Workload, Burnout

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Pathologist workload, burnout, and

wellness: connecting the dots
Ziyad Khatab
,
Kattreen Hanna
,
Andrew Rofaeil
,
Catherine Wang
,
Raymond Maung
&
George M. Yousef
Pages 254-274 | Received 25 Jun 2023, Accepted 15 Nov 2023, Published online: 18 Dec 2023
• Cite this article
• https://doi.org/10.1080/10408363.2023.2285284
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
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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
[Citation1]. 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
[Citation2]. 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 [Citation3].
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
[Citation4]. 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 [Citation5–7].
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 [Citation8]. 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 [Citation8]. 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 [Citation9]. 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 [Citation10]. 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 [Citation11].
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 [Citation12].
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 [Citation12].
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 [Citation13]. 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 [Citation13,Citation14].
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) [Citation15]. 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.

Download CSVDisplay Table
Level 4 Equivalent
The Level 4 Equivalent (L4E) pathologist workload model was developed by the Canadian
Association of Pathologists in 2009 [Citation16]. 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” [Citation17]. 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 [Citation18]. The mean
recommended workload for a pathologist per year is 7,560 L4E equivalent units
(7,115 − 8,089 units) [Citation18]. 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)
[Citation18] 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
[Citation18]. L4E also integrates quality assurance activities in its framework [Citation17] 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 [Citation17].
The L4E system was validated by multiple independent statistical computations [Citation13].
It also provides a direct measurement of consultations and uses data commonly collected in
most clinical laboratories [Citation13]. 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
[Citation9].
Relative Value Unit system
The Relative Value Unit (RVU) system is a popular method for determining pathologist
workload in the United States [Citation19]. 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 [Citation19]. 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
[Citation20]. 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 [Citation19]. One disadvantage of using the RVU system is that it cannot be used for
pathology sub-specialties like autopsy and forensic practice [Citation21].
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 [Citation22].
The point values range from 1-12 (where each point is worth roughly 5 min) [Citation22]. 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
[Citation23].
The RCP workload model is considered an advanced and well-developed system for
evaluating pathologist workload [Citation19]. 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 [Citation24]. 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 [Citation25].
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 [Citation26]. 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 [Citation27]. 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 [Citation27]. 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 [Citation26,Citation27]. 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 [Citation19]. 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
[Citation19].
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 [Citation28].
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 [Citation29]. It accurately reflects the types of cases and the time
and effort required to analyze each specimen [Citation30].
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 [Citation29].
AABACUS has proved to be successful for monitoring clinical workload of anatomical

pathology, hematopathology, and neuropathology in both academic and community settings
[Citation29]. It is also useful for clinical laboratory management [Citation29]. The
information it provides may be used to make decisions on the allocation of resources
[Citation31].
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 [Citation19]. 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
[Citation15].
Table 2. Advantages and limitations of the different pathology workload

models.
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 [Citation29].
A recent study compared four commonly used workload models: L4E, W2Q, RCP and RVU
[Citation32]. 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 [Citation11]. 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 [Citation11]. 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 [Citation21]. 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 [Citation21]. 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 [Citation33]. 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. [Citation34].
In the UK, the RCP has developed guidelines on staffing and workload for pediatric and
perinatal pathology [Citation35]. Recently, a workload model for placental pathology based
on the Amsterdam guideline has been integrated into the latest CAP-ACP (L4E) [Citation36]
workload model, along with molecular testing, immunohistochemistry, and flow cytometry
[Citation37]. According to the RCP workload model, the majority of dermatopathology cases
are classified as low or intermediate complexity [Citation38]. 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 [Citation10].
There are no measures for quantification of workload of other laboratory physicians in the
disciplines of clinical chemistry, microbiology, and molecular pathology [Citation10]. 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”
[Citation22]. 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 [Citation10]. 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 [Citation39]. As well, new disruptive innovations in pathology
may have a significant impact on workload [Citation40].
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 [Citation8], for example, a
system centered on streamlining billing, workload equity, assigning workloads, or calculating
the number of pathologists needed in a hospital [Citation8]. On the other hand, the use of
multiple models is not useful for comparing among institutions or geographical regions
[Citation8].
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 [Citation11]. 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 [Citation41], 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 [Citation42].
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 [Citation43]. The WHO relates burnout to an
occupational context; yet it is evident that burnout may result in personal consequences
[Citation44]. The American Society for Clinical Pathology adds feelings of being
overwhelmed and not caring about work to the definition [Citation45]. Burnout may also be
considered as a result of long-term workplace stresses that have not been managed
appropriately [Citation46]. 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 [Citation47] and analysis
of recent data from the Canadian Medical Protective Association and human resources
available in Canada [Citation48]. Another Canadian study showed a burnout prevalence of
58% with significant differences by gender and years of practice [Citation29]. 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 [Citation1]. It is
important to mention that underlying factors, including heavy workload and the loss of
meaning in work, ranked highly among all groups [Citation1]. The main conclusions are:
pathologists have the poorest mental health and high rates of burnout among physicians
[Citation49], the medico-legal cases related to pathology diagnosis are increasing
[Citation50], 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
[Citation51].
Assessment of burnout
Burnout is commonly measured using the Maslach Burnout Inventory (MBI) [Citation44],
which has three sections: burnout or emotional exhaustion, depersonalization, and personal
achievement [Citation52,Citation53]. 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 [Citation54]. For the depersonalization section, a
score of ≤ 5 is low burnout, 6-11 is moderate, and ≥12 is high burnout [Citation54]. Personal
achievement follows an inverse scale; a score of ≤ 33 is high burnout, 34 -39 is moderate, and
≥40 is low burnout [Citation54].
A profile of burnout is typically shown by having a score within the burnout range for all
three sections [Citation55]. 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 [Citation56, Citation57].
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” [Citation58–61].
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
[Citation41,Citation62]. However, job satisfaction and burnout are distinct parameters.
Another study indicates that pathologists are some of the least happy outside of work
[Citation63]. Two studies have shown that the levels of burnout in pathologists are
comparable to that of nurses, 33.7% or 34% [Citation64,Citation65], whereas the number of
pathology fellows experiencing burnout is higher than both at 44% [Citation65]. 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)
[Citation66]. 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 [Citation67]. 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 [Citation41]. Medical laboratory technologists (MLTs) often go unrecognized in
practice, but they are vital to the functioning of laboratories [Citation68]. 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
[Citation69].
Recent evidence suggests that burnout begins to accumulate during residency training
[Citation70]. 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 [Citation65,Citation70]. A survey also
found that fellows had more burnout than residents, with a rate that was nearly 10% higher
(44% vs. 33.7%) [Citation71].
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. [Citation1]
Women have reported to feeling more stressed than men [Citation41].
Burnout is not specific to North American and European cultures, where most studies have
been conducted, but is rather a global crisis [Citation69]. 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 [Citation67]. 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 [Citation72].
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 [Citation73].
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
[Citation42,Citation74]. Personality traits may also influence an individual’s susceptibility to
burnout [Citation66]; for example, oncology nurses with anxiety or depression are more
likely to experience depersonalization and emotional exhaustion [Citation66].
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.
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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 [Citation63]. 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 [Citation75]. Stressors may also be subspeciality related; one of the
most stressful duties for forensic pathologists is the autopsy examination of children
[Citation53].
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 [Citation52]. Depersonalization relates to increased mental
detachment from one’s job, or negative feelings related to one’s job [Citation52]. 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” [Citation52]. 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
[Citation43, Citation62,Citation71]. 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 [Citation45]. Workload was identified as the primary cause of
stress [Citation45]. 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
[Citation45]. 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 [Citation71]. These include lack of compensation for
extra hours and increase in workload with no reward [Citation71] 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 [Citation76].
A study has shown that workplaces that are committed to providing well-being resources for
their employees are associated with less burnout [Citation77]. 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 [Citation67]. 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
[Citation73,Citation78].
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
[Citation67]. Some pathologists feel that other physicians do not understand the challenges
and limitations of their practice [Citation67].
The constant need to learn about new disease entities and ancillary testing may also
contribute to a sense of lack of accomplishment [Citation70]. 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 [Citation70].
Junior pathologists are more prone to a lower sense of personal achievement due to the need
to establish themselves in a new environment [Citation44]. They may also be more anxious
about making mistakes, which may lead to less recognition by senior colleagues [Citation65].
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 [Citation53]. 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 [Citation39].
Conflict with colleagues may also be overlooked. A recent study found that about one-third
of pathologists experience conflicts with colleagues [Citation67]. 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 [Citation43]. 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 [Citation76,Citation79]. EHRs were implemented in the USA
as part of the American Reinvestment and Recovery plan in 2009 [Citation80]. 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
[Citation76]. EHRs are now common practice in most institutions, but 84% of physicians
using them report frustration with the time spent completing these clerical tasks [Citation81].
There is also a positive correlation between the amount of time physicians spend using EHRs
and job stress [Citation82]. 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 [Citation76]. Standardizing record keeping has led to
a shift in the field toward a focus on “rewards, punishment, and pay for performance”
[Citation80]. The consequence of this is a widespread occurrence of burnout [Citation83].
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
[Citation76].
Consequences of burnout
As shown in Figure 1., there are two main categories of consequences of burnout
[Citation44,Citation63,Citation71,Citation72]. The first is the effects on patients, institutions,
and the economy [Citation71], and the second is the effects on the individual [Citation71].
Reduced quality of care and productivity (patient/economic cost)
A consequence of burnout is the potential for decreased quality of patient care [Citation71].
Pathologists experiencing burnout are less focused, are slow, and may provide suboptimal
diagnoses [Citation71]. 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)
[Citation44,Citation71]. Studies show that individuals experiencing burnout are 30-40% more
likely to reduce their work hours within the next 1-2 years [Citation45,Citation80]; 61% of
physicians reported that they would retire immediately if they had the means to do so
[Citation71]. It is even more alarming that mid-career physicians, who are considered the
most productive group, have the highest rate of burnout [Citation71]. The cost of losing a
qualified pathologist is difficult to quantify, but one can measure the financial benefits of
investing in employee well-being [Citation84]. For every dollar spent on employee wellness
programs, analysis showed that costs associated with medical leave were reduced by $3.27
[Citation71]. 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
[Citation63,Citation71]. Personal consequences may include career regret and suboptimal
professional development [Citation44]. This is compounded by poor mentoring of new
graduates.
In addition to psychological costs, physical side effects are not uncommon [Citation72]. In a
Swiss study, 40% of pathologists reported musculoskeletal problems in the previous month
[Citation63]. Moreover, 90% of surveyed pathologists had an increase in visual refraction
errors [Citation72] that were likely due to ergonomic issues and lack of workplace
optimization [Citation63].
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 [Citation68].
Adaptation mechanisms to burnout and burnout prevention
Pathologists use various mechanisms to cope with burnout [Citation70]. 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

[Citation85], while healthy coping mechanisms include involvement in hobbies like listening
to music, fishing, walking, watching TV, and cooking [Citation53]. They also include taking
a day off work for relaxation, and exercising [Citation70]. Research shows that residents who
meet physical activity guidelines are much less likely to experience burnout [Citation70].
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 [Citation70,Citation71,Citation77].
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 [Citation71].
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 [Citation44].
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
[Citation86] all contribute to the unhealthy imbalance between job demand and resources,
and personal and professional life [Citation44].
What is wellness/well-being?
Wellness comprises more than just physical health, which includes diet, exercise, and weight
management [Citation87]. 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 [Citation56,Citation71,Citation86]. Wellness is an active
process, a choice, and a lifestyle [Citation88]. It is a personalized approach that enables
people to develop into their best self [Citation87]. 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 [Citation86].
Stoewen [Citation87] 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 [Citation87,Citation88].
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 [Citation87].
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 [Citation56]. Pathologists are no
exception, with overwhelming numbers of cases, pressure on turnaround time, and case
complexity threatening to cause suboptimal performance [Citation71]. 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 [Citation71,Citation87]. In institutions that have a
cultural commitment in encouraging wellness, pathologists are less likely to experience
burnout [Citation41].
Wellness in the pathology community
According to a recent poll conducted by the American Society for Clinical Pathology
[Citation89], 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
[Citation89]. 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
[Citation90]. A different poll showed that pathologists had a more pessimistic outlook on
their profession than other physicians [Citation91]. Another survey showed serious
compromise of wellness among pathology residents and fellows [Citation65].
Determinants of pathologist wellness

Understanding the determinants that influence pathologist wellness may help in the
development of interventions for addressing burnout and promoting wellness [Citation92].
These indicators are classified by some studies as physical, personal, and work environmental
determinants [Citation92], or as intrinsic and extrinsic factors [Citation71].
Physical determinants
Although physicians advise patients on healthy dietary habits, research shows that many
ignore their own nutrition [Citation92]. Physicians struggle to stay adequately hydrated at
work. Interestingly, a 2% decrease in total body water affects cognitive abilities, including
attention and memory [Citation93]. Unhealthy work-related habits like working lengthy
hours and prolonged sitting may affect health.
Trockel et al. [Citation94] 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
[Citation95].
Physical activity, on the other hand, enhances wellness [Citation92]. It lowers the risk of
developing anxiety and depression [Citation96]. Incorporating physical activity in one’s self-
care may benefit physicians who are experiencing mental illness [Citation92]. 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 [Citation92].
When it comes to juggling work and home obligations, female pathologists encounter greater
difficulty than male pathologists, which increases work-family conflict and stress
[Citation56]. This could also be an issue with the adoption of digital pathology, which allows
pathologists to work from home [Citation40, Citation97, Citation98] but which could lead to
a conflict between work and personal hours [Citation99].
Other key concepts that may help pathologists to achieve wellness include healthy
relationships (professional and personal), religious beliefs/spiritual practice, and self-care
practices [Citation86,Citation100]. 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 [Citation101].
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 [Citation86]. 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 [Citation92]. Physician satisfaction was higher in organizations that
prioritized patient outcomes and care quality than it was in those that prioritized productivity
[Citation92].
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
[Citation102].
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 [Citation92].
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 [Citation86]. Career contentment appears to be
closely linked to physician well-being [Citation71].
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 [Citation86].
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 [Citation71].
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 [Citation92,Citation99]. 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 [Citation99].
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.
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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
[Citation92]. 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
Enhancing physician fulfillment requires a personalized approach [Citation99]. A study

found that the quality of work-life balance was positively correlated with the frequency of
activities [Citation89]. 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 [Citation89].
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 [Citation103], 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 [Citation103].
Another article [Citation104] 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
[Citation104].
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 [Citation92,Citation105].
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 [Citation86]. 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

[Citation106]. 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 [Citation105].
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 [Citation105].
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
[Citation107]. 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 [Citation105]. 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 [Citation89]. In academic
institutions like university hospitals, extra support may be needed for academic duties,
including teaching, research, and organizational leadership [Citation101].
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 [Citation56]. The incorporation of
wellness programs creates a positive work and learning environment [Citation108], and they
may have a significant positive impact on trainees as well, as detailed above [Citation102].
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 [Citation109].
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 [Citation89].
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 [Citation109].
A recent publication by Shanafelt et al. [Citation105] 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.

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 [Citation110].
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 [Citation92]. The best chance of success to improve professional wellness
is for personal and institutional approaches to be combined and tailored to each individual
[Citation71]. 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.
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Pathologist workload, burnout, and

• Cite this article

No standard tool to measure pathologist workload currently exists. An accurate measure of

Previous articleView issue table of contentsNext article

Overall, in order to address burnout, this multi-dimensional issue requires a comprehensive

Workload models in pathology: a work in progress

There is currently no standard tool to measure the workload of pathologists. Many

The importance of workload assessment

Workloads comes in different flavors with a different focus

Overview of commonly used workload assessment models

Table 1. Brief description of common pathologist workload models.

Relative Value Unit system

Royal College of Pathologists

The W2Q model is acknowledged by a number of laboratories to be useful for human

University of Washington, Seattle slide count

The Automatable Activity-Based Approach to Complexity Unit Scoring

The Automatable Activity-Based Approach to Complexity Unit Scoring (AABACUS) model

AABACUS captures pathologists’ clinical activities from parameters documented in the

AABACUS has proved to be successful for monitoring clinical workload of anatomical

Comparison of workload assessment models

Table 2. Advantages and limitations of the different pathology workload

Specialty - specific workload measures?

As well, some anatomical pathology fields, including neuropathology, hematopathology, and

Challenges to workload assessment models

Moving forward - thoughts on what the future holds

Pathologist burnout: a deep dive into causes and

Other published instruments include “quality-of-life assessment”, “work-life balance rating”,

Burnout in the laboratory medicine community

A recent study attempted to sub-stratify burnout according to practice demographics

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Emotional exhaustion may be defined as the feeling of “being drained” or “lacking

Pathology sub-specialization may contribute to burnout positively or negatively. While

Under-recognition and feelings of lack of accomplishment

Lack of recognition contributes to feelings of unfulfilled accomplishment and personal

Depersonalization due to complex administrative burden

A frequently cited stressor is EHR documentation, which is a major addition to the

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

Negative adaptation mechanisms include denial, self-blame, and substance abuse

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

The roadmap to pathologist wellness

Stoewen [Citation87] listed a number of dimensions of wellness, including physical,

Why should we discuss pathologist wellness?

Wellness is both a professional and a personal obligation. Organizations should actively

Determinants of pathologist wellness

Box 2 Important determinants that can influence pathologist wellness

• Collegial work environment

• Work home life balance

• Religious beliefs/spiritual practice

• Healthy dietary habits

• An institution that prioritizes patient outcome and physician satisfaction over