Jonathan Alexander, BS

COVID-19 is here to stay, at least for now, and so are many changes brought on by the need for adaptability during the early days of the pandemic. The necessity for physical separation drove many employers in all sectors, including medicine, to embrace remote work en masse in a way that had previously not been common, nor accepted in the mainstream. Old stereotypes of working from home have shifted from a luxury to something that is reasonable for anyone to seek out as their primary employment location. 

Remote working has seen a huge increase from pre-pandemic levels. 

of all workers will still be working remotely by the end of this

 Extrapolation of this data suggest that 36.2 million of the American workforce will be working from home by 2025, almost double the incidence before the advent of the pandemic. 

Advances in technology have made remote work equally, if not more, efficient than traditional office work. Many of the lessons learned from the private sector can be applied to the medical field. Although the adoption of telemedicine has been slow in the past, it is now more viable than ever with a corresponding boom in teleradiology.

With regard to our specialty, teleradiology has frequently been used to offset the exploding imaging requirement during off-service hours or otherwise allow for fulfillment of diagnostic responsibilities at off-site locations. 

off-hours teleradiology has jumped from 15

 With emergency department imaging use continuing to rise and new techniques further increasing the imaging volume expectations, a symbiotic relationship and understanding of the value of teleradiology is of great importance, even to those who are not interested in remote work.

The value of remote work exists not only in individual preference, but in more concrete benefits to the radiologist as well as the patient and hospital. For those who enjoy working from home, being allowed to perform some responsibilities remotely appears to confer resistance to the ever -present threat of physician burnout. A survey of radiation oncologists during the height of the original wave of the pandemic demonstrated a surprising reduction in burnout from 40 percent the previous year to 32 percent in May 2020.

 They attributed this resilience to their employees’ attitudes regarding working from home with 74 percent reporting a positive experience. Additionally, despite previous misconceptions, working from a home environment outside of a traditional office work setting appears to confer an increased – not decreased – productivity. Remote workers reported increased focus and less unproductive time.

 There are also the benefits of reduced commute time and cost, and the additional free time that comes with that. 

Diagnostic reading work, in particular, is amenable to remote productivity compared to most other telemedicine work since no physical proximity between physician and patient or other staff is necessary. Since remote work can theoretically be done at any distance, these radiologists can efficiently cover large networks of low-volume rural hospitals without any commute.

Likewise, the use of remote radiologists either in-house or externally sourced to cover overnight call shifts allows physicians to still work during normal hours and reduces the often burnout-inducing frustration of call shifts.

This is not to say that remote work is without its flaws. A common complaint for those who mostly work from home is the inability to disassociate work from home life. It is important to quarantine work responsibilities in a home office, and the lack of one may inhibit the draw of effective remote work. 

Radiology, in particular, requires a high-quality and expensive workstation to simulate the reading experience of in-house work and guarantee the same end product. While many institutions may supply this equipment, this is not universal. Also, remote physicians working across state lines are required to be licensed in both states, reducing a radiologist’s ability to easily do work in multiple states although the COVID-19 pandemic led to temporary reprieve of some of these regulations.

 These regulations may serve to protect radiologists from international outsourcing though. 

Lastly, the complexities of remote work may also be a hinderance to those who are not technologically inclined and may confer challenges in technical support for off-site hardware.

Whether done as a small component of a traditional radiology position or via a stand-alone position, teleradiology has an important role to play in modern medicine. Teleradiologists can help offset burnout and improve productivity and bring increased coverage to rural areas that may not be able to have additional full-time staff. Many radiology responsibilities can be done at home with the increased availability of remote collaboration software. Hospitals should work to offer additional opportunities for staff to spend days without in-person needs at home workstations. In this new, post-COVID landscape, remote work is more accepted, viable, and valuable than ever. It would be a mistake for radiology not to embrace these changes.

1. Ioannou L. 1 in 4 Americans will be working remotely in 2021, Upwork survey reveals. CNBC. Published February 6, 2021. Accessed December 14, 2021. 

2. Hanna TN, Steenburg SD, Rosenkrantz AB, Pyatt RS Jr, Duszak R Jr, Friedberg EB. Emerging challenges and opportunities in the evolution of teleradiology. 

3. Hoffman KE, Garner D, Koong AC, Woodward WA. Understanding the intersection of working from home and burnout to optimize post-COVID19 work arrangements in radiation oncology. 

 2020;108(2):370-373. doi:10.1016/j.ijrobp.2020.06.062

4. Airtasker. The benefits of working from home. Airtasker Blog. Published March 31, 2020. Accessed December 14, 2021. 

5. Van Moore A, Allen B, Campbell SC, et al. Teleradiology: American College of Radiology. American College of Radiology. 

https://www.acr.org/Practice-Management-Quality-Informatics/Legal-Practices/Teleradiology

Articles

With reports of increased productivity and reduced burnout, teleradiology may rapidly become the new normal. 

Exploring the Opportunities of Teleradiology in the Wake of COVID-19

Maintaining personal wellness and preventing professional burnout have an established role in the modern medical theater. The World Health Organization differentiates personal wellness from health as it involves fulfilment and realization of that person both as an individual “physically, psychologically, socially, spiritually and economically” and their perceived role in their social circles.

This heady definition attempts to simplify esoteric components of an extremely personal idea of mental health and satisfaction that really can only be identified by that individual. Burnout on the other hand is a more specific syndrome: emotional exhaustion from stress on the job, de-personalization and detachment from patients, and a demarcated shift in projections of professional self-worth and competence

. Physicians are particularly vulnerable to experiencing burnout and sacrificing their personal wellness for their job, with radiologists facing challenges unique from their colleagues.

These vulnerabilities have only been stressed by recent accommodations necessitated by the COVID-19 pandemic’s strain on the healthcare system. Recent surges in radiologist burnout have raised alarms concerning compromised patient care and deteriorating provider wellness

. Despite these challenges, there are simple practices that the individual can take to help combat the decline of their personal wellness and stave off burnout even with the added stress of the current health emergency.

There are many factors contributing to the rise in work fatigue and declined wellness in radiology. Institutionally, the paradigm of patient-centered physician values and the growing push for productivity and cost/revenue control by the hospital and insurance industries can produce cognitive dissonance

. Specific to radiologists, an increasing emphasis on reading speed and studies per day has resulted in an accumulation of more burnout than ever with rates of burnout symptoms hovering around 50 percent by some measures

Additionally, as patient care and quality control measures get more complex, the burden of work for physicians before care can be performed has become somewhat daunting. Some may feel that more of their time is spent maneuvering bureaucratic tape than performing radiology and medicine

. As more is expected out of radiologists during the workday, the corners that are cut can frequently be those that preserve wellness, such as lunch breaks and diverse time for academics or research. Radiology inherently lends itself poorly to much meaningful personal interaction on the day-to-day with either patients or other faculty. For some, this can be a source of fatigue and should be addressed. With these challenges in the forefront, a radiologist’s risk of facing deteriorating personal motivation and wellness in the modern age of medicine is substantial.

Radiology residents face different challenges from their full-fledged attending physician counterparts and suffer from substantially increased rates of burnout ranging from 40 percent to 80 percent – a level greater than either medical students or physicians

. They still have to deal with all the same issues that practicing radiologists do, but with the added stressors of being in the middle of a chain of educators -- being both student and teacher and being expected to internalize great amounts of information and balance that learning and teaching with their patient responsibilities.

Radiology residents have some of the worst rates of burnout of all fields. Nearly 85 percent of trainees experience some decline in emotional wellness, feelings of personal accomplishment, and other affects consistent with burnout

. This article by Mendoza and Bertino cites tedious training modules, long hours, and low levels of social interaction responsible for producing this number. Residents are also more vulnerable to feelings of inadequacy due to imagined and actual perceptions of being inexperienced.

Resident radiologists are set up to burn out during their training and carry that vulnerability into their working careers. Reinforcing the wellness of their trainees should be a high priority for programs not simply to encourage enrollment or placate concerns of overworking, but to facilitate learning and promote good practices for burnout resilience during and after residency.

While burnout and wellness statistics among radiologists, both attendings and trainees, have been morbid in recent years, the onset of practices to combat COVID-19 has disrupted even those with otherwise stable personal wellness. With long work hours and limited personal interaction already being the cause of much of the burnout radiologists currently experience, the social isolation and increased need for personnel that the pandemic brought on has surely only made this worse.

Studies looking at previous endemics and pandemics have revealed that not only is the populace at large exposed to increased mental stress, but physicians have increased rates of mental distress and even post-traumatic stress disorder following participation in managing these outbreaks

. Between the looming threat of infection and the increased scrutiny by the public and public health officials, stress levels are at an all-time high. Even though much of the public sentiment is positive regarding “healthcare heroes,” those that feel that the title is unwarranted or unfulfilled may have their self-worth damaged by the additional expectations.

Additionally, harassment by social media conspiracy activists claiming mask exemption, pandemic hoaxes, and other similar falsities may exacerbate feelings of not being able to effectively control the outbreak while individuals refuse to follow guidelines. While the focus is appropriately on patient care and increased demands during the ongoing outbreak, attention should still be directed towards maintaining wellness.

Addressing burnout and maintaining wellness can be targeted either at the institutional level or by the individual. Institutions have a vested interest in keeping their workforce healthy and fully functional. Constant interruptions and long hours lead to burned-out physicians and overlooked mistakes

As for residents, while many programs may try to implement mandatory wellness lectures or provide meditation services and other such at-will avenues to increase burnout resilience, only work-hour limits have been strongly associated with improvement in emotional exhaustion and burnout

On the individual level, many small practices can be integrated into daily life to preserve wellness and prevent oneself from being burned out. Drs. Fessell and Cherniss suggest a small list of “micropractices” to help strengthen resilience to burnout and keep wellness balanced

. These are things like diaphragmatic breathing and taking a “moment for mindfulness:” this means taking a moment to reflect inwards when doing something like hand washing, centering oneself, and analyzing their current state. This allows a chance to address feelings from the last case or make sure that personal needs are met.

Another such micropractice involves naming complex emotions as they are experienced to aid self-awareness and facilitate a return to calm. Lastly, sharing cases and frustrations with peers is a great way to acknowledge that others are facing similar problems and get practical tips to internalize

. These are things that must be consciously done regularly to keep wellness a priority during a complex and hectic workday.

Maintaining wellness can be a challenge even under ideal circumstances, let alone during a world-wide health emergency. Maneuvering the modern medical landscape of high demands, impersonal patient interactions, and complicated infectious precautions has produced a large burden of burned-out physicians. The challenges that radiologists face are different from their colleagues and require specific and deliberate attention.

Every radiologist should try to be more aware of the state of their personal wellness and take steps to remedy shortcomings and reinforce resilience to burnout. Sacrificing mental health and wellness in the name of patient care, dedication, or monetary gains in reality is harmful to both the physician and the patient. Burnout is not a burden that has to be borne, but it takes deliberate effort and acknowledgement by institutions and individuals.

1. Maslach, C., Jackson, S. E., & Leiter, M. P. (2018). 

2. Shah K, Kamrai D, Mekala H, Mann B, Desai K, Patel RS. Focus on Mental Health During the Coronavirus (COVID-19) Pandemic: Applying Learnings from the Past Outbreaks. Cureus. 2020;12(3):e7405. Published 2020 Mar 25. doi:10.7759/cureus.7405

3. Berg, S. (2020, May 28). The 12 factors that drive up physician burnout. Retrieved June 07, 2020, from https://www.ama-assn.org/practice-management/physician-health/12-factors-drive-physician-burnout

4. Cohan RH, Davenport MS. Productivity, Meet Burnout. 

. 2018;25(12):1513‐1514. doi:10.1016/j.acra.2018.08.001

5. Busireddy KR, Miller JA, Ellison K, Ren V, Qayyum R, Panda M. Efficacy of Interventions to Reduce Resident Physician Burnout: A Systematic Review. 

. 2017;9(3):294‐301. doi:10.4300/JGME-D-16-00372.1

6. Mendoza, D., & Bertino, F. J. (2019). Why Radiology Residents Experience Burnout and How to Fix It. 

(4), 555-558. doi:10.1016/j.acra.2018.08.009

7. Fessell D, Cherniss C. Coronavirus Disease 2019 (COVID-19) and Beyond: Micropractices for Burnout Prevention and Emotional Wellness. 

. 2020;17(6):746‐748. doi:10.1016/j.jacr.2020.03.013

The role of the pandemic and what radiology can do to mitigate its burnout effect.

Radiologist Wellness and Burnout in the COVID-19 Era

Augmented and virtual reality are among some of the newest technologies to reach a sophistication viable for medical use. Augmented reality (AR) is the integration of virtual components onto the background of reality, while virtual reality (VR) is a complete and isolated virtual display.

The most popular utilization of AR and VR is in entertainment devices, such as video games, but the versatility and responsiveness of the technologies have allowed for exciting developments in healthcare, as well. In some ways, it can be said that interventional radiologists have been using these techniques for their entire existence. In essence, anytime a fluoroscopic projection is used during a procedure, that is technically an augmentation of reality used to help visualize internal structures in real time.

Utilizing recent AR and VR technological advances, radiographic data can now be used to create a display with more integration and interaction. In addition to its utility in image-guided procedures, AR and VR have also found niche roles in the education of trainees and for direct benefits to patients, as well, though the technology is not without its drawbacks.
	
	One of the most promising uses of AR technology, specifically, is procedural planning and guidance. In the operating room, AR displays are generated using advanced algorithms that interpret CT data into a 3D map of structures delineated by density (Tang et al.). This map can, then, be displayed in several ways, such as on a screen nearby, through a headset, or projected onto the patient themselves depending on the needs of the procedure. Then, a plan can be drawn onto the augmented surgical field before the first cut.

Not only can structures, such as vessels and tumors, be overlaid onto a display of the surgical field, but organ movements and deformations can be accounted for in real time to update the display. This gives some compensation for the lack of tactile feedback during laparoscopic procedures and allows for a better real-time visualization of underlying structures. Tang and colleagues demonstrated the value of these displays for hepatobiliary surgery, but these techniques can be applied to just about any surgical procedure that can be planned far enough in advance.

AR projectors can already integrate navigation aids in MRI-guided procedures to assist in carrying out the procedure such as Mewes et al. describes. Wherever radiographic information exists before or during a procedure, AR stands to improve the integration of that information in the OR, and radiologists are the gatekeepers of this technology with their knowledge of medical informatics and mastery of radiologic anatomy.

With AR and VR already in the public consciousness as powerful tools of media consumption, it should come as no surprise that they have been quickly modified to work as compelling interactive forms of education. Progress has been made in developing AR tools for the advance of “tele-mentoring,” the use of displays to mentor trainees at long distance (Andersen et al.). AR allows for mentors to annotate directly on the student’s display so the trainee is no longer required to shift attention between a separate screen and their work and the training procedure can be done collaboratively. This system would also allow a more experienced interventional radiologist or surgeon to assist one doing an unfamiliar procedure without the need for transportation of the expert to the patient.

VR works as a training tool similarly to how it is used to consume media: allowing for a virtual simulation of a subject rather than just a video. New software allows for VR headsets to display a procedure to trainees to observe from anywhere. These students can see the surgical field from a 360-degree view or from the surgeon’s own perspective as each step is narrated, providing more immersion and detail than any 2D animation or lecture could. Interventional radiologist Dr. Ziv Haskal is pioneering this technique to teach complicated trans-jugular intrahepatic portosystemic shunt (TIPS) placement surgery (Barney). He demonstrates that even the most complicated and difficult-to-shadow surgeries could be shared nationwide and simulated through simple VR sets as a powerful teaching aid.

VR sets also have the potential to directly benefit the patient through simulated education and therapeutic benefit. Amazingly, therapeutic VR simulations have been found to reduce a self-reported pain score especially among those with more severe initial pain (Spiegel et al.). This represents an alternative to pharmacological therapy thought to work by distracting from nociceptive perception by fully engaging the other senses. Furthermore, VR can be used to walk a patient through their day at the hospital from check-in to procedure.

Dr. Haskal demonstrated how VR can be used to prep a patient for the same procedure he was teaching before -- a TIPS placement -- with the viewer getting checked in, visiting with their doctor, and being taught the procedure through the VR medium (Davis). Simple VR simulations like these can be programmed into a smartphone that many patients already have and viewed with the addition of a foldable cardboard headset, allowing for these sessions to be conducted in the patient’s own home.

Unfortunately, a technology this new to the field comes with some limitations. AR specifically requires a more robust framework in place compared to VR. The tele-mentoring system suffers from a few significant draw backs: a frame rate which limits the system’s ability to accept annotations from a proctor, the current model can only relay still frames for communication, and audio communication was not integrated (Andersen et al.). Additionally, processing power is a constraining factor especially if a projection is desired due to the increased demand necessary to account for the changes in topography when the field distorts (Tang et al.). And with any additional piece of machinery comes the opportunity for malfunctions and the need for supplementary technical staff and funding.

There is also a significant buy-in in terms of costs and burden of learning for the software. Improvements are needed to make the systems more user-friendly before AR and VR are appealing to the less technologically inclined. There are also limitations to haptic realism in the programs and some develop motion sickness and cannot even use them. Despite all this, as the software becomes more robust and user-friendly, the versatility of AR and VR will quickly overcome its weaknesses.

AR and VR are the future of technology-integrated medicine. Using projectors or headsets to simulate internal structures or peek into a procedure in VR are things that seem in place in a science fiction novel, but that reality is closer than ever. The sheer utility of AR annotation in procedural planning and visualization of radiologic information in real-time is something that will drive the technology forward despite its current drawbacks. The field of radiology has many avenues to apply these technologies, with its wealth of procedures using radiographic displays and the benefit of AR displays to non-invasive surgeries.

With a variety of current applications including patient and trainee education, as well as procedural planning and guidance, the future directions that AR and VR can take medicine in are as varied as remote-assisted home treatments for patients and VR curriculums over specific chronic diseases for patients and students alike. The technology has the potential to integrate with many aspects of the daily medical procedures and medical education, and radiologists are in a position to take those steps first.

1. Andersen D, Popescu V, Cabrera ME, et al. Virtual annotations of the surgical field through an augmented reality transparent display. The Vis Comp. 2015;32(11):1481-1498.

2. Barney J. Virtual Reality Puts Physicians, Trainees – Even You – Right in the Operating Room. 2018, October 19 Retrieved from https://news.virginia.edu/content/virtual-reality-puts-physicians-trainees-even-you-right-operating-room

3. Davis J. Going virtual: How VR is guiding interventional radiology. 2018, September 18  Retrieved from https://www.elsevier.com/connect/going-virtual-how-vr-is-guiding-interventional-radiology

4. Mewes A, Heinrich F, Hensen B, et al. Concepts for augmented reality visualisation to support needle guidance inside the MRI. Health Tech Let. 2018;5(5):172-176.
	5. Spiegel B, Fuller G, Lopez M, et al. Virtual reality for management of pain in hospitalized patients: A randomized comparative effectiveness trial. Plos One. 2019;14(8).

6. Tang R, Ma LF, Rong ZX, et al. Augmented reality technology for preoperative planning and intraoperative navigation during hepatobiliary surgery: A review of current methods. Hepat & Panc Dis Intl. 2018;17(2):101-112.

Radiology is in position to lead the integration of AR and VR into medical procedures and medical education.

Augmented and Virtual Reality – Radiology at the Center of Medical Technology

Radiologists have always been at the forefront of adopters of new technologies, apropos of a field that relies so heavily on technology in its daily operation. Yet, the untapped opportunities and applications of 3D printing have not been fully utilized in our specialty.

Recent improvements in 3D printing have enabled improved printer portability, decreased cost-per-unit, customizability of forms and materials, increased speed from inception to production, and the ability to share files and model plans without needing to ship the physical product. It’s now possible to have separate models made for each unique patient situation or training requirement and have them made quick enough to utilize in relatively urgent situations.

Key emerging applications of 3D printing technology include preprocedural planning, student and resident training, and patient education, all of which could benefit from a radiologist’s expertise and guidance.

One of the most exciting uses of 3D printing for the immediate benefit of patient and physician is the ability to utilize custom models for preprocedural planning. A surgeon facing a difficult operation with complex anatomy may find it difficult to be fully prepared for the unique challenges encountered in a particular patient. One-size-fits-all models would not be able to replicate individual variability sufficiently enough for pre-operative practice or hand-on planning.

 the successful use of a 3D printed model to plan all possible angles prior to a difficult revision hip surgery. Similar models can be produced either as visual planning references or with more realistic materials that allow hands on practice, even accepting sutures. With radiologists’ imaging and anatomical expertise, interdisciplinary work using this technology could be extremely beneficial and could help improve patient procedural outcomes.

In addition to its role in pre-procedural planning, 3D printing technologies can further address a significant need for improved learning devices and hands-on training tools. For instance, 

 that the use of models greatly improved radiology resident understanding of complex anatomical topics.

Particularly for radiology residents who need to master abstract internal anatomy and intricate anatomical relationships, having a set of tactile learning tools for any structure could speed the training process greatly and afford each resident the ability practice on models individually before applying the knowledge later.

The addition of 3D printing to other didactic tools-including virtual reality devices and computer-assisted curricula-can present a set a revolutionary hands-on learning techniques and contribute to a paradigm shift in content delivery and radiology education.

A third highly useful application with a great potential is the utility of 3D printing in patient education and procedural consent. Challenges in obtaining informed consent can often occur with abstract anatomical concepts or presentations that are lacking in patient specificity.

Both these issues can be addressed by the aid of 3D-printed models that can be interacted with and are individualized to a particular patient’s upcoming procedure. 

 has shown that the use of 3D lung models customized with markers for the location of patients’ lung tumors drastically improved patent understanding and satisfaction during the informed consent process. The opportunity to physically manipulate a model specific to the needs of the individual patient can be extremely beneficial in improving patient comprehension. It can also aid decision making-especially given the now-treatable, increasingly-complex pathologies and advanced image-guided procedural techniques offered, such as those offered by radiologists.

Given its practicality, versatility, portability, and effectiveness, 3D printing technology is rapidly emerging as a useful tool with new healthcare-related applications arising everyday. Due to their exceptional understanding of imaging, anatomy, and informatics which are essential elements for successful utilization of 3D printing, radiologists are uniquely equipped to optimize the value of this technology in healthcare and potentially serve as gatekeepers for its safe, effective, and innovative use.

Radiologists can, and should, take advantage of this game changer for the benefit of their patients, trainees, and practices.

How advances in 3D printing could bring significant changes to radiology practices.

Jonathan Alexander, BS

Articles

Exploring the Opportunities of Teleradiology in the Wake of COVID-19

Radiologist Wellness and Burnout in the COVID-19 Era

Augmented and Virtual Reality – Radiology at the Center of Medical Technology

Strides in 3D Printing Offer Game-Changing Applications for Radiology