Less Strain, More Gain
By Dan Harvey
Vol. 19 No. 11 P. 26
Optimized ergonomics can reduce repetitive strain injuries and burnout.
Although radiologists have long advocated for better reading room ergonomics, they may have allies among administrators charged with reading room oversight—especially when an ergonomically infused workstation provides irrefutable evidence of radically positive workstation change.
Case in point: Robert Kilpatrick is the administrative director for nuclear medicine in a major regional hospital who also oversees several other departments. When he learned about ergonomic innovations related to radiology, eg, standing/sitting workstations, he considered personal experience. He had already perceived a problem; with so many departments to cover, 40% of his day is desk time. With a career closely linked to radiology, he understood a shared circumstance with the radiologists he works with: Too much chair sitting equals subsequent discomfort. He, like many others, suffered.
Kilpatrick says he became involved in a project that brought experimental workstations to reading stations, and it proved to be an eye-opening experience. "I thought, 'Why can't I have this, too?'" he says, remembering the back pain he endured and recalling the seemingly near-perfect solution.
He discerned something that would serve radiology and himself equally well: a desk where the entire work surface—computer, keyboard, and writing surface—was on a single level, which would eliminate unnecessary and, ultimately, inefficient body movement. This required proper arrangement, once a theoretical proposition more easily envisioned than applicable.
A Better Approach
Kilpatrick say the process toward a solution involved at least four pilot systems. All were based on variations of one of the elementary concepts of ergonomics in radiology, a sit/stand work area. Some of the solutions that were offered, he says, weren't completely conducive to the problems affecting productive workflow. The main problems—discomfort, pain, and even long-lasting repetitive stress injury—needed a comprehensive approach, preferably from an available and reliable product.
"All solutions piloted offered only bits and pieces of what I felt was needed to foster productivity and reduce stress and strain," Kilpatrick says. "But nothing came wrapped in one package."
Ultimately, he came upon an assemblage provided by RedRick Technologies that best addressed his personal and professional concerns—a sit/stand work surface, attached file cabinet, off-floor computer, matching monitor and work surface, and appropriate writing and paper-handling work area. While he found the chosen solution to be a bit more expensive than the inadequate demos, a cost-justification analysis, wherein all elements were considered, closed the case.
After implementation, Kilpatrick says, it took him only about one week to physically and mentally realize the benefits. Moreover, Kilpatrick found that his office space was perceived less as a closed-off area and more as an open environment in which he is now more easily approached. Previously, he relates, people timidly knocked on his door. Now, his office has become much like a social gathering space where people feel comfortable to walk in and talk.
"An ergonomic setting makes people feel that you are more approachable," Kilpatrick says.
Reimagining the Work Space
Kilpatrick offers a radical way to think about ergonomics, but the creators of the RadFlowSpace system seek to push the envelope further; it's more than chairs and work surfaces.
The RadFlowSpace developers also selected RedRick Technologies for their expertise in designing and delivering reading room solutions, to collaboratively explore and evaluate new design concepts. That collaboration has been foundational and is a successful model that is being extended across the physical, visual, and auditory interfaces present in the radiologist's workstation.
The principal developers of the concept sought to address not only issues such as repetitive strain injuries but also the data-overload factor, a key cognitive factor that contributes to burnout. These principals include John Mukai, MD, chief technical officer of Saint Vincent Radiological Associates in Worcester, Massachusetts, and the director of resident clinical informatics section in the radiology department of Saint Vincent Hospital, and David A. Bader, MD, FACR, president of Saint Vincent Radiological Associates and chief of radiology at Saint Vincent Hospital.
The cocreators issue a discomforting warning: Contemporary, demanding radiology caseloads are rapidly approaching the limits of human capability. They sought a radical recasting and redeployment of radiologists' workspace focused on addressing the exponential increase in workload and its associated visual data, problems compounded by a "mulitiplicity of clinical imaging applications that require simultaneous real-time comparison," Mukai says.
Specific issues they wished to address included poor interoperability ("Too many apps!") and inadequate interfaces ("Why do interfaces keep changing when you are just getting used to them?"). Even deeper, the issues appeared to be symptoms of a root cause—a marketplace characterized by reliance on silo-housed vendors that resulted in vendor-reliant facilities and, ultimately, user-physicians that acquiesced to the "status quo."
Within this status quo, the creators proved to be a disruptive force, but not for chaos. RadFlowSpace creators brought together the visual, auditory, and ergonomic elements of workflow in cohesive fashion. To best understand what RadFlowSpace means, it is necessary to break the syllables down. Mukai explains: Radical means the solution, flow means workflow, and space means workspace.
The creators of RadFlowSpace know first-hand that the adoption of new technologies in the radiology suite occurs long before health care organizations can adapt. While advances in imaging technology have made it much easier to collect imaging data, processing the data remains a largely human endeavor. Currently, their iterations, the hardware that comprises their solution, remain in the prototypical stage. Development of a compelling prototype involved the following three primary challenges:
• The visual challenge: developing a workspace that functions as a command module for the user—the "pilot" of this "cockpit"—and offers a curved visual array of monitors. "There's [industry] dogma that consolidates all into one monitor, the standard 30 inches, wherein you view all planes—the axial, sagittal, and coronal—but you can't look at something static. And it's not enough to scroll," Mukai says. "What you're looking at is a movie within a movie. You just can't turn it off and look at the other movie. There are issues related to time points. There's no way anyone's mind can do this all, linking it all together, a movie with submovies, and all of it happening all at once."
• The ergonomic challenge: designing a navigational interface in three dimensions with instantaneous tactile/voice-activated control.
• The auditory challenge: the user should be able to control sound-in and voice-out with a hands-free wireless headset interfacing with as many devices as needed.
As such, the prototype includes the following platform specifics:
• Visual: a multiple visual horizon that includes up to eight monitors, with time point correlations;
• Ergonomic: a degree-of-freedom up to a five degree-count ergonomic work surface; and
• Audio: an auditory element that involves a six-channel wireless headset.
"We understand that there's a dynamic relationship among these three elements," Mukai says.
Currently, the creators are moving forward with this concept. Along with introducing the design in messaged meetings such as the Society for Imaging Informatics in Medicine (SIIM) and RSNA, the current plan includes the following:
• transitioning prototypes into production;
• introducing an educational outreach program, which includes the development of a learn-by-doing training course; and
• meeting budgetary costs.
Obviously, it's a high-expense effort. They began with an initial investment that quickly grew to $190,000 beyond the outset. The estimated budget heading into 2018 amounted to $1.4 million. The creators think their immersive project is worth the effort and expense; their ambition is to challenge conventional thinking about workflow.
Within this radical thought process, the creators not only want to open real estate on the desktop, they're also seeking a redesign that leads to radiology-centric workspace improvement. They concede, however, that they can't do it alone. While they are showcasing the Multiplex 8 Radiology Workspace Laboratory at SIIM and RSNA meetings, they're not just offering prospective users a test drive; they are using the opportunity to collect the input of radiologists, with the purpose of pursuing continuous improvement.
"It needs to be user driven," Mukai says.
While Mukai and colleagues proceed with new directions from an already well-charted path, research continues to be conducted regarding the efficacy of the ergonomic/radiology connection. Some research provides a macroscopic view; at least one study is much more microscopic.
The underlying subtext of the research reveals an inherent irony. New technology advances such as PACS and digital imaging were developed to increase efficiency and improve workflow. However, the advances would prove to be deleterious to the health of radiologists.
"Today, a great deal is done by computers, which means that radiologists spend almost all of their time at their workstations. As such, numerous elements come into play, such as height and angle of the monitor," says Gordon Sze, MD, FACR, a professor of radiology and biomedical imaging at Yale School of Medicine in New Haven, Connecticut.
He adds that new developments have led to a radiologist workload that has increased exponentially. "Radiology has assumed a much more critical role in a hospital," he says. "For instance, the number of examinations that require emergency interpretation has increased. In settings like the [emergency department], more rapid turnaround is needed."
Such a high-pressure situation has moved beyond high-pressure environments such as the emergency department, Sze says. "Technology has increased the number of studies considered necessary, which means that radiologists are called on for more rapid interpretations, as treatment for conditions such as stroke has improved."
In an article published in 2017 in the Journal of the American College of Radiology, Sze and colleagues Edward Bluth, MD, and Claire Bender, MD, summarized the overall situation. "Use of [new technology] can lead to repetitive strain injuries, many of which can be exacerbated by speciﬁc features of a radiology practice environment," they wrote. "Ergonomic approaches, such as proper reading room structure, lighting, temperature, noise, and equipment setup, can help decrease the frequency and severity of repetitive strain injuries and improve radiologist productivity."
As the authors suggest, ergonomic approaches are complex and involve more than just a workstation, Sze says. "Many elements come into play such as room lighting, temperature, and humidity. Remedies need to include ambient lighting, better temperature control, and sound absorption."
Education is also crucial. "[All ergonomic approaches] are best implemented along with proper training of the practicing radiologists," the authors wrote.
A Closer Look
While Sze and colleagues provide a broad perspective of the current state of radiology, Rebecca L. Seidel, MD, a breast imaging radiologist and assistant professor of radiology and imaging sciences at Emory University School of Medicine in Atlanta, provides a much more intimate view. Along with Elizabeth Krupinski, PhD, vice chair for research in the department of radiology and imaging services at Emory, Seidel engaged in a study keenly focused within their organization. The study, "The Agony of It All: Musculoskeletal Discomfort in the Reading Room," was published in a 2017 issue of the Journal of the American College of Radiology.
Their effort provides a close-up image of how improved ergonomics impacted one setting. The research resulted in many of the same conclusions found in similar research, such as the following:
• Radiologists most frequently reported symptoms in the neck, back, and right upper extremity.
• Musculoskeletal symptoms were more likely to interfere with work as age and years in practice increased.
• More than seven hours each day at a PACS workstation was signiﬁcantly associated with a higher total pain score.
However, Seidel indicates that, for her, it was far more personal. A family member experienced severe back pain resulting from the work environment, and she witnessed how radiologists within the Emory organization endured work-related musculoskeletal injuries that went beyond pain in the neck, shoulder, back, and breast regions. Specific demographics provided clues as to the causes of those injuries. "Within the organization, responders provided age, gender, years of work, certification, and ranking," she says.
This forensic approach helped determined the frequency of symptoms, degree of discomfort, and interference with the ability to work. The purpose of the study was to determine the extent and severity of musculoskeletal discomfort in radiologists using a standardized tool, the Cornell Musculoskeletal Discomfort Questionnaire (CMDQ). The study, approved by Emory University School of Medicine's Institutional Review Board, involved an electronic survey distributed by anonymous link to all radiology residents, fellows, and attending physicians. The survey contained an electronic version of the CMDQ, a 54-item questionnaire about the prevalence of musculoskeletal symptoms in 18 regions of the body. The response rate was substantial enough to be revealing. The survey was distributed to 252 radiologists with a 39% response rate.
"Our data show that [most] radiologists in our sample spent [seven] or more hours per workday at a computer workstation," the authors wrote. "This variable was significantly associated with an overall higher total pain score. In addition, the majority worked in a seated position 100% of the time. This amount of sedentary time potentially places radiologists at risk of 'sitting disease'—the increased incidence of illness and mortality associated with prolonged sedentary time."
One thing that the study indicated was that implementation alone isn't enough. Education is crucial.
"We made the changes that provide us with the sit/stand desks, and, during my own work day, I try to alternate periods of sitting and standing," Seidel says. "But the experience has made me more aware of how I set up my workstation. Before I even get down to the work, I make sure to do any needed adjustments to optimize the ergonomics related to body habitus and work patterns."
The implementation allows Seidel the luxury of orientation time before she plows into the daily work schedule. For workflow and health's sake, she offers this advice: Radiologists need to know how to best optimize ergonomics.
— Dan Harvey is a freelance writer based in Wilmington, Delaware.