressful staff shortage situations. ⁴⁶

The queueing and scheduling process for patients can be improved. For imaging modalities like CT and MRI, patients are bucketed into priority levels, which then inform physicians of the optimal queue order to maximize healthcare outcomes. Improvements made on this front can help reduce wait times that already exceed the recommended standards and, as a result, improve patient satisfaction. Evidence-based analysis of optimal queueing and scheduling frameworks should be performed to identify the recommended practices. As an example, there is evidence that a centralized intake system, if implemented correctly, results in accelerated examination forwarding and elimination of duplicate scans. ³⁶

In the long term, Canada’s imaging equipment supply must be modernized. Currently, equipment used by Canadian radiologists surpasses the lifetime limits recommended by Canadian and international guidelines.^36,47 An older supply not only contributes to potentially inferior diagnostic testing, but also interrupts the efficiency of workflows. Updated machinery may run differently and require different protocols from legacy systems, and this lack of uniformity works against building radiology resilience.

Workplace culture should be shifted away from a hidden curriculum of isolation. Clear communication and frequent collaboration have a burnout-alleviating effect and helps physician deal with the overwhelming pressures of the pandemic. ⁴⁸ Open communication from leadership and more dedicated commitment to mentorship are also aspects of work culture that build resiliency and trust.

Finally, the importance of wellness resources should be re-emphasized. This can include the provision of burnout-specific resources, such as weblinks to coping strategies, and workshops on the management of burnout-related stressors. Physician wellness committees can also be established to regularly assess the overall wellbeing of a particular group of physicians over time or during periods of elevated stress.

Conclusion

In conclusion, burnout is a complex, multifactorial issue that has a significant impact on the Canadian radiology landscape and patient care. Shortages in both human resources and equipment require attention to address the increasing demands of a growing population of aging and older Canadian adults. As well, the COVID-19 pandemic brought forth new concerns, while exacerbating many old ones. Burnout will remain a challenge to overcome as the profession makes transitions to a post-pandemic era. In addition to existing strategies, new programs that encourage flexibility and are problem-targeted are necessary to promote the wellbeing of radiologists in Canada, and their ability to care for patients.