Pathologist workload, burnout, and wellness: connecting the dots

Abstract

No standard tool to measure pathologist workload currently exists. An accurate measure of workload is needed for determining the number of pathologists to be hired, distributing the workload fairly among pathologists, and assessing the overall cost of pathology consults. Initially, simple tools such as counting cases or slides were used to give an estimate of the workload. More recently, multiple workload models, including relative value units (RVUs), the Royal College of Pathologists (RCP) point system, Level 4 Equivalent (L4E), Work2Quality (W2Q), and the University of Washington, Seattle (UW) slide count method, have been developed. There is no “ideal” model that is universally accepted. The main differences among the models come from the weights assigned to different specimen types, differential calculations for organs, and the capture of additional tasks needed for safe and timely patient care. Academic centers tend to see more complex cases that require extensive sampling and additional testing, while community-based and private laboratories deal more with biopsies. Additionally, some systems do not account for teaching, participation in multidisciplinary rounds, quality assurance activities, and medical oversight. A successful workload model needs to be continually updated to reflect the current state of practice.

Awareness about physician burnout has gained attention in recent years and has been added to the World Health Organization’s International Classification of Diseases (World Health Organization, WHO) as an occupational phenomenon. However, the extent to which this affects pathologists is not well understood. According to the WHO, burnout syndrome is diagnosed by the presence of three components: emotional exhaustion, depersonalization from one’s work (cynicism related to one’s job), and a low sense of personal achievement or accomplishment. Three drivers of burnout are the demand for productivity, lack of recognition, and electronic health records. Prominent consequences of physician burnout are economic and personal costs to the public and to the providers.

Wellness is physical and mental well-being that allows individuals to manage stress effectively and to thrive in both their professional and personal lives. To achieve wellness, it is necessary to understand the root causes of burnout, including over-work and working under stressful conditions. Wellness is more than the absence of stress or burnout, and the responsibility of wellness should be shared by pathologists themselves, their healthcare organization, and governing bodies. Each pathologist needs to take their own path to achieve wellness.

Keywords:

• Wellness
• pathology
• pathology workload
• burnout
• well-being
• L4E
• RVU
• W2Q

Introduction

Awareness about physician burnout is gaining increasing attention. However, there is little understanding as to how this affects specialized groups of physicians like pathologists. The first step for overcoming burnout and achieving wellness is to navigate through the root causes of burnout, for example, over-working and working under stressful conditions [1]. Thus, clear workload assessment metrics are required. There are no standard, universally accepted metrics for assessing pathology workload.

Overall, in order to address burnout, this multi-dimensional issue requires a comprehensive view of pathologist workload, causes for stress and burnout, and an understanding of how to achieve wellness for pathologists. This holistic approach will connect the dots among the different components of wellness.

Our review is divided into three sections: workload, burnout, and wellness. However, there is some unavoidable overlap among these sections, and certain concepts need to be emphasized from one section to another to keep the discussion coherent.

Workload models in pathology: a work in progress

There is currently no standard tool to measure the workload of pathologists. Many pathologists are salaried, and workload is not tracked as it bears no weight on compensation [2]. There are, however, significant fluctuations in workload, both in quantity and in complexity, that may range from reading straight forward H&E slides to performing multiple complex procedures like immunostains and molecular testing [3].

Pathologist workload has significantly increased in recent years due to an increase in number of cases as a result of the aging population, together with increased specimens per patient encounter and an ever increasing arsenal of diagnostic procedures and practice standards [4]. Increased case complexity, including synoptic reporting (for example, College of American Pathologist cancer protocols), immunostains, and molecular testing, is another contributing factor. The amount of information contained in histopathological reports (margin status, tumor size, histological subtyping) has increased over the past decades [5–7]. Quality control procedures are mandated and have become more complex. Pathology ­specialization drives more organ system-specific consultations. Moreover, pathologists are participating as essential members in multidisciplinary conferences. Another growing workload dimension is the academic activities of teaching and research.

Unlike other specialties, there is no physical reflection of excessive workload, such as office or operating room hours, that is related to physical limitation, and there are no wait times related to pathologist workload, unlike other disciplines that are usually fee for service based.

The importance of workload assessment

Assessment of workload is essential for both publicly funded and private laboratories. Having an accurate measure of a pathologist’s workload may be helpful in determining the number of pathologists to be hired [8]. It is required for fair distribution of workload among pathologists and for planning future needs. Additionally, it is important in determining the cost of pathology consults [8]. Pathologists have no equivalent time-limiting factor for case sign-outs (no specific time period allocation for revision of slides/cases) as do other physicians.

Increased workload may go unnoticed as it tends to creep upward by 5% annually and the extra work is absorbed by the pathologist in their own personal time (unpublished observation). An unbalanced workload puts pathologists at risk of making mistakes. An overworked pathologist could perform a suboptimal diagnostic job. There is a clear association between workload and clinical error [9]. The implications of pathologist mistakes are significant, and lead to subsequent prognostic and treatment errors by treating physicians.

Estimating a pathologist’s workload is essential for supporting excellent patient care and overall laboratory medicine services planning [10]. In many jurisdictions, pathologists are excluded from parts of the Employment Standards Act. As a result, they could be legally required to work throughout the week without breaks and would not be entitled to overtime pay. Contracts usually stipulate working hours but not productivity. A study has demonstrated that the clinical work of a pathologist has increased considerably over the years [11].

Workload also varies between countries, which differ significantly in the percentage of pathologists to the population. One pathologist serves a population of 16,308 in New Zealand, 24,600 in Australia, 18,154 in the USA, and 27,991 in Canada [12]. However, these figures have to be interpreted with caution because the way in which the number of pathologists is counted in each country differs. For example, in the UK, only anatomic pathologists are counted; in the USA, the list includes anatomical pathologists, clinical pathologists, hematopathologists and neuropathologists; and in Australia and New Zealand, it likely includes only anatomical pathologists. Canada is a mix that varies with each province. This ratio is greater in developing countries that have a lower number of pathologists [12].

Workloads comes in different flavors with a different focus

Because there is no standard tool to measure the workload of pathologists, each organization/institution tends to use its own model for workload assessment. In earlier years, workload assessment was not perceived as important because pathologists had enough time to be able to add on cases, especially when the pathology report was short and simple. When workload issues surfaced, simple tools like counting cases gave a rough estimate of the workload. This crude measure is still used by some institutions but it is a poor representation of the actual value produced [13]. Another crude measure that has serious limitations is counting the number of slides. As more experience is gained in workload assessment, several workload systems have been developed [13,14].

Overview of commonly used workload assessment models

As summarized in Table 1., there are multiple models for assessing pathologist workload. These include the Relative Value Units (RVUs) developed by the Centers for Medicare & Medicaid Services in the USA, the Royal College of Pathologists (RCP) point system in the United Kingdom, the Level 4 Equivalent (L4E) by the Canadian Association of Pathologists, Work2Quality (W2Q) by Path2Quality, the University of Washington, Seattle (UW) slide count method, the Kim Unit (KU) activity method by the Northern General Hospital histopathology department, and the Automatable Activities-Based Approach to Complexity Unit Scoring (AABACUS). Other models include the Resource-Based Relative Value Scale (RBRVS) [15]. This scale is based on the principle that payments for physician services should vary with the resource costs for providing those services and is intended to improve and stabilize the payment system while providing physicians an avenue to continuously improve it.

Table 1. Brief description of common pathologist workload models.

Model	Developer	Brief Description
Level 4 Equivalent (L4E)	Canadian Association of Pathologists	Calculated weighted value Based on complexity levels One L4E unit is roughly equivalent to about 10 minutes of work
Relative Value Unit (RVU)	Medicare	Streamline billing Based on CPT codes
Royal College of Pathologists (RCP)	Royal College of Pathologists of the UK	Six-tiered system Each specimen is assigned a point value based on complexity RCP point values range from 1-12 Each point is worth 5 minutes
Work2Quality (W2Q)	Path2Quality	Guidelines designed to be used at the practice group level, and not to measure individual workload or performance Includes suggestions for appropriate oversight and infrastructure
University of Washington, Seattle (UW) slide count	The University of Washington, Seattle (UW)	A slide count system for determining workload 21.8 slides are equivalent to 1 hour of pathologist work
Kim Unit (KU) activity	Northern General Hospital	Specimen type is assigned a difficulty quotient/weighting on a scale of 1–5 units Based on: dissection time, number of sections/stains required, complexity of specific tests etc.
Automatable Activities-Based Approach to Complexity Unit Scoring (AABACUS)	Collaboration of multisite institutions (mainly in Toronto, Canada)	Captures pathologists’ clinical activities from parameters documented in laboratory information systems Activities are counted, and complexity units (Cus) are generated using a complexity factor for each activity

Level 4 Equivalent

The Level 4 Equivalent (L4E) pathologist workload model was developed by the Canadian Association of Pathologists in 2009 [16]. It has undergone multiple revisions and is considered by a past president of the College of American Pathologists as the “most comprehensive workload model in pathology” [17]. The L4E is a calculated weighted value based on the complexity level of individual pathology consultations (medical value, complexity, work involved, urgency, presence of pathology extenders). It may be applied to both academic and community practice settings. In its most recent iteration, published in 2018, one L4E unit is roughly equivalent to 10 min of work [18]. The mean recommended workload for a pathologist per year is 7,560 L4E equivalent units (7,115 − 8,089 units) [18]. If one assumes 210 working days in a year (based on 6 weeks of vacation, 2 weeks of continuing medical education and 10 statutory holidays), the daily mean pathologist workload is approximately 36 L4E (equivalent to about six hours) [18] inclusive of other essential duties.

The L4E (2018 version) has codes for different medical procedures that range from 0.125 to 10 L4E units, captured in 9 rules (for biopsies, autopsies, core biopsies, currettings, resections, synoptic reports and extra procedures ordered). All cytology procedures except fine needle aspirations (FNAs) have an L4E unit of 1. FNAs have an L4E of 2 units [18]. L4E also integrates quality assurance activities in its framework [17] as it is an essential portion of the work that should not be done only when time permits. The model is revised every three to five years [17].

The L4E system was validated by multiple independent statistical computations [13]. It also provides a direct measurement of consultations and uses data commonly collected in most clinical laboratories [13]. Updated versions of L4E account for multidisciplinary rounds, formal and informal teaching/training, and advanced diagnostics. It also has the flexibility to adjust for the presence and absence of pathologist assistants and cytotechnologists. Finally, it accounts for academic activities (including signing out with residents, lectures) in addition to administration and medical oversight (Department Chief, subsection heads, immunohistochemistry supervision, QA program). Medical oversight may be overlooked, and improper and inadequate oversight of laboratory processes such as immunohistochemistry and advanced diagnostics is a common cause of medical errors [9].

Relative Value Unit system

The Relative Value Unit (RVU) system is a popular method for determining pathologist workload in the United States [19]. Prior to 1989, physicians used to set the charges for their services. The RVU system was developed and endorsed by the Centers for Medicaid & Medicare Services to standardize physician payments. It is based on three components: physician work, practice expense, and professional liability insurance [19]. In 1999, the American Medical Association established codes for healthcare services and developed the current procedural terminology (CPT) system; an RVU was assigned for each CPT code [20]. The CPT codes for physician services include both a professional (pathologist) and technical (non-physician services) component. They were developed to streamline billing and administration, but they do not necessarily accurately reflect the complexity of specimen types [19]. One disadvantage of using the RVU system is that it cannot be used for pathology sub-specialties like autopsy and forensic practice [21].

Royal College of Pathologists

In the UK, the Royal College of Pathologists (RCP) established its own workload guideline. It was first published in 1999 and is now in its fourth edition. The goal of the RCP workload model is to ensure fair workload distribution among pathologists and to aid in pathologist workforce planning. A major advantage is that the Royal College model has been implemented nationally and thus, it may be used to compare institutions and health authorities.

The RCP workload system is a six-tiered system in which specimens are divided by subspecialty, and each specimen is assigned a value based on the complexity [22]. The point values range from 1-12 (where each point is worth roughly 5 min) [22]. It assumes that the pathologist is seeing a mixture of simple and complex cases and it defines a full pathologist workload as 36 points (3–4 h) per day averaged throughout the week.

The initial RCP system did not apply to pathology subspecialties such as neuropathology, pediatric, forensic and ophthalmic pathology, many of which are now recognized as standalone specialties. It takes into account that some specimens require special immunostains but does not allocate additional points for ancillary studies (except for electron microscopy). In addition, no points are allocated for second opinions, reviewing past slides of the same patient, obtaining clinical information, or looking up information in the literature.

The third edition of the RCP workload model addressed many of the shortcomings of previous editions by implementing a subspecialty-specific point system that reflected specimen complexity and provided a more accurate estimate of pathologist workload [23].

The RCP workload model is considered an advanced and well-developed system for evaluating pathologist workload [19]. However, its scoring system uses a number of specialty-specific matrices that are complex to apply and that may not be applied consistently across the different pathology specialties [24]. In addition, some departments have found the RCP system difficult to factor into benchmarking and pathologist workforce planning as a result of inconsistent scoring between pathologists [25].

Work2Quality

The Work2Quality (W2Q) guidelines are a Canadian workload measurement system that was developed in 2012 by the Path2Quality initiative in Ontario, Canada. They are based on a collaborative initiative of the Ontario Medical Association Section on Laboratory Medicine and the Ontario Association of Pathologists [26]. The focus of the W2Q guidelines is to identify the number of pathologists and infrastructure supports that are required to run a pathology practice and it is based on Ontario’s fee codes [27]. It is worth noting that the W2Q guidelines are designed to be used at a practice group level, and not to measure individual pathologist workload [27]. As such, the W2Q guidelines are informative when calculating the appropriate number of pathologists to provide adequate and timely pathology services for institutions of similar complexity, that is, academic to academic centers, but not between academic and community laboratories that evaluate mainly biopsies.

The W2Q model is acknowledged by a number of laboratories to be useful for human resource planning and lobbying for resources [26,27]. However, a major challenge is to ensure that different groups use the W2Q guidelines in a consistent and comparable manner. The guidelines also need to be kept up to date. They have a heavy bias toward small biopsies, and thus favor community-based laboratories that deal primarily with skin and GI biopsies, and it creates a disadvantage to tertiary centers that deal with complex oncologic procedures.

University of Washington, Seattle slide count

The University of Washington, Seattle (UW) slide count uses a slide count system for determining workload in which 21.8 slides are considered equivalent to 1 h of pathologist work [19]. Indirect patient care duties such as sitting on a multidisciplinary tumor board may also be assigned slide equivalents and be factored into total workload. The total slide counts may be measured and converted into hours using the UW conversion rate [19].

Kim method

The Kim Unit (KU, pronounced “Q”) was developed by the Northern General Hospital, UK, histopathology department to calculate departmental workloads. An individual specimen type is assigned a difficulty quotient on a scale of 1–5 units (KU), depending on the time needed for dissection and macroscopic description, number of sections/stains required, time for microscopic diagnosis, complexity of ancillary tests (for example, electron microscopy), and the time to dictate a report [28].

The Automatable Activity-Based Approach to Complexity Unit Scoring

The Automatable Activity-Based Approach to Complexity Unit Scoring (AABACUS) model was established by the University Health Network, Toronto, Canada, through collaboration with multisite institutions [29]. It accurately reflects the types of cases and the time and effort required to analyze each specimen [30].

AABACUS captures pathologists’ clinical activities from parameters documented in the laboratory information systems. The activities within the captured data are then counted, and complexity units (CUs) are generated using a complexity factor for each activity. The annual load of a pathologist was found to be roughly 40,000 CUs [29].

AABACUS has proved to be successful for monitoring clinical workload of anatomical pathology, hematopathology, and neuropathology in both academic and community settings [29]. It is also useful for clinical laboratory management [29]. The information it provides may be used to make decisions on the allocation of resources [31].

Comparison of workload assessment models

The fact that there are multiple workload-measuring systems available points out that there is no “ideal” model that may be universally accepted for all pathology practices. As summarized in Table 2, the main differences between the models come from the weights assigned to various specimen types (biopsy, cytology, resection) and the differential calculation according to tissue types (some favor certain subspecialties). Also, the ability to capture additional tasks like looking at multiple levels of the same tissue under the microscope, immunostain scoring, tumor measurements, and margin status assessment varies among models. For example, the RCP system provides a higher weight for more complex specimens, while RVUs favor specialties with small specimens and higher volume, and slide counts favors specialties with extensively sampled large specimens [19]. The W2Q workload model does not specify or incorporate annual leave, while the Canada Association of Pathologists (CAP, L4E) and Royal College of Pathologists (RCP) models incorporate 6 vacation weeks and 2 CME weeks into their workload recommendations). There have also been instances where there were specific undervalued or overvalued specimens. The L4E uniquely captures teaching, participation in multidisciplinary rounds, and quality assurance activities. A recent study has shown a high correlation (0.902) between the L4E and AABACUS but their correlations with RBRVS were 0.712 and 0.626, respectively [15].

Table 2. Advantages and limitations of the different pathology workload models.

Workload Model	Advantages	Limitation
Level 4 Equivalent (L4E)	Accounts for academic activities, administration, and medical oversight	Complex and a challenge to implement  Certain aspects, like clinician consult, case conferences not consistently well captured in reports Requires regular updates
Relative Value Unit (RVU)	Not dependent on a physician’s charge schedule, insurance coverage Easier for billing	Linked to CPT Vulnerable to shifts in economic and political status
Royal College of Pathologists (RCP)	Incorporates an expected annual leave	Does not apply to consults, neuro, pediatric, forensic, or ophthalmic pathology Scoring uses complex specialty-specific matrices Limited to retrospective audit Not for daily pathology workload assessment
Work2Quality (W2Q)	Useful for human resource planning and lobbying for resources	Bias toward small biopsies Tailor-made to the Ontario practice Not ideal for specialties with higher proportions of complex specimens Does not incorporate annual leave Influenced by government schedule of benefits fees

Models such as the RVU system that assign relative weights based on billing codes are vulnerable to shifts in economic and political situations as they are designed to measure not the actual work done, but rather what a payer is willing to pay at a specific time. This means that the work performed may increase or decrease as the price that is attached to the work fluctuates [29].

A recent study compared four commonly used workload models: L4E, W2Q, RCP and RVU [32]. L4E allocated higher scores for breast and cytology cases compared to biopsies and gastrointestinal cases. RCP scored higher in cytology, gynecology-pathology and dermatopathology than genitourinary and gastrointestinal cases. W2Q and RVU showed close correlation in most categories except lymphomas, renal biopsies, and frozen sections.

Another analysis showed that in Canada, the W2Q and government schedule of benefits fees are so closely related that they cannot be considered independent workload measures. (personal communication, unpublished). In addition, a study showed that the L4E and W2Q systems give dramatically different results in different environments; W2Q favors small specimens and disadvantages environments with large specimens [11]. Another analysis showed that W2Q heavily weights immunohistochemistry (and other ancillary tests) in relation to L4E. (our unpublished data).

In this context, it is worth noting that the RCP pathology workload model in the UK assigns no points for ancillary tests (because they are incorporated in case complexity). A workload model that weights ancillary tests heavily may create significant conflicts of interest/encourage use of ancillary tests that are not required. This may be oversimplified as the majority of pathologist work is auditable, and outlier pathologists may be quickly identified and trained to adapt their practices to those of their peers. Occasionally, however, the majority learn from the outlier.

By design, the L4E workload points depend on the tissue being assessed, not the number of containers. W2Q's valuations may lead to more cost without necessarily adding more value, and significantly underestimate the work involved in assessing large specimens. W2Q indirectly impedes robust comparisons between different practices settings. A recent publication showed that in academic practice, the W2Q significantly undervalued large, complex specimens by a factor of 2 [11]. W2Q may have a negative impact on specialty pathology practice, particularly neuropathology, pediatric pathology, and hematopathology, which, despite having smaller number of cases, require extensive work-up for each case. However, large academic centers also act as “final arbitrators” for difficult and complex cases and the L4E model takes this into account in assigning value for these cases.

Specialty - specific workload measures?

In their initial iterations, most workload models treated all pathology sub-specialties in the same way. As we move toward more specialized pathology practices, it is clear that this should not be the case. Different organ systems (breast, genitourinary, and female reproductive system) vary in their practice style. There is considerable variation between pathology organ systems in terms of RVUs, with median values differing as much as 4-7-fold between subspecialties [21]. These results suggest that the use of a single standard workload measure is not appropriate for specialty-based pathology and that workload models should be developed for each subspeciality [21]. The L4E model had been verified for renal pathology, and the Canadian Association of Pathologists workload committee is working to validate other subspecialty practices. The multiple updates with national input have made the weighting of work more equitable. It is based on the average because the effort to sign out a similar case may vary 5-10 times depending on the presence of a pathologist assistant, standard of practice, and unique practice pattern of the individual pathologist.

As well, some anatomical pathology fields, including neuropathology, hematopathology, and pediatric pathology. are recognized as specialties with their own resident training programs and certification examinations.

Forensic pathology workload is defined in North America by the number of cases per annum, with recommendations to perform not more than 250 autopsies per year [33]. This does not accommodate variability in case to case complexity and the evolving nature of forensic pathology with the introduction of new tools such as CT scanning and molecular studies. [34].

In the UK, the RCP has developed guidelines on staffing and workload for pediatric and perinatal pathology [35]. Recently, a workload model for placental pathology based on the Amsterdam guideline has been integrated into the latest CAP-ACP (L4E) [36] workload model, along with molecular testing, immunohistochemistry, and flow cytometry [37]. According to the RCP workload model, the majority of dermatopathology cases are classified as low or intermediate complexity [38]. Time-motion analysis shows that a dermatopathologist may achieve an hourly workload of greater than 35 RCP units, considerably in excess of the recommended 10 units per hour. Thus, the RCP and the L4E methods underestimate the workload achievable by an experienced dermatopathologist.

Finally, most of the tools developed to date are centered around pathology [10]. There are no measures for quantification of workload of other laboratory physicians in the disciplines of clinical chemistry, microbiology, and molecular pathology [10]. The L4E model has updated work/medical oversight/administration related to hematopathology and transfusion services, and has ongoing projects on autopsies (medico-legal, hospital, pediatrics and CT assisted autopsies).

Challenges to workload assessment models

One must recognize the limitations of each workload model and be careful about its intended application. Data interpretation beyond the primary intended indication of each model may be misleading and may result in more harm than good. The RCP workload model states that it is intended to “facilitate equitable distribution of work among pathologists within a department” [22]. There is a similar guide for equitable work distribution in the L4E model based on the experience in Edmonton, Canada. A statement regarding this indicated that “[The model] was not intended to provide a tool whereby pathologists may limit the amount of work they do on a daily basis”.

Also, activities such as administration, quality assurance, teaching, research, and professional development that are indirectly related to patient care may occupy up to 40-50% of a pathologist’s time [10]. If these aspects are not properly captured in a pathologist workload model, then the calculated value will be seriously undervalued. There is also the added complexity that stems from the recent move toward direct communications between the pathologist and the patient [39]. As well, new disruptive innovations in pathology may have a significant impact on workload [40].

Moving forward - thoughts on what the future holds

There is no “ideal” workload assessment method that we endorse. Each institution may choose the most suitable model based on local circumstances [8], for example, a system centered on streamlining billing, workload equity, assigning workloads, or calculating the number of pathologists needed in a hospital [8]. On the other hand, the use of multiple models is not useful for comparing among institutions or geographical regions [8].

While a universal workload model may not be practical for pathology sub-specialties, system customization of each model to fit a specific subspeciality may seriously hinder the ability to compare workloads between subspecialties and thus prevent external validation.

Pathologist workload is dynamic and continually changing [11]. The system used needs to be continually updated to ensure that the parameters being measured are assessed accurately. The use of artificial intelligence may provide innovative solutions to current limitations of workload measures.

Pathologist burnout: a deep dive into causes and consequences

Burnout among physicians, including pathologists, has recently gained widespread attention and is a cause for concern for both the public and medical professionals. For many years, this issue was under the radar, one reason being that hospital administration underestimated the negative impact of burnout. It has been viewed by the public as the complaining of an elite class. Even in the medical community, burnout has been stigmatized as a sign of weakness.

In recent years, there has been an increased awareness of the matter and its negative impact on healthcare. Research on burnout has been published [41], and there have been reports on news media outlets and social media. This raises the question: is this a trendy subject and are pathologists becoming less resilient? The short answer is no [42].

In this section, we define burnout and discuss methods for assessing it. We then explore groups that are affected, and the causes and consequences of burnout. Finally, we review adaptation mechanisms to burnout and differentiate between the healthy and unhealthy ones.

What is burnout?

According to the WHO, burnout syndrome is characterized by the presence of three components: emotional exhaustion, depersonalization from one’s work (cynicism), and a low sense of personal achievement/accomplishment [43]. The WHO relates burnout to an occupational context; yet it is evident that burnout may result in personal consequences [44]. The American Society for Clinical Pathology adds feelings of being overwhelmed and not caring about work to the definition [45]. Burnout may also be considered as a result of long-term workplace stresses that have not been managed appropriately [46]. These manifestations and their causes are discussed in detail below.

Developed countries such as Canada appear to have the highest rate of burnout as shown by a recent Canadian Medical Association survey on physician wellness [47] and analysis of recent data from the Canadian Medical Protective Association and human resources available in Canada [48]. Another Canadian study showed a burnout prevalence of 58% with significant differences by gender and years of practice [29]. Another study showed a similar burnout rate of 58% across all respondents in the field of laboratory medicine. As well, disparities in burnout rate by race have been observed [1]. It is important to mention that underlying factors, including heavy workload and the loss of meaning in work, ranked highly among all groups [1]. The main conclusions are: pathologists have the poorest mental health and high rates of burnout among physicians [49], the medico-legal cases related to pathology diagnosis are increasing [50], and while hospitals create environments that are conducive to adverse events, pathologists bear the full medico-legal risk of the additional work imposed on them [51].

Assessment of burnout

Burnout is commonly measured using the Maslach Burnout Inventory (MBI) [44], which has three sections: burnout or emotional exhaustion, depersonalization, and personal achievement [52,53]. Each section has 7-8 questions, with a score of 0 – 6 for each answer. For the emotional exhaustion section, a score of ≤17 is low burnout, 18-29 is moderate, and ≥ 30 represents high burnout [54]. For the depersonalization section, a score of ≤ 5 is low burnout, 6-11 is moderate, and ≥12 is high burnout [54]. Personal achievement follows an inverse scale; a score of ≤ 33 is high burnout, 34 -39 is moderate, and ≥40 is low burnout [54].

A profile of burnout is typically shown by having a score within the burnout range for all three sections [55]. Because each section measures a unique dimension of burnout, the three dimensions should not be combined to form a single burnout scale. Also, the MBI score ranges are not universal and may vary by country [56, 57].

Other published instruments include “quality-of-life assessment”, “work-life balance rating”, “appraisal of career satisfaction”, and “the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire 2 question screen” [58–61].

Burnout in the laboratory medicine community

The prevalence of burnout in the pathology community is not consistent. Some reports show that pathologists are ranked in the top 3-6 medical professions in job satisfaction [41,62]. However, job satisfaction and burnout are distinct parameters. Another study indicates that pathologists are some of the least happy outside of work [63]. Two studies have shown that the levels of burnout in pathologists are comparable to that of nurses, 33.7% or 34% [64,65], whereas the number of pathology fellows experiencing burnout is higher than both at 44% [65]. A Medscape survey performed in 2016 showed that pathology ranked 19 out of 25 physician subspecialties on the rate of burnout (45% compared to 40-55% for all specialties) [66]. It seems from recent aggregate studies that the “job satisfaction”, “happiness” and “lack of burnout” are not interchangeable terms.

However, pathologists working in larger hospitals have been shown to be more satisfied with their jobs and to suffer less burnout [67]. This may be the result of the availability of more resources like internal consultation or better infrastructure of the hospital. Notably, pathologists in smaller institutions in the same study reported less conflict with their colleagues.

A recent study showed that other medical laboratory professionals experience more burnout than pathologists, with 85% reporting burnout compared to 71% of pathologists over the same period [41]. Medical laboratory technologists (MLTs) often go unrecognized in practice, but they are vital to the functioning of laboratories [68]. Therefore, it is concerning that burnout is prevalent among MLTs, with an estimated prevalence of 73% in one study, a prevalence that was higher than other healthcare workers during the pandemic [69].

Recent evidence suggests that burnout begins to accumulate during residency training [70]. Two reports showed that over half of the surveyed pathology residents reported struggling with academics, feeling overwhelmed by the amount of information they need to know and feeling that they would never learn enough [65,70]. A survey also found that fellows had more burnout than residents, with a rate that was nearly 10% higher (44% vs. 33.7%) [71].

A recent study attempted to sub-stratify burnout according to practice demographics (including age, number of years in practice, and pathology subspecialty), but it did not find a clear association between any of these factors and the prevalence of burnout. [1] Women have reported to feeling more stressed than men [41].

Burnout is not specific to North American and European cultures, where most studies have been conducted, but is rather a global crisis [69]. A study from Turkey found results similar to American studies; over half of the pathologists were satisfied with their institutions and jobs, yet almost half of them also reported experiencing burnout [67]. This was not related to their level of seniority or type of practice. A study in Switzerland found that almost 90% of pathologists had visual refraction errors, mostly myopia, in addition to musculoskeletal problems [72].

The adoption of digital pathology may have positive and negative impacts; advantages of digitization include flexibility in working hours and location, but drawbacks may include difficulty of adapting to using computer screens and the overlap of work and home environments [73].

Causes of burnout

As shown in Figure 1, the causes of burnout are multifaceted and involve a variety of personal and workplace-related factors that interact in a complex manner [42,74]. Personality traits may also influence an individual’s susceptibility to burnout [66]; for example, oncology nurses with anxiety or depression are more likely to experience depersonalization and emotional exhaustion [66].

Figure 1. Burnout has three main causes, each with their own manifestations within an individual, and their subsequent consequences. The three large contributors to burnout are workload or demand for productivity, under-recognition, and complexity of work tasks. These causes then lead to the manifestations of burnout, which range from increased stress to depersonalization from one’s work. The consequences of these causes and manifestations can be divided into two categories: patient/economic cost, and the personal cost to the pathologist. Finally, the causes, manifestations, and consequences lead eventually to either healthy or unhealthy reactions, depending on the coping mechanisms used and whether viable solutions are available to address the causes of burnout. This is further discussed within the wellness section.

The nature of the job could make people more vulnerable to burnout. Pathologists often work in isolation for long periods of time, interacting only with their microscope and the laboratory information system. This may be exacerbated by the adoption of digital pathology and the option of working from home [63]. However, it should be noted that pathology is also a group practice with continual communication and intra-departmental consultation among pathologists. Some leading causes of burnout amongst MLTs are the lack of sufficient staff and pressure to process a large volume of tests, which may lead them to feel insecure and doubtful of their abilities [75]. Stressors may also be subspeciality related; one of the most stressful duties for forensic pathologists is the autopsy examination of children [53].

Causes for burnout may be organized into three overlapping categories: emotional exhaustion resulting from high demand for productivity, lack of recognition leading to a sense of unfulfilled accomplishment, and administrative complexity resulting in depersonalization. Emotional exhaustion reflects depletion of emotional resources and a lack of ability to attend to one’s psychological needs [52]. Depersonalization relates to increased mental detachment from one’s job, or negative feelings related to one’s job [52]. Reduced personal accomplishment results in workers thinking negatively of themselves and feeling unfulfilled or disappointed with their achievements at work.

Demand for productivity and emotional exhaustion

Emotional exhaustion may be defined as the feeling of “being drained” or “lacking enthusiasm” [52]. It is also the feeling that the pathologist has difficulty getting ready to go to work and is not looking forward to it. The combination of an increase in demand for productivity and lack of appropriate staffing, along with inefficiencies in administration and in the support staff is a significant cause of emotional exhaustion [43, 62,71]. A survey by the American Society for Clinical Pathology found that over 94% of pathologists reported experiencing varying levels of stress, with 47% reporting significant stress [45]. Workload was identified as the primary cause of stress [45]. Close to 60% of those experiencing a lot of stress (about 28% of the total) reported understaffing and listed added responsibilities to be contributing factors [45]. As discussed above, there is currently no universally agreed on workload model that fairly captures pathologist activities. Intricacy of reporting, including additional immunostains, molecular results, and detailed and synoptic reporting all translate to significant increases in workload. In addition, the pathologist may struggle with the need for more ancillary testing versus cost containment dictated by the hospital administration.

In publicly-funded healthcare systems, decisions are often made without considering the impact on the well-being of pathologists [71]. These include lack of compensation for extra hours and increase in workload with no reward [71] and being ignored or not consulted when hiring new physicians (for example. new gastroenterologists with new skills may result in increased workload). As a result, some pathologists struggle to maintain a healthy work-life balance; a study showed that the score for adequate work-life balance dropped by close to 8% between 2011–2014 [76].

A study has shown that workplaces that are committed to providing well-being resources for their employees are associated with less burnout [77]. However, it is difficult to determine a causal relationship between these factors, as institutions that prioritize well-being may also be mindful of employee workload.

Pathology sub-specialization may contribute to burnout positively or negatively. While focusing on specific subspecialties allows for better and faster reports, handling cases outside the area of sub-specialization (for instance, a soft tissue tumor in the genitourinary system) may be stressful. Specialization results in an increased number of consultations. Also, sub-specialization may lead to limited interaction with a fewer number of pathologists and greater isolation.

Under-recognition and feelings of lack of accomplishment

Lack of recognition contributes to feelings of unfulfilled accomplishment and personal achievement, which are key manifestations of burnout [67]. Under-recognition is the feeling of clinical ineffectiveness and that one’s work is not useful to others and has no meaning. At the community level, the changing social support structure, characterized by busy lifestyles and increased use of social media, may also contribute to a lack of recognition [73,78].

Despite 98% of pathologists agreeing that their job is critical for successful patient management, 80% feel that they are largely ignored by both patients and physician colleagues [67]. Some pathologists feel that other physicians do not understand the challenges and limitations of their practice [67].

The constant need to learn about new disease entities and ancillary testing may also contribute to a sense of lack of accomplishment [70]. This is especially true for residents and fellows who are under immense pressure to maintain their research endeavors, stay current with the literature, and participate in clinical services [70].

Junior pathologists are more prone to a lower sense of personal achievement due to the need to establish themselves in a new environment [44]. They may also be more anxious about making mistakes, which may lead to less recognition by senior colleagues [65]. Careful mentoring is essential in integrating new residents to become competent and capable pathologists. Pathology subspecialties such as forensic pathology involve patient interaction and have their own set of challenges; a study found that almost one-third of forensic pathologists experienced verbal abuse from patient communications [53]. Thus, the trend toward pathologists becoming more involved in explaining pathology results to patients may be a double-edged sword: it may enhance self-satisfaction and recognition but it may also lead to negative encounters with patients [39].

Conflict with colleagues may also be overlooked. A recent study found that about one-third of pathologists experience conflicts with colleagues [67]. Other clinicians may not fully understand that pathology is fundamentally a clinical consult rather than a straightforward diagnostic decision. Among pathologists, conflict with colleagues may be caused by disagreement on the diagnoses, level of sub-specializations, and years of practice. Disparities exist in diagnostic precision between general pathologists and tissue specialized pathologists. Pathologists with greater professional experience demonstrate enhanced diagnostic proficiency owing to their extended tenure in the field. Because of the highly hierarchical nature of pathology departments and lack of control over the work environment and workload, there is a higher probability of bullying in pathology.

Depersonalization due to complex administrative burden

Depersonalization is characterized by a feeling that people and things around one seem “lifeless” or “foggy”. It may be expressed as cynicism or distrust and a sense that things are not working out well [43]. The increased complexity of administrative tasks may lead to depersonalization. Over the past several decades, the burden of documentation for pathologists has increased substantially. Extensive documentation for medicolegal purposes, poorly designed electronic health records (EHR), and added layers of bureaucracy for reporting and communications all contributed to burnout.

A frequently cited stressor is EHR documentation, which is a major addition to the responsibilities of pathologists [76,79]. EHRs were implemented in the USA as part of the American Reinvestment and Recovery plan in 2009 [80]. Although EHRs were intended to enhance performance and decrease errors, they have incidentally led to an increase in hours spent meeting digital reporting requirements for a billing audit [76]. EHRs are now common practice in most institutions, but 84% of physicians using them report frustration with the time spent completing these clerical tasks [81]. There is also a positive correlation between the amount of time physicians spend using EHRs and job stress [82]. In pathology, standardized EHRs include synoptic reporting for cancer, documenting quality assurance results, and reporting verbal communications.

Medical students and staff at the University of California reported copying 80% of daily progress notes to meet legal parameters [76]. Standardizing record keeping has led to a shift in the field toward a focus on “rewards, punishment, and pay for performance” [80]. The consequence of this is a widespread occurrence of burnout [83]. The increase in the digitization of health records has also caused physicians to shift their focus from reaching the most accurate diagnosis to meeting clerical responsibilities [76].

Consequences of burnout

As shown in Figure 1., there are two main categories of consequences of burnout [44,63,71,72]. The first is the effects on patients, institutions, and the economy [71], and the second is the effects on the individual [71].

Reduced quality of care and productivity (patient/economic cost)

A consequence of burnout is the potential for decreased quality of patient care [71]. Pathologists experiencing burnout are less focused, are slow, and may provide suboptimal diagnoses [71]. Burnout also has an economic impact in that it may lead to decreased productivity and an increase in absenteeism and/or presenteeism (attending work while sick) [44,71]. Studies show that individuals experiencing burnout are 30-40% more likely to reduce their work hours within the next 1-2 years [45,80]; 61% of physicians reported that they would retire immediately if they had the means to do so [71]. It is even more alarming that mid-career physicians, who are considered the most productive group, have the highest rate of burnout [71]. The cost of losing a qualified pathologist is difficult to quantify, but one can measure the financial benefits of investing in employee well-being [84]. For every dollar spent on employee wellness programs, analysis showed that costs associated with medical leave were reduced by $3.27 [71]. Recruitment cost is substantial and should be considered when institutions receive requests for “health promotion and wellness” programs.

Personal costs

A second serious impact of burnout is the personal cost to the affected individual. These include alcohol or substance abuse, relationship conflicts, and increased risk of suicide [63,71]. Personal consequences may include career regret and suboptimal professional development [44]. This is compounded by poor mentor­ing of new graduates.

In addition to psychological costs, physical side effects are not uncommon [72]. In a Swiss study, 40% of pathologists reported musculoskeletal problems in the previous month [63]. Moreover, 90% of surveyed pathologists had an increase in visual refraction errors [72] that were likely due to ergonomic issues and lack of workplace optimization [63].

A recent publication from the American Association of Clinical Chemistry emphasized that burnout is real and that if it is left unchecked, it may lead to further problems, triggering a snowball effect [68].

Adaptation mechanisms to burnout and burnout prevention

Pathologists use various mechanisms to cope with burnout [70]. Some are healthy ways of preventing or alleviating burnout, while others may represent unhealthy escape mechanisms.

Negative adaptation mechanisms include denial, self-blame, and substance abuse [85], while healthy coping mechanisms include involvement in hobbies like listening to music, fishing, walking, watching TV, and cooking [53]. They also include taking a day off work for relaxation, and exercising [70]. Research shows that residents who meet physical activity guidelines are much less likely to experience burnout [70]. Additional adaptation mechanisms may be inferred from the causes of burnout mentioned earlier. As shown in Box 1, factors that may help to prevent or reduce burnout may be a calmer practice environment, adequate administrative assistance, better and more user-friendly EHRs, and fair compensation [70,71,77].

Box 1 Suggested strategies to address the negative impacts of burnout

• Adequate communication between staff and administration

• Encourage exercise and physical activity

• Create friendlier, calmer, more cooperative work environments

• More efficient, user friendly EHR systems

• Compensation for extra working hours

• Better support resources for staff

• Mental health support

Factors that may improve physician wellness are distinct from those that may precipitate burnout, and it is essential to consider both dimensions when working to prevent burnout and achieve wellness. Burnout prevention is not a one-size-fits-all solution. Plans must be customized to each career phase, age, sex, and pathology subspecialty in addition to practice setting [71].

What is next?

In summary, data suggest that burnout is a significant issue among pathologists. While there is a wealth of literature on burnout and its causes, more research is needed to validate the outcome of these studies, and more multi-institutional and longitudinal follow-up studies are needed to establish causality. Future research should also focus on identifying the most significant factors contributing to burnout, examine the extent of burnout on the quality of pathology reporting, and examine the effectiveness of interventions.

The roadmap to pathologist wellness

The concept of physician wellness was initially acknowledged in 2001 in the USA when the Joint Commission on Accreditation of Healthcare Organization incorporated the identification and management of physician health issues in their standards [44]. However, this did not mean that resources to achieve wellness would be provided. The pressure to improve performance, the constantly evolving professional standards of practice, and government regulations that are insufficiently in line with professional values [86] all contribute to the unhealthy imbalance between job demand and resources, and personal and professional life [44].

What is wellness/well-being?

Wellness comprises more than just physical health, which includes diet, exercise, and weight management [87]. Wellness may be described as a baseline state of physical and mental well-being that allows individuals to handle stress successfully and to thrive in both their professional and personal life [56,71,86]. Wellness is an active process, a choice, and a lifestyle [88]. It is a personalized approach that enables people to develop into their best self [87]. Despite having significant overlap, it is important to remember that preventing burnout and achieving well-being are independent goals that must be worked on simultaneously [86].

Stoewen [87] listed a number of dimensions of wellness, including physical, intellectual, social, emotional, spiritual and occupational wellness. The physical dimension encompasses taking care of one’s body. The intellectual dimension includes being open to new challenges and wanting to learn new things to evolve intellectually. The social dimension is the ability to maintain healthy professional personal and relationships. The emotional dimension consists of acknowledging and appreciating self and others’ values and feelings. The spiritual dimension examines one’s personal values and beliefs. Lastly, the occupational dimension combines using one’s unique skills to participate in work that is personally fulfilling and meaningful [87,88].

However, not all factors need to be equally balanced. One should strive for personal harmony that feels genuine on an individual level because each person differs in their priorities, goals, and perspective on what it means to truly live [87].

Why should we discuss pathologist wellness?

For some, wellness is seen as a luxury. In reality, it is a “responsibility”. Wellness is a core requirement for good patient care and productivity. A study has shown that physicians who work shifts longer than 24 h are more prone to attention failures and commit more medical errors than those who work shifts of less than 16 h [56]. Pathologists are no exception, with overwhelming numbers of cases, pressure on turnaround time, and case complexity threatening to cause suboptimal performance [71]. An Australian study showed that pathologists who worked less than 40 h per week produced work of noticeably higher quality.

Wellness is both a professional and a personal obligation. Organizations should actively pursue plans to promote pathologist well-being and individual pathologists should take active steps to promote their own wellness [71,87]. In institutions that have a cultural commitment in encouraging wellness, pathologists are less likely to experience burnout [41].

Wellness in the pathology community

According to a recent poll conducted by the American Society for Clinical Pathology [89], most pathologists experience high levels of job satisfaction and consider their well-being to be fair to good. About two-thirds of pathologists felt appreciated by their institution and approximately the same percentage felt excited about being a pathologist. The poll also showed positive responses for feeling energetic, respected, and valued at work [89]. However, it also highlighted that most respondents (around 50%) felt a little to a lot of stress, and that stress was due mainly to the workload or call duties, followed by problems with colleagues.

Another study that compared job satisfaction found that, among specialists in the middle stage of their career, pathologists were among those who ranked the lowest in job satisfaction [90]. A different poll showed that pathologists had a more pessimistic outlook on their profession than other physicians [91]. Another survey showed serious compromise of wellness among pathology residents and fellows [65].

Determinants of pathologist wellness

Understanding the determinants that influence pathologist wellness may help in the development of interventions for addressing burnout and promoting wellness [92]. These indicators are classified by some studies as physical, personal, and work environmental determinants [92], or as intrinsic and extrinsic factors [71].

Physical determinants

Although physicians advise patients on healthy dietary habits, research shows that many ignore their own nutrition [92]. Physicians struggle to stay adequately hydrated at work. Interestingly, a 2% decrease in total body water affects cognitive abilities, including attention and memory [93]. Unhealthy work-related habits like working lengthy hours and prolonged sitting may affect health.

Trockel et al. [94] showed that sleep deprivation led to poor performance and significant medical errors. Sleep deprivation may be caused by excessive workload or the stress of potential medical/legal responsibilities and inadequate consultation support. Pathologists who are sleep deprived have a higher rate of clinically significant errors [95].

Physical activity, on the other hand, enhances wellness [92]. It lowers the risk of developing anxiety and depression [96]. Incorporating physical activity in one’s self-care may benefit physicians who are experiencing mental illness [92]. This is important for pathologists, whose worklife is sedentary in nature, as it requires sitting in front of a microscope for long hours.

Personal determinants

These include gender, marital status, religion/spirituality, and personality traits [92]. When it comes to juggling work and home obligations, female pathologists encounter greater difficulty than male pathologists, which increases work-family conflict and stress [56]. This could also be an issue with the adoption of digital pathology, which allows pathologists to work from home [40, 97, 98] but which could lead to a conflict between work and personal hours [99].

Other key concepts that may help pathologists to achieve wellness include healthy relationships (professional and personal), religious beliefs/spiritual practice, and self-care practices [86,100]. Proactively pursuing personal interests and self-awareness may enhance well-being. Certain personality traits such as workaholism, perfectionism, and type A personality are linked with poor health outcomes like depression, anxiety, eating disorders, burnout, and cardiovascular disease [101].

Possessing a positive work attitude provides a purpose for one’s work and the motivation to continue working. Creating a life philosophy that emphasizes a positive outlook, recognizing and living one’s values, and developing a balance between one’s professional and personal life is important for one’s well-being [86]. Some important factors that influence pathologist wellness are summarized in Box 2.

Box 2 Important determinants that can influence pathologist wellness

• Personal relationships

• Collegial work environment

• Work home life balance

• Religious beliefs/spiritual practice

• Healthy dietary habits

• Physical activity

• An institution that prioritizes patient outcome and physician satisfaction over productivity

• Awareness

• Self-care practices (e.g. physical activities, spa, socializing)

Work environment determinants

A prerequisite for well-being is a safe and secure working environment. Studies have shown that hospital/public sector workers are four times more likely than private sector workers to be assaulted at work, and 75% of all reported violent workplace incidents take place in a healthcare setting [92]. Physician satisfaction was higher in organizations that prioritized patient outcomes and care quality than it was in those that prioritized productivity [92].

Wellness may improve when institutions implement wellness resources and when one seeks these resources. Saint Martin et al. conducted a study examining the effects of implementing a wellness program for pathology trainees; residents reported that, after implementation, their knowledge of factors that contribute to burnout increased by 54%, and there was a 45% improvement in belief that their opinions were considered when decisions were made [102].

Pathology is a group practice and, as such, the corporate environment may have a significant impact on performance. An employee-centered practice leads to businesses having content employees. On the contrary, working nonstop without breaks in small under-ventilated rooms with inadequate light may be exhausting [92].

Well-being is closely associated with characteristics that create an economically sound and successful healthcare organization as manifested by limited physician turnover, high patient satisfaction, and evidence of quality treatment [86]. Career contentment appears to be closely linked to physician well-being [71].

Intrinsic factors

Factors that foster wellness include appreciation by patients (pathologists often do not see patients), mentorship and peer support, opportunities for personal and professional development, and engagement in scientific discovery. These factors provide work motivation, quality, fulfillment, and support at every career stage [86].

Interventions: the roadmap to wellness

The basis of wellness is finding purpose in work, building meaningful relationships, developing growth opportunities, and maintaining a manageable workload.

There is no universal one-size-fits-all wellness strategy. Below, we provide guiding principles that should be tailored to the particular practice context based on characteristics such as age, years of professional experience and country of practice [71].

Figure 2 shows three pillars to achieve wellness. The first is awareness, which is to recognize that a problem exists, to assess its severity, and to understand the detrimental effects of burnout on productivity in the workplace and on individuals [92,99]. The second is education, which includes researching and gaining information about the magnitude of the problem and potential solutions. The final pillar is action, which focuses on improving workplace and personal conditions [99].

Figure 2. Roadmap to wellness. Wellness is a multistep, shared responsibility. In addition to avoiding burnout, an active approach to wellness starts with awareness, where individuals become informed of the topic through different forms of communication. Following this, education plays a Central role through multiple forms of engagement. Lastly, organizational and individual interventions are important to better wellbeing. At the organization level, institutions should offer supportive resources, mentoring, and guidance in building resilience. At the individual level, individuals should avoid several things and be encouraged to do other things.

While a growing number of studies focus on improving the well-being of physicians, much of the research is centered on identifying the problems. In this discussion, interventions to promote wellness are categorized into individual-focused and organizational interventions [92]. Some suggested interventions to achieve wellness are found in Box 3.

Box 3 Suggested interventions at the individual and organization levels that can promote wellness

Table

Individual-Focused Interventions
Build connection with colleagues and people Exercise regularly Pursue interests Ensure work-life balance Focus on positive experiences Seek volunteer opportunities in the community
Organizational Interventions
Build connection with colleagues and people Exercise regularly Pursue interests Ensure work-life balance Focus on positive experiences Seek volunteer opportunities in the community

Individual-focused interventions

Enhancing physician fulfillment requires a personalized approach [99]. A study found that the quality of work-life balance was positively correlated with the frequency of activities [89]. Wellness activities that align with one’s personal values, like spending time with family, exercising, pursuing interests, community volunteering, and not bringing work home, enhance well-being. Interestingly, pathologists who engaged in their interests less than once or twice a week reported that their workload was the barrier that prevented them from engaging in activities [89].

In the emerging era of digital pathology, working from home may be a double-edged sword. Pathologists may enjoy flexible working hours, cross coverage, and saving time on transportation. However, attention is needed to dedicate a specific area at home and hours for work so that one does not mix work life with personal life.

According to a Harvard Business Review report [103], people tend to focus on negative experiences in a typical workday as this may feel therapeutic. However, it is positive experiences that reduce stress. Researchers asked participants to write about something that had gone “really well” that day and found that this simple practice reduced stress levels and mental and physical complaints. This change arose from positive emotions and feelings of contentment [103].

Another article [104] highlighted that negative emotions and distress are contagious. People may be affected by exposure to negative comments or financial or other bad news. Creating a positive mindset, keeping one’s mind occupied with spe­cific tasks, and developing a sense of appreciation of life may help to counter the negative impact of secondhand stress [104].

Organizational interventions

As an initial step, acknowledgement of the problem and trust must exist between pathologists and their institutions. This may be built through naming the problem and showing a willingness to listen [92,105].

Several approaches exist to enhance wellness within an organization. Promotion of autonomy is one. Adequate office resources and support staff remove some workload from pathologists. Cultivating a collaborative work environment establishes an atmosphere that encourages positive interactions among colleagues [86]. A healthy work environment may also allow a flexible schedule, fair compensation, and reasonable work hours. Additional tools in the pathology environment include transparency in workload distribution, improvement in intra-departmental consultations, accurate assessment of workload, sufficient numbers of pathologists, and pursuit of innovative approaches like digital pathology.

Additionally, wellness should be identified in the organization’s mission statement [106]. The mission statements of most healthcare institutions focus on patients and quality of care, and tend to overlook employee wellness. An organization’s success in fulfilling its mission is largely determined by its culture and values [105].

Selecting a leader who is trained on engagement and leadership is key to creating a culture of wellness. Leadership performance should be evaluated periodically by colleagues. A successful leader understands the motivations and unique skills of physicians [105]. A study conducted by Shanafelt et al. revealed that the leadership style of medical supervisors had a significant impact on the well-being of the physicians they supervised [107]. A leader should be involved in the work as well as administration, so he/she will have a balanced approach to the needs and current standard of practice of the working pathologist and the resources that are needed.

Another important consideration is to avoid linking salary directly to productivity. When a pathologist’s salary is based on productivity, they may work longer hours or be compelled to spend less time on each case to complete more cases. This productivity principle may compromise their quality of care and raise their risk of burnout [105]. Some institutions, for example, the University of Alberta, suggest that pathologists should voluntarily take on extra workload only for a few months, to limit the risk of burnout (verbal communication, unpublished).

Furthermore, institutions may offer resources that promote wellness and mental or emotional well-being; these include resources for addressing and managing burnout, depression, substance abuse, recreational or recharge activities; mentorship programs or resources for mentoring; peer support; and resources on time management [89]. In academic institutions like university hospitals, extra support may be needed for academic duties, including teaching, research, and organizational leadership [101].

Organizations could also incorporate wellness training, including a wellness curriculum, sessions with resilience coaches, mindfulness practices, networking and volunteer opportunities. Fitness center discounts to encourage exercise and alleviate stress could be offered. Institutions should also consider the dimensions of quality when creating these wellness programs to ensure the program’s success [56]. The incorporation of wellness programs creates a positive work and learning environment [108], and they may have a significant positive impact on trainees as well, as detailed above [102]. Those who spend at least 20% of their time working on a task that they find most fulfilling have been found to have significantly lower risk of burnout [109].

A follow-up examination of a well-being survey revealed that those who reported their institution did not offer any resources had a higher percentage of burnout than those who reported they had access to at least one resource to promote well-being [89].

An example of such an initiative is the “Beyond Silence” developed by McMaster University in Canada. To improve early intervention and mental health support for frontline healthcare personnel, this project will launch a mobile health app. The project strives to reflect the diversity of healthcare workers, including those in laboratory medicine [109].

A recent publication by Shanafelt et al. [105] highlighted organizational strategies to reduce burnout and promote well-being. These start with the need to recognize and evaluate the problem. Once the problem is identified, physician well-being may be measured using the institution’s performance metrics. These metrics differ among organizations but are associated with things that the organization believes are important to their mission. Another important step is to have leaders trained in leadership skills and to align values and culture with the mission. As well, the impact of organizational planning on a pathologist’s sense of professional fulfillment is often overlooked.

Publicly available resources

A wealth of online wellness resources are freely available for pathologists. Some of these are provided in Table 3.

Table 3. Useful publicly available wellness resources.

Organization	Organization’s wellness link
American Association for Physician Leadership	www.physicianleaders.org/resources/wellness
American College of Physicians	www.acponline.org/practice-resources/physician-well-being-and-professional-fulfillment/individual-physician-wellness-and-burnout-tools
American Medical Association	www.ama-assn.org/practice-management/physician-health
British Medical Association	www.bma.org.uk/advice-and-support/your-wellbeing
British Red Cross	www.redcross.org.uk/get-help/get-help-with-loneliness/wellbeing-support
Canadian Medical Association: Physician Wellness Hub	www.cma.ca/physician-wellness-hub
Canadian Medical Protective Association	www.cmpa-acpm.ca/en/advice-publications/physician-wellness
College of Physicians and Surgeons Ontario	www.cpso.on.ca/en/Physicians/Your-Practice/Physician-Advisory-Services/Physician-Wellness
National Academy of Medicine	https://nap.nationalacademies.org/catalog/26744/national-plan-for-health-workforce-well-being
National Health Service: Health in Mind	www.health-in-mind.org.uk/wellbeing_resources/d139/
Ontario Medical Association of Canada: Physician Health Program	https://php.oma.org/about-php/
Royal College of Physicians and Surgeons of Canada	https://www.royalcollege.ca/ca/en/canmeds/physician-wellness.html
University of Toronto	www.temertymedicine.utoronto.ca/wellness-resources-faculty
Wellness books	E.g. Physician Wellness: The Rock Star Doctor’s Guide. By Rebekah Bernard and Steven Cohen

Conclusion

Promoting pathologist wellness improves the person as a whole. The relationship between pathology and wellness may be thought of through this analogy: a pathologist, trainee, or laboratory technologist without wellness may look at a half-filled cup of water as half-empty. If a pathologist looks at the same cup as a half-full glass of water, an intervention would be a means to fill the glass of water. This intervention would ultimately assist the pathologist in reaching their full potential in their professional and personal life [110].

Each pathologist will take a unique path to achieve wellness. The responsibility of pathologist wellness is shared among the pathologist themselves, their healthcare organization, and their governing bodies [92]. The best chance of success to improve professional wellness is for personal and institutional approaches to be combined and tailored to each individual [71]. It is evident from our discussion that there exists a clear interrelationship among pathologist workload, burnout, and overall well-being. These factors are intricately connected, and it is essential that we connect the dots to develop a comprehensive solution.

Abbreviations
AABACUS	=	Automatable Activities-Based Approach to Complexity Unit Scoring
CPT	=	current procedural terminology
KU	=	Kim Unit
L4E	=	level 4 equivalent
MBI	=	Maslach Burnout Inventory
MLT	=	medical laboratory technologist
RCP	=	Royal College of Pathologists
RVU	=	Relative Value Unit
UW	=	University of Washington, Seattle
WHO	=	World Health Organization
W2Q	=	Work2Quality

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.