By Matt Skoufalos
For as much as the shortage of incoming professionals is discussed as a deep-seated problem in the medical imaging space, perhaps some comparable amount of attention should be paid to what’s being done to retain their services in the field.
The 2023 Medscape Physician Burnout & Depression Report showed 54 percent of radiologists are feeling the impact of burnout in their careers, a top 10 result among 29 physician specialties surveyed for several years in a row. In a December 2023 survey of more than 18,000 academic physicians published in JAMA Network Open, nearly 40 percent of radiologists reported intentions of leaving their current jobs within the next two years, tied with critical care physicians for fifth among specialties surveyed. A March 2023 Journal of the American College of Radiology (JACR) survey of practicing radiologists within the largest coalition of wholly radiologist-owned, independently practicing diagnostic radiology groups in America reported that “about one-half of radiologists were burned out, and just over one-quarter were professionally fulfilled.”
If the medical imaging world needed any clearer signal that its staff were on the edge of a breakdown, the data are practically screaming for culture change in a workplace culture that is high on burnout, short on patience and in which professionalism has come to be defined as swallowing the small harms often perpetuated by other colleagues.
Tricia Trammell, imaging operations manager for the Moncrief and Las Colinas imaging clinics of UT Southwestern Imaging Services of Fort Worth, Texas, is a medical imaging technologist of 25 years. When she considers the climate of workplaces in her industry, Trammell said she believes that incivility among coworkers is rampant. Although the issue isn’t necessarily a novelty, its prevalence and intensity since the novel coronavirus (COVID-19) pandemic – and the workforce depletion that followed – “has unfortunately accelerated.”
Regardless of the root of the problem, Trammell said the cost of failing to confront incivility in the workplace can create even greater concerns, from lost productivity to staff shortages to mistakes that can lead to negative outcomes for patients.
“In health care, incivility can be downright dangerous because we have people’s lives in our hands,” she said.
Author Christine Porath, who’s studied workplace incivility, especially in customer-facing professions, wrote on the subject in the Harvard Business Review.
“Even amid a global health crisis in which frontline workers were heralded as essential and heroic, these employees still became punching bags on whom weary, stressed-out, often irrational customers (and sometimes fellow employees) took out their anxieties and frustrations,” Porath wrote. “This kind of incivility leads to negative outcomes not only for the workers who experience it directly but also those who witness it – all of which harms businesses and society.”
Porath’s work described how reports of incivility are both on the rise, and leave a negative impact on those who witness them, even if they weren’t the original target of the behavior. After a global survey of 2,000 people in various industries, 76 percent of respondents reported having experienced incivility in the workplace at least once a month, and 70 percent reported having witnessed such incidents at work two or three times a month.
“Merely being exposed to rude words reduces our ability to process and recall information,” Porath wrote. “Dysfunctional and aggressive thoughts (and sometimes actions) can skyrocket. Witnessing rudeness and triggers of incivility – such as reading a nasty comment on social media or listening to an argumentative interview – takes a cognitive toll, interfering with our working memory and decreasing our performance. And these disruptions can be catastrophic.”
When coworkers decide that they just won’t communicate with one another because of a mutual dislike, or experiences of disrespect, they may simply remain silent instead of interacting at all. In that silence is a lack of shared information that could result in a delay of patient care, and blaming behaviors that follow.
The antidote, Trammell said, is establishing a culture of psychological safety by encouraging employees “to bring their authentic selves to work every day,” and speaking up when they witness or perceive behaviors that are incompatible with that goal. She described walking the line between being professional while being authentic in the workplace, and modeling the appropriate way to interact among the rest of her team.
“I have multiple roles as a manager,” she said; “I refuse to not be my authentic self. It’s important for the team to know this is who I am, and we can still be professional all the time. Humans are going to make mistakes whether they’re 20 or 50, and we all have to have grace and extend forgiveness. And we also sometimes need a reminder that particular behaviors are inappropriate.”
Trammell offered a few pointers for bringing authenticity to the workplace, including behaviors that generally boil down to: taking an interest in colleagues, using measured speech and behavior, taking ownership of mistakes, and being willing to forgive offenses and perceived slights from others.
“I think the art of relationships is lost, and the lack of relationships breeds more incivility,” Trammell said. “It would be far more difficult to be more uncivil to someone you have a good relationship with. It’s not a weakness to have friendship with people; there is strength in friendships and relationships.”
Wendy Dean, CEO and co-founder of Moral Injury of Healthcare, is a psychiatrist who studies distress among professionals in high-stakes environments. After having observed clinicians from across the country in different settings, Dean noted that they shared common struggles, and were reluctant to describe themselves as “burned out.”
“These were people at the tops of their games; really sought after, brilliant,” she said. “They would all say almost the same thing, and they would almost use the same words: ‘I love my patients. I love the medicine that I practice. It’s everything else that’s grinding me to dust.’ ”
Together with her colleague, Simon Talbot, Dean began exploring whether burnout might be an incomplete diagnosis, and the two discovered that the source of distress among health care professionals wasn’t just being overworked, although that was certainly a contributing factor. Professionals know they’re signing up for working long hours and attempting to achieve difficult results against sometimes long odds. What they hadn’t squared intellectually was the challenge in getting their patients access to necessary care.
Rather than burnout, which is most commonly used to describe emotional fatigue, their experiences seemed to more closely match with the experiences of moral injury: bearing witness to acts that transgress deeply held moral beliefs and expectations. In short, physicians could manage being overworked, but not ethically compromised by the system they are working to uphold.
“It really starts as betrayal by a legitimate authority in high-stakes situations,” Dean said. “You have a moment where you can either stand up, and push back and defend your deeply held moral beliefs and expectations, or you can acquiesce to that betrayal. We were hearing people saying, ‘I’m at this point where I either need to stand up and speak out, and risk everything that I’ve worked for, or I put my head down and do the best I can, but it’s going to eat at me if I do that.”
When asked to compromise either their professional capacity or their moral code, health care professionals will disengage or become mistrustful of their leadership, Dean said, which means that they might experience a disconnect between what their organizations say they stand for and how they’re run in practice. When clinicians don’t trust their organizations, patients feel it; they trust the institution less, and they’re more likely to question the recommendations their clinicians make. The same impacts can be felt up the leadership chain, especially amid the environment of consolidation that has defined the health care space for decades.
“These folks who used to be CEOs of their small hospital, they had authority and agency,” Dean said, “but when you roll them into a giant corporation, they become middle managers that no longer have the agency and authority to make the decisions they used to make.”
In the radiology department, examples of moral injury can be found in challenges related to workflow, scheduling, and case volumes, among others. In the effort to hit peak efficiency, keeping scanners 95 percent booked has long been cited as a financial and productivity goal; however, that doesn’t allow for urgent cases to be seen in a timely fashion, and that can mean that people who are in pain suffer longer while awaiting care.
“You have physicians saying, ‘I made a promise to take care of patients to the best of my ability without self-interest, and yet you are demanding that I put some other consideration before my patients, which is the well-being of this organization,’ and that doesn’t comport,” Dean said.
“Do we want profit to take precedence over patients? We have never had to imagine what it would be like to live somewhere where you can’t get the amount of health care you need, where you need it, when you need it. That has now become a reality for us.”
As disheartening as these challenges are, Dean doesn’t believe they’re insurmountable. But, she warns, the next decade is critical to shift the pendulum, because “we’re going to lose the last of those folks who lived in an era when right was valued.”
“When you put somebody in a toxic system and they need to survive, they do whatever it takes,” she said. “If you take them into a different environment, those things go away.”
“We need to have organizations with leaders who are committed to caring for those who care for their patients, who are transparent, who are authentic, who are human, who are trustworthy, who have aligned values, so the talk they talk is the walk they walk,” she said. “We need to acknowledge that this is really hard work that we do and that moral injury is a risk.”
Licensed clinical psychologist Austin Johnson of the consultation firm Executive Counseling of Lubbock, Texas, believes that burnout is a cultural illness, and thus requires cultural approaches to remedy. Those health care institutions that can leverage cultural and social dynamics to address such challenges will find greater successes rather than hoping to address individuals as outliers from the mean, he said. 
In contemplating the major environmental factors that contribute to burnout, Johnson identified three clear challenges. The first is fatigue, or a complete loss of energy. The second is stagnation – a feeling that, no matter how hard you work, there’s no progress being made. The third is depersonalization, or the loss of individual identity in a greater, often oppressive, system.
“When that sets in, that’s the danger zone,” Johnson said. “Factors that tend to go along with it are crazy expectations. Everybody is trying to make the absolute most of every single minute because the demand is huge.”
To his thinking, the antidote to these circumstances involves exploring the cultural factors that set up people for failure in the workplace. They can be small, like the uncivil encounters that contribute to overall feelings of depersonalization, or they can be large, like the foundational questions of purpose and underlying meaning that have led many health care professionals to leave the field altogether.
“Usually things that inspire a mass exodus of staff are surprisingly small things,” Johnson said. “Whenever they’re facing a burnout problem, which presents itself as a turnover problem, a lot of managers brains go first to money: ‘We can make them happy if we pay them more, or give them more PTO, or more money to hire more people.’ And whenever they’re feeling strapped for cash in the first place, that option feels closed.”
Perhaps counterintuitively, Johnson said when the same question was put to a group of nurses – what would make your jobs easier? – their responses were all related to how they were treated interpersonally, not how much they were paid, nor how much time they were allowed away from the office.
“When it comes to burnout culture, don’t overlook the power of non-monetary things,” Johnson said. “This is not me versus you; this is me and you versus an extremely challenging set of circumstances. Anything you can do to signal we’re on the same side, you save money, time, energy, lives.”
Or, more simply put, the adage that “people don’t quit their jobs, they quit their bosses,” still rings true.
“If you’re at the top, you can actively discourage bad manners,” Johnson said. “If you’re not at the top, positive reinforcement really does go a long, long way. What that means is you have to build a better radar system that pings so loudly whenever you get something different. Any time there’s a counter-example of people being treated poorly, you stop, let people know you notice, and how much you appreciate it on a personal level. It retrains your brain for what to look for and what to expect. In that act right there, you’re starting to slowly change the microculture around you.”
