Burnout crisis in radiology

Moral injury, design thinking, and Health 3.0

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Yoga, massage, stretching, scented candles, and breathing exercises are ok, but systemic realignment — profits, patient health, and physician welfare — will be critical to deep, lasting burnout solutions.

ou’ve heard of burnout — emotional detachment, depression, suicide. In radiology, we’re feeling the effect of burnout as much as some of the most affected specialties. Articles that recognize the widespread prevalence of this condition help us to realize that we’re not alone. But how do we fix it? At the center of a new movement, sometimes incorporated into the still-nebulous Health 3.0 ethos [1], is the recognition that healthy diets, yoga, and mindfulness are not enough. Burnout runs deeper than that — it’s the effect of moral injury, the condition where profits, patient health, and physician welfare are individually and systematically misaligned [2].

At the financial heart of radiology and other specialties is volume-based reimbursement. The more we read and report, the more we bill. Nothing else matters more to the financial equation of a practice, whether it’s physician-owned or corporate. In order to maximize practice revenue under this equation, we’re fundamentally pressured to read as fast as reasonably possible. To be fair, patients and radiologists are both beneficiaries of this system: patients get faster reports, and our ability to meet this demand justifies our earnings. Profit is important to sustain and motivate a highly-skilled healthcare team. But what’s missing from the volume equation is direct reward for quality of service. Fast-but-inaccurate reads are clinically meaningless, wasteful and even capable of harm. Moreover, current legislative quality measures are invariably simplistic or counterproductive.

Enter the concept of autonomy, defined as freedom from external control or influence. Loss of autonomy is the magnifying lens which amplifies the burning rays of moral injury. Autonomy in the radiology workplace is divided into three categories: financial, professional, and social. When radiologists lose autonomy in relation to their earnings, expertise, and family commitments, the moral injury of volume-based reimbursement is exacerbated. Where do we go from recognizing that moral injury and loss of autonomy are fueling radiologist burnout? Design thinking provides some guidance on this matter.

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Examples of losses of autonomy in radiology that magnify moral injury

Design thinking is a human-centered approach to identifying and solving complex problems that was popularized at academic departments like the Stanford Design School, and private design groups like IDEO. It’s the reason why using your iPhone to check email feels effortless. Lack of design thinking is why viewing outside images from a CD drive requires a graduate degree in patience. At the core of design thinking are experimentation and iterative refinement.

Design thinking is practical in its acknowledgement that we are dealing with finite resources to arrive at a solution. It advocates for small experiments when exploring causes and solutions. The “small” part of this approach is key. Financial capital must initially be distributed across several candidate solutions, and only later channeled into leading candidates. In the startup space, an initial candidate solution is called a minimum viable product (MVP) because it is both inexpensive (minimum) and sufficient (viable) to reveal the validity of a proposed solution (product).

One inspiring example of design thinking in radiology is the problem of inbound phone calls at Stanford Radiology, circa 2014. Faced with rising volume, resident physicians at Stanford realized that inbound phone calls had substantially eroded their professional autonomy by hijacking their ability to focus on image interpretation. By quantifying the frequency and timing of these inbound calls, these residents used evidence to make the case for hiring a reading room assistant. Certainly, this revelation isn’t specific to Stanford, and programs elsewhere have likely dealt with similar concerns. In fact, key academic papers suggest that inbound phone calls aren’t just a nuisance — they can also be dangerous to patient care [3]. Some private practice groups also incorporated reading room assistants early, and some of the largest corporate radiology groups in the country now provide enterprise-wide access to assistants. These assistants screen and route inbound and outbound calls, which helps to restore our professional autonomy, allowing us to focus on delivering quality care. They also improve the alignment/moral injury problem in radiology. As we work faster and produce higher quality reads, patients receive better care, and groups see larger profits — aligning all three interests.

The crisis of burnout is complex, and no single entity (insurance companies, hospitals, practice groups, radiologists, technologists, referring physicians, government policy, patients) is solely responsible — believing so would risk a comprehensive solution. On the other hand, the distributed nature of this problem means that each of these various stakeholders has the opportunity to improve the system in meaningful ways. Exploring the solution space is a moral imperative for practice leaders, practitioners, regulators, and patients alike.

Ultimately, coordinating the effort to implement systemic change may be difficult. Per diem and employed radiologists may not wield sufficient influence in their practices. Partners in physician-owned groups will need to form consensus with other partners in the group. Paradoxically, large corporate radiology groups may be in the best position to rapidly restore autonomy and heal moral injury, because decision-making in these groups is consolidated centrally. For groups that embrace design thinking in addressing the burnout crisis, the rewards of restoring alignment and autonomy will be more than worth the effort — greater profits, healthier patients, and more fulfilled radiologists.

Biography

Ram Srinivasan MD PhD is an engineer and board-certified neuroradiologist in Palo Alto, California with a passion for simplifying lives through education technology. He’s also Course Director at Core Physics Review, which teaches clinically-relevant radiology physics to more than 400 resident physicians in radiology from over 60 residency programs, and now offers the NRC-80 Adventure, which empowers residency directors to deliver an engaging hands-on learning experience that also satisfies the NRC 80-hour requirement.

Most recently, Ram launched Orbit to help combat burnout at the system level by streamlining the process of satisfying annual CME requirements based on existing learning at point of care, delivering subspecialty article recommendations, automating compliance for credentialing leadership, and increasing reimbursements through QPP/MACRA/MIPS.

Email Ram at ram@orbitcme.com or follow him on Medium or Twitter.

References

[1] Venu Julapalli, “Health 3.0: Where Medicine Needs to Go”, Medium, July 27, 2016, [link]

[2] Zubin Damania, “It’s not burnout, it’s moral injury,” YouTube, March 8, 2019, [link]

[3] Ram Srinivasan, “Phone calls to the reading room may be killing your patients”, Medium, Nov 25, 2017, [link]

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Orbit is the easiest way for physicians and PAs to finish their credits for state and national boards.

Orbit’s mission is to invest in the wellness of medical professionals.

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