Dear Sir,

I have read with great interest the paper: Well-being and Burnout Amongst Interventional Radiologists in the United Kingdom by Ahmad Al Rekabi et al. [1]. Also, the commentary by Uberoi et al. supports the conclusion of the survey and comes with some practical solutions to solve the problem of high prevalence of burnout among interventional radiologists in the UK [2]. Their recommendation is that urgent measures are required to tackle the workforce shortage, next to recognition of IR workload and control IR resources. It is most likely that the UK results will also be applicable to IRs in Europe. There is no doubt that there is a high prevalence of burnout among interventional radiologists, and although I also think that the solutions as proposed by Uberoi et al. are important, I do not think that only increasing workforce will solve the problem of burnout among interventional radiologists. This problem goes deeper than just workload and has to do with a more existential problems related to the position of IR within the medical community. Burnout symptoms have a great similarity with fatigue and stress but often have a different origin than simply too much work. Moreover, a recent survey showed that during the Covid-19 pandemic, a low workload period, cases of employee burnout increased, while 67% respondents said that during the pandemic burnout worsened [3]. Burnout results from chronic physical and emotional exhaustion and stress. Research on burnout has identified six key domains which all play an important role: workload, control, reward, community, fairness and values [4,5,6].

Work overload contributes to burnout by depleting the capacity of people to meet the demands of the job, as was seen in the UK survey about burnout. However, burnout is also linked to lack of control. This is when employees have the feeling that they have little capacity to influence decisions that affect their work, to have no professional autonomy and no access to the recourses that are needed for their work. The domain lack of reward for the work performed also makes people vulnerable to burnout. It devalues both the work and the workers and is closely associated with feelings of inefficacy and less job satisfaction. The domain of community has to do with the ongoing relationships that employees have with other people on the job. When these relationships are characterized by a lack of support and trust, and by unresolved conflicts, then there is a greater risk of burnout. The domain fairness is the extent to which decisions at work are perceived as being fair and equitable. Cynicism, anger and hostility are likely to arise when people feel they are not being treated with respect. Finally, the domain of values picks up the cognitive-emotional expectations and goals of the job. When there is a value conflict on the job, and thus a gap between individual and organizational values, employees will find themselves making a trade-off between work they want to do and work they have to do, and this can lead to greater burnout.

If we project these recognized domains for burnout onto the job of interventional radiologists, we come to a frightening conclusion. Work overload has clearly been identified by the UK survey. Lack of control is what interventional radiologists experience every day as other medical specialities, like vascular surgery, often decide and control the ultimate treatment plan and the role of the IR within this treatment plan. Lack of reward is often seen by referring consultants, the hospital management, the diagnostic radiologists and sometimes also by the patients, who do not recognize the IR as their primary caretaker. Lack of community is present when IR is seen as a misconception by the mother specialty (radiology), which is often experienced throughout Europe. Also, a lack of fairness is often experienced as interventional radiologists have a heavy burden of night and weekend shifts compared to their diagnostic colleagues. The struggle holding up the expectation and goals of a job as IR, forcing interventional radiologists to make unsatisfying decisions, is also daily practice.

These six domains that contribute to burnout, leaving out the workload, all have a direct relation with the current position of interventional radiology not being recognized as a fully independent specialty. As long as interventional radiology is not an independent specialty with all the rights and privileges other specialties have, the problem of burnout will most likely not be solved by only increasing the workforce and resources as being proposed as a solution to the problem. The problem is much more complex.