 J. Neal Rutledge, MD |
In the late 1990s when helping plan the PACS project for Austin Radiological Association (ARA) in Austin, Tex, I had heard little about the psychosocial issues that may occur. I had been told that a significant number of radiologists resigned when their groups converted to PACS and was concerned that this did not happen in our group. As radiologists, we were surrounded by hi-tech imaging, but few of us used computers on a regular basis. None of us could really grasp how events would force so much change, so quickly.
Because of my belief that radiology was not different from other businesses, I looked at what others had done in similar circumstances. I found a significant body of research about exposure to rapid change in individuals and organizations and the psychosocial ramifications. I also learned that the rate of technological change is increasing exponentially!
Change results in two very different sets of psychological effects. The initial effect is arousal, creating positive feelings such as curiosity, excitement, and wonder. Reciprocally, there are also negative feelings, including confusion, tension, and fear. Unfortunately, arousal with increased rates and amounts of change cannot be sustained, and as fatigue sets in, negative feelings and problem solving decline, resulting in a loss of control.
Reactions to this loss of control may be expressed as aggression, frequently manifest as sabotage of the change process, but this is usually a short-term reaction. Other likely responses are anxiety and fear, which can become constant. Anxiety is usually manifest as sleeplessness, irritability, and dread. If the process is prolonged or there is a failed attempt to control the change process, individuals can become apathetic and depressed.
When implementing change, stair-step processes are more easily integrated than linear ones. Within each step, multiple changes can occur simultaneously. ARA, for example, used a stair-step process by first implementing a radiology information system followed by a conversion to PACS, rather than implementing both changes simultaneously. Implementations were also staged on an office-by-office basis.
In planning our implementation strategy, we tried to predict the necessary changes as completely as possible. As a result, we explained our mission, educated and re-educated our employees, and tried to make change seem the norm. This strategy resulted in minimizing backlash to change and allowed burdensome old procedures to be discarded.
It is critical to give individuals a sense of control. One way to accomplish this is by encouraging individual adaptations. The search for personal solutions is essential for problem solving. This minimizes the natural tendency to blame others for causing distress. Self-pacing needs to be encouraged so individuals can rest when efficiency drops. Developing an environment conducive to asking for help is also vital.
ARA worked hard to make change less stressful by using extensive training and trial runs. Private training sessions were used to encourage questions with physicians separated from technical and clerical training. Everyone underwent two sessions to help with memory retention.
Most managers are not taught to efficiently manage rapid change. ARA brought in trainers to teach management courses helping others accept change. We revised our employee evaluation to look for flexibility. What we found was that more highly skilled managers were required and changed our hiring based on best management practices. We discontinued requiring managers to have been technologists previously.
In PACS implementation, changes for radiologists are the most profound. From the relatively static analog world of film, we rapidly moved into the new digital world where we experience an environment with temporal flexibility, transcendence of space, and a new equalization of status.
One of the first issues encountered in this world can be information overload. Too much information can be overwhelming, resulting in a sense of loss of control. To address this, one factor we used to choose a PACS product was a display that minimized buttons and distractions. Similar to a fighter pilot cockpit with heads-up display, we wanted to limit information to what was essential and timely.
ARA’s workflow was also redesigned to condense information to just what was necessary. We used specialized architects to redesign our workplaces with a focus on ergonomics, lighting, sound, and limiting distractions. Because multi-tasking ability appears to be innate, not learned, radiologists who lack it have been allowed to naturally migrate to outpatient office locations versus more chaotic hospital settings.
Given that there is a natural tendency to resist change, people wishing to effect that change must be prepared for both emotional and logical resistance. No matter how successful the change, the agents of change are ultimately always disliked.
The threat of change stirs strong, primitive survival instincts and powerful emotions. As we grow psychologically, we learn to temper emotions with logic, but when under stress or required to make rapid decisions that cause stress, emotions usually dominate.
Negative emotions are best dealt with by opposing positive emotions, and logical arguments should be answered with logical arguments. Presenting logical arguments to emotional issues can often make things worse. It is easy to respond to logical arguments by employing needs assessment, cost justification, and return-on-investment analysis for PACS.
When faced with strong emotions, one useful strategy is to bring in an outside authority. As in school and sports, these authorities can help referee emotional differences. Another strategy is to use salespeople. Persuasion and marketing go hand in hand, and salespeople promoting change can deal directly with individual emotional needs
ARA’s transition to PACS went very smoothly, and no one would go back to our pre-PACS days. None of our radiologists would likely say that psychology was involved in the strategy to manage the changes that occurred. Nonetheless, I believe that our implementation went well because knowledge about the psychology of change was considered and we addressed issues of change before they became problems.
The most challenging problems in switching to PACS are not technical, but the emotional impact of change.
J. Neal Rutledge, MD, is an interventional neuroradiologist with the Austin Radiological Association. He is medical director for neuroradiology, Seton HealthCare Network, and adjunct professor of psychology at the University of Texas at Austin. This article has been excerpted from Psychology of Change with PACS, which he presented at the 9th Annual Digital X-ray and PACS: An Educational Forum, on February 28, 2005, in Scottsdale, Ariz.
