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JACC Cardiovasc Interv. Author manuscript; available in PMC 2023 Dec 11.
Published in final edited form as:
JACC Cardiovasc Interv. 2023 Jun 12; 16(11): 1401–1407.
PMCID: PMC10712288
NIHMSID: NIHMS1925517
PMID: 37316149
Bahadir Simsek, MD,a Athanasios Rempakos, MD,a Spyridon Kostantinis, MD,a Judit Karacsonyi, MD, PhD,a Bavana V. Rangan, BDS, MPH,a Olga C. Mastrodemos, BA,a Ajay J. Kirtane, MD, SM,b Anna E. Bortnick, MD, MS,c Hani Jneid, MD,d Lorenzo Azzalini, MD, PhD, MSc,e Anastasios Milkas, MD,f Khaldoon Alaswad, MD,g Mark Linzer, MD,h Mohaned Egred, MD,i,j Salman S. Allana, MD,a Sunil V. Rao, MD,k Yader Sandoval, MD,a and Emmanouil S. Brilakis, MD, PhDa
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The publisher's final edited version of this article is available at JACC Cardiovasc Interv
Associated Data
- Supplementary Materials
Optimizing physician psychological health and reducing burnout is increasingly becoming a priority1,2 as professional fulfillment and satisfaction from one’s work are associated with well-being and could impact patient care.3,4 Clinician burnout is rising,5 and the American College of Cardiology, American Heart Association, European Society of Cardiology, and the World Heart Federation consider clinician well-being a priority.3 Interventional cardiology (IC) practice often includes long hours and a stressful working environment. We conducted an international, online survey of IC attendings and fellows to assess their psychological well-being.
METHODS
The survey questions were prepared by the coauthors: 78 questions in the English language were included in the survey (Supplemental Appendix). The survey was administered via the Research Electronic Data Capture (REDCap), and was distributed to the IC attendings and fellows in January 2023 via social media and email lists.
The questions used in this survey were shown to perform similarly to the Maslach Burnout Inventory,6–8 a valid and reliable survey to measure burnout in medical professionals.
On a scale of 0 to 10, 0 represented the lowest grade and 10 represented the highest grade. Categorical variables were presented as absolute numbers and percentages, and compared using the chi-square or Fisher exact test, as appropriate. Continuous variables were presented as median (IQR) and compared using the Mann-Whitney U test.
Statistical analyses were performed using Stata V17.0 (StataCorp). The study was approved by the Allina Health institutional review board.
RESULTS
The survey was completed by 1,159 IC attendings and 192 IC fellows, representing 12% of US interventional cardiologists and 19% of US IC fellows. Most IC attendings were from the US (50%), followed by the European Union (16%) (Figure 1). Most IC attendings were from academic institutions (37%), 91% were men, median age was 41 to 45 years, and mean clinical work hours were 63 ± 14 hours per week.
FIGURE 1
Geographical Distribution of Participants
Most IC attendings (86%) had a partner with whom they lived. Most IC attendings (84%) felt lonely overall and almost one-half (41%) considered leaving their job during the past year, and nearly one-third (32%) are now considering to leave. Compared with the prior year, 12% had increased enthusiasm and 44% had decreased enthusiasm toward work. One-third (33%) of IC attendings felt overwhelmed ≥3×/week, and 20% doubted the significance of their work ≥3×/week. Almost one-half (40%) thought they achieved less than they think they should ≥3×/week.
Most IC attendings (78%) felt they are “working too hard”, were emotionally exhausted (64%), and frustrated by work (58%). Almost one-third (30%) considered themselves physically unhealthy. One-quarter (28%) were unhappy with their life (Figure 2).
FIGURE 2
Impact of Burnout on IC Physicians
IC = interventional cardiology.
Unhappiness was lowest (21%) in >60-year-olds, and highest (33%) in 51- to 60-year-olds, followed by 31- to 40-year-olds (31%). Single IC attendings were more unhappy compared with those living with a partner (54% vs 25%; P =0.001). Unhappiness was similar between men and women (27% vs 30%; P = 0.604) and was numerically lower in Asia (26%) and highest in North America (30%) (P = 0.465). Most participants (69%) stated that burnout impacted their life, without a difference between men and women (68% vs 73%; P = 0.370). Those on call ≥3×/week were more likely to be burned out than those on call <3×/week (74% vs 66%; P = 0.010).
Two-thirds (67%) of IC attendings reported having somebody they could share their mental health concerns with, and only 37% reported having access to mental health support if needed through their hospital/practice. Most IC attendings (76%) were not under professional mental health care and were not looking for professional help.
Most IC fellows were from the US (42%), followed by the European Union (22%), and from academic institutions (67%), 88% were men, the median age was 31 to 35 years, and the mean clinical work hours were 67 ± 14 per week.
Most IC fellows (67%) lived with a partner. One-half (48%) felt lonely overall, 29% considered leaving their job in the past year, and 15% are now considering leaving. Compared with the prior year, 27% had increased enthusiasm, and 32% had decreased enthusiasm toward work. More than one-quarter (29%) of IC fellows felt overwhelmed ≥3×/week, and 26% doubted the significance of their work ≥3×/week. Almost one-half (45%) thought they achieved less than they think they should ≥3×/week.
COMPONENTS OF BURNOUT.
Contributors to IC attending burnout were mainly working too hard 7.5 (5.3–8.5), being worn out 7.2 (5.2–8.2), and too stressed 7.0 (5.0–8.0) (Figures 3 and and44).
FIGURE 3
Burnout in IC Physicians
(A) Components of burnout, (B) contributors to burnout, (C) coping with burnout, and (D) solutions for burnout stratified by interventional cardiology (IC) attendings and IC feLLows.
FIGURE 4
International Psychological Well-Being Survey of ICs in 2023
Components of burnout, contributors to burnout, coping with burnout, and solutions for burnout are ranked. IC = interventional cardiologist.
The U.S. attendings had worse burnout metrics compared with non-U.S. attendings (Table 1).
TABLE 1
Burnout in U.S. vs Non-U.S. Participants
| U.S. Participants (n = 618) | Non-U.S. Participants (n = 628) | P Value | |
|---|---|---|---|
| Components of burnout | |||
| Working too hard | 7.5 (5.8–8.6) | 7.5 (5.3–8.5) | 0.644 |
| Worn out | 7.4 (5.9–8.3) | 7.1 (5.0–8.1) | 0.116 |
| Stress | 7.0 (5.6–8.0) | 7.0 (4.5–7.9) | 0.081 |
| Impact of burnout | 6.9 (4.0–8.0) | 6.3 (3.7–7.5) | 0.009 |
| Emotional exhaustion | 6.7 (3.3–7.9) | 6.1 (3.2–7.5) | 0.008 |
| Frustrated by work | 6.9 (3.5–8.2) | 5.0 (2.2–7.2) | <0.001 |
| Contributors to burnout | |||
| Too much paperwork | 8.0 (6.8–9.2) | 6.7 (4.0–8.0) | <0.001 |
| Lack of administrative support | 7.5 (5.1–9.0) | 7.0 (4.8–8.2) | <0.001 |
| Too many bureaucratic tasks | 7.5 (5.9–9.0) | 6.9 (3.8–8.0) | <0.001 |
| Insufficient income | 6.6 (3.0–8.1) | 7.6 (4.0–9.0) | <0.001 |
| Lack of respect by employers | 7.0 (2.8–9.0) | 5.7 (2.4–8.0) | <0.001 |
| Trouble in equipment acquisition | 5.3 (2.3–7.3) | 6.4 (3.3–7.8) | <0.001 |
| Increased computerization | 6.0 (2.5–7.9) | 5.0 (2.2–7.3) | <0.001 |
| Government regulations | 5.0 (2.0–7.3) | 5.2 (2.3–7.5) | 0.230 |
| Lack of autonomy | 4.5 (2.0–7.5) | 5.1 (2.0–7.3) | 0.879 |
| Stress related to COVID-19 | 2.6 (1.0–5.7) | 2.9 (1.0–6.8) | 0.250 |
| Coping with burnout | |||
| Talking with family/friends | 6.9 (3.5–8.2) | 6.6 (3.0–7.7) | 0.018 |
| Watching movies/series | 6.8 (2.7–8.0) | 5.9 (2.1–7.8) | 0.028 |
| Listening/playing music | 6.2 (2.2–7.6) | 5.3 (2.1–7.7) | 0.895 |
| Sleeping | 5.0 (2.1 −7.1) | 5.0 (2.3–7.4) | 0.374 |
| Self-isolation | 4.8 (0.9–7.4) | 4.9 (1.2–7.1) | 0.958 |
| Exercising | 6.0 (2.0–7.9) | 3.8 (1.6–7.1) | <0.001 |
| Eating junk food | 5.1 (1.1–7.2) | 3.5 (1.0–7.1) | 0.291 |
| Binge-eating | 3.1 (0.8–7.0) | 3.7 (1.0–6.9) | 0.499 |
| Meditating | 0.9 (0.0–0.0) | 0.7 (0.0–3.0) | 0.531 |
| Drinking alcohol | 1.0 (0.0–5.0) | 0.6 (0.1–2.9) | 0.133 |
| What the hospitals/practices can do to improve burnout | |||
| Getting rid of rules/regulations that do not contribute to patient care | 8.3 (6.9–9.9) | 8.0 (6.3–9.6) | 0.043 |
| Better administrative support | 8.0 (6.8–9.7) | 8.0 (6.9–9.3) | 0.215 |
| Growth opportunities | 7.3 (5.0–8.6) | 8.4 (7.3–9.7) | <0.001 |
| Less paperwork | 8.3 (6.9−9.8) | 7.4 (4.9–9.2) | <0.001 |
| More respect | 7.7 (6.0–9.5) | 7.8 (6.7–9.4) | 0.367 |
| Increased compensation | 7.1 (5.0–8.8) | 7.6 (6.5–8.9) | 0.004 |
| Better hospital food | 6.8 (2.0–8.4) | 7.6 (5.0–9.1) | <0.001 |
| Better hospital infrastructure | 7.4 (5.0–9.0) | 7.6 (6.0–9.5) | 0.019 |
| More time off | 7.6 (6.S-9.5) | 7.3 (5.2–8.3) | <0.001 |
| Better access to equipment | 6.5 (2.7–8.0) | 7.5 (5.2–8.7) | <0.001 |
| Better on-call rooms | 2.0 (0.0–7.2) | 7.5 (3.5–9.4) | <0.001 |
| Access to mental health professionals | 2.6 (0.7–6.3) | 5.0 (1.6–7.5) | <0.001 |
Open in a separate window
Values are median (IQR). Components of burnout, contributors to burnout, coping with burnout, and requests to improve burnout are on a scale of 1 to 10.
IC = interventional cardiologist.
Burnout metrics of IC attendings and IC fellows are outlined in Figure 3A.
CONTRIBUTORS TO BURNOUT.
Contributors to burnout included excessive documentation requirements 7.5 (5.9–8.8), lack of administrative support 7.2 (5.0–8.8), too many bureaucratic tasks 7.2 (5.0–8.6), and insufficient income 7.0 (3.3–8.7) (Figure 4).
U.S. IC attendings reported a higher contribution of too much paperwork, lack of administrative support, too many bureaucratic tasks, and lack of respect from administration to their burnout than non-U.S. IC attendings (Table 1). Non-U.S. IC attendings reported a higher contribution of insufficient income and equipment acquisition to their burnout compared with U.S. IC attendings (Table 1).
IC attendings rated the contribution of excessive paperwork requirements, bureaucratic tasks, challenges in equipment acquisition, and excessive government regulations to burnout higher compared with IC fellows (Figure 3B). IC fellows rated insufficient income as the most significant contributor to burnout (Figure 3B).
COPING WITH BURNOUT.
The leading coping mechanisms were talking with family/friends 6.8 (3.1–8.0), watching movies 6.4 (2.5–7.9), and listening/playing music 6.0 (2.1–7.7) (Figure 4).
U.S. IC attendings more often used talking with friends and family, watching movies, and exercising to cope with burnout compared with non-U.S. IC attendings (Table 1).
IC attendings were more likely to use exercise as a coping skill, and IC fellows were more likely to watch movies/series, sleep, and eat junk food to cope with burnout (Figure 3C).
WHAT THE HOSPITALS/PRACTICES CAN DO TO IMPROVE BURNOUT.
IC attendings asked for removal of rules/regulations that do not contribute to patient care (eg, reforming prior authorization) 8.1 (6.7–9.8), better administrative support 8.0 (6.8–9.6), and professional growth opportunities 7.9 (6.1–9.4) to improve their well-being (Figure 4).
Whereas U.S. IC attendings more often asked for more time off and less paperwork to improve their well-being, non-U.S. IC attendings more often requested growth opportunities, increased compensation, availability of better food in the hospital, better hospital infrastructure, streamlined access to equipment, better on-call rooms, and access to mental health professionals to improve their well-being (Table 1).
IC fellows were more likely to request professional growth opportunities, availability of better food in the hospital, and better on-call rooms compared with IC attendings (Figure 3D).
DISCUSSION
Our study provides a contemporary snapshot of the psychological well-being of IC physicians in 2023. The main findings of our study are: 1) 28% of interventional cardiologists are not happy with their life, and 69% are affected by burnout; 2) being single, aged 36–40 or 51–60 years, and on call ≥3×/week were associated with worse psychological health; 3) the leading contributor to burnout was excessive paperwork (79%); 4) the leading coping activity was talking with family/friends (66%); 5) the main proposed solutions were better administrative support (86%) and getting rid of rules/regulations that do not contribute to patient care (84%)9–11; and 6) contributors to burnout and solutions differed for U.S. vs non-U.S. participants and attendings vs fellows.
According to the Medscape Cardiologist Lifestyle, Happiness & Burnout Report 2022, 29% of cardiologists were either somewhat unhappy or very unhappy outside work (vs 28% in our study).12 The COVID-19 pandemic adversely impacted well-being, and unhappiness was almost twice as prevalent in 2022 compared with the pre-COVID-19 era (18% vs 35%).12 Decreased income, increased workload, social isolation, and inflation during the pandemic might have contributed to increasing burnout.12 Although the stress related to COVID-19 is currently low (Table 1), burnout seems to continue to rise. In our study, burnout was overall higher but similar between men and women (68% vs 73%; P = 0.370). The overall higher burnout in our study might be related to IC practice, and the similar burnout between men and women could be due to limited representation of women in IC.
The American College of Cardiology surveyed 5,931 cardiologists and found that younger (aged <55 years), women, and single or divorced cardiologists were more likely to have mental health conditions.13 Similarly, we found that unhappiness in IC physicians was lowest (21%) in those >60 years old, and those living together with a partner were less likely to be unhappy compared with those who are single (25% vs 54%; P < 0.001). We did not find a difference between unhappiness in men vs women (27% vs 30%; P = 0.604),14 respectively, or between various regions (eg, North America vs Asia).
The leading request of the participants was to remove rules/regulations that do not contribute to patient care and better administrative support. Automating the inclusion of specific information, such as vital signs or keywords required for reimbursem*nt to notes, and incorporating machine learning tools to draft the notes might help reduce paperwork burden. In addition to contributing to physician burnout, extensive paperwork required to convince insurance companies might discourage prescription of indicated drugs and further worsen patient outcomes.
U.S. participants had worse burnout metrics compared with non-U.S. Excessive paperwork requirements, lack of administrative support, bureaucracy, lack of respect by employers, and increased computerization were the main drivers of this difference. The only 2 metrics rated higher by non-U.S. (mainly European Union and Turkey) participants were insufficient income and difficulties with equipment acquisition. These differences might be explained by differences in health care systems and expenditures between the U.S. vs non-U.S. Whereas in the U.S., practices often involve private insurers and private hospitals with higher cost, outside the U.S., nationalized health care systems represent the largest health care providers/employers.
Contributors to burnout were different between IC attendings and fellows. Our results indicate that burnout may have different contributors in different roles (attending vs fellow) and countries, and solutions may differ. Therefore, institutions may benefit from performing internal polls to assess what interventions could benefit their employees the most.15
In our study, most participants (69%) were affected by burnout, but were either not seeking mental health support or not willing to share whether they are under treatment (14%). One of the reasons why physicians might be avoiding mental health care could be related to the stigma associated with mental disorders and fear of professional consequences.16,17 State medical boards may refine their questions on mental health in licensure applications in ways that could address these concerns.18 In a recent survey of IC fellows, 16% reported not having enough psychological support.19 One-third of those fellows requested improved access to affordable mental health.19 In our study, only 37% reported having access to a mental health professional through their employer if needed. Employers may provide their employees with mental health professionals in anonymized ways that could incentivize the use of such resources without fear of repercussion.
STUDY LIMITATIONS.
First, participating IC attendings and IC fellows might be more interested in mental health, which might result in selection bias. Second, distribution by email lists and social media (#Med on Twitter and Linkedln) might also introduce selection bias towards younger participants and academic interventionalists. Third, questions on past mood/feeling are subject to recall bias (tendency to over/underestimate positive or negative past experiences). Fourth, whereas burnout is often dichotomized, there is no accepted standard definition. Fifth, differences in cultural practices, expectations, and language barriers might affect the understanding of burnout in different parts of the world.
CONCLUSIONS
Our survey provides an assessment of the current mental well-being of IC physicians and identifies opportunities for improvement. We show that burnout impacts most IC physicians and provide insights into the components of burnout, contributors to burnout, coping skills, and what improvements are requested by the IC community to improve their well-being. System-level interventions could improve IC well-being.
Supplementary Material
Appendix
Click here to view.(494K, pdf)
ACKNOWLEDGMENTS
The authors thank the philanthropic support of the generous anonymous donors, and the philanthropic support of Drs Mary Ann and Donald A Sens; Mrs Diane and Dr Cline Hickok; Mrs Wilma and Mr Dale Johnson; Mrs Charlotte and Mr Jerry Golinvaux Family Fund; the Roehl Family Foundation; the Joseph Durda Foundation, for their gifts to the Minneapolis Heart Institute Foundation’s Science Center for Coronary Artery Disease.
FUNDING SUPPORT AND AUTHOR DISCLOSURES
The Minneapolis Heart Institute Foundation’s Science Center for Coronary Artery Disease (CCAD) helped support this research project. The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Footnotes
APPENDIX For a sample of the survey, please see the online version of this paper.
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