Stress reflects dichotomy in march of progress

March 1, 2006
Bruce Reiner, MD

,
Eliot Siegel, MD, FACR, FSIIM

If a man does not keep pace with his companions, perhaps it is because he hears a different drummer.

If a man does not keep pace with his companions, perhaps it is because he hears a different drummer.

Let him step to the music which he hears, however measured or far away.

-Henry David Thoreau

If you were to ask any veteran radiologist what the best and worst parts of his or her radiology practice are today, you might get the same answer to both questions: technology. While technology is what attracts many medical students to the field in the first place, it is also one of the primary variables increasing stress in the radiology workplace. For better or worse (and till death do us part), radiologists and technology go hand in hand. It is therefore not surprising that technology brings out both the best and the worst in its practitioners.

The relationship between technology and stress likely accelerated around 1936, when Hans Selye first described the general adaptation syndrome, otherwise known as stress. Within the next few years, several important technological inventions specifically related to the computer occurred, including the development of digital electronics by Claude Shannon in 1937, the Atanasoff-Berry computer in 1938, and the ENIAC in 1943. From that point on, technology and stress became inextricably intertwined.

A number of factors contribute to increasing levels of stress in the radiology workplace today; many are directly job related, and others are unique to the individual. Job-related stressors include the imbalance of supply and demand for both radiologists and technologists, the increasing size and complexity of imaging data sets, ever-changing imaging and information technologies, decreasing reimbursements, and heightened medicolegal risk. Internal stressors unique to each individual involve genetics, lifestyle, and personality. Examples of type A personalities abound throughout medicine, as the profession often self-selects for highly motivated, driven, and goal-oriented individuals who place tremendous internal stress on themselves in their pursuit of excellence.

The convergence of these increasing stressors, both external and internal, and rapidly evolving technology has created an atmosphere ripe for job burnout, which represents a combined physical, mental, and emotional response to repetitive levels of intense stress within the workplace. The stress itself represents a temporary state of mind that typically dissipates over time, while burnout represents a state of emotional fatigue that is long lasting. The end result is job-related exhaustion, cynicism, and ineffectiveness. In the end, many radiologists and technologists elect to drop out.

Surprisingly, little scientific study has been done within the radiology community regarding the relationship of stress and technology. While technology has been championed as the catalyst for productivity gains and advanced clinical care, little is really known about its impact on cumulative stress. At the same time, questions remain unanswered concerning how specific factors such as personality affect perceived stress levels from one individual to another and how we can use this knowledge to customize technology to simultaneously enhance job performance and minimize stress.

In an attempt to facilitate this understanding, we have designed a survey that investigates the relationship of personality, perceived stress, technology, and practice environment. The survey is available in both print and electronic versions and can be completed in 12 to 15 minutes. All responses will remain anonymous and confidential, and summary data will be made available to all participants.

FUTURE SCENARIO

Here is how we see technology evolving in the near future.

Radiologist R enters the sound-proof high-tech reading suite after being recognized by the retinal scanner. Before the environmental factors are adjusted to his individual preferences, an "affective scan" evaluates his facial expression, heart rate, body temperature, and galvanic skin response. Based on a combination of affective and personality data, the computer recognizes our radiologist as unusually anxious this morning (due to the combination of an argument over his daughter's new tattoo, the ticket he received on his way to work, and his favorite football team's loss in the playoffs). The ubiquitous computing network adjusts the environmental factors accordingly by dimming the lights, setting the air conditioning to 68 degrees and high ventilation, playing Pachelbel's Canon in D Major, and displaying the amber external light that suggests that a visitor enters at his or her own risk. The network directs the computerized ergonomic chair to the incline position, presents a cup of ginseng tea (no coffee today!), and pulls up the CNN Financial Web Page (knowing Dr. R's stock portfolio was up 2.1% yesterday). As Dr. R begins to relax (as detected by the affective computing sensors), the computer asks if he is ready to begin work.

Radiologist R puts on his computerized headset and issues the verbal command, "Open unread CT work list." Based on Dr. R's personality and technology profiles, affective data inputs, and recent workflow data, the computer selects the optimum hanging protocol and navigation formats, user interface, and decision support tools. As the unread CT work list is opened, Dr. R realizes that his supposed close friend and colleague Dr. S left 20 cases on the queue from the prior day, including a postoperative neck. As soon as this information is registered, the computer senses his heightened anxiety and responds in kind by adjusting the navigational device (foot pedal instead of mouse), selecting the "simplified" UI, and 1:1 display format. The reading queue is rearranged to display the noncontrast trauma head CT first, allowing Dr. R to regain his composure. Before beginning, Dr. R directs the PACS to send the unread postoperative neck CT case to Dr. S's reading queue with an attached audio file that would not pass the scrutiny of this journal's censors.

After successfully completing the first five cases, Dr. R begins to settle in and relax. As he does, the computer senses his more relaxed state and makes "on the fly" adjustments accordingly. As he opens up a chest CT angiography exam, the computer notifies him that another user is reviewing the same study. Dr. R decides to consult electronically with Dr. P, the pulmonologist, as she simultaneously reviews the same exam in the mobile ICU. Dr. R instant messages Dr. Q to notify him that he is reviewing the same case. After a few kind words are exchanged (using the pleasantries template), Dr. R directs the computer to use Dr. Q's default settings for the consultation. One might not even realize they were reviewing the same exam or using the same PACS, given the vast differences in the presentation state, reconstruction algorithms, workstation tools, and user interface. In the old one-size fits-all days, every user was forced to use standardized software that allowed for a bare minimum of customized features.

USER PROFILES

The first generations of PACS trained the users rather than the other way around. Now, with user-specific personality and technology profiles embedded into the sign-on and adjustments made based on real-time affective data inputs, workflow is consistently optimized to each end user's preferences and abilities. One single CT data set can be processed, displayed, navigated, interpreted, and reported using completely different schemas, which to the untrained eye appear completely different from one another.

As Dr. R continues his work, the computer continuously updates its user-specific database, based on numerous variables (including the modality, exam size and complexity, clinical indication, affective state, time of day, work list size, and recorded abnormalities). These data are, in turn, processed to automatically provide future workflow recommendations and contrast with other users with similar personality and technology profiles. This step has served to provide valuableshort-cuts, in a continuous attempt to optimize each user's productivity, in accordance with his or her unique skill set, personality, and technical aptitude.

While this scenario may seem futuristic and far-fetched, it is actually not out of the realm of near-term reality. Recent affective neuroscience and psychology studies have reported that human affect and emotional experience play a significant, useful role in learning and decision making. Affective-based personality assessments can be a valuable resource in optimizing job selection and performance. These findings validate our experiential knowledge that tells us some people are better suited for some professions.

Many of us have experienced the notion that internists think and behave differently from surgeons, who in turn are different from radiologists. But in the end, we must ask ourselves where the similarities and differences among the radiologist community begin and end. How can we use this knowledge to make better informed decisions regarding subspecialty training, job selection, and practice planning? As radiologists everywhere experience increasing levels of job-related stress, what impact does this have on overall work performance, and what can be done to alleviate these stressors? Does technology serve as an enabler or impediment to stress, and which types of technology are best suited to which types of personality?

While technology continues to evolve at a breakneck pace, the engineering that goes into these technical advances is typically conducted in a vacuum. To a large extent, engineering is designed by technologically savvy nonclinicians who do not always appreciate the diversity of the end-user population. The one-size fits-all approach does not take into account considerable differences in personality and affect, education and training, technical skills, and susceptibility to stress. An adaptive approach to technology development is necessary, but before that can be done, it is essential that we better understand similarities and differences in personality and stress.

We encourage all of our readers and colleagues to play an active role in this endeavor and take a few minutes out of your stressful schedules. In addition to letting off a little steam, responding to our survey should be fun, informative, and maybe a little therapeutic. We thank you in advance for your participation and look forward to using this information to serve the betterment of the community. You can complete the survey at www.zoomerang.com.

Dr. Reiner is director of radiology research at the VA Maryland Health Care System, and Dr. Siegel is vice chair of diagnostic radiology at the University of Maryland School of Medicine and chief of radiology and nuclear medicine at the VA Maryland Health Care System.