A survey comparing workload amongst radiologists, gastroenterologists, surgeons and oncologists in the United Kingdom reported the highest level of burnout amongst radiologists. Although it is generally impractical for most trained specialists to simply change their clinical specialty in order to decrease stress levels, identifying the inherent characteristics of the work that lead to work satisfaction or stress is paramount, as these factors are likely to be modifiable. Edwin Locke, a noted expert in the area, defined work satisfaction as "...a pleasurable or positive emotional state resulting from the appraisal of one's job or job experiences". The ability to identify factors influencing work satisfaction, or for that matter work stress, provides the opportunity to develop methods to avoid the resultant risk of burnout. In this paper, we describe some of the important reasons public sector radiologists report higher stress levels than private radiologists, and describe a way of managing this to minimise the risk of burnout in the radiological team.
Survey on Stress & Satisfaction
We performed a nationwide survey of New Zealand radiologists to identify those work factors that result in either stress and/or satisfaction. New Zealand radiological sector consists of public and private radiology practice operating in tandem. While the public system is entirely funded by central government, the private sector is predominantly driven by a fee-for-service pay structure, with payment of radiological tests covered either by private insurance companies or patients themselves. Generally speaking, the public setting tends to deal with more complex or emergent cases as well as elective outpatients. In contrary, private radiology tends to manage less complicated, elective cases. As many radiologists work in both environments during the course of their working week, this allowed us a unique opportunity to identify differences in the public and private radiology environment. We concluded that radiologists in the public hospital setting experience significantly higher levels of work stress, burnout and lower job satisfaction compared to the private sector.
Inappropriate Exams Source of Public Sector Stress
To explore why this might be the case, one has to understand that inherently, radiology is about providing clinical support. By this, I mean that rather than caring directly for patients and making clinical decisions that directly impact on patient care, radiologists are called upon by other physicians when there is a clinical question to be answered by imaging, a causative contributor to work related stress, as we shall see.
Rationing of health resources, especially in socialised medical systems, is common. In a public hospital setting, where funding is derived primarily through the central or federal government, radiologists often find themselves acting as the gatekeeper to more sophisticated imaging modalities such as CT, MRI and PET/CT. However, radiologists are under increasing pressure to approve scans due to patient expectations and clinician demands. This in turn has to be balanced against the limited availability of essential resources. Indeed, dealing with clinicians' requests for what radiologists deemed as inappropriate examinations ranked significantly higher as a source of work stress in the public setting compared to private sector in our survey. In the private setting, where a user-paid or private insurance-based system is more often the norm, there is greater onus on clinicians and/or patients to justify the examination, thus potentially decreasing the amount of inappropriate requests.
Moreover, in most private practices in New Zealand, there is very little or no inpatient work to contend with. Thus the reporting radiologist is unlikely to be saddled with urgent requests from clinicians to multi-task. Furthermore, the current trend towards shorter hospital stays has resulted in greater pressure on clinicians to diagnose or otherwise exclude important medical conditions in order to facilitate prompt discharge. Consequently, there is an expectation that radiological investigations will be available on an almost emergent basis.
Chronic Understaffing & Conflicting Demands
Conflicting demands on radiologists' time ranked as the highest source of work stress for those who work in public radiology. We postulate that chronic understaffing in the public sector is likely to be the culprit. Radiology workload has increased worldwide, but this has not necessarily been compensated for with an increased number of consultant posts. In an understaffed public radiology department, existing radiologists are usually expected to cover the additional workload. This creates a vicious cycle where the stressed radiologist is burdened with greater demands, resulting in increased work stress and decreased job satisfaction.
Furthermore, additional tasks such as chairing multi-disciplinary conferences or teaching obligations all add to radiologists' daily schedule. At our institution, conference cases are submitted at least 24 hours prior, to allow adequate time for case review. A dedicated time slot is crucial for adequate preparation on the radiologist's part and frequently adds additional value beyond the official radiology report. Non-clinical sessions are also allocated and the time used to pursue research interests or catching up on administrative matters.
Sources of Work Satisfaction in Private Sector Imaging
We identified some of the most significant sources of work satisfaction for radiologists in the private sector, which include having a high level of clinical autonomy, satisfactory remuneration and having the necessary staff to perform the task at hand. Clinical autonomy stems from the ability to control and impact on one's work environment. In the private sector, radiology practices are often set up as partnerships. Therefore, radiologists usually have a say in the dayto- day running as well as the long-term goals of the practice. In contrast, public, hospital-based radiology departments are generally administered by business managers.
Facing today's ever-expanding demand for radiological procedures and imaging studies, practice managers have a difficult task keeping departmental cost within the prescribed budget. Maintaining an open channel of communication and scheduling regular departmental meetings to resolve problems and obtain feedback are some steps that can be taken by business managers to empower clinical staff. Radiologists and managers need to understand each other's viewpoint, to be able to compromise and cooperate in their common goal of providing the best radiological service to patients and clinicians alike.
Although it would seem from our survey that private sector radiology provides a superior work environment in terms of work stress and satisfaction, all is certainly not lost in the public radiology department. Finding the solutions to minimise the sources of stress in a public radiology department requires regular consultations between business administrators and radiologists, having an open mind as well as the flexibility to adapt to new approaches. Implementation of these solutions will go a long way towards improving radiologists' job satisfaction and ultimately, their mental health.