Introduction
The higher incidence of occupational burnout (OB) among various healthcare professionals
brings about the need for more studies identifying the reasons and solutions.[1] The World Health Organization's (WHO) 11th revision of international classification
of diseases refers burnout as an occupational phenomenon and defines it as a syndrome
that results from chronic work-related stress leading to emotional exhaustion, depersonalization,
and reduced personal accomplishment in their profession.[2] Burnout is characterized by blunt emotions in contrast to overreactive emotions
seen in stress. The stages of burnout are onset of stress (waning of job satisfaction,
inability to focus, being irritable), chronic stress (procrastination at work and
physical tiredness), burnout (pessimism, self-doubt, self-isolation, and behavioral
changes), and habitual burnout (chronic physical and mental fatigue and depression).[3] OB among physicians has been widely discussed in the literature. It is reported
that medical professionals suffer from a higher rate of burnout. OB leads to reduced
professional efficacy.[4] In general, the incidence of burnout among interventional radiologists (IRs) is
more than that of diagnostic radiologists and other medical professionals (71.9 vs.
54–61% vs. 43%).[5] Few of the main reasons for high burnout among IRs are lack of role clarity and
encroachment on IR work by other departments.[6]
Literature focusing on measures to avoid or combat burnout among physicians, especially
among IRs, is scarce. Hence, we conducted a survey among IRs focusing on work–family–health
(WFH). WFH balance has become an essential component of healthy survival. Maintaining
an equilibrium helps to reduce stress, burnout, and mental health problems such as
depression and anxiety. In this study, we report the survey results affecting WFH
balance among IRs.
Materials and Methods
Data Collection
Since the survey consisted of a set of new questionnaires, it was internally validated
by 10 senior IRs who had varying duration of experience (median: 7 years). There were
30 questions covering work, health, family, or a combination of these. The questions
also addressed knowledge, attitude, and practice ([Table1]). This anonymous survey was created using a Google form (Google Inc., Mountain View,
California, United States) and disseminated via social media platforms such as WhatsApp
(WhatsApp Inc., Mountain View, California, United States), Telegram (Telegram Messenger
Inc.; Dubai, United Arab Emirates), and via e-mail to IRs.
Table 1
List of questions in the survey including options for responding, domain being analyzed
and components
|
No
|
Question
|
Options for responding
|
Domain being analyzed
Work (W)
Health (H)
Family (F)
|
Component
Knowledge (K) Attitude (A) Practice (P)
|
|
1
|
Consent: my responses may be included in the analysis and published. I may be contacted
for any clarifications by the investigators maintaining the confidentiality
|
Y/N
|
–
|
–
|
|
2
|
In which country do you practice?
|
|
-
|
-
|
|
3
|
Since how many years have you are in IR practice?
|
|
W
|
−
|
|
4
|
Your practice includes night duty
|
Y/N
|
W
|
K
|
|
5
|
Your practice includes weekends
|
Y/N
|
W
|
K
|
|
6
|
Are you the only IR practitioner where you practice?
|
Y/N
|
W
|
K
|
|
7
|
Do you have a support group that can stand by you, if you have a difficult time especially
patient death or a major complication?
|
Y/N
|
W
|
K
|
|
8
|
Do you have a difficult time with your administration or difficult turf battles within
the hospital you practice?
|
Y/N
|
W
|
K
|
|
9
|
When go through a difficult time how do you relax or get yourself out of this mood?
|
|
W
|
A
|
|
10
|
How do you rate the quality & duration you spend for your work?
(10 is the best)
|
0 1 2 3 4 5 6 7 8 9 10
|
W
|
K
|
|
11
|
Rate level of work-related stress
(10 is the worst)
|
0 1 2 3 4 5 6 7 8 9 10
|
W
|
K, A
|
|
12
|
When did you have a formal health checkup last?
|
Never
More than 1 year
Less than 1 year
|
|
K, A, P
|
|
13
|
Are you having any health problem necessitating daily medication?
|
|
H
|
K, P
|
|
14
|
What is your BMI?
|
Lesser / normal / higher
|
H
|
K
|
|
15
|
Your exercise hours per week
|
|
H
|
A
|
|
16
|
Your predominant source of exercise
|
Walking
Running
Swimming
Cycling
Playing games
Others
None
|
H
|
K, A, P
|
|
17
|
If others were the answer to the previous question, please specify
|
|
H
|
K, A, P
|
|
18
|
Smoking habit
|
Past/present/never
|
H
|
A, P
|
|
19
|
Drinking habit
|
Past/present/never
|
H
|
A, P
|
|
20
|
How do you rate the quality and duration of exercise for your health? (10 is the best)
|
0 1 2 3 4 5 6 7 8 9 10
|
H
|
K, A, P
|
|
21
|
If you developed any occupation related health problem(s), please mention below
|
|
|
K
|
|
22
|
Have you heard any IR practitioner landing up in major health problems possibly due
to poor balancing between work–health–family life?
|
Y/N
|
H
|
K
|
|
23
|
How do you rate the quality and duration of the time you spend on your family life?
(10 is the best)
|
0 1 2 3 4 5 6 7 8 9 10
|
F
|
K, A, P
|
|
24
|
Is your IR lifestyle adding a lot of stress to your family life especially in a relationship
with your spouse/children?
|
Y/N
|
F
|
K, A
|
|
25
|
Do you have the responsibility to look after senior citizens at home?
|
Y/N
|
F
|
K
|
|
26
|
Mention your hobby(s)
|
|
H
|
K, A, P
|
|
27
|
Ability to find time to do things that you enjoy (10 is the best)
|
0 1 2 3 4 5 6 7 8 9 10
|
H
|
K, A, P
|
|
28
|
Rate your ability in time management (10 is the best)
|
0 1 2 3 4 5 6 7 8 9 10
|
H
|
K, A, P
|
|
29
|
Your message to your IR colleagues with respect to balancing work–health and family
life
|
Open-ended
|
W,H,F
|
K, A, P
|
|
30
|
Your rating regarding this survey (10 is the best)
|
0 1 2 3 4 5 6 7 8 9 10
|
W,H,F
|
K
|
Abbreviations: BMI, body mass index; IR, interventional radiologist.
Study Design
The survey consisted 30 questions; 9 were related to work: years of IR practice, presence
of night and weekend duties, quality and duration of working hours, rating the level
of work-related stress, availability of a support group during difficult times, and
presence of turf war with other departments or administration. Questions related to
personal health were body mass index (BMI), hours of exercise per week, predominant
source of exercise, smoking and drinking habit, time since last formal health checkup
and hobbies. There was also a question regarding the presence of occupation related
health problems and other chronic health problems necessitating daily medications.
Questions related to family management were quantity and quality of time spent with
the family, correlation between IR lifestyle, and relationship with partner/spouse
or children and responsibility to look after senior citizen at home. Quality questions
were rated over a scale of 1 to 10 as mentioned in [Table 2]. The most important question regarding the advice to IR colleagues on balancing
work, health, and family life was an open ended, free response question.
Table 2
Percentages of causative factors of stress and burnout reported by IRs
|
Causative factors of stress and burnout
|
Percentages of IRs reported
|
|
Night and week end duties
|
90
|
|
Sole IR practitioner
|
30
|
|
No support group during major events
|
31
|
|
Issues with administration
|
56
|
|
Occupation related health problem
|
25
|
|
Poor quality of work
|
16
|
|
Poor quality of time spent on family
|
50
|
|
Inability to spend time on things that provide happiness
|
59
|
Abbreviation: IR, interventional radiologist.
Statistical Methods
Summary data were presented as mean (standard deviation) for continuous variables
and categorical variables as numbers and percentages. The characteristics of burnouts
were compared using a t-test for continuous data and categorical data were compared using chi-squared/Fisher's
exact test as appropriate. Important factors associated with burnouts were explored
using logistic regression analysis and expressed as odds ratio with 95% confidence
intervals (CI). Statistical significance was defined as p-value less than 0.05. All analyses were performed using SPSS v25.
Results and Analysis
The total number of responses was 137. Following the circulation of the survey, there
was a rapid response in the first 2 days as compared to the subsequent days. All the
participants (n = 137, 100%) consented for the survey. Among the respondents, 87% (n = 119) were from India, while rest were from USA, UK, Australia, Canada, and UAE.
However, almost everyone was of Indian origin.
Work Related
The total number of years of IR experience of the participants ranged from 1 to 40;
the majority had an experience of 6 to 10 years with a median of 7 years. Two of our
participants had an experience of more than 30 years ([Fig. 1]).
Fig. 1 Number of years of interventional radiology practice of the participants.
Approximately 90% (n = 123) of the participants reported participating in night and weekend duties. Thirty
percent (n = 41) of the participants were sole IR practitioners in their clinic/hospital. Almost
31% (n = 42) reported having no support during difficult periods such as those in the event
of a major complication or patient death. About 56% (n = 76) of respondents acknowledged having difficulties with their administration or
practice-related turf battles.
We received a heterogeneous response when we asked to rate the quality of work. The
quality of work was rated on a scale of 1 to 10, 1 being the worst and 10 being the
best. Sixteen percent (n = 22) of participants reported a score of less than or equal to 5, indicating a poor
quality of work. Questions focusing on work-related stress were rated on a 5-point
Likert scale; score of 0 and 1 strongly disagrees the statement that IR work adds
significant stress to life, whereas score of 2 and 3 disagrees, score of 4 and 5 is
neutral, score of 6 and 7 agrees, and score of 8, 9, and 10 strongly agrees. About
67.1% (n = 92) of participants reported a score of more than 5 out of 10, indicating
a significant level of stress due to work ([Fig. 2]).
Fig. 2 A 5-point Likert scale demonstrating the level of work-related stress.
Of the respondents who indicated they had a stressful time at work, 33% (n = 45) sought help from mentors, family, and friends. Others responses included taking
a break from work, a vacation, and resorting to hobbies ([Fig. 3]).
Fig. 3 Different ways of combating difficult times mentioned by the participants.
Health Related
Almost 62% (n = 82) of the participants were able to meet the WHO recommendation on exercise requirement
for a healthy lifestyle. On the contrary, 14% (n = 19) of the participants were not able to spend any time on exercise and 24% (n = 31) were able to devote only less than 2 hours/week for physical activities ([Fig. 4]). The predominant method of exercise was walking (53%, n = 72), followed by running (6%, n = 8) cycling (4%, n = 5), and other form of sports (4%, n = 5). The other sources of physical activity to quote few were yoga, gymnasium, and
hiking.
Fig. 4 Approximate hours of exercise per week as mentioned by participants.
We checked two habits that could adversely affect health. Eighty-three (n = 113) participants never smoked in the past, 11% (n = 15) had quit, and only 6% (n = 8) are active smokers. Alcohol was not consumed by 62% (n = 85), 8% (n = 11), had quit and 30% (n = 41) are active consumers.
The BMI distribution was high in 33% (n = 45), normal in 61% (n = 83), and low in 6% (n = 8) of participants. We found that 23% (n = 31) were having health problems necessitating daily medication. Twenty-nine percent
(n = 40) participants had their annual health checkup within the year. Forty-nine participants
(n = 67) had their health checkup more than a year ago and 22% (n = 30) never had a health checkup.
Occupation-related health problems were observed in 25% (n = 34) of our participants, out of which 30% (n = 10) reported backache. A few mentioned hypertension, varicose veins, and hair loss.
One of the participants had developed radiation-induced cataract.
When we enquired, “Have you heard any IR practitioner landing in major health problem
possibly due to poor balancing of work-health-family life?,” 74% (n = 102) responded “yes.” Almost all of the participants had a hobby to keep themselves
away from the busy and tiring schedule of day-to-day life. Approximately 22% (n = 37) of the participants were playing or watching sports or doing exercise as a
mode to keep the stress away. Music or singing was able to comfort 21% (n = 35) of the participants. Reading and watching movies/television were other common
hobbies (19%, n = 26 and 16%, n = 22, respectively). Other less common hobbies were cooking, dancing, trekking, traveling,
photography, walking, gardening, performing yoga activities, hiking, sleep, sketching/drawing,
social service, and playing with pets ([Fig. 5]).
Fig. 5 Various hobbies mentioned by respondents. Some candidates have mentioned more than
one hobby.
The next question was related to their ability to find time to do things that provided
joy/happiness to them. Total of 59% (n = 81) participants were not able to fulfil that.
Family Related
About 59% (n = 82) reported having the responsibility of looking after senior citizens at home.
When asked about IR lifestyle adding stress to family life especially in relationships
with spouse or children, 44% (n = 60) mentioned “yes.” Also 50% (n = 68) participants answered that they were not able to spend quality time with family
([Table 2]).
WFH Balance
The open-ended question for suggestions to IR colleagues for better lifestyle by balancing
WFH was responded by 96% (n = 131) of participants. Of these, nearly 19% (n = 26) suggested incorporating exercise and focusing on health and 24% (n = 33) suggested prioritizing family and friends over work. Interestingly, 25% (n = 34) suggested teamwork and hard work. Approximately 42% (n = 57) suggested discrete other factors. Certain answers to note were as follows:
avoiding ego at workplace, vacations, being grounded, spirituality, and making profession
as passion ([Fig. 6]).
Fig. 6 Area of focus for a better work–life balance suggested by respondents.
The last question was on rating the survey itself on a Likert scale, 10 being the
best. More than 93% (n = 127) rated above 7 ([Table 3]).
Table 3
Different items rated by the participants in the survey
|
Question number
|
Items
|
0
|
1
|
2
|
3
|
4
|
5
|
6
|
7
|
8
|
9
|
10
|
|
10
|
Quality of work (10 is the best)
|
0
|
1
|
3
|
1
|
1
|
16
|
20
|
25
|
37
|
21
|
12
|
|
20
|
Quality time spent on physical health? (10 is the best)
|
8
|
13
|
23
|
17
|
8
|
23
|
14
|
9
|
9
|
8
|
3
|
|
23
|
The quality of time spent on family life? (10 is the best)
|
2
|
3
|
11
|
14
|
9
|
30
|
19
|
23
|
16
|
7
|
3
|
|
27
|
Ability to find time to do things that you enjoy (10 is the best)
|
2
|
10
|
12
|
25
|
13
|
19
|
19
|
17
|
15
|
3
|
2
|
|
30
|
Usefulness of survey (10 is the best)
|
0
|
0
|
0
|
0
|
0
|
3
|
7
|
14
|
44
|
30
|
38
|
Univariate and multivariate analysis with burnout:
On univariate analysis, the major risk factors for burnout were presence of weekend
duties (n = 91, 98.9%, p-value = 0.02), absence of support group at workplace (n = 36, 39.1%, p = 0.005), having tough time with administration (n = 61, 66.3%, p = 0.001), not able to spend quality time on family (n = 30, 32.6%, p = 0.035), and inability to find time to do things that one enjoys (n = 53, 57.6%, p = 0.0002). However, multivariate analysis revealed that those having tough time with
administration (odds ratio = 2.77, 95% CI: 1.12–6.48, p = 0.02) and those who could not find time to do things one enjoys (odds ratio = 4.79,
95% CI: 1.42–16.1, p = 0.01) were only statistically significant ([Table 4]).
Table 4
Results of univariate and multivariate logistic regression analysis of major risk
factors influencing work–family–health balance
|
Sl.
No.
|
Variables
|
Univariate analysis
|
Multivariate analysis
|
|
Burnout
|
p-Value
|
Odds ratio
(95% CI)
|
p-Value
|
|
≤ 5 (n, %)
|
> 5 (n, %)
|
|
1.
|
Night duty
No
Yes
|
6 (13.3)
39 (86.7)
|
6 (6.5)
86 (93.5)
|
0.19
|
1.00
1.19 (0.19–7.62)
|
0.85
|
|
2.
|
Weekend duty
No
Yes
|
6 (13.3)
39 (86.7)
|
1 (1.1)
91 (98.9)
|
0.02
|
1.00
7.84 (0.59–104)
|
0.12
|
|
3.
|
Sole IR practitioner
No
Yes
|
34 (75.6)
11 (24.4)
|
62 (67.4)
30 (32.6)
|
0.33
|
1.00
0.95 (0.36–2.56)
|
0.92
|
|
4.
|
Support group at work
Present
Absent
|
38 (84.4)
7 (15.6)
|
56 (60.9)
36 (39.1)
|
0.005
|
1.00
2.28 (0.82–6.38)
|
0.12
|
|
5.
|
Tough time with administration
No
Yes
|
29 (64.4)
16 (35.6)
|
31 (33.7)
61 (66.3)
|
0.001
|
1.00
2.77 (1.12–6.48)
|
0.02
|
|
6.
|
Occupation related health problem
No
Yes
|
37 (82.2)
8 (17.8)
|
69 (75.0)
23 (25.0)
|
0.34
|
1.00
2.03 (0.68–6.07)
|
0.20
|
|
7.
|
Quality of time spent on family
Good
Poor
|
38 (84.4)
7 (15.6)
|
62 (67.4)
30 (32.6)
|
0.035
|
1.00
0.69 (0.17–2.74)
|
0.60
|
|
8.
|
Ability to find time to do things that you enjoy
Good
Poor
|
36 (80.0)
9 (20.0)
|
39 (42.4)
53 (57.6)
|
0.0002
|
1.00
4.79 (1.42–16.1)
|
0.01
|
Abbreviation: CI, confidence interval.
Discussion
The incidence and prevalence of depression and suicide among various healthcare professionals
are increasing at an alarming rate.[7] The most important reason is burnout resulting from poor balance between work, health,
and family.[8] Balancing professional and personal life of a healthcare professional is entirely
different and difficult as compared to most of the nonhealthcare professionals. IRs
are more commonly affected due to their complex working conditions including being
available on call after hours. This survey analyzes the predictors of OB, provides
a snapshot of personal life focusing on health and family of IR, and provides ideas
to master the act of balancing work, family, and health.
There is direct causal association between increased workload and OB.[9]
[10] Overload on a daily basis can lead to significant physical and mental strain, further
leading to poor balance between professional and personal life. The Yerkes-Dodson
law demonstrates a strong relationship between stress and performance. With increase
in stress, the performance improves until it reaches a point, after which with further
increase in stress, the performance drops steadily.[11] IR with night duties, duties during weekend, and being a sole practitioner in the
working area can prolong working hours per week. Bundy et al in his survey highlights
burnout is high among IRs working more than 80 hours per week.[5] In our survey, more than 90% of respondents having night and weekend duties indirectly
indicate long working hours. They felt that it was not possible in their profession
to avoid night and weekend call. However, they also felt that reducing weekly working
hours to offset night and weekend duties could be a solution. Another important aspect
of better work life is to have a good social interaction both within the interventional
suite and outside, with colleagues from other departments and administration.[12] Issues with administration can directly affect professional life. More than half
of our respondents were found to have difficulties with the administration. Recognition
of the problem, finding a solution, opportunity to explain, and implementing solutions
can reduce such difficulties. In developing countries such as India, the field of
IR is still in slow growing pace due to lack of knowledge among other clinicians about
the treatment options that can be availed using image guidance. Hence, the referrals
to IR are on the lower side and always an IR feels that they should be successful
in procedures being performed to avoid lack of faith in image guided procedures amongst
other healthcare professionals. Ultimately, stress and burnout are much higher amongst
IR even after many decades of IR being in frontline decision making.
A study by Mensah and Adjei found that there is a strong association between poor
work/life balance and health among European working adults.[13] Poor work–life balance can lead to poor health outcome like stress, depression,
and substance abuse.[14]
[15] The WHO recommends 150 to 300 minutes of moderate intensity physical aerobic activity
per week for a healthy lifestyle in the age group of 18 to 64 years. Approximately
62% of our participants were able to meet this criterion. Almost 14% did not spend
any time at all exercising. Lack of exercise can lead to obesity and poor physical
health.[16] BMI was high in 33% of our participants. Smoking was observed in only a small percentage
and alcohol intake was noted in 33%. Excessive smoking and alcoholism can lead to
OB or it can be a result of it. However, we did not evaluate abuse or addiction related
to tobacco, alcohol, or other substance as a result of work-related stress. One fourth
of our participants have occupation-related health problem and the majority was backache.
Presence of physical illness can affect mental peace and produce a negative impact
on work.[17] Thorough knowledge of radiation protection and strict adherence to good practice
and good ergonomic design in the workplace can help to prevent this occupation related
health hazards.
Time spent at workplace and with family is inversely proportional. Stress at either
sides can affect each other drastically.[18] In our survey, it is alarming to witness that approximately 40% had stress in family
life due to profession. This indicates a strong need to identify solutions like modification
in workflow and pattern, so that the quality time spent with family increases. Especially
in a country like India, where the concept of old age homes is lower, the responsibility
to take care of senior citizens adds further burden to the existing one. More than
half of the participants in our study have the responsibility to take care of senior
citizens at home. Increase in workload is one of the causes for care giver burnout.
Care giver burnout is characterized by physical and mental exhaustion and change in
attitude toward the person who needs attention or care.[19] This can be reduced by increasing time spent on family by reducing workload by setting
practical work environment, realistic goals to take care of senior citizens, forming
social support group, and seeking help from others.
Conclusion
In conclusion, we found that in a cross-sectional group of IR, 67% experienced significant
stress related to work, 25% had occupation-related health problem, and 44% experienced
poor family life due to work. The results implicate the urgent need for attention
toward balancing WFH. Having tough time with administration and inability to find
time to do things one enjoys were statistically significant risk factors for burnout
on multivariate analysis. Solutions at individual level must be planned to overcome
the above-mentioned factors for a healthy balance of work–life. Teamwork at workplace,
physical exercise, and regular health checkup for a healthy lifestyle should be prioritized.
Attempts for a quality family time should top the must to do list. This article quantifies
burnout and work–life balance among Indian IR; our results can act as a foundation
for any further studies.
